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AcknowledgementsLead AuthorMarina Green RN MSN IBCLCBreastfeeding Committee for Canada Contributing AuthorsBeverley Chalmers, DSc(Med), PhDInternational Perinatal Health Consultant Louise Hanvey, RN, BScN, MHASenior Policy Analyst Michelle LeDrew, RN, BN, MN, CHEBoard of Directors member Lynn M. Menard, RN, BScN, MATeam Leader Nancy E. Watters RN, BScN, MScNNursing Faculty ReviewersDina Ryan Davidson RM IBCLCRegistered Midwife, Lactation Consultant M. Shirley Gross MD, CCFPDirector Cheyenne Joseph, RN, BScK, BScN, MPH, CCHN(C)Senior Nursing Instructor Carley Nicholson, RD, MPHPolicy Analyst Catherine M Pound, MDAssociate Professor Kate Robson, MEdNICU
Family Support Specialist IntroductionBreastfeeding is recognized as the unequalled way to provide optimal nutritional, immunological and emotional nurturing of infants.Footnote 1Footnote 2Footnote 3 Consistent with the World Health Organization (WHO) global recommendation for public health, Health Canada recommends exclusive breastfeeding for the first 6 months, and sustained for up to 2 years or longer with appropriate complementary feeding to support nutrition needs, for immunological protection and growth and development of infants and toddlers. Breastfeeding is also linked to many of the United Nations Sustainable Development Goals, such as no poverty, zero hunger, good health and well-being, no inequity, and responsible consumption and production.Footnote 4 There is no doubt about the importance of breastfeeding for infants, young children, and mothers. The effects occur both during and beyond the breastfeeding period. Recent studies and position statements reflect findings of the dose–response effect of breastfeeding: the more exclusive breastfeeding is in the first 6 months and the longer the duration beyond 6 months, the greater the impact and protection. Important factors for the infant include:Footnote 5Footnote 6Footnote 7Footnote 8Footnote 9
Important factors for the mother/family include:Footnote 10Footnote 11Footnote 12Footnote 13
Important factors for society include:Footnote 14Footnote 15Footnote 16
Family-centred care respects parents’ informed choices on how they choose to feed their infant. Choosing a feeding method is influenced by a number of factors, including personal experience, knowledge, culture, marketing practices and attitudes of partners, family and friends. Health care providers (HCPs) play an important role in helping families make informed decisions – and in respecting and supporting their decision. Additional resources on breastfeeding: See appendix A Breastfeeding in CanadaBreastfeeding initiation rates in Canada have increased from less than 25% in 1965 to 90% in 2015/16, a significant improvement.Footnote 17Footnote 18 But breastfeeding duration falls short of recommendations and, of the mothers who initiate breastfeeding, close to 25% stop before their infant is 1 month old.Footnote 2 The most common reasons mothers give for stopping breastfeeding before 6 months are “not enough milk” (44%) and “difficulty with breastfeeding technique” (18%).Footnote 19 Although the percentage of Canadian mothers who breastfeed their infant exclusively to 6 months has increased from 17% in 2003, it remains low, at 32%.Footnote 18Footnote 19 In 2011/12, over half (57%) of mothers who breastfed continued some breastfeeding beyond 6 months. This percentage dropped to 19% after the infant’s first year of life.Footnote 3 Breastfeeding rates also vary across the country along a general west-to-east gradient. In 2011/12, breastfeeding initiation ranged from 96% in British Columbia and Yukon to 57% in Newfoundland and Labrador.Footnote 19 The greatest increase in breastfeeding initiation between 2003 and 2011/12 was in Quebec, from 76% to 89%. There is little information about the extent to which Canadian women continue to breastfeed until their children are 2 years or older, as per WHO/UNICEF and Health Canada recommendations. Breastfeeding Protection, Promotion, and Support – The Baby-Friendly InitiativeBreastfeeding initiation and duration increase with active protection, promotion, and support. The evidenced-based policies and practices of the WHO/UNICEF Baby-friendly Hospital Initiative (BFHI) have been shown to improve breastfeeding initiation, duration, and exclusivity.Footnote 20Footnote 21Footnote 22Footnote 23Footnote 24Footnote 25Footnote 26Footnote 27Footnote 28Footnote 29Footnote 30Footnote 31Footnote 32 The BFHI is based on the policies and practices described in Ten Steps to Successful Breastfeeding (the Ten Steps) and the International Code of Marketing of Breast-milk Substitutes.Footnote 33Footnote 34 The process of becoming a designated Baby-Friendly facility can often be a catalyst for changing a facility’s environment around infant feeding and it motivates facilities to transform their practices. As a result of becoming designated Baby-Friendly, care is more patient centred, quality of care improves, staff attitudes regarding infant feeding improve, and use of infant formula and nurseries decrease.Footnote 33 The 2017 WHO Guideline: Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services provides evidence-based recommendations to support the protection, promotion and support for breastfeeding in facilities that provide maternity and newborn services.Footnote 35 It examined the evidence of the original Ten Steps and developed 15 recommendations relating to immediate support to initiate and establish breastfeeding, feeding practices and additional needs of infants, and creating an enabling environment. The 2018 WHO/UNICEF update of the Implementation Guidance: Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services: the revised Baby-Friendly Hospital Initiative provides the first update of the Ten Steps since 1989 and complements the 2017 WHO guideline.Footnote 36 The topic of each of the Ten Steps remains the same; however the updated wording is based on the latest evidence and global policies.Footnote 36 Additionally, the WHO Code of the Marketing of Breast-Milk Substitutes is incorporated into Step 1. The first 2 steps address critical management procedures while Steps 3 to 10 describe clinical practice standards. In Canada, the Baby-Friendly Initiative (BFI) has been adapted from the BFHI to incorporate the continuum of care between hospital and community health services, and to include recommendations for breastfeeding the older infant and young child.Footnote 37 A hospital providing maternity services or a community health facility is designated as Baby-Friendly if it meets the criteria for achieving the Ten Steps and adheres to the International Code of Marketing of Breast-milk Substitutes. The Breastfeeding Committee for Canada (BCC) is the BFI authority for the majority of Canada, and oversees the initiative’s implementation and assessment. Provincial and Territorial Committees collaborate with the BCC and hospital and community facilities to implement the BFI at the local level. In the province of Quebec, the Ministère de la Santé et des Services sociaux (MSSS) is the authority for breastfeeding and the BFI, and applies its own standards and assessment process within the province. The joint statement, Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months (NHTI recommendations), co-authored by Health Canada, the Public Health Agency of Canada (PHAC), the Canadian Paediatric Society (CPS), Dietitians of Canada, and the BCC, recommends that hospitals and community health services implement BFI policies and practices.Footnote 2 Accreditation Canada has incorporated the BFI and the content of the Ten Steps and WHO Code into the Obstetrics Services Standards for hospitals.Footnote 38 In The BFI 10 Steps and WHO Code Outcome Indicators for Hospital and Community Health Services, the BCC describes the breastfeeding data collection required for Baby-Friendly designation.Footnote 37 Consult the MSSS for data requirements in the province of Quebec. Despite the recommendations and the endorsement of many professional health organizations, hospitals and community health facilities have a poor record, so far, of implementing the BFI.Footnote 39Footnote 40 Currently, 21 hospitals, 8 birthing centres and 117 community centres have been designated as Baby-Friendly facilities in Canada.Footnote 41 Globally only 10% of infants are born in a hospital designated Baby-Friendly. WHO emphasizes that countries should scale up BFI implementation to universal coverage and ensure sustainability. A growing body of literature also focuses on optimizing breastfeeding outcomes for newborns within neonatal intensive care units (NICUs). Work is underway internationally to adapt the BFHI to these settings, referred to as Neo-BFHI.Footnote 42Footnote 43 The underlying philosophy of the BFI is based on the basic principles of family-centred care. Mothers and babies are mutually interdependent units, and breastfeeding is the unequalled method of infant feeding. Each mother–infant dyad and their family is supported in finding the best possible approach within their unique context. The role of HCPs includes supporting this normal process, removing barriers to success, and providing additional support when challenges arise. The content of this chapter is organized according to the sequence in the Ten Steps to Successful Breastfeeding (2018).Footnote 33 The heading of each of the Ten steps includes the WHO description from the BFHI, followed by the Canadian wording from the BCC.Footnote 37 This chapter does not outline the specific criteria for achieving Baby-Friendly designation. Refer to The BFI 10 Steps and WHO Code Outcome Indicators for Hospital and Community Health Services for Baby-Friendly designation requirements and assessments, and consult the MSSS for criteria in the province of Quebec.Footnote 37 1. Written Breastfeeding PolicyStep 1: WHO/UNICEF
Canada
The CodeThe International Code of Marketing of Breast-milk Substitutes, published in 1981 and reaffirmed by the World Health Assembly in 2018, to which Canada is a signatory, was developed in response to inappropriate marketing practices that contributed to the decline of breastfeeding, particularly in developing countries.Footnote 44 The WHO Code was developed to ensure that health priorities – not profit interests – influence women’s decisions to breastfeed. The Code prohibits the promotion and marketing of infant formula, bottles, nipples, and complementary foods for infants less than 6 months of age. The WHO Code strives to “...provide safe and adequate nutrition for infants, by the protection and promotion of breast-feeding, and by ensuring the proper use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing.” This Code seeks to protect and promote breastfeeding by ensuring the ethical marketing of breastmilk substitutes by industry and states. There should be:Footnote 37
In addition:
Governments are responsible for implementing the marketing restrictions through social and legislative means. The infant formula industry must ensure that their marketing and labelling practices are compliant with the legislation. HCPs should promote and protect breastfeeding and avoid any influence by or cooperation with industry marketing of infant formula. The health care system should promote and protect breastfeeding by not promoting infant formula products.Footnote 45 The marketing of infant formula has a negative effect on breastfeeding, playing a role in normalizing a mixed feeding culture of breastfeeding and formula feeding.Footnote 46 Aggressive marketing practices are direct violations of the International Code of Marketing Breast-milk Substitutes. When a relationship is created between formula companies and HCPs, the result is brand loyalty and dependency.Footnote 47 The Canadian Hospital Maternity Policies and Practices Survey found that 68% of hospitals still had exclusive contracts with formula companies in 2007, although that this was down from 82% in 1993.Footnote 39 Still, 90% of hospitals reported that they did not give out sample formula packages – up from 58% in 1993.Footnote 48 The MES found that 64% of women reported that they were not offered or given free sample packages. Women who were younger, having their first babies, with lower education level or living in low income were more likely to be offered free samples.Footnote 49Footnote 50 The relationship between physicians and the pharmaceutical industry influences professional practice. This is also the case with infant formula companies.Footnote 51 International studies have demonstrated that between 80% and 95% of physicians regularly see sales representatives from pharmaceutical companies, despite evidence that their information is biased and affects prescribing habits.Footnote 52 A number of medical associations and other groups are calling for specific measures to disentangle the relationship between HCPs and industry. There have been known cases of violations of the WHO Code by the formula industry in Canada.Footnote 45 In the Labelling Requirements for Infant Foods, Infant Formula and Human Milk, the Canadian Food Inspection Agency (CFIA) and Health Canada strongly urge the infant formula industry to respect and implement the principles of the Code.Footnote 53 In addition, certain principles set out in the Code also align with section 5(1) of the Food and Drug Act.Footnote 53 Two provincial governments (British Columbia and Nova Scotia) have formula purchase agreements supporting facilities to purchase formula and feeding products rather than accepting free gifts or marketing materials. Refer to The BFI 10 Steps and WHO Code Outcome Indicators for Hospital and Community Health Services for the WHO International Code of Marketing of Breast-Milk Substitutes code compliance checklist.Footnote 37Footnote 44 Infant Feeding PolicyBreastfeeding is the unequalled method of infant feeding for their healthy growth and development – and policies to do with infant feeding need to reflect that. Nevertheless, support for mothers who choose to feed their infants breastmilk substitutes (i.e., formula) or who are unable to breastfeed should be included in these policies. Templates and examples of infant feeding policies are available from Baby-Friendly facilities or online to help in the policy development process. The implementation of policies requires “carefully planned, multipronged and multilevel approaches,” ideally involving multiple stakeholders including families, to be effective and sustainable.Footnote 46 Change management strategies are available from the growing field of implementation science to target organizational culture and clinical practice. The infant feeding policy development process should include a scan of all existing policies through a Baby-Friendly lens. For example:
Resources that can help develop breastfeeding policies and practice guidelines include:Footnote 2Footnote 3Footnote 35Footnote 36Footnote 37Footnote 44Footnote 54Footnote 55Footnote 56
Because families interact with staff other than their HCPs in hospitals and community health facilities, it is important that everyone – managers, administrators, auxiliary staff, students, clerks, allied health professionals, volunteers, and all HCPs – know about the importance of breastfeeding, the BFI, and the International Code of Marketing of Breast-milk Substitutes. Families also need to be aware of the standard of care that they can expect, and can learn about these from their HCPs and via social media, print materials, and prenatal classes. Monitoring and data collectionCollecting breastfeeding data is an essential component of health surveillance, and monitoring of trends is important in program development, implementation, and evaluation. Lack of consistent data collection and standardized definitions across facilities and provinces/territories can be problematic and create challenges at all levels.Footnote 40 Data collection should include:
2. Knowledge and Skills to Implement Breastfeeding PoliciesStep 2: WHO/UNICEF
Canada
Undergraduate and Postgraduate EducationAs awareness of the importance of protecting, promoting, and supporting breastfeeding increases, undergraduate and continuing professional education of HCPs needs to address the biological, social, and emotional components of breastfeeding – and the multiplicity of factors that affect this dynamic relationship. However, numerous studies describe the lack of formal breastfeeding information in HCPs' educational programs.Footnote 57Footnote 58Footnote 59Footnote 60 HCPs are known to affect the breastfeeding relationship. Women who perceive their HCPs as supportive of breastfeeding are more likely to breastfeed than those who perceive them as neutral or favouring formula feeding.Footnote 61Footnote 62 In fact, the more often breastfeeding is mentioned during pregnancy, the more likely women will breastfeed.Footnote 63 Continuing EducationEveryone who works at a health facility – administrators, managers, volunteers, allied health professionals, auxiliary staff, students, clerks, and all HCPs – needs to be aware of the facility's policies, including the BFI. Specific training in keeping with everyone's role should be provided. For example, phlebotomists should actively support mothers in breastfeeding or holding the baby in skin-to-skin contact to comfort their child through blood tests. Continuing professional education needs to be developed to address the breastfeeding needs of families and enhance the care of mothers and babies. A holistic and interprofessional approach to professional continuing education should be a responsibility shared by HCPs and health facilities. Education StrategiesWHO and UNICEF recommend 18–20 hours of breastfeeding education (including 3 hours of clinical experience) for HCPs who provide direct breastfeeding care, for example, lactation consultants, perinatal nurses, midwives, obstetricians, and family physicians. Providers responsible for clinical support of breastfeeding mothers and infants require specific knowledge, skills, and attitudes.Footnote 59 Research suggests that clinical mentorships, didactic learning modules, and Internet learning options are also useful training opportunities.Footnote 64 The specific knowledge and skills required are outlined in The BFI 10 Steps and WHO Code Outcome Indicators for Hospital and Community Health Services.Footnote 37 At a minimum, all HCPs require orientation in the policies and practice guidelines of the facility, including the BFI (i.e., the Ten Steps and International Code of Marketing of Breast-milk Substitutes). Ongoing Competency ValidationPractice change requires more than education.Footnote 65 Numerous professional organizations have breastfeeding guidelines – yet professional practice often does not reflect the guidelines.Footnote 59 To be effective, implementation of evidence-based policies in hospitals and community facilities requires a combination of various education strategies and clinical support. 3. Informing Pregnant Women and their Families about BreastfeedingStep 3: WHO/UNICEF
Canada
Informed decision-making is central to family-centred care. Families need to get the information necessary to make decisions about feeding their infant before birth, through their HCP or prenatal classes. Informed decision-making includes having opportunities to discuss goals and concerns with HCPs so that families can expand their knowledge about:
Infants in Specialized CareSome situations require specialized expertise and care. Mothers at high risk of preterm or medically complicated births require information tailored to their specific needs. If a baby is anticipated to require specialized care, families need additional information about:
If a mother is unsure or is choosing not to breastfeed her infant in specialized care, sensitively providing information about the value of breastmilk for their sick or preterm infant can be beneficial. For example, breastmilk is effective in preventing necrotizing enterocolitis, leading to fewer severe infections, reducing colonization by pathogenic organisms, improving neural development, and leading to a shorter hospital stay.Footnote 66 Given this information, some mothers will choose to express milk for their preterm infant even if they do not plan to breastfeed. Addressing the Needs and Concerns of Women and Their FamiliesIn Canada, most women choose to breastfeed their infants. The women who are least likely to breastfeed are younger, at lower-income and education levels, and living in Eastern Canada. Also, few women continue to breastfeed for 2 years or longer, falling short of the NHTI recommendations. Effective strategies for improving breastfeeding rates require focusing on the full continuum of the mother–child experience, from before pregnancy and through the early parenting years.Footnote 67Footnote 68 Most women decide how to feed their baby early in pregnancy, if not before.Footnote 69 However, decisions about breastfeeding initiation and duration are complex and deeply embedded in the cultural context. Lack of positive peer and effective clinical support, lack of confidence in their ability to breastfeed, perceptions of their family’s and friends’ views about breastfeeding, and exposure to pervasive formula marketing are just a few of the psychosocial factors that affect women’s ability to make truly informed, autonomous decisions about initiating breastfeeding and following through with the decision. HCPs have a strong influence on women’s decisions to breastfeed. Studies have shown that women who perceive their physician as supportive of breastfeeding are more likely to breastfeed than those who perceive their physician as neutral or favouring formula feeding.Footnote 61Footnote 62 When HCPs take a neutral stance on breastfeeding, women are more likely to consider them not to be in favour of breastfeeding.Footnote 61Footnote 62 On the other hand, the more often breastfeeding is mentioned during the prenatal period, the more likely women will breastfeed.Footnote 63 It is important that all HCPs and all health care facility staff know about the importance of breastfeeding and provide positive messages about it. Current feeding practices are affected by a long tradition of bottle-feeding in North America.Footnote 49Footnote 70Footnote 71Footnote 72 Beliefs that feedings need to be scheduled or timed and that breastfeeding babies have to learn to bottle-feed must be addressed. Cultural beliefs that breastfeeding is only appropriate for young babies – that extended breastfeeding is abnormal – can limit the duration of breastfeeding. Families may come from a culture with a long tradition of breastfeeding. Recent immigrants, noticing the lack of visible breastfeeding, may assume that the norm in Canada is to bottle-feed. Others may have come from countries where breastfeeding is not the norm. Special care must be taken to avoid making assumptions about new immigrants’ feeding beliefs based on their country of origin.Footnote 73 Women need the opportunity to discuss their concerns and have them addressed to facilitate their decision to breastfeed. Self-efficacy strategies benefit all women even while such strategies need to be tailored to meet their personal needs.Footnote 68Footnote 74Footnote 75Footnote 76 The attitudes and beliefs of partners, parents, and extended family affect women’s decisions to breastfeed and how long they choose to breastfeed.Footnote 77Footnote 78Footnote 79 Strategies for Providing InformationHCPs need to adopt the principle that women will breastfeed – especially as over 90% of Canadian women intend to. For example, asking open-ended questions before asking a woman to make a decision about breastfeeding helps HCPs provide information; this method has been shown to increase the likelihood of breastfeeding initiation.Footnote 80 A variety of types of education strategies over a period of time are most likely to influence a woman’s decision about breastfeeding initiation and duration.Footnote 32Footnote 81Footnote 82Footnote 83 Reports stress the value of face-to-face interaction rather than just providing print materials. Similarly, needs-based and repeated informal sessions are more effective than generic, formal prenatal sessions. Because partners and family members affect women’s decisions, it is important to find strategies to include the family in breastfeeding education.Footnote 77 Evidence suggests that it is best to avoid routine, forced choice questions about feeding on hospital admission forms. After placing her newborn in skin-to-skin contact with the mother, ask her how she plans to feed her baby.Footnote 84 Women who choose not to breastfeed will let staff know. Regardless, babies who will not be breastfed require the same supportive skin-to-skin contact in the early hours following birth. Dispelling Common MythsMothers and families are often influenced in their decisions about breastfeeding by the many common myths on the subject. Common Myths About Breastfeeding
Supporting Families who are not BreastfeedingWHO uses the acronym AFASS (for Acceptable, Feasible, Affordable, Sustainable, Safe in their situation) to describe the process of assisting families who are not breastfeeding to choose breastmilk substitutes. The Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months joint statement provides guidance on the use of breastmilk substitutes including safe preparation and storage.Footnote 2 It is important to provide families with information on responsive, cue-based feeding; signs of satiation; and the importance of skin-to-skin contact as well as information on professional and peer support regardless of feeding method. Provide non-judgmental and supportive care for families who choose not to breastfeed, whether for medical, personal, or social reasons. Families may feel guilt or shame for not breastfeeding and may require individualized support to deal with these emotions as well as information to optimize their infant’s nutritional well-being. Lactation SuppressionIf women do not breastfeed, lactogenesis still occurs. Research on lactation suppression has primarily focused on pharmacological measures. It is important that HCPs provide women with information on comfort measures for sore breasts, including analgesics, cold compresses, supportive bras, and limited hand expression.Footnote 89 Breast binding and restricting fluids are not recommended. If lactation suppression is required because the child dies or is placed for adoption, comfort measures and gradually increasing the time between expressing/pumping milk will allow breasts to gradually involute. Mothers who are bereaved or who place their baby for adoption may also want to express their milk and donate it as part of their grieving or separation process.Footnote 90 Consider providing the mothers with information about the process of becoming a milk donor. 4. Skin-to-Skin Contact Immediately Following BirthStep 4: WHO/UNICEF
Canada
Research over the last 40 years has clearly identified the importance of caring for mothers and babies as an inseparable biological unit, especially in the hours immediately following birth, and on promoting uninterrupted skin-to-skin care during those hours. Incorporating this research into practice requires a shift from the northern European and North American routine of separating mothers and babies at birth.Footnote 91Footnote 92Footnote 93 Skin-to-skin care means placing the naked infant (who may be in diaper) with their chest and abdomen against the mother's naked chest in a position that enables the baby to fully expand the lungs. The infant's arms should be on either side of their body, and not trapped underneath, and the mouth and nose should be uncovered and easily visible.Footnote 94 Warm blankets should cover the mother and baby together until temperature stability is achieved or if the newborn's temperature becomes unstable. Skin-to-skin care benefits the infant by:Footnote 25Footnote 95Footnote 96Footnote 97Footnote 98Footnote 99Footnote 100Footnote 101Footnote 102
In North America, the media, especially television, still show images of non-evidence-based hospital practices.Footnote 103 For example, babies are often shown being dried off, cleaned up, and weighed before being given to the mother for bonding. Consequently, families are sometimes not aware that optimal care of the newborn includes immediate skin-to-skin care and uninterrupted contact with the mother until the first feeding is completed. Public health and prenatal class messaging can help change the knowledge and expectations of the family. Current evidence demonstrates that Canadian practices, although changing, still need to be improved. The Canadian Maternity Experiences Survey (MES) found that although 71.9% of mothers reported holding their infant immediately or within 5 minutes of birth, only 31.1% had skin-to-skin contact. Younger women (15–19 years) were even less likely (18.1%) to report skin-to-skin contact with their babies immediately following birth. Only 29.0% of women who had a caesarean birth reported holding their baby immediately following birth (compared with 85.7% of those giving birth vaginally), and only 7.5% reported holding their infant skin-to-skin.Footnote 49 The Importance of the First Hour Following BirthGenerally, infants show signs of readiness to latch on to the breast and feed within the first hour of birth.Footnote 104 Families should be supported in keeping their baby in uninterrupted skin-to-skin contact immediately following birth until at least after the first feeding is completed. The partner can also provide skin-to-skin contact if the mother cannot.Footnote 105 If the mother and newborn are separated for medical reasons, babies should be reunited as soon as possible. Newborn infants should be dried and assessed while in skin-to-skin contact with the mother.Footnote 94Footnote 106 Unobtrusively check to see that families know how to position their infant safely while skin-to-skin, breastfeeding, or otherwise holding the baby, and encourage partner participation. Ensure the safety of the infant if the mother has received opioid medications for pain or is very fatigued. Babies who went through a stressful birth or infants of mothers given medication during labour may take longer to complete the first feeding.Footnote 107 They may be at risk for lower rates of breastfeeding initiation and earlier cessation.Footnote 108 Special attention needs to be given to these mothers and infants. Mothers who have a caesarean birth are more likely to experience breastfeeding difficulties, and their babies are more likely to receive supplements in the hospital.Footnote 49Footnote 109Footnote 110 The delay in skin-to-skin contact and early suckling because of separation after caesarean birth may be responsible for these difficulties.Footnote 25 Early skin-to-skin contact as well as breastfeeding when babies cue to feed while in the operating room and the recovery room can decrease the need for early supplemental feeding.Footnote 111 Skin-to-skin care with appropriate supervision should be the norm for all births, including caesarean births. Effects of Skin-To-Skin Care on BreastfeedingWhen placed in uninterrupted skin-to-skin contact with their mother, newborns exhibit a pattern of behaviours—breast seeking, rooting, licking, sucking, and feeding —that may be triggered by maternal odour.Footnote 112Footnote 113 Skin-to-skin contact also increases the likelihood of a successful first feeding and improves breastfeeding in the early postpartum period as well as rates of exclusive breastfeeding.Footnote 114Footnote 115Footnote 116Footnote 117 Bramson et al (2010) found a dose–response relationship between early skin-to skin contact and exclusive breastfeeding in the hospital.Footnote 118 See the CPS practice point Kangaroo Care for the Preterm Infant and Family and Neo-BFHI: The Baby-friendly Hospital Initiative for Neonatal Wards for more information on the benefits of skin-to-skin care of the preterm infant.Footnote 56Footnote 119 Maternal Hormonal ResponseDelivery of the placenta triggers the maternal hormonal responses necessary for lactation. Skin-to-skin contact and newborn suckling enhance this hormonal response by releasing surges of oxytocin. Oxytocin facilitates uterine contractibility. When the infant stops suckling, he or she may start massage-like movements of their hands on the mother's breast. These hand movements also cause surges of oxytocin release.Footnote 120 Early skin-to-skin contact and suckling may increase maternal sensitivity towards and reciprocity with their infants even up to the age of 1 year.Footnote 25Footnote 121 Providing InformationHCPs need to remove institutional barriers (customary practices, attitudes, values, and environmental limitations) and inform mothers and families about how essential skin-to skin care is to the stability of their infant, regardless of how families choose to feed their infants. Babies who will not be breastfed require the same supportive skin-to-skin care in the early hours following birth. Painful ProceduresBreastfeeding comforts infants when they experience painful procedures such as heel pokes, blood tests, and immunizations. Numerous studies support the use of skin-to-skin contact and breastfeeding to help infants endure painful procedures.Footnote 97Footnote 122Footnote 123Footnote 124Footnote 125Footnote 126 Skin-to-skin contact and breastfeeding before a painful procedure helps infants cope with pain. Ideally, this skin-to-skin contact should be maintained for at least 15 minutes before the procedure. Reassure parents that even if their child reacts, cries, or fusses their perception of pain is lessened. 5. Assist Mothers with Breastfeeding ChallengesStep 5: WHO/UNICEF
Canada
Step 5 encompasses 2 components: providing breastfeeding support and assistance when mothers and infants are together, and providing this support when they are separated because of newborn instability or illness of mother or child. Creating the Context for Successful BreastfeedingMothers and babies find a wide range of successful approaches to breastfeeding. Many babies placed skin-to-skin with their mothers find the breast and feed well, while others may need assistance. Timely intervention by knowledgeable staff is helpful. Learning about breastfeeding and newborn care and feeding ideally occurs in a family-centred context with many of the other BFI steps:
Key Skills for MothersIn addition to the emotional and physical changes mothers experience after birth, mothers need to learn skills that their HCPs can help them develop: 1. Supporting their infant’s feeding abilities: Understanding and responding to infant cues Infants feed best when they are in a quiet, alert state. If babies are in skin-to-skin contact, they may begin to demonstrate feeding cues. If not in skin-to-skin contact, babies should be close to their mother so that she can become aware of early cues rather than waiting for crying, which is a very late feeding cue. Crying infants usually require calming before they will attempt to feed.Footnote 54 Similarly, infants wakened from a deep sleep often will not feed. 2. Positioning for mothers and infants Mothers and babies find a wide range of positions that are comfortable and effective, and mothers should be encouraged to experiment and find their preferred positions. It is important to support mothers in using the principles of body mechanics to be comfortable while feeding. Using pillows for support can be helpful. 3. How babies latch At birth, many babies latch unassisted on to the breast while the mother is in a recumbent position, as a result of the infant’s rooting reflex, which may influence breastfeeding.Footnote 127 Some mothers also find this position effective postpartum if their baby is having difficulty attaching to the breast. Other mothers prefer to sit up using a conventional cradle, modified cradle, or football (clutch) position. With practice, mothers often find lying on their side enables them to rest while they feed. Initially, mothers may appreciate help in assisting their baby to latch in this position. A variety of latching techniques are described in the literature, and mothers should be encouraged to find what works for them.Footnote 128 General principles include:
4. Effective feeding HCPs can support mothers to learn to recognize how well their infants are feeding. When babies are well-positioned on the breast, their cheeks appear full and their mouth is wide open. The infant will suck with brief pauses between bursts of sucking and does not easily slide off the breast. At the end of the feeding, the nipple is not distorted when released. While most mothers experience some nipple soreness in the first week, breastfeeding should not be painful.Footnote 130 When feeding well, infants exhibit signs of milk transfer: sounds of swallowing, satiety following feedings, appropriate output (stool and urine), and appropriate weight loss in the first 72 hours with subsequent weight gain. 5. Hand expression There is limited evidence that any 1 type (hand, manual or electric pump) to express breast milk is better than another, yet women should be taught to hand express as it is always readily available and there is reduced potential for microbial contamination if a pump cannot be easily cleaned.Footnote 36 It is important that all mothers learn to hand express their colostrum or milk.Footnote 34Footnote 131Footnote 132 Hand expression helps to:
Encouraging mothers to hand express early and often enables them to practice this skill and become more comfortable with their breasts. Teaching mothers that they can express milk by hand may diminish the growing perception that all breastfeeding women need breastmilk pumps. One study found that mothers with initial breastfeeding difficulties who hand expressed were more likely to be breastfeeding at 3 months than those who used pumps.Footnote 133 Tips for teaching hand expressionFootnote 134 Teach women to:
There has been little research on the best techniques for hand expression, and mothers are encouraged to experiment with techniques to learn what works for them.Footnote 135 See the Perinatal Services BC Breastfeeding Healthy Term Infant guideline for guidance on hand expression.Footnote 54 Key Skills for Health Care ProvidersFundamental skills for HCPs include breastfeeding assessment and knowing the key skills for mothers described above and how to teach those skills. Effective teaching/counselling helps mothers become increasingly confident in their ability to understand their infant’s cues, feed their baby, and recognize the signs that their infant is feeding well. 1. Feeding assessment Feeding assessments require knowing the normal changes that mothers and infants go through and the feeding relationship – and how each of these parameters changes with time. Perinatal Services BC Breastfeeding Healthy Term Infants guideline has recommendations on breastfeeding assessment and discharge criteria.Footnote 54 As the length of hospital stay for mothers and infants varies from just a few hours to 72 hours or more, appropriate follow-up after discharge, including breastfeeding assessment by a skilled HCP, is essential. The Society of Obstetricians and Gynaecologists of Canada (SOGC) recommends that all mothers and infants be assessed by an HCP within 48 hours of discharge from a hospital or birthing centre.Footnote 136 The CPS gives recommendations on newborn surveillance related to breastfeeding and jaundice in their Guidelines for Detection, Management and Prevention of Hyperbilirubinemia in Term and Late Preterm Newborn Infants.Footnote 137 Several tools exist for breastfeeding assessment; however, clinically relevant, reliable and valid tools have yet to be developed.Footnote 138 If breastfeeding assessment tools are used, additional assessment parameters must also be applied by HCPs to ensure effective feeding and milk transfer: elimination pattern, infant weight, and growth.Footnote 138 Test weighing may be helpful in some clinical settings but should not be part of a routine assessment. A complete feeding assessment should include all 3 components of the breastfeeding relationship: mother, baby, and feeding.
Increasing Milk Production Medications to increase milk production The usefulness of medications to increase breastmilk production (galactagogues) is unclear. The Academy of Breastfeeding Medicine recommends that medicinal galactagogues be considered only after other modifiable barriers have been addressed and mothers have been provided with ample support and strategies to enhance milk production.Footnote 140 Traditional foods as galactagogues Most cultures use a variety of foods or herbal products for breastfeeding mothers – many to help increase milk. Families that use traditional foods to increase milk productions need to be respected in their decision, as they may help to relax the mother and give her confidence. However, in spite of a long history of the use of herbs, there is a lack of evidence of the safety and effectiveness of herbal galactagogues.Footnote 128 Herbal preparations lack standardization, regulation, and evidence as to their efficacy and should be used with caution.
2. Infant weight loss and expected gain In the first two weeks, newborns experience normal weight decline and recover, provided they are feeding well.Footnote 2 Milk intake in the first 24 hours varies by newborn from 15cc +/- 11 cc.Footnote 143 A newborn’s stomach capacity gradually increases over the first 3 days of life.Footnote 144 The exact parameters of weight loss and gain remain unclear, but a typical weight loss of an exclusively breastfed infant can be 6–8% of their birth weight by 3 days after birth.Footnote 137 Loss of greater than 7-10% in the first 4 postpartum days indicates a need for close assessment and possible intervention.Footnote 54 From day 4 onward, weight gain of approximately 20-35g per day during the first 2 months of life should continue.Footnote 13Footnote 145 CPS recommends that an infant who loses more than 10% of their birth weight be carefully assessed by an HCP experienced in supporting breastfeeding mothers.Footnote 137 The CPS, College of Family Physicians, Community Health Nurses of Canada and Dietitians of Canada recommend using the WHO growth charts to monitor infant and child growth.Footnote 146 3. Interventions to support breastfeeding and overcoming challenges Time, support, and patience resolve most breastfeeding concerns. Common problems in the early postpartum days include an infant who is unable to latch or feed effectively, sore nipples, engorgement, and insufficient milk or, more likely, mistaken perceptions of insufficient milk. When families are struggling with feeding issues, plans for overcoming challenges should be simple, easily understood, and manageable by the family. There are 3 guiding principles:
These principles apply regardless of the age of the infant. Specific interventions may be required (such as antibiotics for mastitis, frenotomy for tongue-tie, or a brief interruption of breastfeeding for severely damaged nipples), but the basic tenets underlying interventions should include these 3 principles. Appendix C lists common concerns with breastfeeding. When Baby is Preterm, Late Preterm, or IllPreterm InfantsInternational work on Neo-BFHI recommends that all NICU babies room-in with their mothers; experience unrestricted skin-to-skin care and other care provided by the parent; and become fully breastfed. Breastfeeding initiation and progression should be based on the infant’s stability rather than the length of gestation or weight.Footnote 43Footnote 56Footnote 147 For preterm infants, the best outcome – sufficient milk for infants and eventual breastfeeding – is supported by skin-to-skin care, early hand expression, and breast expression. HCPs should be supporting and assisting mothers throughout. Starting expression as soon as possible, ideally within the first hour of birth, is associated with increased milk supply.Footnote 132Footnote 148Footnote 149Footnote 150 Promotion of early colostrum can increase the success and duration of feeding with breastmilk among infants in the NICU.Footnote 151 Mothers need to establish an ample volume of milk even before their preterm infant requires full feeding volumes. As a general guideline, mothers who are able to establish milk production sufficient for a full-term baby by 2 weeks are more likely to have enough milk when their preterm baby needs it. Mothers who can pump at least 500ml per 24 hours at 2 weeks postpartum are more likely to have sufficient milk for their infants.Footnote 152 Mothers may be producing enough milk for their premature infant and not recognize that their total 24-hour volume is below 500ml. It is important to provide ongoing support for mothers as they continue to express milk for their preterm infants. See the CPS practice point Kangaroo Care for the Preterm Infant and Family for more information on the benefits of skin-to-skin care between the preterm infant and parent.Footnote 119 The Late Preterm or Near-Term InfantThe late preterm infant (34+0 through 37+6 weeks) is increasingly considered mature enough to room-in with the mother and is cared for in standard postpartum units. However, late preterm infants can exhibit characteristics of both term and preterm infants.Footnote 131Footnote 153 They are at higher risk for readmission for jaundice, excessive weight loss, and poor feeding. Careful monitoring, skin-to-skin contact, early hand expression and spoon feeding of colostrum are essential elements of care.Footnote 131Footnote 133Footnote 148 The Perinatal Services BC guideline Breastfeeding Healthy Term Infants and the CPS position statement Safe discharge of the late preterm infant offer guidance on breastfeeding the late preterm infant.Footnote 54Footnote 154 Infants in Pediatric FacilitiesEstablishing and maintaining breastfeeding when infants and children are ill can be challenging. Illness often affects feeding behaviours. It is important to support breastfeeding whenever the infant or child is able to, and effective milk removal if the child is unable to breastfeed. HCPs need to continually assess the mother–infant dyad to ensure that mothers have the support and assistance needed to effectively breastfeed or provide sufficient milk for their infants. Breastfeeding When the Mother is HospitalizedBeing hospitalized postpartum – for a short or long time – for reasons other than the birth can be potentially difficult for the mother, infant, and family. If the mother’s goal is to breastfeed, hospitals need to support her in her efforts and help her maintain her milk supply through hand expressing/ pumping if feeding at the breast is interrupted. Hospital policies need to support breastfeeding by minimizing separation as much as possible; by encouraging skin-to-skin contact; by supporting and assisting with expressing/pumping; and by helping families in their time of crisis.Footnote 155 Expert lactation support may be required to assist in the selection of breastfeeding-compatible medications, if at all possible, as well as to advise on appropriate collection and storage of breastmilk being fed to the baby. 6. Supplements Only When Medically IndicatedStep 6: WHO/UNICEF
Canada
The Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months advocate exclusive breastfeeding for the first 6 months, and sustained for up to 2 years or longer with appropriate complementary feeding.Footnote 2Footnote 3 Exclusive breastfeeding means an infant is only fed breastmilk. No other food or liquid (not even water) is given to the infant, although exclusively breastfed infants may still receive vitamin and mineral supplements, medicines and oral rehydration solution if needed.Footnote 156 It is essential to support families in exclusive breastfeeding for the first 6 months of the infant’s life unless there is a medical need to give additional or alternative foods. Supplemental FeedingSupplemental feeding of newborns occurs frequently in Canadian hospitals. In 2009/10, 32% of breastfed babies were given fluids other than breastmilk (water, glucose solution, or infant formula) before being discharged from hospital.Footnote 39 Similarly, only about two-thirds of newborns in Ontario and British Columbia had been exclusively breastfeeding at discharge.Footnote 157Footnote 158 Supplemental feedings can interfere with establishing and maintaining the maternal milk supply and contribute to engorgement.Footnote 22Footnote 138 Because supplemental feedings may interfere with successful breastfeeding, it is important that HCPs support families in making informed decisions before providing or recommending supplements. Occasionally, the infant’s medical condition may mean they require supplementation. Infants may also require supplemental feeding when, in spite of effective breastfeeding support, the mother’s milk supply is insufficient to sustain infant growth. Once supplements are started, even for short-term medical indications such as hypoglycemia, the practice tends to continue, and babies often continue to receive supplements after the medical indication has resolved.Footnote 159 If supplemental feedings are indicated, give small, physiologically appropriate amounts of breastmilk substitutes and advise families about how to withdraw the supplement once it is no longer needed.Footnote 160 It is important to assist families who provide supplemental feedings with strategies to preserve and improve the breastfeeding relationship. Choice of SupplementsIn situations when infants are not exclusively breastfed for personal, social, or medical reasons, the family requires information on breastmilk substitutes and support in choosing, safely storing, and handling these.Footnote 3 The Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months states “infants who cannot or should not be fed their mother’s breastmilk, pasteurized human milk from appropriately screened donors and commercial infant formula are suitable alternatives.”Footnote 2 Access to pasteurized breastmilk from milk banks in Canada is limited and is primarily for sick and preterm infants. Milk banks currently exist in 4 provinces: British Columbia (BC Women’s Provincial Milk Bank), Alberta (NorthernStar Mothers Milk Bank), Ontario (Rogers Hixon Ontario Human Milk Bank), and Quebec (Public Mothers’ Milk Bank). See the CPS Position statement Human Milk Banking and the Human Milk Banking Association of North America (HMBANA).Footnote 66 Increasingly, families are looking for donor milk from other mothers, a process referred to as “milk sharing.”Footnote 161 Although women have shared milk (wet nursed) throughout history, milk sharing usually occurred between relatives and close friends.Footnote 162 The use of the Internet as a vehicle for milk sharing between strangers is a relatively new practice. Concerns about sharing milk between strangers are because:Footnote 163Footnote 164
The Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months does not endorse the sharing or use of unprocessed and unscreened human milk.Footnote 2 Contraindications to BreastfeedingSome rare conditions require replacement of human milk with an appropriate artificial substitute, for example:Footnote 15Footnote 34Footnote 165Footnote 166 In infants
In mothers
Temporary InterruptionsMost cases of maternal illnesses are compatible with breastfeeding. See the CPS practice point Maternal Infectious Diseases, Antimicrobial Therapy or Immunizations: Very Few Contraindications to Breastfeeding for recommendations to do with breastfeeding and maternal infectious diseases.Footnote 167 Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months also offers guidance on maternal infection, medication use, and natural health products while breastfeeding.Footnote 2 If a mother’s severe illness or injury prevents her from caring for her infant, families who wish to express breastmilk may require assistance from HCPs. Substance UseIt is important that families know about the effects on breastfeeding before using alcohol, tobacco, or drugs.
See the Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months for guidance on alcohol, smoking, and drug use.Footnote 2 Barriers to Exclusive BreastfeedingAmong the most common reasons breastfeeding infants receive supplements is the concern that the infant is not getting enough milk and mothers’ lack of breastfeeding self-efficacy.Footnote 171Footnote 172Footnote 173 In the first few days following birth, families may perceive frequent cueing to feed, especially during the night, as an indication of insufficient breastmilk rather than the typical behaviour of the newborn who depends on frequent feeding for calories and comfort.Footnote 159 It is important to reassure families and explain about normal feeding patterns and the effect of this typical newborn behaviour on establishing maternal milk production. It is common for infants to feed frequently, or cluster feed, during the evening, when many mothers feel their breasts are softer and that they have less milk. In addition, infants increase their frequency of feeding every few weeks as they go through growth spurts. The increased feeding frequency usually lasts 24 to 48 hours, during which time milk production increases. After the growth spurt, the infant may feed less frequently. Parents may interpret increased cueing to feed as a shortage of breastmilk. Informing families ahead of time can help families recognize this increased feeding frequency as normal infant behaviour. Some hospitals contribute to the short duration of exclusive breastfeeding by not adhering to the Ten Steps: they do not promote skin-to-skin contact or rooming-in; and they supplement without medical indications, do not follow a cue-based feeding strategy, use pacifiers, and provide mothers with free samples of infant formula.Footnote 174 Strategies to Support Exclusive Breastfeeding During pregnancy
Birth
Early postpartum days
Early postpartum weeks
If supplements are used
Creating a Breastfeeding CultureFamilies need to feel comfortable breastfeeding their children anytime, anywhere. However, many families do not, or feel they need to cover up – a practice often rejected by the older baby. Feeling pressured to breastfeed discretely or in private contributes to early weaning.Footnote 178 If mothers request privacy, it is important that HCPs and agencies provide a comfortable environment. 7. Mother and Infant Rooming-InStep 7: WHO/UNICEF
Canada
Continuous contact between mothers and their infants enhances the stability of the newborn, breastfeeding, and their emotional bonding and attachment. In Canada, 24% of women reported that their infants spent between 1 and 5 hours outside of their rooms in the first 24 hours following birth. Another 11.2% said their infants were not in their rooms for 6 hours or longer.Footnote 49 Mothers who have had a caesarean birth are less likely to room-in with their infants (46.5%) than those who had a vaginal birth (70.9%).Footnote 49 Facilities need to develop policies and an environment that supports rooming-in, such as having a cot for a family member so they can stay overnight and help care for the mother and infant.Footnote 79 As typical hospital stays range from several hours to a few days, maximize opportunities to educate families by caring for mother and babies together and including the family. Keeping mothers and infants together for all routines (vital signs, blood tests, and assessments) optimizes the opportunity to provide information about care and feeding of the infant. Safe SleepNight feedings make an important contribution to total milk intake and infants continue to feed through the night for many months.Footnote 175Footnote 179 In addition, breastfeeding is associated with lowering the risk of SIDS, and exclusive breastfeeding raises the protective effect. However, any amount of breastfeeding provides some protection compared with no breastfeeding.Footnote 180 The need to breastfeed during the night may be perceived as a conflict with recommendations against bed-sharing as a measure to reduce the incidence of SIDS.Footnote 175 It is important to reassure mothers that they can successfully breastfeed during the night without bed-sharing. HCPs need to support families in finding strategies that enable them to meet their infants' nighttime needs and get enough rest. Close proximity to the infant facilitates breastfeeding during the night, and sleeping in the same room as the parents is recommended for the first 6 months.Footnote 181 While PHAC's Joint Statement on Safe Sleep: Preventing Sudden Infant Deaths in Canada does not discuss swaddling, the Registered Nurses' Association of Ontario guidelines Working with Families to Promote Safe Sleep for Infants 0–12 Months of Age highlights concerns with swaddling.Footnote 181Footnote 182 8. Cue-Based FeedingStep 8: WHO/UNICEF
Canada
Cue-based, Responsive FeedingIn Canada, half (49.8%) of all mothers reported feeding their infants on cue in the first week following birth.Footnote 49 Frequent, unrestricted breastfeeding is associated with successful breastfeeding.Footnote 183 Feeding on cue supports the demand-and-supply basis of establishing breastmilk production and flow. Timed, restricted, or delayed feedings should be avoided.Footnote 179 With cue-based or infant-led feeding, the mother learns to recognize and respond to her infant’s signals about their appetite, hunger, and fullness.Footnote 2 HCPs need to support new parents in identifying and responding to infant feeding cues – restlessness, rooting, or sucking on a hand – and in identifying signs that their infant is receiving sufficient breastmilk.Footnote 2 Feeding cues can be subtle, and babies who are tightly wrapped or swaddled are less likely to show these cues.Footnote 121 Responsive feeding recognizes that successful breastfeeding is a sensitive, reciprocal relationship between a mother and her child. Breastfeeds can be long or short, and breastfed babies cannot be overfed or spoiled by too much feeding.Footnote 37 Infants who are fed when they are hungry, and who suckle effectively, will obtain what they need for satisfactory growth. Infant-led breastfeeding encourages self-regulation.Footnote 184 To encourage mothers to breastfeed on cue, it is important to avoid setting limits on the number of feedings infants should have in a 24-hour period. In the early postpartum period when families are looking for guidance, language such as “offer the breast at least 8 times in 24 hours” is more appropriate than limits such as “feed every 3 hours” or “8–12 times a day,” as infants exhibit a wide range of frequency of feedings.Footnote 179 Addition of Solid FoodsExclusive breastfeeding provides the nutrients most healthy infants need until they are 6 months old. The infant may be ready for complementary foods a few weeks before the 6-month mark or just after. The Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months recommends that HCPs and families consider the infant’s signs of readiness before introducing complementary foods.Footnote 2 The signs of physiological and developmental readiness for complementary foods include:Footnote 2Footnote 185
The first complementary foods to introduce include iron-rich foods, such as meat, meat alternatives (e.g., eggs, tofu, and legumes), and iron-fortified infant cereals.Footnote 3 For further guidance on the introduction of complementary foods, see Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months and Nutrition for Healthy Term Infants: Recommendations from Six to 24 Months.Footnote 3 The principles of cue-based feeding apply when other foods are added to the diet, and are not confined to one stage of infant or child development. Responsive feeding means that a parent or caregiver responds in a prompt, emotionally supportive, and developmentally appropriate manner to the child’s hunger and satiety cues.Footnote 186 Supporting Sustained Breastfeeding of the Older Infant and Young ChildBreastfeeding is also an important source of nutrition for the older infant and young child. Breastfeeding can provide 50% or more of the energy needs of the infant aged 6 months to 1 year, with other foods supplying the remainder.Footnote 187Footnote 188 One-third of the 12- to 24-month-old toddler’s energy needs can come from breastmilk.Footnote 188Footnote 189 In addition, the act of breastfeeding is comforting to the child. Many mothers continue to breastfeed because they believe it enhances their relationship with their child.Footnote 190 Breastfeeding beyond infancy and well into toddlerhood is common in many cultures. In 2011/12, the rate of breastfeeding beyond the baby’s first year of life was 19%.Footnote 3 Although the reasons for earlier weaning are multifactorial, lack of knowledge about the value of prolonged breastfeeding and the lack of support for mothers breastfeeding older infants and toddlers are contributing factors. Mothers who continue to breastfeed into toddlerhood may face negative attitudes and criticism, and be reluctant to say they are still breastfeeding, a practice called closet nursing.Footnote 2Footnote 128Footnote 191Footnote 192 Increased public awareness of the importance of breastfeeding beyond infancy, including by visually representing breastfeeding toddlers, facilitates sustained breastfeeding. Sustained or long-term breastfeeding must be destigmatized and normalized, with education targeted at the public and HCPs rather than focusing on the mothers themselves.Footnote 191 If a breastfeeding mother becomes pregnant, encourage her to continue and reassure her that breastfeeding is not contraindicated during pregnancy unless the mother is not gaining enough weight, there is unexplained vaginal bleeding, or there is a risk of premature labour. The Nutrition for Healthy Term Infants: Recommendations from Six to 24 Months has strategies for encouraging sustained breastfeeding.Footnote 3 WeaningWeaning practices are largely culturally determined. In many countries, breastfeeding continues for 2 years or longer.Footnote 128Footnote 193 One anthropological analysis of when humans would wean based on physiology alone rather than culture suggested that the physiological age of weaning is between 2.5 and 7 years.Footnote 193 For some families, weaning is the natural progression from exclusive breastfeeding, to the addition of other foods and liquids to the infant’s diet while they continue to breastfeed, until the child no longer breastfeeds. For other families, weaning is the intentional replacement of breastfeeding with other fluids (often human milk substitutes) and solid foods. This weaning strategy can be done very quickly (e.g., the mother requires long-term use of medication or treatment where breastfeeding is contraindicated) or over a longer period of time. Ideally, the process is done as slowly as possible to allow the mother’s body and for the infant to adjust. Mothers may be surprised by the feelings of sadness and loss they experience at the end of the breastfeeding relationship and the hormonal shift that occurs.Footnote 194 Weaning may also be unintentional such as because the infant refuses to breastfeed. Refusing to breastfeed can occur for many reasons and is usually temporary and can be resolved.Footnote 195 Informing families ahead of time that infants can have nursing strikes and how to resolve these, can support families in continuing sustained breastfeeding. It is important that HCPs provide families with information to make informed decisions about weaning. See the CPS position statement Weaning from the Breast.Footnote 195 Working and BreastfeedingWomen have always skilfully combined parenting, breastfeeding, and working. Breastfeeding and working only became problematic when the places of employment separated mothers and young children. Families with children benefit from community support wherever mothers work, be it at home or away. Canadian women have the right to breastfeed their children. “For children breastfeeding provides the highest attainable standard of health; a basic human right. For women, the right to breastfeed in public and the right to be accommodated by the employer or educational institution to continue to breastfeed on returning to work or school is a human right.”Footnote 196 Accommodations in the work environment must consider the needs of breastfeeding mothers.Footnote 197 Unsupportive workplaces could be in violation of the Canadian Charter of Rights and Freedoms and of provincial human rights legislation/policies. Evidence shows that women can successfully work or go to school and breastfeed, although support from the work or school environment is essential.Footnote 198Footnote 199Footnote 200 HCPs also need to provide guidance and support breastfeeding mothers returning to work or school to facilitate this transition. Breastfeeding and Human RightsFootnote 197Footnote 201Footnote 202Footnote 203Footnote 204 Canadian women have the right to breastfeed their children wherever women have the right to be, including in the work environment. International and national statements affirm this right:
9. Artificial Teats or SoothersStep 9: WHO/UNICEF
Canada
Artificial TeatsThe onset of lactogenesis II, or copious milk production, depends on frequent, effective milk removal from the breasts.Footnote 192 Feeding in ways apart from breastfeeding (with donor milk or infant formula) may interfere with the supply-and-demand process of establishing milk production. Supplemental feedings, unless medically indicated, are not recommended for breastfed infants. For small amounts of supplement given for documented medical indications during the early postpartum period, spoons or small cups may be used.Footnote 54Footnote 205Footnote 206 Using these alternatives to bottles when providing supplements in the hospital is associated with increased breastfeeding duration.Footnote 160Footnote 207Footnote 208 Though research into other feeding devices is scarce, supplemental feedings can be given via a syringe, dropper, or a feeding tube at the breast.Footnote 206 Cup feeding has also been used for preterm infants during the transition from gavage (tube) feeding to full breastfeeding.Footnote 147 Studies on the effects of artificial teats on breastfeeding duration are inconclusive. The possibility of an infant imprinting on a particular type of nipple, preferring a fast flow of milk requires further research as does the possibility of nipple confusion.Footnote 192Footnote 209 Although occasional bottle use after breastfeeding has been established may not be problematic, routine use, especially when milk is not frequently removed from the breasts, may jeopardize milk production. Some families may be concerned that they need to teach their breastfeeding infant to take a bottle just in case a situation rises where the mother cannot breastfeed. Reassure the family that this is not necessary. The Nutrition for Healthy Term Infants: Recommendations from Six to 24 Months encourages the use of an open cup when introducing liquids other than breastmilk at 6 months, and when transitioning from a bottle. HCPs are referred to the joint statement for further advice.Footnote 3 PacifiersThe use of pacifiers, also called soothers or dummies, varies depending on the culture, and remains controversial in Canada. Many authorities suggest using these with caution, especially in the early postpartum period before breastfeeding is established.Footnote 15Footnote 78Footnote 128Footnote 205 Routine use of pacifiers can delay breastfeeding or decrease the frequency, and interfere with breastmilk production. Some studies also link pacifier use with decreased breastfeeding duration or with breastfeeding difficulty in the first 3 months.Footnote 20Footnote 208 Other concerns include:
The Joint Statement on Safe Sleep: Preventing Sudden Infant Deaths in Canada identifies a protective effect of pacifiers against SIDS.Footnote 181 The joint statement recommends delaying the introduction of a pacifier until breastfeeding is well established. The statement also recommends that infants who use a pacifier have one consistently, for every sleep. Pacifiers may also be helpful for preterm infants during gavage feedings or painful procedures if breastfeeding is not possible.Footnote 210Footnote 211 However, minimizing the use of a pacifier is positively associated with earlier attainment of exclusive breastfeeding by preterm infants and with exclusive breastfeeding at discharge.Footnote 149Footnote 150 See the CPS guideline Recommendations for the Use of Pacifiers guideline for further recommendations on pacifiers.Footnote 212 10. Breastfeeding Support in the CommunityStep 10: WHO/UNICEF
Canada
Partnerships between hospitals and community services to seamlessly transition care during pregnancy, labour, birth, and the postpartum period is essential given the short length of hospital stays and the importance of establishing breastfeeding and lactation in the first 1 to 2 weeks following birth. Collaboration between public health agencies and between HCPs (e.g., midwives, general practitioners, and pediatricians) ensures that families receive support from the most appropriate service in a timely manner, which is vital for the well-being of the baby and mother. The BFI provides a model of community-wide care. The specifics of how continuity and seamless transition are accomplished vary, but certain essential components increase its effectiveness:Footnote 37Footnote 67Footnote 68Footnote 82
Sources of Information and SupportInternetFederal and provincial government departments, regional/local health agencies, and professional groups, are important sources of information for breastfeeding women, and these can be accessed via the Internet and social media. But because there are plenty of sources of inaccurate information, it is helpful if agencies and HCPs direct families to credible sources and even show them how to recognize such sources when they are searching for breastfeeding information. Telephone HelplineSome provinces or communities have implemented specialized lactation support phone lines. For example, the Breastfeeding Hotline in Ontario provides 24/7 access to advice on breastfeeding. In some jurisdictions, public health or community agencies offer telephone support lines for breastfeeding women. Peer SupportBreastfeeding mother-to-mother (peer) support groups emerged in the 1950s with groups such as La Leche League and Nursing Mothers of Australia (now called Australian Breastfeeding Association). These community-based organizations developed as a grass roots network of support for breastfeeding mothers. The model of mother-to-mother support also now exists in a variety of health-related organizations. Research demonstrates that peer support positively impacts the duration and exclusivity of breastfeeding, likely because it normalizes the breastfeeding experience as women learn they are not alone in their successes and challenges. Participants were satisfied with this form of support, benefitting from the sense of community and belonging.Footnote 69Footnote 82 Peer-support programs can also help connect women with important community resources, which can be particularly important for those who cannot easily access mainstream services.Footnote 213 Hospitals and community health agencies should actively support existing peer-support groups and facilitate the development of new ones. The Best Start Resource Centre has developed a useful resource to help communities develop and sustain breastfeeding peer-support programs.Footnote 214 Vulnerable PopulationsSome groups of women have lower rates of breastfeeding. These include women who are younger; have lower levels of education; are living in low income situations; have little or no support from their partners, family, or friends; face cultural or societal barriers; and find accessing health care and other types of support challenging. Geographical location also makes a difference: women in the Atlantic provinces were less likely to breastfeed than those living elsewhere in Canada.Footnote 49 It is critical that vulnerable populations have support that is tailored to their needs.Footnote 215Footnote 216 A focus on support, education, intervention, and care is the best strategy for reaching women at risk of not breastfeeding or stopping breastfeeding early.Footnote 215 An example is the Canada Prenatal Nutrition Program (CPNP), a population health intervention jointly managed by the federal and provincial/territorial governments that aims to improve health outcomes for pregnant women and their newborn children facing conditions of risk. CPNP has resulted in an increased likelihood of women breastfeeding and breastfeeding for longer. The overall rate of breastfeeding initiation among CPNP participants (89%) was the same as the rate for the general Canadian population (88%) – a significant finding given the risks faced by the women in the program. Participants with high exposure to CPNP programming were 4 times more likely to breastfeed longer than those with lower program exposure.Footnote 217Footnote 218 ConclusionFamily-centred care creates the context for successful breastfeeding. This includes supporting early and ongoing skin-to-skin contact; mother–baby togetherness and rooming-in; family involvement; and informed decision-making about infant feeding. Regardless of the chosen feeding method families require support and education, and to be treated with respect and dignity. Breastfeeding is recognized as the unequalled method of feeding infants, and being unparalleled with respect to supporting normal growth and development and protecting from acute and chronic illness. Health Canada, PHAC, CPS, Dietitians of Canada, and the BCC recommends that babies be breastfed exclusively for the first 6 months, and sustained for up to 2 years or longer with appropriate complementary feeding to support the nutrition, immunological protection, growth and development of infants and toddlers. This is consistent with the WHO global public health recommendation. In Canada, breastfeeding initiation rates have significantly improved, although breastfeeding exclusivity and duration do not achieve the WHO recommendations. Breastfeeding rates also vary across the country, decreasing along a general west-to-east gradient. Breastfeeding initiation and duration increase with active protection, promotion, and support. The WHO/UNICEF BFHI evidenced-based policies and practices have been shown to improve breastfeeding outcomes – duration and exclusivity. Canada continues to work on improving breastfeeding rates across the country through ongoing research, policy development, education, and collaborations and partnerships. Appendix A - Additional ResourcesClinical Practice Guidelines Relating to Breastfeeding
Community-based and support programs
Guides for health care providers
Hand expression
Human milk banks
Appendix B - Maternal Conditions that may Impact BreastfeedingPostpartum Anxiety and DepressionBreastfeeding can reduce the risk of postpartum depression.Footnote 128 The release of oxytocin and prolactin during breastfeeding can bring about a sense of calm and encourage a positive mood. Breastfeeding can also reduce the mother's stress levels.Footnote 219Footnote 220Footnote 221Footnote 222 Little is known about the efficacy and safety of antipsychotic and antidepressant medications during breastfeeding.Footnote 175Footnote 223 HCPs need to consider individual medications and their effects on breastfeeding and infant health to balance the risk of exposure against the benefits of the treatment and the importance of breastfeeding. Chronic IllnessAs the average age of childbearing is increasing, a higher number of pregnant and breastfeeding women have chronic illnesses. Many chronic illnesses are exacerbated by a lack of sleep. Therefore, women require not only assistance with breastfeeding, but also practical assistance with infant and family care so that they can get adequate rest. AsthmaApproximately 9% of Canadian girls/women over the age of 12 years have asthma.Footnote 224 It may improve, worsen, or remain unchanged during pregnancy. If women have asthma or a family history of asthma, they should be encouraged to breastfeed since it has long-term protective effects on asthma for the breastfed child.Footnote 225 DiabetesSince studies show that women with diabetes are less likely to initiate breastfeeding, they should be given information about the importance of breastfeeding and the necessary encouragement sooner.Footnote 226Footnote 227 Evidence indicates that lactation improves glucose metabolism in the early postpartum period.Footnote 228 Because women with gestational diabetes may have a delayed onset of lactogenesis II, they often require support from a lactation specialist.Footnote 229Footnote 230 Women who have type 1 diabetes typically have a delay in lactogenesis II of about 1 day.Footnote 231Footnote 232Footnote 233Footnote 234Footnote 235 Therefore, early frequent feedings and support are important. As with all women and babies, breastfeeding should begin as soon as possible after birth as colostrum helps to stabilize the infant's blood sugar. Sometimes babies of mothers with type 1 diabetes require care in a NICU. Families should be encouraged to stay with the infant and mothers to hand express or pump breastmilk.Footnote 128 Increasingly, women with diabetes are expressing colostrum in the last weeks of their pregnancy to use if their infants blood sugar is low immediately after birth.Footnote 236 The physical and emotional issues for women with type 2 diabetes are similar to those with type 1 diabetes, except that their glucose control may not be as unstable during the early postpartum period.Footnote 128 Women with diabetes may be more susceptible to mastitis. They should be knowledgeable about the signs – particularly if their blood glucose is not well controlled or if any infection raises their blood glucose levels.Footnote 237Footnote 238 Thyroid DiseasePospartum thyroid dysfunction is fairly common and includes hypothyroidism, hyperthyroidism, and postpartum thyroiditis (PPT). Most women who have thyroid disorders can continue to breastfeed with treatment.Footnote 128 If women with hypothyroidism are on replacement therapy, they need to be re-evaluated postpartum to see if any changes need to be made to their treatment. Usually, the thyroid replacement dose is reduced to the level it was before pregnancy.Footnote 239 If a woman has undiagnosed hypothyroidism postpartum, her milk supply may be reduced, but if she receives acceptable replacement therapy, her milk supply is likely to increase dramatically and her symptoms will be relieved.Footnote 128 Hyperthyroidism does not affect the ability to breastfeed. The usual treatment for hyperthyroidism is antithyroid medication.Footnote 240 Postpartum thyroiditis is the most common form of postpartum thyroid dysfunction, affecting about 7% of women in the first year postpartum. The symptoms, which may go undiagnosed, are fatigue, depression, and anxiety. Epilepsy (Seizure Disorders)As most seizure disorders are so well controlled with medication that seizures rarely occur, all women with epilepsy should be encouraged to breastfeed their babies.Footnote 128 If the mother does have seizures, breastfeeding is not contraindicated: the risk of harm to the infant during breastfeeding is no more likely than during bottle-feeding. ObesityMaternal obesity is associated with lower rates of breastfeeding initiation, duration, and exclusivity. Research suggests that these lower rates of breastfeeding among obese women are due to delayed lactogenesis II, thyroid dysfunction, and psychological factors.Footnote 241 As a result, obese mothers may benefit from additional support and guidance on how to know if their infant is getting enough milk; demonstrations of different feeding positions; assistance in supporting large breasts and seeing the baby's latch; and demonstrations of reverse pressure softening around the areola to enable deeper latch. Support from a lactation consultant has been demonstrated to positively affect breastfeeding outcomes for obese women.Footnote 241 Autoimmune DisordersInflammatory Bowel DiseaseRates of inflammatory bowel disease (IBD) have increased with time and the highest incidence and prevalence rates are in western countries – northern Europe, Canada, and Australia.Footnote 242 While older studies on other autoimmune disorders found that breastfeeding may be associated with an increased risk for developing postpartum relapse, more recent studies found that the risk of relapse of Crohn's disease was either reduced or unchanged in mothers who were breastfeeding versus those who were not.Footnote 243Footnote 244Footnote 245 Systemic Lupus ErythematosusSystemic lupus erythematosus (SLE) is a multisystemic autoimmune disease that primarily affects women of childbearing age, which means that lactation experts need to be familiar with the disease. Most women with SLE are able to breastfeed.Footnote 246 As with all conditions, treatment is based on the individual woman's needs. The safety of her medications during breastfeeding needs to be considered and balanced with the importance of breastfeeding. Multiple SclerosisIn most cases, the disease-modifying therapies used to treat multiple sclerosis (MS) are discontinued prior to conception or when pregnancy is diagnosed.Footnote 128 Women need to make informed decisions regarding what medications to take postpartum and infant feeding choices. The evidence on the impact of breastfeeding on postpartum exacerbations of MS is mixed, but a recent study found that mothers with MS who exclusively breastfed their babies for the first 2 months postpartum increased their well-being and had a reprieve from their illness for 6 months.Footnote 247 While more research is needed on the impact of breastfeeding on the risk of relapse, a woman with MS must be given evidence-based information so that she can choose what is right for her and so that support is tailored to her needs.Footnote 128 Rheumatoid ArthritisIt is common for women with rheumatoid arthritis (RA) to have their symptoms go into remission during pregnancy and then to relapse postpartum.Footnote 128 This occurs more often with breastfeeding mothers, most likely due to their hyperprolactinemic condition (prolactin has been shown to act as an immunostimulator).Footnote 248Footnote 249 Limited and largely older studies exist about the experiences of women with RA and breastfeeding. Breastfeeding women with RA can feel very fatigued and while they need rest, they also need continued range-of-motion exercises.Footnote 250 Lactation experts can help support women with RA to meet their individual needs and consult with her care team to ensure she has individualized care. Women with Physical DisabilitiesSupport for breastfeeding by women with disabilities should be based on their individual goals and abilities. A normalized approach to the care of mothers and babies and appropriate assessment are essential for families. Women's experiences enhance their ability to problem-solve creatively.Footnote 128 Breastfeeding is an important confidence and self-esteem booster for all women, confirming their body's ability to nourish her infant. Many women with spinal cord injuries breastfeed without difficulties. However, the higher and more complete the injury, the more likely difficulties will occur. The physical ability of the breasts to function normally will become apparent over time during early postpartum. Family and other support are essential to assist mothers with their own physical needs as well as the needs of their infants. HCPs can help mothers define their own breastfeeding success given their sensory completeness and mobility. Women with disabilities often find breastfeeding more convenient than bottle-feeding. However, there may be stigma associated women with disabilities breastfeeding. HCPs may need education and families and mothers support in overcoming any challenges and breastfeed effectively. Peer support from other women with disabilities can often be helpful for the breastfeeding mother. Appendix C - Common Breastfeeding ConcernsNipple PainThere is widespread clinical consensus on the importance of effective position and latch technique in preventing and resolving sore nipples.Footnote 251Footnote 252 Despite the plethora of pharmacological and non-pharmacological treatments and devices for sore or damaged nipples, there is little evidence of their effectiveness. Applying no treatment or expressing breastmilk may be equally or more beneficial than applying an ointment.Footnote 251 In fact, there is evidence that several nipple treatments, such as occlusive dressings and hydrogel dressings, are potentially harmful and should be avoided. Applying expressed breastmilk to the sore nipple before and after every feeding may help to prevent or hasten healing of sore nipples.Footnote 252 Given the availability of breastmilk in breastfeeding women, the lack of cost, the biological components, and the widespread endorsement of breastfeeding by international bodies such as WHO and UNICEF, this may be the optimum treatment. It is important to examine the infant’s mouth. If the lingual frenulum is attached to the anterior portion of the tongue, the mobility of the tongue may be restricted, causing nipple damage. There is no standard definition or assessment technique to diagnose tongue-tie (ankyloglossia).Footnote 253 The CPS statement, Ankyloglossia and Breastfeeding, recommends a frenotomy only if significant tongue-tie is associated with major breastfeeding difficulties.Footnote 253 Mammary candidiasis, a yeast infection of the nipple, can also lead to nipple pain. Caused by Candida albicans, a normal constituent of the gut microbiota in 80% of the population, this symbiotic organism can become invasive given the right conditions. The risk factors for mammary candidiasis include antibiotic use, a history of vaginal yeast infections, and thrush or a monilial diaper rash in the child.Footnote 254Footnote 255 The most common symptom of candidiasis is burning, deep, or sharp pain in the affected breast that is out of proportion to any physical finding. The pain can radiate along the T4 dermatome around the body to the base of the scapula. Physical findings are erythema with lichenification, or flaking, of the central areola. The erythema has a sharp active edge and does not typically extend beyond the area of the baby’s latch. Secondary bacterial infection can develop. Diagnosis is clinical as C. albicans is difficult to culture in breastmilk; the lactoferrin in breastmilk inhibits the growth of C. albicans.Footnote 256 Careful consideration of other causes of nipple pain, including vasospasm or Raynaud’s phenomenon, and local nipple trauma should be ruled out before treatment with antifungal agents.Footnote 257 Depending on the severity, mammary candidiasis may clear up on its own. Treatment options can include antifungal ointment, cream, or gel on the nipples or in the infant’s mouth, or maternal oral antifungal medications in resistant cases. Pain medication may be used with severe symptoms.Footnote 258 As C. albicans is common on skin and in the gut, there is no need to discard milk that was pumped prior to treatment.Footnote 259 EngorgementBreast fullness at around the third day postpartum is a reassuring sign of normal lactation. About two-thirds of women experience at least moderate signs of engorgement or swelling and distension of the breasts, usually between the third and fifth day postpartum.Footnote 192 Frequent, effective feeding (or milk removal) and breast massage may minimize severe symptoms. With engorgement, “the breast is enlarged, painful, shiny and edematous with diffuse red areas. The nipple may be effaced, milk often does not flow easily, and the infant can have difficulties latching. Contributing factors include delayed breastfeeding initiation, infrequent or time-restricted feedings, supplementation, inefficient infant latch, breast surgery, or any situation where milk stasis occurs.”Footnote 54 Prevention and treatment of engorgement is important as unrelieved engorgement can decrease milk production and cause involution of the breast tissue. The most effective prevention and treatment of engorgement is effective breastfeeding. Plugged DuctsPlugged or blocked ducts are usually seen as a tender area of local engorgement or palpable lump. They are often associated with missed feedings, pressure from restricting clothing, and an overabundant milk supply.Footnote 54 Care for plugged ducts can include warm compresses prior to breastfeeding, breast massage before and during feeding, breastfeeding often and starting with the affected breast, avoid missing feedings, and not wearing tight clothes/bras.Footnote 54 MastitisMastitis is characterized by localized tenderness, redness, heat, and systemic symptoms of fever, malaise, and occasionally nausea and vomiting.Footnote 192 Onset is usually within the first 6 weeks postpartum, but can occur at any point during lactation. “Technically, mastitis is an inflammation of the breast, which may or may not involve an infection. It is not uncommon for the problem to start with engorgement, then become noninfective mastitis, followed by infective mastitis.”Footnote 192 Mastitis can also be a precursor to abscess formation. In this case, the clinical symptoms of mastitis improve but a tender mass develops. Once the mass is fluctuant, generally within 1 week, treatment is with needle aspiration, ideally under ultrasound guidance. Patients who do not respond to aspiration may require surgery.Footnote 260 Comparison of engorgement, plugged ducts, and mastitisFootnote 54Footnote 128Footnote 192Footnote 257
JaundiceIt is important to understand the interaction between jaundice and breastfeeding. Infants who become jaundiced may feed poorly and, conversely, infants who feed poorly are at risk of becoming jaundiced (“starvation jaundice” of the newborn or breast non-feeding jaundice).128 All jaundiced infants should be carefully assessed by experienced HCPs to determine the cause and if therapy is required. When phototherapy is required, most babies can be treated at the mother’s bedside – mothers and babies should remain together as much as possible to ensure breastfeeding is not compromised as the CPS recommends that breastfeeding continue during phototherapy.3,137 If the infant is not breastfeeding effectively, it is important to support the mother in expressing/pumping her milk for the baby. Similarly, if babies are readmitted, mothers should be accommodated to stay with their baby to encourage continued breastfeeding. The CPS Guidelines for Detection, Management and Prevention of Hyperbilirubinemia in Term and Late Preterm Newborn Infants and Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months offer recommendation on assessing and monitoring infants.2,137 ReferencesFootnote 1 World Health Organization. Global strategy for infant and young child feeding [Internet]. Geneva (CH): WHO; 2003 [cited 2018 May 1]. Available from: http://apps.who.int/iris/bitstream/handle/10665/42590/9241562218.pdf;jsessionid=CE1022E8F58B7C57F1A85F340B05ED8C?sequence=1 Return to footnote 1 referrer Footnote 2Health Canada, Canadian Paediatric Society, Dietitians of Canada, Breastfeeding Committee for Canada. Nutrition for healthy term infants: recommendations from birth to six months [Internet]. Ottawa (ON): HC; 2012 [cited 2018 May 2]. Available from: https://www.canada.ca/en/health-canada/services/food-nutrition/healthy-eating/infant-feeding/nutrition-healthy-term-infants-recommendations-birth-six-months.html. Return to footnote 2 referrer Footnote 3Health Canada, Canadian Paediatric Society, Dietitians of Canada, Breastfeeding Committee for Canada. Nutrition for healthy term infants: recommendations from six to 24 months [Internet]. Ottawa (ON): HC; 2014 [cited 2018 May 2]. Available from: https://www.canada.ca/en/health-canada/services/food-nutrition/healthy-eating/infant-feeding/nutrition-healthy-term-infants-recommendations-birth-six-months/6-24-months.html. Return to footnote 3 referrer Footnote 4Victora C, Bahl R, Barros A, França G, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475-90. Return to footnote 4 referrer Footnote 5Kramer M, Aboud F, Mironova E, Vanilovich I, Platt R, Matush L, et al. Breastfeeding and child cognitive development: new evidence from a large randomized trial. Arch Gen Psychiatry. 2008;65(5):578-84. Return to footnote 5 referrer Footnote 6Quigley M, Hockley C, Carson C, Kelly Y, Renfrew M, Sacker A. Breastfeeding is associated with improved child cognitive development: a population-based cohort study. J Pediatr. 2012;160(1):25-32. Return to footnote 6 referrer Footnote 7Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evid Rep Technol Assess (Full Rep). 2007(153):1-186. Return to footnote 7 referrer Footnote 8Arenz S, Rückerl R, Koletzko B, Von Kries R. Breast-feeding and childhood obesity-a systematic review. Int J Obes. 2004;28(10):1247-56. Return to footnote 8 referrer Footnote 9Hauck F, Thompson J, Tanabe K, Moon R, Vennemann M. Breastfeeding and reduced risk of sudden infant death syndrome: A meta-analysis. Pediatrics. 2011;128(1):103-110. 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A new paradigm for depression in new mothers: the central role of inflammation and how breastfeeding and anti-inflammatory treatments protect maternal mental health. Int Breastfeed J. 2007;2(1):6. Return to footnote 222 referrer Footnote 223McDonagh MS, Matthews A, Phillipi C, Romm J, Peterson K, Thakurta S, et al. Depression drug treatment outcomes in pregnancy and the postpartum period: a systematic review and meta-analysis. Obstet Gynecol. 2014;124(3):526-34. Return to footnote 223 referrer Footnote 224Statistics Canada. Asthma, by age group [Internet]. Ottawa (ON): SC; 2018 [cited 2018 July 17]. Available from: https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310009608&pickMembers%5B0%5D=1.1&pickMembers%5B1%5D=3.3. Return to footnote 224 referrer Footnote 225Dogaru CM, Nyffenegger D, Pescatore AM, Spycher BD, Kuehni CE. Breastfeeding and childhood asthma: systematic review and meta-analysis. Am J Epidemiol. 2014;179(10):1153-67. 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Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review. Gastroenterology. 2012;142(1):46-54.e42. Return to footnote 242 referrer Footnote 243Julsgaard M, Norgaard M, Hvas CL, Grosen A, Hasseriis S, Christensen LA. Self-reported adherence to medical treatment, breastfeeding behaviour, and disease activity during the postpartum period in women with Crohn's disease. Scand J Gastroenterol. 2014;49(8):958-66. Return to footnote 243 referrer Footnote 244Mañosa M, Navarro-Llavat M, Marín L, Zabana Y, Cabré E, Domènech E. Fecundity, pregnancy outcomes, and breastfeeding in patients with inflammatory bowel disease: A large cohort survey. Scand J Gastroenterol. 2013;48(4):427-32. Return to footnote 244 referrer Footnote 245Moffatt DC, Ilnyckyj A, Bernstein CN. A population-based study of breastfeeding in inflammatory bowel disease: initiation, duration, and effect on disease in the postpartum period. Am J Gastroenterol. 2009;104(10):2517-23. Return to footnote 245 referrer Footnote 246Tsokos GC. Mechanisms of disease: systemic lupus erythematosus. N Engl J Med. 2011;365(22):2110-21. Return to footnote 246 referrer Footnote 247Hellwig K, Rockhoff M, Herbstritt S, Borisow N, Haghikia A, Elias-Hamp B, et al. Exclusive breastfeeding and the effect on postpartum multiple sclerosis relapses. JAMA Neurol. 2015;72(10):1132-8. Return to footnote 247 referrer Footnote 248Brennan P, Silman A. Breast-feeding and the onset of rheumatoid arthritis. Arthritis Rheum. 1994;37(6):808-13. Return to footnote 248 referrer Footnote 249Hampl JS, Papa DJ. Breastfeeding‐related onset, flare, and relapse of rheumatoid arthritis. Nutr Rev. 2001;59(8):264-8. Return to footnote 249 referrer Footnote 250Carty EA, Conine TA, Wood-Johnson F. Rheumatoid arthritis & pregnancy: helping women to meet their needs. Midwives Chron. 1986;99(1186):254-7. Return to footnote 250 referrer Footnote 251Dennis C, Jackson K, Watson J. 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Diagnosis and management of candida of the nipple and breast. J Midwifery Womens Health. 2006;51(2):125-8. Return to footnote 256 referrer Footnote 257Amir LH. ABM clinical protocol #4: mastitis, revised March 2014. Breastfeed Med. 2014;9(5):239-43. Return to footnote 257 referrer Footnote 258Berens P, Eglash A, Malloy M, Steube AM, Brodribb W, Noble L, et al. ABM clinical protocol #26: persistent pain with breastfeeding. Breastfeed Med. 2016;11(2):46-53. Return to footnote 258 referrer Footnote 259Hoppe J. Treatment of oropharyngeal candidiasis in immunocompetent infants: a randomized multicenter study of miconazole gel vs. nystatin suspension. Pediatr Infect Dis. J 1997;16(3):288-93. Return to footnote 259 referrer Footnote 260Kataria K, Srivastava A, Dhar A. Management of lactational mastitis and breast abscesses: review of current knowledge and practice. Indian J Surg. 2013;75(6):430-5. Return to footnote 260 referrer How does breast milk compared to cow's milk?While cow milk has the same fat content as human milk, human milk contains more mono- and polyunsaturated fatty acids (PUFAs) than cow milk. The fat in human milk specifically contains the essential PUFAs arachidonic and docosahexaenoic acids, which are not found in cow milk.
How does human breast milk differ from cow's milk quizlet?in human breast milk and formula differ slightly. In contrast, cow's milk provides too much protein & too little carbohydrate. conditions such as prematurity or inherited diseases. Infants allergic to milk protein drink soy based formulas.
Does breast milk have more protein than cow's milk?4.4. Cow Milk-Based Formula. Bovine milk is the basis for most infant formula. However, bovine milk contains higher levels of fat, minerals and protein compared to human breast milk.
What differences are there between human milk and formula feeds?As a group, breastfed infants have less difficulty with digestion than do formula-fed infants. Breast milk tends to be more easily digested so that breastfed babies have fewer bouts of diarrhea or constipation. Breast milk also naturally contains many of the vitamins and minerals that a newborn requires.
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