Which recommendation would the nurse make to a new breast feeding mother who asks how do you care for her nipples?

What is in this session?

Breastfeeding plays a crucial role in the health, growth and development of babies and has benefits for the mother too. Women may need some help to successfully feed their babies. They need support and reassurance as they learn this skill. This session focuses on the initiation of breastfeeding following birth and when and how to refer women who are experiencing difficulties.

What skills will I develop?

• Providing information and demonstrating breastfeeding techniques

• Encouragement and support

• Shared problem-solving

What am I going to learn?

By the end of this session you should be able to:

1. Communicate the advantages and benefits of breastfeeding for both mother and baby

2. Demonstrate how to breastfeed a baby, including positioning and attachment

3. Assess actual and potential difficulties and how to work with women on ways to overcome them

4. Explain the opportunities for HIV-infected mothers to breast feed and improve HIV-free survival of their baby

During pregnancy and after the birth it is important to discuss with women the importance of exclusive breastfeeding for six months. Try to include the partner or other family members and communicate to them all about the benefits of breastfeeding for the mother and baby, the process of breastfeeding and when and how long to feed for. You should also discuss continued breastfeeding after six months and introduction of other foods in addition to breast milk. You might find it useful to refer to more specialized breastfeeding tools and materials to support your discussion.

What is so good about breastfeeding?

• Breast milk provides all the nutrients that a baby needs for the first six months of life to grow and develop.

• Breast milk continues to provide high-quality nutrients and helps protect against infection up to two years of age or more.

• Breast milk protects babies from infections and illnesses.

• Babies find breast milk easy to digest.

• The baby's body uses breast milk efficiently.

• Breastfeeding can contribute to birth spacing.

• Breastfeeding helps the mother's uterus to contract reducing the risk of bleeding after birth.

• Breastfeeding lowers the rate of breast and ovarian cancer in the mother.

• Breastfeeding promotes a faster return to mother's pre-pregnancy weight.

• Breastfeeding promotes the emotional relationship, or bonding, between mother and infant.

REMINDER

As well as benefits for the baby in terms of survival, breastfeeding has other advantages. It is easier to carry out than feeding formula; it takes no preparation; is always at the correct temperature, it is always clean and is always available. It is the perfect nutrition for babies.

Communicate information on the advantages of breastfeeding (including health benefits, economic benefits, etc.), to help women decide which method of feeding they will choose. Be sure to also discuss the risks of not breastfeeding. Answer any questions or concerns the woman may have. For example, some women do not realize that it is normal for the baby to lose weight in the first three or four days after birth and that this is not a reflection of how she is breastfeeding or the quality of her breast milk. Women can still breastfeed while taking most medications, such as antibiotics, antiretroviral or TB medication.

Some women may choose not to breastfeed. You should respect this decision, even if you disagree with it and support her to replacement feed safely.

Women need support to help them decide and carry out their infant feeding choice

RISKS OF NOT BREASTFEEDING

• Babies may get sick more often with diarrhoea, malnutrition and pneumonia and are at increased risk of dying.

• Babies do not get natural protection to illnesses.

Initiating skin-to-skin contact and breastfeeding

After birth, dry the baby. Place him/her on the mother's chest, preferably with skin-to-skin contact. Use a blanket to cover both baby and the mother, to keep the baby warm. When the baby seems ready, encourage the mother to help the baby to her breast. Babies show they are ready to take the breast when they start “rooting”, or looking for the breast. Some babies need encouragement to latch-on at this stage.

It is important for all mothers to start skin-to-skin contact from birth as soon as possible following birth – preferably in the first hour. They should let their baby suckle when they appear to be ready. Some babies may take longer to start breastfeeding. As a health worker you have an important role in helping the mother to do this. Early contact will help a mother to bond with her baby - that is, to develop a close, loving relationship. It also makes it more likely that she will start to breastfeed.

SKIN-TO-SKIN CONTACT HELPS

• to keep the baby warm

• to establish breastfeeding

• to encourage mother-child bonding.

Positioning and attachment

To help a mother learn how to breastfeed first encourage her to get herself into a comfortable position. Show her how to hold the baby straight, with both the baby's head and body turned to face her breast and with the baby's nose opposite her nipple. She should hold the baby close supporting the whole body, not just the neck and shoulders. Refer to breastfeeding aids and materials to help you become more familiar with correct positioning and attachment.

Encourage and support women as they learn to breastfeed

Observe the mother breastfeeding her baby and offer help and assistance if needed. Look for signs of good attachment and effective suckling (slow deep sucks with pauses). If the attachment is not good, encourage the mother to reposition the baby. Show the mother how to take the baby off the breast, by inserting her little finger into the corner of the baby's mouth. Keep encouraging and reassuring the mother the whole time. Encourage her to reposition the baby until she feels comfortable and the baby is sucking well. Reassure her that there is no need to rush, even if the baby is crying.

REMINDER

Correct breastfeeding positioning occurs when the baby's:

• head and whole body are well supported and held close to mother

• face and stomach face the mother

• ear and shoulder are in one straight line, neck is not twisted.

Good attachment occurs when the baby's:

• mouth covers most of areola (dark part of the nipple) with some of the areola visible above the mouth

• mouth is wide open

• chin touches the breast

• lower lip is turned outwards.

Effective suckling occurs when:

• slow, deep firm sucks alternate with bursts of suckling

• no other sounds except swallowing sounds are heard.

Exclusive breastfeeding

All mothers should be encouraged to exclusively breastfeed their babies until they are six months old. Exclusive breastfeeding means that the baby is not given any other food or drink, not even water. They are only given breast milk. Make sure that you or others in the facility do not give the baby anything that will interfere with exclusive breastfeeding.

REMINDER

To encourage and support exclusive breastfeeding there are key things you can do:

1. Encourage breastfeeding frequently, day and night, and advise the mother to allow the baby to feed for as long as he/she wants. Tell her it is quite normal for a baby to feed up to eight times a day. Explain to her the signs a baby will show when he/she needs to be fed (such as “rooting”, looking for the nipple, sucking on the hand).

2. Reassure the parents that there is no need to give the baby any other drink or food, not even water – breast milk has all a baby needs.

3. Help the mother whenever she needs assistance and especially if she is a first time or adolescent mother or a mother with other special needs.

4. Explain to the mother she should let the baby finish the first breast and come off on its own before offering the second breast.

5. Encourage the mother to start each feed with a different breast. For example, if the left breast is used to start one feed, at the next feeding start with the right breast.

6. If it is necessary to express breast milk, show the mother how to do this and show her how to feed expressed breast milk by cup. You may need to refer her to a trained infant feeding counsellor for this.

7. Reassure the mother that her body will make enough breast milk to satisfy her baby's needs. Just because a baby is crying, it does not mean that she does not have enough breast milk. A baby who is demanding more breast feeds may be growing. By allowing the baby to suckle more often, her body will produce more breast milk to meet her baby's needs.

8. Explain that the mother can provide all the breast milk her baby needs for the first 6 months and beyond.

9. Explain that the mother can continue breastfeeding if she has to return to work or school, either by expressing breast milk or feeding more often when she is at home.

10. Advise her to seek help (or come back to see you) if the baby is not feeding well or if she has any difficulties or concerns with breastfeeding, sore nipples or painful breasts. If needed, refer her to a trained infant feeding counsellor.

Activity 1

In many health facilities breastfeeding is supported in a number of different ways. This activity is designed to get you and your colleagues to assess how you provide breastfeeding counselling and support, and what could be improved or strengthened.

1. Gather the following information from ten women who have recently given birth. If you are working in a group, each group member should do the same.

   • At what point in pregnancy did the health worker discuss breastfeeding with them?

   • Do they think these discussions should have started earlier in pregnancy or later, or was this the right time?

   • Do they remember what was discussed with them? (Make a list of the different points discussed.)

   • Did they feel the information was clear and easy for them to understand?

   • After birth, what advice and support was given to them to breastfeed their babies? When was this given?

   • Was skin-to-skin contact promoted after birth (the baby placed on the mother's upper abdomen)? How soon after birth was it started?

   • Was ongoing support, advice and reassurance given to them? How was this given?

   • Who gave them support and advice once they were home? Did they feel they had enough support and advice or did they need more? What additional support and advice did they think would be helpful?

   • What are some of the barriers women face to exclusive breastfeeding and how can the health staff help them to solve these?

   • Ask women for suggestions on how staff could better respond to their needs.

2. Discuss the responses with the rest of the group working through this handbook if applicable. Do you need to do anything differently? How can you as a team better respond to the support women need to successfully breastfeed? With the manager, make a plan for any changes that should be introduced, including reviews to check on how you are progressing. For example, you could carry out this activity again, six months after making changes to evaluate whether you have made any improvements.

Discussion of breastfeeding should start during pregnancy by asking women how they plan to feed the baby. At this time you do not need to overload women with too much information. Stick to the basic facts about the benefits of breastfeeding for the baby and for the mother. Talk to women about the benefits of initiating skin-to-skin contact as soon as possible following the birth (preferably within one hour) to facilitate early initiation of breastfeeding. You should help the mother with the first breastfeed to show her how to position and attach the baby. Demonstrations are important as breasfeeding is a skill that mothers learn. Have dolls available to demonstrate position. Remember to provide as much support and reassurance as each woman needs - it will vary according to the woman.

Consider how you might be able to provide support and reassurance to women once they have left the health facility and are at home. Once home many women experience feeding problems such as engorged breasts or cracked nipples. Others may be pressured by family members to offer supplementary foods or drinks. How can you work with women to overcome some of these problems? One way is to talk with all family members on the importance of exclusive breastfeeding. You can also make sure you assess breastfeeding at any visit or meeting during the postnatal period. Also consider holding a special session for breastfeeding problems.

Often in the community, groups exist to support women who are breastfeeding. Find out what support exists, or contact women who have successfully breastfed and see if they would be available to support women after birth.

Before discharge and if the mother returns to the health facility during the postnatal period you need to assess how breastfeeding is going. You should also assess breastfeeding and provide relevant information during routine visits and at any time if there is feeding difficulty or the mother is concerned about feeding.

Supporting breastfeeding

Women need extra support, encouragement and reassurance while breastfeeding. Although we view breastfeeding as a natural process, it is still a skill that has to be learned. Initially breastfeeding can seem demanding, as the baby may have a desire to feed/suck frequently. Babies however, begin to establish their own pattern over time, and the mother will begin to feel more comfortable and at ease.

Some women also find that the initial ‘let down’ reflex is very strong which causes them pain or they get strong after-pains as their wombs contract. Reassure them that this will pass. The ‘let down’ reflex may also cause them to leak milk when they have sexual intercourse. Reassure them that this is normal and that they may need to tell their husband or partner that this is normal.

Sometimes husbands or partners may feel excluded from the breastfeeding process. Encourage them to be involved in other ways. This may ease the situation and help men to provide more support for breastfeeding; for example, by asking him to fetch the baby for the feed, helping make the woman comfortable, or looking after the other children while she is feeding. Massaging the baby, and humming to calm a crying baby are other very useful ways of involving men.

Many women find breastfeeding difficult due to problems such as engorgement or sore nipples. Engorgement may happen a few days after birth or at any time when the baby's feeding pattern changes. The breasts become overfull with milk and tissue fluid; milk does not flow well and the skin is tight (especially the nipple). This makes it difficult for the baby to latch on. Sometimes the skin looks red and the woman has a fever which usually disappears in 24 hours. To prevent engorgement, help women to start breastfeeding soon after birth, ensure good attachment and encourage unrestricted breastfeeding. To treat engorgement, recommend that the mother puts warm compresses on her breasts or takes a warm shower and expresses enough milk to reduce discomfort which helps make attachment easier. After expressing milk she can use cold compresses to reduce the inflammation. Cracked or sore nipples occur mainly because the baby is not attaching properly. Help the mother to make sure the baby is attaching properly.

Support for feeding preterm and/or low birth weight babies

Low birth-weight or preterm babies should be fed their mother's own breast milk. The mother may need extra support to initiate breastfeeding or expressing breastmilk as soon as possible after birth. Because low birth-weight babies can sometimes get easily tired when feeding, it is particularly important that the mother feeds her baby as often as possible, responding to demand and at least 8 feeds during 24 hours, during the day and night

If a mother cannot feed her own baby, it is still best for a low birth-weight baby to be fed human breast milk. Another woman could feed the baby, so long as she is not HIV-infected. Some facilities have established breast milk banks, where breast milk from healthy donor women is collected, pasteurised and kept frozen. If your facility does not have a breast milk bank, maybe the local referral hospital can put you in contact with a breast milk bank. Try to find out about breast milk banks in your area and keep this information available for mothers who cannot breastfeed for a while due to health problems. If the low birth-weight or preterm baby cannot be fed breast milk, either by the mother, a wet nurse or from a breast milk bank, then the baby can be given standard infant formula by cup. Look at Session 26 of the WHO Breastfeeding Counselling: A training course (http://www.who.int/maternal_child_adolescent/documents/who_cdr_93_3/en/), for further information on how to help a mother breastfeed a low birth-weight baby.

Encouraging continuous skin-to-skin contact can help low birth weight babies keep warm and support breastfeeding on demand. Make sure parents are aware of all the newborn danger signs and that they understand it is especially important to bring a low birth-weight newborn to a health facility if they have any worries, as these small babies are at particular risk from infections and feeding difficulties.

Support for the mother who is not yet breastfeeding

If the mother or baby is ill or the baby is too small to suckle you need to give extra support and help. First teach the mother how to express milk and feed the baby by cup. If you have not been trained to do this, you should refer to an infant feeding counsellor where possible. If the mother and baby are separated for any reason then reassure the mother about the baby's progress whenever she asks. Encourage the mother to start breastfeeding the baby as soon as she or the baby is able.

Support for breastfeeding twins

Many mothers who give birth to two or more babies are worried they will not have enough milk. Reassure her that she will have enough milk for both babies. Encourage the mother to feed one baby at a time until breastfeeding is established. You can then show her different ways she can feed the babies and work with her to find out which method she is most comfortable with. If one twin is weaker or smaller than the other, make sure that the weaker twin also gets enough milk.

Advice to women who are not breastfeeding

Some women may not be able to breastfeed and others may choose not to. A woman's right to take an informed decision should be supported and respected. If after discussing the benefits of breastfeeding and the risks of not breastfeeding the mother decides not to breastfeed, she should be shown alternative methods.

These mothers need to learn how to safely prepare and feed formula to their babies. You may also have other women whose babies have died or who have had a stillbirth. These women may experience discomfort in their breasts for a period of time. Advise them not to stimulate the breasts or nipples. Show them how to support the breasts with a firm well fitting bra or a cloth. Teach the mother how to express just a little milk to relieve discomfort but not enough to stimulate more milk production.

REMINDER

Advise all women to seek care if their breasts become painful, swollen, and red or if they feel ill.

Mothers who are HIV-positive

Babies of HIV-positive mothers can benefit from breastfeeding for all the same reasons outlined above. HIV may pass from an HIV-infected mother to her baby during pregnancy, childbirth and breastfeeding. Antiretroviral treatments can dramatically reduce the risk of mother-to-child transmission during breastfeeding and increase the chance of HIV-free survival of the baby (that is, staying free of HIV infection and also staying alive). Although there is still a small chance that the baby could become HIV positive even when the mother is being treated with antiretroviral drugs, babies who are not breastfed, but given replacement feeds, are more likely to die from infections.

National health authorities should have a policy to indicate whether health services should promote and support breastfeeding or replacement feeding among HIV-infected mothers. You need to be aware of this recommendation and you should develop the skills to support women to achieve this. However, it is a mother's right to choose how to feed her baby and you will need to support her choice. Mothers who are aware they are HIV infected should be counselled on safe infant feeding by a trained infant feeding counsellor. Where specialist help is not available, you should support women as best you can.

Ask her to repeat back to you in her own words to make sure she has understood the information correctly. Work together to make a plan that she can implement in order to carry out safe infant feeding.

Women who are HIV-positive and plan to breastfeed need support, particularly in the early stages when breastfeeding is being initiated. Try to help the women to avoid getting mastitis or nipple damage, as these difficulties increase the risk of transmission to the baby. Advise the woman to return if she has any problems with her breasts.

Women who have chosen replacement feeding for their babies must have regular follow-up to ensure that the baby is growing and to support replacement feeding. These women need extra support and reassurance, especially if they are from a community where breastfeeding is the norm. Many communities may stigmatize or shun a woman who chooses replacement feeding. Work with families and communities to support women in their choice of infant feeding.

WHO RECOMMENDATIONS FOR INFANT FEEDING FOR HIV-POSITIVE WOMEN

Mothers known to be HIV positive should be provided with lifelong antiretroviral therapy or antiretroviral prophylaxis (preventative treatment) to reduce HIV transmission to the baby during pregnancy, childbirth and breastfeeding.

National health authorities should decide whether health services in that country should principally promote and support breastfeeding or promote and support replacement feeding among HIV-infected mothers.

In settings where national authorities recommend breastfeeding, HIV infected mothers and/ or their babies should be given antiretroviral treatment or prophylaxis to reduce the risk of transmission throughout the breastfeeding period.

These mothers should exclusively breastfeed their babies for the first 6 months of life, then introduce appropriate complementary foods with continued breastfeeding for the first 12 months of life. Mothers should stop breastfeeding only when they can provide a safe and adequate diet.

If a mother decides to stop breastfeeding, she should do so gradually within one month.

HIV infected mothers should only give commercial infant formula milk as a replacement feed to their baby when specific conditions of safety and hygiene, affordability and supply of formula, access to health care and family support for replacement feeding are met.

Guidelines on HIV and infant feeding 2010. Principles and recommendations for infant feeding in the context of HIV and a summary of evidence

http://www.who.int/maternal_child_adolescent/documents/9789241599535/en/

What did I learn?

Breastfeeding should be encouraged and supported for all women. In this session you examined how to explain the importance of exclusive breastfeeding for six months and continued breastfeeding up to two years or beyond. You learned how to support women and how to demonstrate ways to effectively breastfeed soon after the birth. You also learned that mother who are HIV-infected can also breastfeed and give their baby all the benefits of breast milk with very little risk of transmitting HIV.

Take some time to reflect on how you can improve your own skills in communicating breastfeeding and demonstrating how to position and attach the baby. You could use your notebook to write down tips or advice you can give to women who are experiencing problems.

Encourage women to learn from one another; often women have helpful home remedies or suggestions for alleviating some of the discomforts associated with breastfeeding in the early stages. Determine what support exists in the community. Make contacts with these groups.

Finally, remember that it is important for successful breastfeeding that the woman has the support of her partner and her family.

What advice would you give a new mother considering breast feeding?

What will the nurse recommend to a breastfeeding client experiencing sore nipples?

What recommendations about breastfeeding would you give to a woman WHO has just given birth to a baby?

What are three recommendations for breastfeeding?