BFHI, Exclusive breastfeeing, Breastfeeding technique, pattern of feeding

BFHI, EXCLUSIVE BREASTFEEDING,
BREASTFEEDING TECHNIQUE, CHANGING
PATTERN OF FEEDING
• SUBMITTED TO
• DR. HEPSI BAI J
• ASSISSTANT PROFESSOR
• CON, AIIMS BBSR
• PUNAM BISWAS
• M.SC. NURSING 1ST YEAR
• PEDIATRIC NURSING
• CON, AIIMS BBSR
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BFHI

Introduction:
The Baby Friendly Hospital Initiative (BFHI), launched in
1991, in an effort by UNICEF and the WHO to ensure
that all maternities, whether free standing or in a
hospital, become centres of breastfeeding support.
Bottle-feeding is the biggest killer of babies so BFHI
launched to resurrect the dwindling practice of
breastfeeding.

Aims:
Improving the knowledge, attitude and
practices of health care workers
10 specific steps to support successful
breastfeeding.

Recommendation:
37
38
39
40
41
42
43
44
45
BREASTFEEDING INITIATED WITHIN 1
HOUR
EXCLUSIVE BREASTFEEDING AFTER 6
MONTHS OF AGE
BREASTFEEDING AFTER 2 YEARS OF AGE
BREASTFEEDING PRACTICES

Age Foods
6-12 months  Breast milk
 Iron-fortified infant formula
 Begin introducing solid foods
 Whole cow's milk (3.25%)
 Whole cow's milk (3.25%)
 2% milk is sufficient if the child is
growing well and eating a variety of
foods
2-5 years  2% milk

STEPS OF SUCCESSFUL BREAST
FEEDING
The 2018 version of the Ten Steps is separated into critical
management procedures, which provide an enabling
environment for sustainable implementation within the
facility, and key clinical practices, which delineate the care
that each mother and infant should receive. The key clinical
practices are evidence-based interventions to support
mothers to successfully establish breastfeeding.

1. Have a written
breastfeeding policy
that is routinely
communicated to all
health care staff.

2. Train all health
care staff in skills
necessary to
implement the
policy.

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

4. Help mothers
initiate
breastfeeding
within one and a
half hour of birth.

5. Show mothers
how to breastfeed
and maintain
lactation, even if
they should be
separated from
their infants.

6. Give newborn
infants no food or
drink other than best
milk unless medically
indicated.

7. Practice rooming
in, i.e., allows
mothers and infants
to remain together
24 hours a day.

8. Encourage
breastfeeding on
demand.

9. Give no artificial
teats or pacifiers
(also called dummies
or soothers) to
breastfeeding infants.

10. Foster the
establishment of
breastfeeding support
groups and refers
mothers to them on
discharge from the
hospital or clinic.

Some information about hospitals
• https://www.bfhi-india.in/list-of-accredited-hospitals

RECOGNITION AS BABY FRIENDLY HOSPITAL
• A hospital that conducts a minimum of 250 deliveries per year
can seek the recognition.
• The hospital/nursing home meeting all the ten criteria is visited
by an "Assessor" for on the spot checks and to interview the
mothers and health care staff.
• The hospital fulfilling the national BFHI requirements are
recognized as "Baby Friendly". The National Task Force
organizes a public ceremony for presentation of BFHI certificate
and a logo.

ROLE OF FACULTIES IN BFHI
• To ensure that mothers and newborns receive timely and appropriate care
before and during their stay in a facility providing maternity and newborn
services
• To enable the establishment of optimal feeding of the newborn, thereby
promoting their health and development.
• Respect the mother’s preferences and provide her with the information
needed to make an informed decision about the best feeding option for
her and her infant.
• To ensure that all people have equal access to quality health services
• Decide whether health services will mainly counsel and support mothers
known to be living with HIV to either (i) breastfeed and receive
antiretroviral drug interventions; or (ii) avoid all breastfeeding.

• World breastfeeding week = 1st – 7th august
• Theme (2023)- LET’S MAKE BREASTFEEDING AND WORK,WORK!

PHYSIOLOGY OF LACTATION:
•Milk secretion reflex (prolactin reflex)
•Mammogenesis (growth of breast)
•Galactopoesis (maintaining the production of milk)
•Milk ejection reflex (oxytocin reflex)
Reflex:
Reflex of mother - Milk secretion reflex, Milk ejection reflex
Reflex of baby - Rooting, Sucking, Swallowing

LACTATION

NO TYPES DAYS OF DELIVERY CHARACTERISTICS CONTENT
1 Colostrum 3-4 days after deliver Yellow, thick Ab ,vitamins, immune
factors, growth factors,
2 Transition milk >3-4 days to 2 weeks Less protein & Ig Fat and sugar increases
3 Mature milk >2 weeks Thinner & watery All nutrients in
appropriate quantity
4 Preterm milk Who deliver prematurely Richer in SIPFIC Sodium, iron, protein, fat,
Ig, calories
5 Fore milk
(satisfies baby’s
thirst)
Start of a feed , bluish
milk
Watery Rich in protein, sugar,
vitamin, minerals, water
6 Hind milk(satisfies
baby’s hunger)
End of feed, whiter milk Richer in fat More energy

Nutrient Human milk Cow’s milk
Protein
 Casein
 Lactoalbumin
1.2g
0.4 g
0.8 g
3.5 g
2.8 g
0.7 g
Lactose 6.5 g 4.5g
Fat 3.5 g 3.5g
Ca 34mg 22mg
Po4 15mg 90mg
Calories 67 67
Vit A 64mcg 53 mcg
Vit D 0.03 mcg 0.03 mcg
Vit E 0.3mcg 0.7 mcg
Vit C 5mcg 1 mcg
Water 87.5% 88%
Composition
of milk/100

ADVANTAGES OF EXCLUSIVE BREASTFEEDING: (BABY)

ADVANTAGES OF EXCLUSIVE BREASTFEEDING:
(MOTHER)

PROBLEMS IN BREASTFEEDING:

ORALASSESSMENT OF THE INFANT
RECEDED JAW

ADEQUACY OF BREAST FEEDING:

FREQUENCY OF FEEDING:
•Time schedule – 2to 3 hours interval
•Demand feeding – when baby is hungry
•Night feeding – due to prolactin release and
avoid long interval between feeding and
disturbed sleep

CONTRAINDICATION OF BREAST
FEEDING:
• Neonatal conditions – Galactosemia, lactose intolerance
in the baby.
•Maternal conditions - Psychosis (untreated) in the
mother or if the mother is receiving cancer
chemotherapy, ant thyroid drugs, (carbimazole,
methimazole), Ergotamine, MAO inhibitors, lithium, gold
salts, or radioactive pharmaceuticals (125I, 131I, 69GA).
Mother is affected to Herpes simplex virus.

SUCCESSFUL BREASTFEEDING:
Motivate
Early
initiation
Rooming
in
Frequent
suckling
exclusively
breastfed
Complementary
feeds
Avoid
prelacteal
feeds
Cleaning
the breast
Avoid
bottle
feeds
Feeding
from both
breast

LATCH ON CORRECT STEPS

GOOD POSITIONING IS RECOGNIZED
BY THE FOLLOWING SIGNS:
• Infant's neck is straight or bent slightly back,
• Infant's body is turned towards the mother,
• Infant's body is close to the mother,
• Infant's whole body is supported.

BURPING

COUNSELLING ABOUT OTHER FEEDING
PROBLEMS
• Advise mother to increase the frequency of breastfeeding. Breastfeed as
often and for as long as the infant wants, day and night.
• If the infant receives other foods or drinks, counsel the mother about
breastfeeding more, reducing the amount of the other foods or drinks,
and if possible, stopping altogether. Advise her to feed the infant any other
drinks from a cup, and not from a feeding bottle.
• Advise mothers not to discard colostrum
• If mothers complain of inadequate milk output, encourage mothers to
increase breast-feeding frequency, drink plenty of fluids, eat a normal
diet.

TECHNIQUES OF
BREAST FEEDING

CRADLE POSITION

CROSS CRADLE POSITION
• This is good for
premature babies or
babies who are having
trouble latching on
• Mother holds her baby
along the opposite arm
of opposite breast

SIDE LYING POSITION
• This allows mothers
to rest or sleep while
baby nurses,
especially who have
had caesarean births
• Mother lies on her
side using pillows
under head and back

FOOTBALL POSITION(CLUTCH)
Good for mothers
with large breasts
or inverted
nipples.

TWIN FOOTBALL(CLUTH)
Nursing in the
football/clutch
hold is
common for
twins.

TWIN CROSS CRADLE
Baby's head in each
of mother's arms.
Heads may rest in the
bend of her arm near
her elbow.
Babies' bodies will
be in her lap turned
toward her abdomen.

FOOTBALL AND CRADLE HOLD
COMBINATION
Mother holds one baby
using the football hold and
the other baby using the
cradle hold.

SUCKING AND SWALLOWING
COORDIANTION

Taste, temperature, touch receptors in face, mouth, pharynx, larynx, esophagus send
information through sensory branch of cranial nerves (CN V, VI, X, XII) in
brainstem
NEURAL CONTROL
Neurotransmitter sent massage via interneurone with motor nuclei in
brainstem and spinal cord
Motor nuclei direct the massage and end organ to carry out sequential
movement of swallowing

REFLEXIVE CONTROL
• Rooting reflex
• Transverse tongue reflex
• Phasic bite reflex
• Swallowing reflex
• Cough reflex
• Gag reflex

CHANGING PATTERN OF
FEEDING:

FORMULA FEED:
• TYPES
1. Iron fortified formula
2. Soy based infant formula
3. Hypo allergic infant formula
• Advantage
Meeting need of infant
Others can feed
All nutrients are contained
• Disadvantage
Expensive
More prone to infection
Must be fresh at each time

EXPRESSED BREAST MILK:
EBM Room
temperature
Refrigerator Freezer
Freshly
prepared
6-8 hrs. Not >72
hours
2weeks in
freezer
6-12 months in
deep freeze

PALADAI/KATORI SPOON FEEDING:
After feeding the
utensils should be
washed thoroughly with
soap and water.
Boil for 10 minutes to
sterilize before next
food.

COMPLIMENTARY FEEDING:
CAUSES OF INTRODUCTION: The breast milk in reasonable quantities
alone cannot provide all the energy and protein required for maintaining an
adequate velocity of growth for the infant after the age of 4-6 months.
AGE OF INTRODUCTION: Full-term, healthy infants reach developmental
readiness to begin complementary foods 6 months old.
READINESS OF INTRODUCTION: By this age, infants begin to show their
desire for food by drooling, opening their mouths, and leaning forward.

EARLY AND LATE WEANING:
• Weaning before 4 months is called early and after 9 months is
called late weaning.
• Early weaning is associated with reduction of breastfeeding,
diarrhoea, increased morbidity and mortality.
• Late weaning put the child at risk of developing malnutrition,
anemia and poor growth.

STAGES OF WEANING:
1
• At this stage, a small amount of foods, such as cereal gruel,
followed by a basic mix, is introduced and the food is offered
after the breastfeeding.
2
• In this stage, the weaning foods are offered gradually in
increasing amounts, switching to the multimix, along with the
breastfeeding.
3
• There is decreasing amount of breast milk from partial to token
breastfeeding with increasing amount of family foods, ultimately
to a meal to complete weaning

QUANTITY OF COMPLEMENTARY FOOD
AGE IN
MONTH
CALORIES FROM
BREASTFEEDING
(%)
CALORIES FROM
COMPLEMENTARY
FEEDING (%)
SUGGESTED FREQUENCY
FOR OFFERING
COMPLEMENTARY FOOD
QUANTITY
6-9 70 30 2-3 times: gradually with
breakfast, lunch, dinner
Start with 2-3 spoonful
and increase to ½ wati
per feed
9-12 50 50 3-4 times: as above and
once in between meals
more than half of calorie
intake
½ wati to full wati
12-24 30 70 5 times or more as above
and twice in between
meals
>than 1 wati as per
child’s need

Appropriate Food Like This: Initial Food Like Ghee

INCREASE OF FOOD CONSISTENCY
AGE IN
MONTH
FOOD TYPE NEUROMUSCULAR
DEVELOPMENT
6-8 Mashed
8-10 Finger food Munching
10-12 Home food Crush

SAMPLE MENU FOR
COMPLEMENTARY FEEDING
Breakfast Lunch Dinner
Raggi/rice khir, suji
halwa, stewed apple
with curd, boiled egg
and bread finger.
Khichri, mixed
vegetable soup, rice
with curd.
Same as lunch.

PRINCIPLES OF COMPLEMENTARY FEEDING:
• Introduce new foods one at a time.
• Introduce single-ingredient foods initially to determine the infant's
acceptance to each food.
• Introduce a small amount of a new food at first
• Observe the infant closely for adverse reactions
• Gradually increase the frequency and quantity.
• Use spoon initially and allow handling the food and encouraging feed
himself.
• First year- give the breastfeeding first and Second year give the
complementary foods first.

CONT …
• Avoid making separate food preparations unless routine family food is excessively
spicy
• Avoid watery dal, rice water, soups, juices
• Snacks should be used in between meals - Freshly cut and softened fruits or Curd with
sugar and salt
• > 3 parts rice and I part of dal washed, dried and ground to a coarse powder. This can
be stored in a tin for 7-10 days.
• Sprouts and fermented food have better nutritive value and give protection against
infection.
• Some children like sweet dishes while some may like spicy food. Children should be fed
to their liking. 'Feeding sweet dishes and sweets lead to worm infestation' is a myth.
• Non-vegetarian food can be introduced after 9 months
• Foods like biscuits, noodles, wafers, chocolates, aerated cold drinks, cakes, pastries
and sauce should be avoided.

FAMILY POT MEAL:
Breakfast Lunch Evening
snack
Dinner
Bread+butter
+egg
Rice+dal+curry+
fish/vegetables
Milk+biscuit Same as lunch

STATUS OF BREASTFEEDING PRACTICES IN INDIA
Energy Potein vitamin A Iron
Series 2 63 45 24 95
Series 1 37 55 76 5
37
55
76
5
63
45
24
95
0
20
40
60
80
100
120
BREAST MILK IN 2ND YEAR

CONCLUSION:
The children are the pillar of nation so by improving the health of
all children we will be able to turn our country into healthy
nation. WHO and UNICEF have developed courses for training
health workers to provide skilled support to breastfeeding mothers,
help them overcome problems, and monitor the growth of
children, so they can identify early the risk of undernutrition or
overweight/obesity.

BIBLIOGRAPHY:
• Reddy N, S., Dharmaraj, A., Jacob, J., & Sindhu, K. N. (2023). Exclusive
breastfeeding practices and its determinants in Indian infants: findings
from the National Family Health Surveys-4 and 5. International
breastfeeding journal, 18(1), 69. https://doi.org/10.1186/s13006-023-
00602-z
•Abstract
• Background
The World Health Organization (WHO) recommends exclusive breastfeeding
(EBF) in infants for the first 6 months of life. This analysis aims to estimate
the proportion of Indian infants exclusively breastfed for the first 6 months
using the National Family Health Surveys (NFHS)-4 and 5, and further,
determine factors associated with EBF practices.

•Methods
EBF for this analysis was defined as when infants received only
breast milk and no complementary feeds (solid food, water,
animal milk, baby formula, juice, and fortified food) in the last
24 h prior to the survey. The proportion of infants exclusively
breastfed was plotted from birth to 6 months as per the age of
children at the time of the survey, and this was computed for
individual states, union territories, and overall, for India.
Univariate and multivariable logistic regression analyses were
performed to examine factors influencing EBF in Indian infants.

•Results
The proportion of Indian infants exclusively breastfed for 6 months was
31.3% (1280/4095; 95% CI 29.9, 32.7) and 43% (1657/3853; 95% CI 41.4,
44.6) as per the NFHS-4 and 5 surveys, respectively. In NFHS-5, infants of
scheduled tribes (aOR 1.5; 95% CI 1.2, 1.9) and mothers who delivered at
public health facilities (aOR 1.3; 95% CI 1.1, 1.5) showed an increased
odds of being exclusively breastfed at 6 months of life compared to their
counterparts. Further, infants of mothers aged < 20 years (aOR 0.5; 95%
CI 0.4, 0.7), low birth weight infants (aOR 0.6; 95% CI 0.4, 0.8), and
infants in whom breastfeeding was initiated one hour after birth (aOR
0.8; 95% CI 0.7, 0.9) showed a reduced odds of being exclusively
breastfed at 6 months compared to their counterparts.

•Conclusions
The overall EBF practice showed an increasing trend in the NFHS-
5 compared to the NFHS-4 survey. However, a vast gap remains
unaddressed in the Indian setting with > 50% of the population
still not exclusively breastfeeding their infants for the WHO
recommended duration of first 6 months. Behavioral studies
dissecting the complex interplay of factors influencing EBF within
the heterogenous Indian population can help plan interventions
to promote and scale-up EBF in Indian infants.

BOOKS
• Genna WC. Supporting sucking skills in breastfeeding infant. Jones and Barlet
learning. 3rd edition. 170-195
• Gupta P. Textbook of Pediatrics, CBS publishers. 2nd edition. 143-149
• Sharma R. Essential of Pediatric Nursing. Jaypee. 2nd edition. 112-123
• Nair M, Menon P, Kundu R et al. Indian Academy Of Paediatrics Textbook.
Jaypee. 6th edition. 128-136
• Singh M. Care of the newborn. CBS publisher. 6th edition. 96-110
• Hockenberry , wilson ; Wong’s nursing care of infants and children ; 11th edition
;2019 ; health promotion of the preschool age and family ; Elsevier ; 423-438
• Kyle terri and charman susan ;Eessential of pediatric nursing; 2nd edition ; 2017
; growth and development of preschool children ; Kluwer ; 128-140
• Pal Panchali ; Textbook of pediatric nursing ; 3rd edition ; 2018; growth and
development of preschooler age : paras medical publisher; 80-83

ELECTRONIC SEARCH:
• https://www.slideshare.net/JustForHearts/pediatric-nutrition-
15586115
• https://www.slideshare.net/MAILYNVIODOR1/the-family-meals

BFHI, Exclusive breastfeeing, Breastfeeding technique, pattern of feeding

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