BFHI & exclusive breastfeeding

1. M R . S A N T H O S H . S . U .
A S S O C I A T E P R O F E S S O R
H . O . D . C H I L D H E A L T H N U R S I N G
S C P M C O L L E G E O F N U R S I N G &
P A R A M E D I C A L S C I E N C E S , G O N D A .
U . P .

2. DEFINITION
• The Baby-Friendly Hospital Initiative ( BFHI ), launched in
1991, is an effort by UNICEF and the World Health
Organization to ensure that all maternities, whether free
standing or in a hospital, become centers of breastfeeding
support.
• BFHI is A successful movement to promote breastfeeding
through hospitals.

3. • The Baby Friendly Hospital Initiative (BFHI), also known as
Baby Friendly Initiative (BFI), is a worldwide programme of
the World Health Organization and UNICEF, launched in
1992 in India following the adoption of the Innocenti
Declaration on breastfeeding promotion in 1990.

4. • The initiative is a global effort for improving the role of
maternity services to enable mothers to breastfeed babies
for the best start in life. It aims at improving the care of
pregnant women, mothers and newborns at health facilities
that provide maternity services for protecting, promoting
and supporting breastfeeding, in accordance with the
International Code of Marketing of Breastmilk Substitutes

5. • The GLOBAL initiative was co-sponsored by USAID and
SIDA.
• The Baby Friendly Hospital Camping was launched by the
WHO/UNICEF in Mid 1991 in Ankara to boost the
breastfeeding practices and to counter the trends of bottle
feeding

6. • UNICEF, the World Health Organization, and many national
government health agencies recommend that babies are
breastfed exclusively for their first six months of life.
Studies have shown that breastfed babies are less likely to
suffer from serious illnesses, including gastroenteritis,
asthma, eczema, and respiratory and ear infections.

7. • Adults who were breastfed as babies may be less likely to
develop risk factors for heart disease such as obesity and
high blood pressure. There are benefits for mothers too:
women who don't breastfeed have increased risk of
developing heart disease, hypertension, diabetes, high
cholesterol, breast cancer, ovarian cancer and hip fractures
in later life.

8. • The BFHI aims to increase the numbers of babies who are
exclusively breastfed worldwide, a goal which the WHO
estimates could contribute to avoiding over a million child
deaths each year, and potentially many premature maternal
deaths as well.

9. • To help in the implementation of the initiative, different
tools and materials were developed, field-tested and
provided, including a course for maternity staff, a self-
appraisal tool and an external assessment tool. Additional
tools were developed afterwards, such as monitoring and
reassessment tools.
“Since its launching BFHI has grown, with more than 152
countries around the world implementing the initiative.”
• In many areas where hospitals have been designated Baby-
Friendly, more mothers are breastfeeding their infants
exclusively for the first six months, and child health has

10. Key Dates In The History Of Breastfeeding
and BFHI
Year History
1991 Launching of Baby-Friendly Hospital Initiative
1992 BFHI launched in India
2000 WHO Expert Consultation on HIV and Infant Feeding
2001 WHO Consultation on the optimal duration of exclusive
Breastfeeding.
2002 Endorsement of the global Strategy for infant and
Child feeding by the WHO
2006
&
2018
Revision of BFHI

11. • Baby Friendly Hospital are required to adopted breast
feeding policy and follow the
“Ten Steps of Successful
Breastfeeding”
as recommended by code of Practice of WHO/UNICEF 1992

12. • (i) There must be a written breastfeeding policy;
• (ii) All health care staff must be trained to implement this
policy;
• (iii) All pregnant women must be informed about the benefits
of breastfeeding;
• (iv) Mothers should be helped to initiate breastfeeding within
half an hour of birth;
• (v) Mothers are shown the best way to breastfeed;

13. • (vi) Unless medically indicated, the newborn should be
given no food or drink other than breast milk;
• (vii) To practice ‘rooming-in’ by allowing mothers and
babies to remain together 24 hours a day;
• (viii) To encourage demand breastfeeding;
• (ix) No artificial teats to babies should be given; and
• (x) Breastfeeding support groups are established and
mothers are referred to them on discharge.

14. Ten Steps to Successful
Breastfeeding
(Revised 2018)-WHO

15. CRITICAL MANAGEMENT PROCEDURES
• 1a. Comply fully with the International Code of Marketing
of Breast-milk Substitutes and relevant World Health
Assembly resolutions.
• 1b. Have a written infant feeding policy that is routinely
communicated to staff and parents.
• 1c. Establish ongoing monitoring and data-management
systems.
• 2. Ensure that staff have sufficient knowledge, competence
and skills to support breastfeeding.

16. KEY CLINICAL PRACTICES
• 3. Discuss the importance and management of
breastfeeding with pregnant women and their families.
• 4. Facilitate immediate and uninterrupted skin-to-skin
contact and support mothers to initiate breastfeeding as
soon as possible after birth.
• 5. Support mothers to initiate and maintain breastfeeding
and manage common difficulties.
• 6. Do not provide breastfed newborns any food or fluids
other than breast milk, unless medically indicated.

17. • 7. Enable mothers and their infants to remain together
and to practice rooming-in 24 hours a day.
• 8. Support mothers to recognize and respond to their
infants’ cues for feeding.
• 9. Counsel mothers on the use and risks of feeding
bottles, teats and pacifiers.
• 10. Coordinate discharge so that parents and their infants
have timely access to ongoing support and care.

28. • Indian hospital are still in early stages of joining this
movement. The national BFHI task force was formed in
1992, towards the efforts to improve the breastfeeding
practices.
• The task force comprising of Govt of India, UNICEF, WHO
and Professional Organization (TNAI, BPNI, NNF, IMA,
FOGSI, IAP, CMAI, CHAI, IBFAN, ACASH) is working for
evaluation of breastfeeding practices in the hospitals and
appropriate certification as “Baby Friendly Hospital”
• The certificate needs re-registration on every 2 years to
ensure the standard and quality for successful

29. • Beside promotion of breastfeeding, BFHI in INDIA also
proposed to provide:-
- Improved antenatal care
- Mother friendly delivery services
- Diarrhea management.
- Standardize institution support of immunization.
- Promotion of healthy growth and good nutrition.
- Widespread availability and adoption of family planning

30. • Govt of India has made significant efforts to promote and
protect breastfeeding by enacting a law “The Infant Milk
Substitutes, Feeding Bottles and Infant Act, 1992”.
• The act Prohibits advertising of infant milk substitutes
(IMS) and feeding bottles to public, free sampling, hospital
promotion and gifts of samples of IMS to health workers.

31. RECOMMENDATIONS
Following are the key recommendations:
• Training in breastfeeding and lactation management should be made a
priority for all health professionals especially nurses.
• Breastfeeding and lactation management should be included in basic
training of existing peripheral workers.
• A strong link through NGOs involvement should be established
the hospital and the community to achieve success in promotion of
breastfeeding in the community.
• Periodic evaluation to document effectiveness and progress of BFHI
programme should make essential element of this programme.
• Longitudinal studies should be carried out to qualitatively see the effect
of counselling on women’s behaviours to adopt exclusive breastfeeding.

32. PROTECTING, PROMOTING AND SUPPORTING BREASTFEEDING IN
FACILITIES PROVIDING MATERNITY AND NEWBORN SERVICES
1. GUIDELINE
https://apps.who.int/iris/bitstream/handle/10665/259386/9
789241550086-eng.pdf?sequence=1
2. IMPLEMENTATION GUIDANCE
https://apps.who.int/iris/bitstream/handle/10665/272943/9
789241513807-eng.pdf?ua=1

33. EXCLUSIVE
BREAST FEEDING

34. DEFINITION:
• The feeding of an infant or young child with breast milk
directly from female human breasts rather than from a
baby bottle or other container.
• Breastfeeding, also known as nursing, is the feeding of
babies and young children with milk from a woman's
breast

35. LACTATION
• Changes early in pregnancy prepare the breast for lactation. Before pregnancy
the breast is largely composed of adipose (fat) tissue but under the influence of
the hormones estrogen, progesterone, prolactin, and other hormones, the
breasts prepare for production of milk for the baby. There is an increase in blood
flow to the breasts. Pigmentation of the nipples and areola also increases. Size
increases as well, but breast size is not related to the amount of milk that the
mother will be able to produce after the baby is born.
• By the second trimester of pregnancy colostrum, a thick yellowish fluid, begins to
be produced in the alveoli and continues to be produced for the first few days
after birth until the milk "comes in", around 30 to 40 hours after delivery.
Oxytocin contracts the smooth muscle of the uterus during birth and following
delivery, called the postpartum period, while breastfeeding. Oxytocin also
contracts the smooth muscle layer of band-like cells surrounding the alveoli to
squeeze the newly produced milk into the duct system. Oxytocin is necessary for
the milk ejection reflex, or let-down, in response to suckling, to occur

36. Breast Milk.
Not all of breast milk's properties
understood, but its nutrient content is
relatively consistent. Breast milk is made
from nutrients in the mother's bloodstream
and bodily stores. It has an optimal
of fat, sugar, water, and protein that is
needed for a baby's growth and
development. Breastfeeding triggers
biochemical reactions which allows for the
enzymes, hormones, growth factors and
immunologic substances to effectively
defend against infectious diseases for the
infant. The breast milk also has long-chain
polyunsaturated fatty acids which help with
normal retinal and neural development.

37. • The composition of breast milk changes depending on how long the baby
nurses at each session, as well as on the child's age. The first type,
produced during the first days after childbirth, is called colostrum.
Colostrum is easy to digest although it is more concentrated than mature
milk. It has a laxative effect that helps the infant to pass early stools,
aiding in the excretion of excess bilirubin, which helps to prevent jaundice.
It also helps to seal the infants gastrointestional tract from foreign
substances, which may sensitize the baby to foods that the mother has
eaten. Although the baby has received some antibodies through the
placenta, colostrum contains a substance which is new to the newborn,
secretory immunoglobulin A (IgA). IgA works to attack germs in the
mucous membranes of the throat, lungs, and intestines, which are most
likely to come under attack from germs.

38. TYPES OF BREAST MILK
1. COLOSTRUM - It is the milk secreted during the first 3 days after
delivery. It is thick and yellow in color and rich in antibodies and
A, D, E and K.
2. TRANSITIONAL MILK -it is the milk secreted during the next 2 weeks.
The immunoglobulin and protein content decrease while fat and sugar.
3. MATURE MILK - It follows transitional milk. It is thinner and watery but
has all nutrients for optimum growth of baby.
4. FORE MILK - It is the milk secreted at the start of feed . It rich in
proteins , sugar , vitamins and water.
5. HIND MILK - It comes later , towards the end of a feed and rich in fat
and energy and satisfies the baby's hunger.

39. BREAST MILK VS COWS MILK
NUTRIENT HUMAN MILK COW'S MILK
Protein
Casein
Lactalbumin
Lactose
Fat
Calcium
Phosphate
Calories
Vitamin A
Vitamin D
Vitamin C
Water
1.2 g
0.4g
0.8g
6.5g
3.5g
34 mg
15 mg
67mg
64 mg
0.03 mg
5 mg
87.5%
3.5 g
2.8g
0.7g
4.5g
3.5g
22mg
90 mg
67 mg
53 mg
0.03 mg
1 mg
88%

40. BREAST MILK VS FORMULA FEEDING

42. TECHNIQUE OF BREAST FEEDING
STEP 1: PREPARING THE INFANT AND THE MOTHER
• Ensure that the infant is clinically stable
• Ensure that infant is alert
• Make sure that the mother is comfortable and relaxed
• Make her sit down in a comfortable and convenient
position

43. STEP 2: DEMONSTRATE VARIOUS POSITIONS FOR
BREAST FEEDING A BABY
• Underarm position
• Using the opposite arm
• Mother in lying down position

44. STEP 3: DEMONSTRATE THE FOUR KEY POINTS IN
POSITION
• Baby’s head and body should be straight
• Baby’s face should face mothers breast
• Baby’s body should be close to her body
• Mother should support the baby’s whole body

45. STEP 4: SHOW THE MOTHER HOW TO SUPPORT HER
BREAST WITH THE OTHER HAND
Explain the mother that she should
• Put her fingers below her breast
• Use her first finger to support the breast
• Put her thumb above the areola helping to shape the
breast
• Not to keep her fingers near the nipple

46. STEP 5: SHOWING THE MOTHER HOW TO HELP THE
BABY TO ATTACH
Ask the mother to
• Express a little milk on to her nipple
• Touch the Baby’s lip with her nipple
• Wait until the Baby’s mouth is opening wide, and the
tongue is down and forward
• Move the baby quickly onto her breast, aiming the
towards the bays palate and his lower lip well below the
nipple

47. STEP 6: LOOK FOR SIGNS OF GOOD ATTACHMENT
The four key signs of good attachment are:
• More areola is visible above the baby’s mouth than
it
• Baby’s mouth is wide open
• Baby’s lower lip is turned outwards
• Baby’s chin is touching the breast

48. STEP 7: ASSESS IF THE INFANT IS SUCKLING AND
SWALLOWING EFFECTIVELY
Effective suckling
• Infant takes several deep sucks followed by swallowing and
then pauses.
• Ineffective suckling
• Infant suckles for a short time but tires out and is unable to
continue for long enough
• Frequency of breast feeding
• A healthy newborn baby can be breastfed on demand i.e
whenever the baby cries for feeds
• The usual time interval between each feed is about 2 to 3
• They should not omit any night feeds

49. ASSESSING THE ADEQUACY OF BREAST FEEDING
• Passes urine 6-8 times in 24 hours
• Goes to sleep for 2-3 hours after the feeds
• Gains weights at 10-15 gm/kg/day
• Crosses birth weight by 2 weeks

50. POSITION
• Correct positioning and technique for latching on are
necessary to prevent nipple soreness and allow the baby to
obtain enough milk.
• Babies can successfully latch on to the breast from multiple
positions. Each baby may prefer a particular position. The
"football" hold places the baby's legs next to the mother's side
with the baby facing the mother. Using the "cradle" or "cross-
body" hold, the mother supports the baby's head in the crook
of her arm. The "cross-over" hold is similar to the cradle hold,
except that the mother supports the baby's head with the
opposite hand. The mother may choose a reclining position on
her back or side with the baby lying next to her

53. TIMING
• Newborn babies typically express demand for feeding every
one to three hours (8–12 times in 24 hours) for the first two to
four weeks. A newborn has a very small stomach capacity. At
one-day old it is 5–7 ml, about the size of a large marble; at
day three it is 22–30 ml, about the size of a ping-pong ball; and
at day seven it is 45–60 ml, or about the size of a golf ball. The
amount of breast milk that is produced is timed to meet the
infant's needs in that the first milk, colostrum, is concentrated
but produced in only very small amounts, gradually increasing
in volume to meet the expanding size of the infant's stomach
capacity.

54. DURATION AND EXCLUSIVITY
• Health organizations recommend breastfeeding exclusively for six
months following birth, unless medically contraindicated. Exclusive
breastfeeding is defined as "an infant's consumption of human
milk with no supplementation of any type (no water, no juice, no
nonhuman milk and no foods) except for vitamins, minerals and
medications." In some countries, including the United States, UK,
and Canada, daily vitamin D supplementation is recommended for
all breastfed infants.
• After solids are introduced at around six months of age, continued
breastfeeding is recommended. The AAP recommends that babies
be breastfed at least until 12 months, or longer if both the mother
and child wish. WHO's guidelines recommend "continue[d]
frequent, on-demand breastfeeding until two years of age or

55. ADVANTAGES FOR BABY
• Deaths of an estimated 8,20,000 children under the age of five
could be prevented globally every year with increased
breastfeeding.
• It is the wholesome food for baby as it contain all nutrients that
a baby needs in first 6 mn of life for optimum growth and
development.
• Fat - higher content of mono unsaturated fatty acids especially
linoeic acid in human milk promotes brain growth and protects
the individual from atherosclerosis in later life.
• Minerals - human milk contain a smaller but more balanced
proportion of calcium and phosphorous as compare to cow's

56. • Lower risk of infection - Human milk contains high level of lysozyme and Ig A
which offers the baby against the several viral and bacterial disease. breast milk
especially colostrum contains numerous host defense factors like macrophages,
granulocytes, T and B lymphocytes.
• Protects from allergy - higher concentration of secretory Ig A in breast milk
allergy to the baby so, it is the safest food for the baby.
• Therapeutic effect - breast feeding protects the baby from E coli infection due
to high levels of bifidus factors in it. lactoferrin present in breast milk protects the
baby from enteric factors.
• Physiological adaptation - mothers milk is very suitable for the baby. milk of
mother who has deliver a preterm baby is different from the milk of term baby
mother's contains more energy, protein, fat, sodium, zinc etc.
• Economic factors - breast milk is available free of cost for the baby. Also it is safe
and free from contamination. So there is no risk of infection to the baby.
• Emotional bonding- breast feeding promotes emotional and physical bonding
between the mother and the baby. This leads to the better child and mother
relationship.

57. ADVANTAGES FOR MOTHERS
• Lactation suppresses ovulation in the mothers who gives
exclusive breast feeding to their infants and serves as a natural
contraceptives.
• Breast feeding lowers the risk of ovarian breast cancer.
• Breast feeding is convenient for the mother as she is not
required to clean the bottle and prepare milk whenever she
feeds the baby.
• Breast feeding the baby helps mother lose extra weight that she
had put during pregnancy.
• Breast feedings promotes involution of uterus, thus brings back
the mothers in shape after delivery.

58. DIFFICULTIES IN BREASTFEEDING AND THE MANAGEMENT
Due to mother:
• Reluctance or dislike to breastfeeding—careful listening to mother and intelligent counseling can
solve the problem.
• Infant’s attachment to breast —when poor, it leads to quick shallow sucks instead of slow and
deep. Areola remains outside the lips. This causes nipple pain. Skilled support from health care
provider can improve the technique of breastfeeding. Prelacteal feeds (e.g. honey, milk) inhibit
lactation process and should be avoided.
• Anxiety and Stress, previous history of failed lactation or elderly primipara—the mother fails to
relax during feeding and as such, the baby refuses to suck. Reassurance and practical support is
helpful.
• Following operative delivery such as cesarean section or following prolonged and exhaustive
labor often there is a delay. So mother should be helped to feed the baby in a comfortable
position as early as possible.
• Milk secretion is inadequate—unrestricted feeding, well positioned infant, practical and
emotional support to mother all are important. Dopamine antagonist (metoclopramide) may be
useful.
• Breast ailments such as engorgement of breast, cracked nipple, depressed nipple and mastitis

59. Due to infant:
• Low birth weight baby—The baby is too small or feeble to suck .
• Temporary illness such as respiratory tract infection, nasal
obstruction due to congestion, lethargy due to jaundice and oral
thrush. All these conditions lead to imperfect suckling and is
managed appropriately
• Overdistension of the stomach with swallowed air—The problem
can be overcome by breaking the wind of the baby several times
during feeding.
• Congenital malformation such as cleft palate needs surgical
correction.

60. CONTRAINDICATIONS OF BREASTFEEDING
Temporary Permanent
Maternal
1. Acute puerperal illness 1. Chronic medical illness such as
decompensated organic heart lesion, active
untreated pulmonary Tuberculosis
2. Acute breast complications such as
cracked nipples, mastitis or breast
abscess
2. Puerperal psychosis
3. Herpes simplex lesion of the breast 3. Mother having high doses of antiepileptic,
antithyroid, antipsychotic or anticancer drugs
Neonatal
1. Very low birth weight baby 1. Severe degree of cleft palate
2. . Asphyxia and intracranial stress 2. Galactosemia
3. Acute illness