Readers are advised that the Family-Centred Maternity and Newborn Care: National Guidelines were developed and released in the year 2000. The content has not been revised since the original publishing date and there may be new findings that are not reflected in this publication.
Appendix 5 - Infant Nutrition Resources: Assessment Guide
This chapter was adapted, with permission, from the 1996 National Breastfeeding Guidelines for Health Care Providers, Canadian Institute of Child Health (CICH). These National Breastfeeding Guidelines provide detailed reference information for health care providers working with families during the preconception, prenatal, labour and birth, postpartum, and infancy periods. This current review highlights key breastfeeding issues for the policy, practice, and systems of care. It is recommended that health care providers obtain and read these National Breastfeeding Guidelines.
As a method of feeding infants and young children, breastfeeding is both superior and normal. It is best to breastfeed exclusively for about six months, and then to continue breastfeeding, while adding complementary foods, until at least two years of age or beyond (WHO/UNICEF, 1981; 1989; 1990; World Health Assembly, 1994; Breastfeeding Committee for Canada, 1996).
Since 1978, the World Health Organization (WHO), UNICEF, and Health Canada have made the promotion of breastfeeding a primary goal. National and provincial organizations in Canada have endorsed efforts by WHO and UNICEF to promote breastfeeding through the development of international standards, as reflected in the WHO 1981 International Code of Marketing of Breast Milk Substitutes; the WHO/UNICEF 1989 joint statement Protecting, Promoting and Supporting Breastfeeding; the WHO/UNICEF 1990 Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding; and the 1992 WHO/UNICEF Baby-Friendly Hospital Initiative. The WHO's Ten Steps to Successful Breastfeeding and the WHO Code (see Appendices 1 and 2) are evidence-based (Saadeh and Akre, 1996; Neilson et al., 1998) and form the basis for the Baby-Friendly Hospital Initiative, which has been implemented in over 12,800 hospitals worldwide. A number of Canadian health organizations have endorsed these documents as well (Canadian Hospital Association, 1994; Ontario Hospital Association, 1994). The Brome-Mississiquoi-Perkins Hospital in Cowansville, Quebec is the first hospital in Canada to be designated a Baby-Friendly Hospital, receiving this designation in 1999. At the time of publication, it is the only hospital to have this title. Appendix 3 describes the steps that need to be taken for a hospital to achieve this designation. This initiative has been endorsed as a priority focus by national and provincial organizations under the auspices of the Breastfeeding Committee for Canada (1996) (Levitt et al., 1996; Chalmers, 1997; Levitt, 1998).
Many factors influence a family's decisions about feeding and breastfeeding. Because of their close contact with families throughout pregnancy and the newborn period, as well as their influence on health care policies and practice, health care providers can contribute in a major way to the worldwide effort to promote breastfeeding. The critical role of breastfeeding knowledge, skills, and education for health care workers, stressed in the above position statements, is reflected in the Ten Steps to Successful Breastfeeding (WHO/UNICEF, 1989) (see Appendix 1).
Protecting, supporting, and promoting breastfeeding reflect the guiding principles of family-centred maternity and newborn care.
Specifically, it is essential that:
All health care providers working with expectant or new mothers should familiarize themselves with the literature that deals with the health benefits of breastfeeding as well as the hazards of infant formula. A thorough discussion of the unique nutritional, psychological, and immunological benefits of breastfeeding is available in National Breastfeeding Guidelines for Health Care Providers (CICH, 1996). When considering the superiority of breastfeeding, health care providers might also find the International Lactation Consultant Association's Summary of the Hazards of Infant Formula2 ( 2. This document describes and references the following hazards of infant formula: allergic manifestations, morbidity such as infection; excesses, deficiencies, and omissions of essential ingredients in infant formula; contaminants; cost; mortality; and potential for injury.)(1992), and the subsequent Summary of Hazards of Infant Formula, Part 2 (1998), to be comprehensive resources.
The prevalence of breastfeeding reflects the importance placed upon it by society (Riordan and Auerbach, 1993). In effect, the non-valuing of women, children, and breastfeeding creates a fundamental obstacle to the success of women and breastfeeding. For a cultural shift to further promote breastfeeding, policy development at both the institutional and community levels is necessary (WHO/UNICEF, 1990). Health care providers need to be proactive in stimulating the development of policies. They can begin by endorsing the facts outlined in Table 7.1.
Table 7.1 Facts About Breastfeeding
Adapted from: CICH. National Breastfeeding Guidelines for Health Care Providers, 1996, p. 14.
Institutional and community policies should deal with the following issues:
Policies for institutions could be based on the Ten Steps to Successful Breastfeeding and the WHO Code, which form the core of the Baby-Friendly Initiative (see Appendices 1 and 2). Policies for community-based services could be based on the Ten Steps to Baby-Friendly Communities (see Appendix 4).
By early pregnancy, most parents have decided whether to breastfeed or not. In fact, this decision is often made before the first prenatal visit or class. Prenatal intent is a strong predictor of breastfeeding outcome (Health Canada, 1994). Choice of feeding method is influenced by a number of factors, including personal experience, knowledge, culture, and attitudes of significant others. Parents most often choose breastfeeding because they believe that mother's milk is healthier for their infant than formula or cow's milk (Losch et al., 1995). However, some women do make (or change) their decision about infant feeding during pregnancy or during the early postnatal period.
During pregnancy, it is up to health care providers to ensure that families are given the opportunity to make well-informed decisions about infant feeding. They should explain that breastfeeding and formula feeding are not equivalent choices. They should ensure that women and their partners are informed about the benefits of breastfeeding and the risks of not breastfeeding. Some health care providers may avoid providing this information for fear of making a woman feel "guilty" if she chooses not to breastfeed. However, breastfeeding information should be a routine part of health promotion, along with such topics as regular prenatal care, maternal nutrition, use of infant car seats, and use of tobacco. Health care providers also have the responsibility to accept the choices made by families - once they have ensured that the family has received accurate information.
The approach of the health care provider to discussions with the mother and family in the prenatal period should be based on the individual needs of both mother and family. Some mothers and families will need a lot of information on breastfeeding; some will only need reassurance that they are doing the right thing; others may require an in-depth approach because of breastfeeding problems with a previous baby. (In the latter instance, a referral to someone specialized in helping mothers with breastfeeding, such as La Leche League, lactation consultants, clinics, or the maternity ward, might be useful for the health care provider as well as the mother and family.) All mothers and families should be given information about the community resources available for guidance and help - both during the prenatal period and once the baby is born. This is especially important because women often find support for breastfeeding only when it is going well. Whenever health care providers feel uncomfortable about giving advice on breastfeeding, they should refer the mother and family to one of the professionals or services mentioned above.
There are many myths about breastfeeding that might deter a woman from choosing to breastfeed her infant. Health care providers should explore these myths with women. The following myths are examples of disinformation:
Myth 1: Many women who apparently choose to formula feed never consider breastfeeding in the first place. The role of the health care provider is to raise the issue of breastfeeding.
Myth 2: Breastfeeding and formula feeding are essentially equivalent in quality. This is not the case. Breastfeeding is a superior method of infant feeding.
Myth 3: Breastfeeding is complicated and painful. It is common for women and babies to take one to two weeks to learn the skills of breastfeeding. However, once well established, it is much easier and less tiring than formula feeding. Breastfeeding should never hurt - if it does, something is wrong. In most cases, slight alterations in position and latch will alleviate the pain.
Myth 4: Fathers cannot be involved with the baby if the mother is breastfeeding. The father can do a good deal for the mother and baby besides feed the baby. For example, he can cuddle, play with, bathe, dress, and change the baby.
Myth 5: Breastfeeding complicates family life. Breastfeeding need not "tie a mother down." It is a question of attitude. The baby is, in fact, more portable when breastfed. The mother can go anywhere and breastfeed. Not only is "discreet" nursing possible, but "supper" is always ready.
Myth 6: Women cannot be employed and breastfeed. Women can combine mothering and paid employment in different ways (see page 26 on Paid Employment Outside the Home). If women choose to continue breastfeeding and return to outside work at six months or later, strategies are available to help make it easier. When early return to work is contemplated, or necessary, breastfeeding can be continued through pumping and/or partial breastfeeding. In effect, three weeks of breastfeeding are better than none, and six weeks are better than three.
Myth 7: Breastfeeding ruins the mother's figure. This is not true. It is pregnancy and age that cause changes in the mother's breasts. Breastfeeding helps with weight loss and involution of the uterus.
A woman's personal experiences and psychosocial support will also influence her decision to breastfeed. For example, women with supportive partners and families are more likely not only to choose to breastfeed but to succeed (Kearney, 1988; Inch, 1989). On the other hand, women who have been sexually or physically abused may not want to breastfeed. It is critical that psychosocial assessment and counselling be an integral part of prenatal care (see Chapter 4).
It is important too for all health care facilities to be "breastfeeding friendly" and to demonstrate that with posters and information brochures. Posters and brochures are some of the visible ways of supporting and valuing breastfeeding and the breastfeeding mother. As well, descriptive literature endorsed by governments and advocacy groups is often available free of charge.3(3. For example, Health Canada's Breastfeeding Media Kit and brochures, 10 Valuable Tips for Successful Breastfeeding and 10 Great Reasons to Breastfeed. (See Companion Documents.)) Of course, health care facilities should not be centres for marketing infant formula. Nor should posters, flyers, and other items from formula companies be endorsed, for they are in direct conflict with the International Code of Marketing of Breast Milk Substitutes and the Baby-Friendly Hospital Initiative and, in many cases, undermine breastfeeding. Their distribution has been shown to shorten the duration of breastfeeding (Frank and Wirtz, 1987). (Appendix 5 provides a guide for use when assessing whether print materials support breastfeeding.)
Most women's breasts and nipples are well adapted to feeding their babies. It should be noted that breasts and nipples that are of concern during the prenatal period may prove to be just fine once the baby starts nursing. (Typical of the latter situation is the mother who seems to have flat or inverted nipples during pregnancy.)
Women's breasts should be assessed as a part of prenatal care. A few situations may require extra help. For example, if a woman has true inverted nipples she may have great difficulty getting her baby to latch onto the breast. Although intervention before the baby's birth may or may not be useful, any situation with which health care providers are uncomfortable should result in a referral to health care providers experienced in dealing with breastfeeding problems (e.g. lactation consultants or breastfeeding clinics). Making such a referral may avoid problems; at the same time, it sends the message that the health care provider believes that breastfeeding is important enough to warrant the referral. A referral may be indicated in the following situations:
Early, frequent, unrestricted, exclusive, and effective breastfeeding is important for the establishment of normal lactation. Skilled, consistent help from a care provider with a positive approach should be available to support this process. This is a learning experience for both mothers and babies - just as mothers learn, so do babies. The following pointers are recommended.
Concern that the baby is not getting enough milk is one of the most frequent reasons for stopping breastfeeding. Mothers need reassurance - not only that breastfeeding is the best and most natural way to feed their baby, but also that they can produce enough milk. However, failure to establish an effective latch during the first week can lead to infant dehydration or failure to thrive. All parents should know how to tell when breastfeeding is going well and when to seek help.
Evaluating whether or not breastfeeding is going well involves assessing a number of criteria - the effectiveness of the feedings, the frequency of feedings, the baby's stools and urine, and the baby's growth. Parents can be reassured that babies are getting enough milk and breastfeeding is going well if the following signs are present:
Guidelines for taking a feeding history are found in Appendix 6.
All parents should know when to get immediate breastfeeding help. They should be made aware of the following signs. While it is possible that a healthy breastfeeding baby may have a few of these signs, a thorough assessment of the situation is still warranted, especially in the early days and weeks, to determine if the baby is feeding effectively.
Hospitals and other agencies should produce an easy-to-read handout or sign, listing these indicators, for parents to post on their wall or refrigerator.
Weight loss and subsequent gain is one indication of how well breastfeeding is going (Cooper et al., 1995; Lawrence, 1995; Meek, 1998; Tounsend and Merenstein, 1998). However, it should not be considered in isolation, and it is crucial to assess the effectiveness of the baby's feeding at the breast, as well as his or her stools, urine and behaviour. It is often difficult to accurately assess differences in the baby's weight in the early days of life, due to differences in scales. Babies should always be weighed unclothed, without a diaper. The following guidelines are suggested in the literature. An initial weight loss during the first 10 days of up to 10 percent of birth weight can be normal. However, during the first week a weight loss of 7 percent warrants a close assessment of the breastfeeding situation. Babies return to birth weight by two to three weeks of age, and gain one-half to one ounce per day for the first few months. A checkup to assess and weigh the baby is recommended by one week of age or earlier by a skilled and knowledgeable health care provider, depending on length of hospital stay (see Chapter 6).
Many babies go through several growth spurts during which they will nurse more frequently (i.e. 10 to 12 times a day), the purpose being to increase mother's milk supply to meet their new needs. Mothers may need reassurance that they can and will produce enough milk to meet the baby's needs during these times of growth. They should also be reassured that the baby's emptying of the breast actually promotes milk production.
Parents should be given written information identifying the signs of successful breastfeeding and when to get help. (A sample of such a handout is found in Appendix 7.) They should also be given a list of sources of breastfeeding help available in the community. This might include the public health department; the parent help line; breastfeeding support clinics, hospital clinics, or drop-in centres; the local La Leche League; private lactation consultants; and the physician or midwife. Some hospital mother-infant units also offer 24-hour telephone and/or on-site breastfeeding help.
It is recommended that breastfeeding mothers eat a balanced diet, based on a variety of healthy foods. They should also eat as their appetite dictates. Canada's Food Guide to Healthy Eating (Health Canada, 1997) is meant to guide mothers in eating the requisite wide variety of healthful foods.
The following are a few practical considerations:
Many women are discouraged from breastfeeding because of incorrect advice about nutrition. The following are some of the myths:
Myth 1: A breastfeeding mother has to avoid, or eat, certain foods. A breastfeeding mother should try to eat a balanced diet. However, she need not eat any special foods or avoid certain foods. Furthermore, a breastfeeding mother need not drink milk in order to make milk.
Myth 2: A breastfeeding mother has to eat more in order to make enough milk. Even women on very low calorie diets usually make enough milk, at least until their caloric intake has been critically low for a prolonged period of time. Generally, babies will get what they need. Although some women worry that if they eat poorly for a few days this will affect their milk, there is no need for concern. Such variations will not affect the quantity or quality of the milk supply. Traditional wisdom has dictated that breastfeeding women need to eat 500 extra calories a day. But this is not necessarily so for all mothers. Some women do eat more when they breastfeed; others do not; some even eat less. None of these practices seems to harm the mother, baby, or milk supply. The bottom line is that the mother should eat a balanced diet, dictated by her appetite.
Myth 3: A breastfeeding mother must drink lots of fluids. The mother should drink according to her thirst. Although some mothers feel thirsty all the time, many others drink no more than usual. In fact, the mother's body knows if she needs more fluids, and tells her so by making her feel thirsty. Drinking excessive fluids can decrease milk supply.
Myth 4: Breastfeeding is contraindicated if a mother smokes or drinks alcohol. Although it is important that women be supported in all attempts to stop or reduce smoking, breastfeeding is still the best choice even if smoking continues. Moreover, while heavy consumption of alcohol has been shown to interfere with milk supply and to harm the breastfed infant, "light" social drinking is commonly thought to be compatible with breastfeeding (CICH, 1996).
The trend toward shorter hospital postnatal stays has important implications for breastfeeding outcomes and follow-up. Flexibility in the timing of the hospital discharge is key, based as it is on the individual circumstances of both mother and baby and the availability of community follow-up services. Some women may be ready and prefer to return home with their babies several hours after birth; others may not meet the discharge criteria for several days or longer. No matter when mothers and babies go home, they should be assessed for their follow-up needs.
Establishment of lactation in the first three to five days is vital to the well-being of the newborn. Early contact with qualified professionals is recommended. Support and assessment of both mother and infant should be undertaken to promote effective patterns of feeding and to prevent such problems as the infant's dehydration, hypoglycemia, exaggerated physiologic jaundice, lethargy, and failure-to-thrive; and the mother's lowered self-esteem, guilt, perception of failure, and even depression.
The normal newborn may take from birth to 48 hours to establish feeding; that is, to show regular cues for feeding and to consistently succeed at latching and suckling at the breast with a minimum of help. With effective breastfeeding, the onset of lactation (i.e. an increase in maternal milk supply) usually takes two to three days. Consistent, appropriate and professional support during this crucial early period can make a profound difference in long-term breastfeeding success.
A number of criteria for discharge have been proposed (CPS, 1996; SOGC, 1996). Specific breastfeeding discharge criteria include:
Follow-up should be provided by a health care provider (nurse, physician, midwife) who is knowledgeable, skilled, and experienced in breastfeeding assessment and counselling. If discharge occurs prior to 48 hours after birth:
Many mothers may be exhausted, or live a long distance from their care providers, hospitals, and/or clinics. The guidelines for follow-up within 48 hours of discharge must therefore reflect the provision that follow-up will be provided in the family's home, if appropriate.
If discharge is at 48 hours or more after birth:
Follow-up is especially important for mothers and babies discharged before 48 hours after birth. The reason is that it may be difficult to assess the adequacy of breastfeeding, along with certain other aspects, before that period of time has elapsed.
Care providers should be knowledgeable about the prevention, assessment, and treatment of the following potential breastfeeding problems:
It is rarely appropriate to interrupt breastfeeding for neonatal jaundice. Two distinct conditions are associated with jaundice and breastfeeding: "poor breastfeeding" jaundice, and the "breast milk jaundice syndrome."
Poor breastfeeding jaundice refers to an exaggeration of normal physiologic jaundice. Caused by infrequent and/or ineffective breastfeeding, it results in delayed passage of meconium and low caloric intake. Prevention includes early, frequent, and unrestricted breastfeeding: a good latch; maximum mother-infant contact; minimal maternal intrapartum drugs; and anticipatory guidance for parents. Treatment includes increasing the frequency and effectiveness of feedings to a minimum of eight in 24 hours, thereby upping the infant's intake and stimulating breast milk production. Inappropriate supplementation, particularly when given with an artificial nipple, can interfere with the establishment of breastfeeding. Strategies to wake a sleepy baby include skin-to-skin contact with the mother; enticement with expressed breast milk; and tactile stimulation of the infant's palms, head, and feet during feeding.
Breast milk jaundice syndrome is an uncommon condition. Affecting 2 to 4 percent of breastfeeding newborns and appearing toward the end of the first week, it peaks between approximately days 10 to 15 and may last 3 weeks or longer. Because the condition is benign in infants who are otherwise healthy, it is not necessary to interrupt breastfeeding. However, it is essential that other conditions such as hypothyroidism be ruled out so that breast milk jaundice is not confused with conditions that may require treatment.
The indications for supplementation are few in number. Suggested indications for giving fluids or food in addition to, or in place of, breast milk - as outlined in UNICEF's 1992 Baby Friendly Hospital Initiative and Programme Manual - are the following:
Infants who are too small or ill to receive fluids orally may initially require total or partial fluid therapy intravenously. Maintenance of gastrointestinal function, to introduce at least minimal enteral feedings early on, is beneficial.
When breastfeeding is temporarily delayed or interrupted and/or supplementation is medically indicated, fresh expressed mother's milk, if available, should be used. Bottle feeding, which may interfere with the infant's ability to suckle well at the breast, can be avoided by using a number of alternative methods such as the use of a lactation device, cup feeding, finger feeding, or a spoon or dropper. When breastfeeding is delayed or interrupted, mothers should be helped to establish lactation through regular milk expression with breast pumps.
The nutritional, immunological, and psychosocial benefits of breastfeeding are vital to the well-being of the premature or sick infant. As well, breastfeeding is desirable and possible in such special situations as preterm births, multiple births, and babies with congenital abnormalities. In fact, in these situations, where the risk of illness is even higher than for the normal term infant, breast milk can help in preventing complications. Maternal breast milk has also been shown to be the single most effective avenue for preventing necrotizing enterocolitis (NEC) in the preterm infant (CICH, 1996). However, special breastfeeding support may be required in these cases and should be formally acknowledged in the calculation of workload for nursing staff.
Obstacles to breastfeeding the preterm infant can be overcome in neonatal intensive care units. These units should:
Often, breast pumps are not accessible to women with minimal financial resources. Hospitals and community agencies should work together to make pumps available on an equitable basis to all women.
For the premature infant, breastfeeding has been shown to be less physiologically demanding than bottle feeding (Meier, 1988). Preterm infants can begin to feed at the breast as soon as they can be stable outside the isolette for short periods and are able to coordinate sucking and swallowing - often by 32 weeks' gestation. However, the baby can approach the breast to lick or nuzzle before this time. "Kangaroo care" provides early preparation for breastfeeding. Breastfeeding the preterm infant often proceeds through several stages - deciding to breastfeed, establishing a milk supply, gavage feeding of expressed breast milk (EBM), in-hospital breastfeeding (early and later cue-based feeding), and following up after discharge (Meier and Mangurten, 1993).
Twins, triplets, and even quadruplets can be successfully breastfed, either entirely by breast or with added supplements, preferably expressed breast milk. For the first few months, much time and energy is required to feed these multiple babies, regardless of the feeding method chosen. If a mother plans to breastfeed only, it is important to let the babies nurse frequently. The build-up of a good supply of milk is thus ensured (CICH, 1996).
In most instances, with adequate support, a mother can successfully breastfeed a baby born with a disability or special problem. Health care providers should provide mothers and families with information about support agencies and groups in their community.
Given the benefits of breastfeeding, it is rarely appropriate to discontinue breastfeeding due to maternal medication. Information about the transfer of specific drugs into human milk and the potential effects on the infant is constantly expanding. It is therefore difficult to maintain up-to-date lists of drugs and their effects on breastfeeding. However, the following points should be considered:
The question to be considered is whether the enormous benefits of breastfeeding to both baby and mother outweigh the risks of the infant's exposure to the drug.
The 1994 American Academy of Pediatrics statement - The Transfer of Drugs and Other Chemicals into Human Milk - is the most commonly used reference in this area. A number of other references are recommended as well; for example, Thomas Hale's Medication and Mothers' Milk (1999). The National Breastfeeding Guidelines for Health Care Providers (CICH, 1996) gives detailed information regarding drugs that are contraindicated during breastfeeding and drugs to be used with caution. Drug information centres are also excellent sources of information concerning drugs in breast milk. Examples are the Motherisk Clinic in Toronto at The Hospital for Sick Children (Tel.: 1-877-327-4636, Fax:  813-7562, http://www.motherisk.org); the Breastfeeding Collaborative Program, The Hospital for Sick Children (416) 813-5757; and the Lactation Fax Hotline (Thomas Hale; Fax:  356-9480). Up-to-date information can be accessed via fax from this hotline; a registration fee applies.)
As well, the special section on drugs and breast milk in the Canadian Compendium of Pharmaceuticals and Specialties (Canadian Pharmacists Association, 1998) contains general information of possible interest. However, the individual drug monographs are usually inadequate as a source of information about drugs and lactation; they are limited and often overly restrictive.
The main reason for early termination of breastfeeding is the perception of insufficient milk. Other reasons for quitting, during the first six weeks, include sore nipples, engorgement, problems with technique, and maternal fatigue. Later, from four to six months, the mother's paid employment outside the home may become a reason for stopping.
All breastfeeding parents should understand the principle of "supply and demand"; that is, mothers will produce enough milk in direct response to the baby's frequent suckling. This is an important time for the mother to attend to her own rest and nutrition needs, while at the same time focusing on infant feeding. (See the National Breastfeeding Guidelines for Health Care Providers [CICH, 1996] advice about taking an infant-feeding history and responding to common parental concerns about milk inadequacies.)
It is important, too, that parents have an understanding of the infant growth spurt phenomenon. Depending on the situation and the time of hospital discharge, babies should have a follow-up assessment by seven to ten days of age or earlier.
Many factors interfere with milk supply. The following are among the most common:
The Canadian Paediatric Society recommends that breastfed infants receive vitamin D (10 /zg or 400 IU) daily, until weaned. This recommendation is the subject of ongoing controversy. Although it is recognized that some babies will be at risk for vitamin D deficiency, the controversy revolves around whether all babies should receive supplementation. As well, fluoride supplementation is not recommended for infants under six months. The recommendation is that infants between the ages of six months and two years, living in areas where the household water supply contains less than 0.3 ppm (ug/L) fluoride, should receive daily supplementation of 0.25 mg fluoride. However, where the principal drinking water source contains 0.3 ppm (ug/L) or more fluoride, supplementation is not recommended (CPS et al., 1998). In other words, excessive intake of fluoride is to be avoided. As for iron supplementation, full-term infants who are breastfed do not need extra iron until the age of six months. After that, for healthy, term infants, the iron in solid foods usually provides sufficient intake.
Since time began, women have skilfully combined childbearing, breastfeeding, and working. Breastfeeding and working only became problematic when the place of employment began to separate mothers and children in early childhood. As increasing numbers of women work outside the home, Canadian society faces challenges related to breastfeeding and childbearing. Wherever mothers work, be it at home or away, community support will benefit families with children. The children themselves benefit from consistent, loving care - the first three years being especially critical. And breastfeeding is the optimal way to provide the best nutrition, health, and secure emotional attachment (Jones and Green, 1996, p. 19). Family policies should be developed with these principles in mind.
The first step is to help families have a real choice between staying at home or working outside of the home so that the return to work will not be influenced by economic pressure only. When women do work outside the home, it is in the best interest of Canadian children to see that mothers are supported in pursuing a variety of options. For example, they might take an extended period of time off when the children are young, before returning to paid employment; they might "sequence" their careers; or the workplace might be made more flexible to accommodate the needs of mothers, fathers, and children (Jones and Green, 1996, p. 19).
In all communities, therefore, action is needed to:
Appendix 9 outlines the "Ten Steps to Creating a Mother-Friendly Workplace" (Jones and Green, 1996).
Mothers whose breastfeeding becomes well established are more likely than others to continue breastfeeding after returning to paid employment or school. When a mother can delay regular separation from her baby until the baby is four months old and/or return to work on a part- rather than a full-time basis, she is more likely to maintain her milk supply and her child is more likely to remain interested in breastfeeding. Although many women returning to full-time work earlier than four months after birth are able to maintain their breastfeeding relationship, their incidence of premature introduction of solids and of weaning is much higher than for those returning later (Jones and Green, 1996, p. 19; Auerbach, 1987).
Women choosing to continue to breastfeed on their return to work follow many different pathways to success. Strategies used to combine breastfeeding and employment vary, depending on the mother's beliefs, goals, and the support available. Whereas some women will arrange to nurse their babies during their breaks, others will pump or express milk during the work day in order to maintain their milk supply and store milk for subsequent feedings. (See Appendix 8 for advice for mothers regarding the collecting and storing of breast milk.) Other women will partially wean their baby from the breast and provide artificial milk during their absence. Babies commonly rearrange their pattern so as to nurse more frequently during the hours that the mother is available and to sleep more often during her absence. Families need to understand that breastfeeding is most likely to continue when, to the best of their ability, they limit the separation time between the mother and baby, assist the mother to regularly express or pump her milk, and provide maximum support for the mother to focus on meeting her baby's needs (Jones and Green, 1996, p. 20).
For about the first six months, breast milk is all that is needed to support growth. Ideally, the baby will continue to benefit from breastfeeding for the first year or so. Indeed, both mother and baby receive nutritional, immunological, emotional, and other benefits for as long as breastfeeding continues.
Weaning is the process whereby infants move away from complete dependence on their mother's milk. The ideal time to wean is when mother and baby are both ready. Because the two parties may be ready at different times, weaning can be either more "baby-led" or more "mother-led." Nevertheless, at whatever age the weaning occurs, it is more comfortable for the mother and easier for the baby if the weaning is gradual. (See CICH, 1996, for tips on weaning.)
Follow-up support services can be especially useful for breastfeeding families. These services include:
A list of all breastfeeding support services should be compiled for each community. Breastfeeding committees or formalized networks have been successful in developing, coordinating and maintaining consistent breastfeeding promotion, support, and protection initiatives at the local, provincial, and national level.
American Academy of Pediatrics (AAP). The transfer of drugs and other chemicals into human milk. Pediatrics 1994; 93(1): 137-50.
------. Hospital stay for healthy term newborns. Pediatrics 1995; 96(4): 788-90.
------. Breastfeeding and the use of human milk: policy statement. Pediatrics 1997; 100(6): 1035-39.
Annas G. Women and children first. Legal Issues in Medicine 1995; 333(24): 1647-51.
Auerbach K. Maternal employment and breastfeeding. Lactation Consultant Series. New York: Avery Publishing, 1987.
------. Beyond the issue of accuracy: evaluating patient education materials for breastfeeding mothers. JHum Lact 1988; 4(3): 105-10.
BC Council on Health Promotion. Physician alert. BCMedjf 1995; 37(9): 614.
Beaudry M, Dufour R, Marcoux S. Relationship between infant feeding and infections during the first six months oflik.JPediatr 1995; 126(2): 191-7.
Braveman P, Egerter S, Pearl M, Marchi K, Miller C. Early discharge of newborns and mothers: a critical review of the literature. Pediatrics 1995; 96(4): 716-26.
Breastfeeding Committee for Canada (BCC). Breastfeeding Statement of the Breastfeeding Committee for Canada. Ottawa: Author, 1996.
Briggs G, Freeman R, Yaffe S. Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk. 4th ed. Baltimore: Williams and Wilkins, 1993.
Canadian Hospital Association. Policy Statement on Breastfeeding. Ottawa: Author, 1994.
Canadian Institute of Child Health (CICH). National Breastfeeding Guidelines for Health Care Providers. Ottawa: Author, 1996.
Canadian Paediatric Society (CPS). Facilitating Discharge Home Following a Normal Term Birth. A Joint Statement with the Society of Obstetricians and Gynaecologists of Canada. CPS Statement: FN96-02. Ottawa: Author, 1996.
Canadian Paediatric Society, Dietitians of Canada, Health Canada. Nutrition for Healthy Term Infants. Ottawa: Minister of Public Works and Government Services Canada, 1998.
Canadian Pharmacists Association. Compendium of Pharmaceuticals and Specialties. Ottawa: Author, 1998.
Chalmers B. The baby-friendly hospital initiative in Canada: some observations. JSoc Obstet Gynaecol Can 1997; 19: 978-82.
------. Implementing the WHO/UNICEF baby-friendly hospital initiative. JSoc Obstet Gynaecol Can 1998; 20: 271-9.
Cooper WO, Atherton HD, Kahana M, Kotagal UR. Increased incidence of severe breastfeeding malnutrition and hypernatremia in a metropolitan area. Pediatrics 1995; 96(5): 957-60.
Cunningham A, Jelliffe D, Jelliffe E. Breastfeeding and health in the 1990's: a global epidemiologic review. JPediatr 1991; 118(5): 659-66.
Enkin M, Keirse M, Renfrew M, Neilson J. A Guide to Effective Care in Pregnancy and Childbirth. 2nd ed. Oxford: Oxford University Press, 1995.
Frank D, Wirtz S. Commercial discharge packs and breastfeeding counselling - effects on infant feeding practices in a randomized trial. Pediatrics 1987; 80(6): 845-54.
Freed GL, Clark SJ, Sorenson J, Lohr JA, Cefalo R, Curtis P National assessment of physicians' breastfeeding knowledge, attitudes, training, and experiences. JAMA 1995; 273(6): 472-6.
Green M, Jones E WHO code? Who cares? Do nurses promote breastfeeding? Can Nurse 1991; 87(1): 26-8.
Hale T. Medication and Mothers' Milk. 5th ed. Amarillo, Tx: Pharmasoft Medical Publishing, 1999.
Health Canada. Breastfeeding Advocacy Kit. Ottawa: Author, 1991.
------. 10 Great Reasons to Breastfeed. Ottawa: Author, 1993.
------. 10 Valuable Tips for Successful Breastfeeding. Ottawa: Author, 1993.
------. Breastfeeding Support: Part 1. Ottawa: Author, Health Promotion and Programs Branch, 1994.
------. Breastfeeding Poster Series. Ottawa: Author, 1994-1996.
------. Canada's Food Guide to Healthy Eating. Ottawa: Public Works and Government Services Canada, 1997.
------. Breastfeeding: A Selected Bibliography and Resource Guide. Ottawa: Public Works and Government Services Canada, 1997.
Inch S. Antenatal preparation for breastfeeding. In: Chalmers I, Enkin M, Keirse MJN (eds.). Effective Care in Pregnancy and Childbirth. Oxford: Oxford University Press, 1989, pp. 335-44.
International Lactation Consultant Association. Summary of the Hazards of Infant Formula. Chicago: Author, 1992.
------. Summary of the Hazards of Infant Formula, Part 2. Chicago: Author, 1998.
Jones F, Green M. British Columbia Baby-Friendly Initiative: Resources Developed Through the BC Breastfeeding Resources Project. Vancouver: BC Baby-Friendly Initiative, 1996.
Kearney MH. Identifying psychosocial obstacles to breast-feeding success. Obstet Gynecol Neonatal Nurs 1988; 17: 98-105.
Lawrence R. Breastfeeding-A Guide for the Medical Profession. 4th ed. St. Louis, Mo.: Mosby, 1994.
------. Early discharge alert. Pediatrics 1995; 96(5): 966-7.
Levitt C. The breastfeeding committee for Canada. Focus on the baby-friendly initiative. Perinatal Newsletter 1998; 15(1): 5-7.
Levitt C, Kaczorowski J, Hanvey L, Avard D, Chance G. Breastfeeding policies and practices in Canadian hospitals providing maternity care. Can Med Assoc J 1996; 155(2):181-8.
Losch M, Dungy CI, Russell D, Dusdeiker LB. Impact of attitudes on maternal decisions regarding infant feeding. JPediatr 1995; 126(4): 507-14.
McKenna JJ. Co-sleeping. In: Encyclopedia of Sleep and Dreaming. Carskadon MA (ed.). Toronto: Maxwell Macmillan, 1993.
McKenna JJ, Mosko SS. Sleep and arousal, synchrony and independence, among mothers and infants sleeping apart and together (same bed): an experiment in evolutionary medicine. ActaPaediatr 1994; suppl 397: 94-102.
Meek JY. Recommendations for supplementation.JHumLact 1998; 14(2): 148-9.
Meier P Bottle- and breast-feeding: effects on transcutaneous oxygen pressure and temperature in pre-term infants. Nurs Res 1988; 37(1): 36-41.
Meier P, Mangurten H. Breastfeeding the pre-term infant. In: Riordan J, Auerbach K (eds.). Breastfeeding and Human Lactation. Boston: Jones and Bartlett, 1993, pp. 253-76.
Neilson JP, Crowther CA, Hodnett ED, Hofmeyr GJ (eds.). Pregnancy and Childbirth Module of the Cochrane Pregnancy and Childbirth Database [database on disk, CD-ROM and on-line; updated 02 December 1997]. The Cochrane Collection; Issue I. Oxford: Update Software, 1998. Updated quarterly.
Ontario Hospital Association. Breastfeeding: Protecting, Promoting, Supporting. Toronto: Author, 1994.
Ontario Ministry of Health. Community Support for Early Maternal Newborn Discharge: The Early Discharge Project. Toronto: Women's Health Bureau, 1993.
Riordan J, Auerbach K. Breastfeeding and Human Lactation. Boston: Jones and Bartlett, 1993.
Saadeh R, Akre B. Ten steps to successful breastfeeding: a summary of the rationale and scientific evidence. Birth 1996; 23(3): 154-60.
Saskatoon District Health Board. Healthy and Home Program: Program Overview and Evaluation Reports. Saskatoon: Author, 1992-94.
Society of Obstetricians and Gynaecologists of Canada (SOGC). Early Discharge and Length of Stay for Term Birth. A joint policy statement with the Canadian Paediatric Society. Policy statement no. 56. Ottawa: Author, 1996.
Sullivan P CMA supports breastfeeding, "condemns" contracts between formula makers, hospitals. Can Med Assoc J 1992; 146(9): 1610-3.
Tounsend SF, Merenstein GB. The history of policy and practice related to hospital perinatal stay. Clin Perinatal 1998; 25: 257-70.
UNICEF. Baby-Friendly Hospital Initiative and Programme Manual. Geneva: Author, 1992.
Valaitis RK, Sheeshka JD, O'Brien M. Do consumer infant feeding publications and products available in physicians' offices protect, promote and support breastfeeding? JHumLact 1997; 13(3): 203-8.
WHO/UNICEF. International Code of Marketing of Breast Milk Substitutes. Geneva: World Health Assembly, 1981.
------. Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services. A Joint WHO/UNICEF Statement. Geneva: Author, 1989.
------. Ten Steps to Successful Breastfeeding. Geneva: Author, 1989.
------. Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding.
Breastfeeding in the 1990's: global initiative. WHO/UNICEF sponsored meeting, Florence, Italy, 1990.
Wiessinger D. Watch your language. JHum Lact 1981; 12(1): 1-4.
World Health Assembly. Infant and Young Child Nutrition. Forty-Seventh World Health Assembly. WHA 47.5. agenda item 19,09 May 1994.
Every facility providing maternity services and care for newborn infants should:
Step 1: Have a written breastfeeding policy that is routinely communicated to all health care staff.
Step 2: Train all health care staff in skills necessary to implement this policy.
Step 3: Inform all pregnant women about the benefits and management of breastfeeding.
Step 4: Help mothers initiate breastfeeding within a half-hour of birth.
Step 5: Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.
Step 6: Give newborn infants no food or drink other than breast milk, unless medically indicated.
Step 7: Practise 24-hour rooming-in.
Step 8: Encourage breastfeeding on cue.
Step 9: Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
Step 10: Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.
Source: WHO/UNICEF Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services. A Joint WHO/UNICEF Statement, Geneva, 1989.
Source: World Health Assembly. WHO/UNICEF International Code of Marketing of Breast Milk Substitutes. Geneva, 1981.
The first significant step on the road toward full Baby-Friendly Hospital status is completion of the Hospital Self-Appraisal Tool, included in Part 2 of the BFHI Manuals (see Appendix A). Parts 1 and 2 of the BFHI Manuals contain information on evaluating the Ten Steps to Successful Breastfeeding as well as a questionnaire enabling a hospital/maternity facility to review its practices. This initial self-appraisal facilitates analysis of the practices that encourage or hinder breastfeeding. Hospitals/maternity facilities may request information and clarification from the respective Provincial/Territorial Baby Friendly Initiative (BFI) Implementation Committee or the Breastfeeding Committee for Canada (BBC)* at any time. It may be helpful for the hospital/maternity facility to develop a multidisciplinary committee to address protection, promotion and support of breastfeeding.
The role of this committee might include:
Having accomplished all of the above, the hospital/maternity facility may complete the WHO/UNICEF Hospital Self-Appraisal Tool.
*The BCC will assume the responsibility for BFHI implementation in a specific province or territory until the respective BFI Implementation Committee is in place.
If the results of the self-appraisal tool are primarily positive, the hospital/maternity facility requests the Provincial/Territorial BFI Implementation Committee to arrange a pre-assessment. A pre-assessment is required as a mechanism for assuring a more successful external assessment. A pre-assessment consists of an intensive, abbreviated evaluation by a BFHI assessor assigned in collaboration with the BCC. It is strongly recommended that this person has no past or current affiliation with the hospital. The pre-assessment would include detailed discussions with staff, examination of hospital facilities and systems, and review of available documentation regarding training programs, prenatal education, breastfeeding and BFHI policies, etc. A pre-assessment will typically take one full day.
THE PROCESS OF PRE-ASSESSMENT
Over a period of two to four days, a team of assessors, under the direction of a master assessor, conducts an extensive assessment of hospital/maternity facility practices and policies and does appropriate interviews as outlined in the WHOAJNICEF Global Hospital Assessment Criteria. The external assessors selected must have no past or current affiliation with the hospital. Random interviews of both staff who work in, and mothers who have delivered in, the hospital/maternity facility will take place. Practices in labour and delivery, postpartum, and special care nurseries will be observed.
THE PROCESS OF EXTERNAL ASSESSMENT
The following resources are available from the sources listed:
1. BFHI Manuals 1 and 2; and
2. Breastfeeding Management and Promotion in a Baby-Friendly Hospital: The 18-Hour Course
433 Mount Pleasant Road
Toronto, Ontario M4S 2L8
Tel.: (416) 482-4444 Fax: (416) 482-8035
3. Protecting Infant Health: A Health Workers' Guide to the International Code of Marketing of Breast-Milk Substitutes. 8th ed.
6 Trinity Square,
Toronto, Ontario M5G 1B1
Tel.: (416) 595-9819
The following written materials, required by the WHO/UNICEF Global Hospital Assessment Criteria, certified by an officer of the hospital/maternity facility, must accompany the signed contract for external assessment:
Step 1: UNICEF designates all community hospitals delivering maternity services as "Baby Friendly."
Step 2: All health care facilities promote, protect, and support breastfeeding.
Step 3: Health care institutions work together to increase the vailability of breastfeeding support.
Step 4: The community is informed as a whole about the benefits of breastfeeding and the risks of not breastfeeding.
Step 5: Attitudes are addressed within the community that perceive bottle feeding as the norm and provide education directed at changing these attitudes.
Step 6: Communities recognize the importance of supporting the mother-baby relationship.
Step 7: Education is provided about breastfeeding as the natural and normal method of infant feeding.
Step 8: All public and private facilities, including parks and recreation centres, restaurants, and stores, support the need to be mother- and baby-friendly.
Step 9: Work settings promote breastfeeding through the provision of extended maternity leave and/or provide facilities for mothers to express milk and maintain their breastfeeding relationship.
Step 10: Support is given to women who do not meet their breastfeeding goals so as to resolve their feelings and to find the most suitable alternatives.
Adapted from: Jones F and Green M. British Columbia Baby-Friendly Initiative: Resources Developed Through the BC Breastfeeding Resources Project. Vancouver: BC Baby-Friendly Initiative, 1996.
A mother's concerns frequently centre around the adequacy of the milk supply. The baby's general behaviour pattern as well as weight gain are helpful indicators to perceived, potential, or real problems. A feeding history should include the following:
It is important to always explore the mother's perception of any problem and to also ask "What makes you feel this has happened?" The age of the baby taken in the history will be a clue to the intervention, as well. It is usually helpful to observe the infant and mother breastfeeding.
Adapted from: Canadian Institute of Child Health. National Breastfeeding Guidelines for Health Care Providers. Ottawa: 1996, p. 139.
A baby who is doing well:
Note: This is easier to notice in cloth diapers. A facial tissue can be placed inside disposable diapers, if you are not sure.
Get help if any of these signs listed above are not present, or if:
Help is available from:
Public Health nurse
La Leche League
Your midwife or doctor
A breastfeeding-support clinic/drop-in centre
Breastfeeding is the best and most natural way to feed your baby. You will be able to produce enough milk. The keys to success are early, frequent feeding and proper positioning of the baby at the breast.
Source: Adapted with permission from the Breastfeeding Promotion Committee of Ottawa-Carleton, 1999.
Expressing and storing your milk allows your baby to get breast milk when you are separated from each other. If you do express milk, it's best to wait until breastfeeding is going well (after 4-6 weeks), before giving your baby a bottle*. Many mothers find it best to express milk in the morning, after a feeding, or when their breasts feel fullest.
Some mothers prefer to take their baby with them when they go out and don't need to express their milk.
Use a Clean Container
For premature or hospitalized infants, containers should be sterile. To sterilize:
Expressing Breast Milk
*However, offering your baby bottles of breast milk or formula at any age can affect your milk supply and the baby's interest in breastfeeding.
EXPRESSING BY HAND
EXPRESSING WITH A PUMP
A variety of pumps are available for rent or sale from lactation consultants, hospitals, medical supply outlets, drug stores, and some children's stores. Lactation consultants provide instructions and support for the pumps they supply. You can consult the Health Department, a lactation consultant, La Leche League, nurse, or midwife about which pump is best for you.
Full-size Electric Breast Pumps
Battery-operated and Small Electric Pumps
Follow pump manufacturer's instructions for the safe operation and cleaning of pumps. Do not exceed recommended pumping pressures. After every use, wash the pump parts that come into contact with your milk in hot, soapy water. Rinse and leave to air dry. These parts should also be sterilized once a day: boil for five minutes in enough water to cover the equipment.
Do not use pumps with rubber bulbs:
BREAST MILK STORAGE
For a premature or hospitalized baby:
In Freezer on Top or Side of Fridge
For a healthy baby:
Longer storage times may be recommended by other sources. Guidelines in this pamphlet are conservative, and may change as more research is done.
WARM AND SERVE STORED BREAST MILK
Developed by the Breastfeeding Promotion Committee of Ottawa-Carleton, a sub-committee of the Perinatal Committee of Eastern Ontario, 1999. Reprinted with permission.
Ten Steps to Creating a Mother-Friendly Workplace
Adapted from: Jones I; Green M. British Columbia
Baby-Friendly Initiative: Resources Developed Through the BC
Breastfeeding Resources Project. Vancouver: BC Baby-Friendly