1. BREASTFEEDING: The Clinician’s Role
Dr Mona AlSumaie, IBCLC Head of Community Nutrition Supervisory Food & Nutrition Administration MOH/KUWAIT

2. about 800,000 child lives would be saved every year. WHO
Breastfeeding is one of the most effective ways to ensure child health and survival.
If every child was:
breastfed within an hour of birth,
given only breast milk for their first six months of life, and
continued breastfeeding up to the age of two years 
about 800,000 child lives would be saved every year. WHO

3. Factors Influencing the Change in Breastfeeding Patterns
MORE WORKING MOTHERS
PROMOTION OF ARTIFICIAL FEEDING
by manufacturers
“MODERN” HEALTH SERVICE
medicalisation of birth
HEALTH PROFESSIONALS
(taught about formula, not breastfeeding)
MASS MEDIA make it fashionable to bottle feed
BACK TO NATURAL BIRTH
BETTER EDUCATION OF DOCTORS BF
CAMPAIGN
CHANGES IN WORKPLACE
BFHI
I. CODE
& Resolutions

4. Levels of Influence in the Social-Ecological Model
Structures, Policies, Systems
Local policies and laws to regulate & support healthy actions
Institutions
Rules, regulations, policies & informal structures
Community
Social Networks, Norms, traditions, Standards
Interpersonal
Family, peers & social networks
Individual
Knowledge, attitudes & beliefs

5. The Global Policies to regulate & support Breastfeeding:
I. Code of Marketing of Breastmilk Substitutes, 1981
Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding, Florence, Italy, 1990
BFHI program of the WHO and UNICEF, launched in 1991
IYCF Global Strategy 2002
WHO Maternal, Infant and Young Child Nutrition Plan, 2014

6. Breastfeeding: The Clinician’s Role Promote, Support & Protect
Promote Breastfeeding

8. Importance of Breastfeeding
“Recognize breastfeeding as a unique process that:
Provides ideal nutrition for infants
contributes to their healthy growth and development,
reduces incidence and severity of infectious diseases,
lowering infant morbidity and mortality.
Contributes to women's health by reducing the risk of breast and ovarian cancer.
Provides social and economic benefits to the family and the community.

9. Risks of Not Breastfeeding
Less immunity
More diseases:
diarrhoea
respiratory tract infections
otitis media
More allergies
Lower IQ – 8 points or more
Higher infant mortality
More breast and ovarian cancer in mothers

10. Infant formula contaminants
Materials: Broken glass, Fragments of metals
Metals: Aluminum, Manganese, Cadmium, Lead, Mercury, Arsenic
Chemicals: Melamine, Nitrates, MSG Neurotoxins, Phthalates and Bisphenol A, Phytoestrogens in Soya based formula, Pesticides, weedkillers, insecticides, solvents, chlorine biproducts
Microbes: E. sakazaki, Salmonella, E. Coli, Citrobactor, Clos butolinum Cryptosporidium & Giardia.

11. Melamine found in 8 brands of powder milk in Bangladesh

12. 2008 Melamine Tragedy in China
At least 14 children have died
Over 50,000 became sick
Children in Thousands developed renal failure and renal stones

13. 2004: WHO and FAO stated
Infant formula is not a sterile product and there may be microbes in the powder milk
No technology is available at present to produce sterile powder milk

14. Safe preparation, storage and handling of powdered infant formula: guidelines
FAO/WHO, 2007 Available at:

15. Rates of Breastfeeding and Exclusive Breastfeeding

16. Breastfeeding Indicators Source: Kuwait Nutrition Surveillance System (2006-2014)% %

17. Breastfeeding Promotion & BFHI Implementation Program 1998
BirthKuwait Non-profit Community Mother Support Group
May 2011
Breastfeeding Promotion & BFHI Implementation Program
1998

18. February 2014
Al-Adan Hospital given the title 'Baby Friendly Hospital', making it the first in Kuwait

19. The Clinician’s Role
Support Breastfeeding

20. Unethical to promote breastfeeding without implementing supporting practices

21. Skin-to-Skin contact
(SSC) placing a naked baby on the bare chest of his mother, with a cover over the baby's back for warmth immediately after birth for at least an hour
is a vital practice for all newborns full-term and preterm.

22. Effects of SSC Baby Mother Thermoregulation Temperature regulation
Optimal oxygenation;
Increased oxytocin
Lowers serum cortisol
Adequate milk volume
Reduced crying
Stimulates right brain intuition
Stabilizes blood glucose & heart rate
Promotes bonding
Stimulates self-latching
Less breastfeeding problems
Coordinated suckling
Heightens confidence
Provides the baby with colostrum
Decrease anxiety
Faster excretion of the meconium this will help prevent jaundice
Faster expulsion of the placenta therefore reducing blood loss.

23. Routine Supplements
can interfere with breastfeeding and can contribute to health problems in mother and baby
making him less interested in breastfeeding and lead to nipple confusion.
Water supplements contribute to newborn jaundice.
Formula supplements can sensitize some babies to allergy.
Increase the engorgement, and decrease milk supply.
Strongly correlated with a shorter duration of breastfeeding.

25. Biological Nurturing Position
has recently been introduced by the Breastfeeding literature (Mohrbacher 2010; LLL 2010; Genna Watson 2010).
By maternal positioning and extended baby holding.
Promotes release of
Primitive Neonatal Reflexes
A normally developing newborn should respond to certain stimuli with reflexes, which eventually become inhibited as the child matures.

26. Primitive Neonatal Reflexes
Galant Reflex
emerges 20 wks in utero and is inhibited by 9 months
Palmar grasp
emerges 11 wks in utero, and is inhibited 2-3 months after birth
Asymmetric Tonic Neck Reflex
Babinski Reflex
Emerges at 18 weeks in utero and disappears by 6 months after birth
Stepping Reflex 
appears at birth, lasts for 3-4 months

27. BAD Latch Signs of a good latch
Pain is the #1 sign of something being wrong with breastfeeding.
Lips rolled in or circle “o” lips.
Clicking, or smacking sounds at the breast.
“biting” sensation during feed.
Compression stripe on nipple after feeding.
Nipple easily slips out of mouth when baby pauses.
Bleeding or injured nipple after feed.
Baby is not gaining weight.

28. Take home message to support Breastfeeding
Importance of SSC and early breastfeeding initiation.
Types of breastfeeding positions.
Correct latch.
If breastfeeding hurts---Review the basics (positioning & latch on) or refer her to a lactation specialist.
Avoid supplements as possible and support exclusive breastfeeding.
Check the weight gain using the WHO Growth Standards.

29. The Clinician’s Role
Protect Breastfeeding

30. Understanding Marketing How do Companies get to Mothers & Babies?

31. Kuwaiti Code of Marketing of Breastmilk Substitutes
Adoption of the Code 1985, local Kuwaiti code developed August 2014
Challenges:
The implementation of the code is still in process
MOH accepting ready-to-feed formula free supply.
Government subsidizes infant Formula for Kuwaitis.

32. The Clinician’s Role Monitoring can be done anytime, anywhere!
Monitoring … everyone’s responsibility
Monitoring can be done
anytime, anywhere!

33. Definition of Conflict of Interest
Professionals have a conflict of interest when their interests or commitments compromise their independant judgement or their loyalty to whom they have an ethical and/or legal duty to serve.
Rodwin MA
Both these are good definitions and are apprpriate for the conflict of interest in infant nutrition. In the present day world the conflict of interest and its effect is largely responsible not only for the erosion of breastfeeding practices but also it is a big stumbling block for the promotion , protection and support of breastfeeding .The conflict of interest in infant nutrition by an individual, a professional, a group or a professional body will be killing many poor children in the resourse poor countries.Conflict of interest is a mild/soft terminology.we should look at the implication of the conflict of interest. We are seeing for ourselves how a gift or a dinner to a doctor is taking him away from promoting breastfeeding and he/she is quickly recommending a motherto start the child on infant formula and as result the child is trapped in the vicious cycle of infections, diarrhoea and malnutrition which will lead to death.It may also be defined as an action by which an individual’s attention/commitment takes him away from the more important cause which becomes a drterent to the primary cause

34. Milton Friedman “There is no such thing as a free lunch”
“Better starve free than be a fat slave”
Aesop

35. Conflict of interest Case: 25th International Pediatric Association (IPA) Congress
25th IPA congress in 2007 attended by over 6,000 Pediatricians at Athens sponsored by milk companies
All 24 previous congresses were sponsored by milk companies
Letter of protest and appeal to IPA executives from WABA signed by the President and 8 Pediatricians
Letter of protest and appeal to IPA executives from IBFAN Asia not to accept sponsorship from formula industry

36. 25th IPA congress IPA offered breastfeeding symposium at the Congress
IPA offered booth to disseminate information on breastfeeding
IPA offered to jointly organise workshop and courses for Pediatricians at the national and regional levels
In 2009 the IPA President has said, “…companies that produce breast milk substitutes for infants are strictly banned (from sponsoring the IPA congress) since their activities conflict with our goals on exclusive breastfeeding for babies.”

37. Areas of conflicts of interest in infant nutrition
Infant formula
Commercial complementary foods
Research publications in medical journals funded by milk company or food industry
Accepting sponsorships by International and National Medical Associations from milk companies to hold seminars and conferences

38. “Knowing is not enough; we must apply
“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe

39. THANK YOU Dr Mona AlSumaie, IBCLC
Coordinator of Breastfeeding Promotion & BFHI Implementation Prgram/MOH/KUWAIT