1. Nutrition for Health and Development, World Health Organization Baby Friendly Hospital Initiative and Rules of Obstetricians & Midwives omar

2. Nutrition for Health and Development, World Health Organization GOALS (Aims) OF BFHI Transform hospitals and maternity wards to a place where breastfeeding carried out: a. Exclusively b. Successfully

3. Nutrition for Health and Development, World Health Organization BFHI Rules of Obstetricians and Midwives 1. Course for Hospital Decision-makers 2. 20 hour Course for Maternity Staff (health care staff) 3. Ten steps to successful breastfeeding 4. Hospital Self-appraisal & Monitoring 5. External Assessment & Reassessment Materials for Initiation of BFHI 4

4. Nutrition for Health and Development, World Health Organization Materials for Initiation of BFHI 5 Health care staff ? 1.Obstetricians 2.Midwifes 3.Nurses in Antenatal ward. 4.Maternity staff in Polyclinics. 5.Pediatricians. 6.Nurses in Neonatal and Pediatric departments.

5. Nutrition for Health and Development, World Health Organization I- During Pregnancy 6 1. in size of breast 2. weight of breast 3.Hyper pigmentation 4. size & mobility of nipple and areola 5.Estrogen: Deposition of the fat : Lactiferous duct proliferation 6. Progesterone: growth of lobules : Development of alveoli and it's secretary cells. 7. Colostrums from 16 weeks gestation. Physiological changes of breast during pregnancy

6. Nutrition for Health and Development, World Health Organization I- During Pregnancy 6 A. Antenatal Breast Care 1. At booking visit. History. Examination: size, abnormality,…. 2. With any complain 3. History about breast each visit

7. Nutrition for Health and Development, World Health Organization I- During Pregnancy 7 B. Antenatal Education Groups Single

8. Nutrition for Health and Development, World Health Organization I- During Pregnancy Advantages and benefits of breastfeeding Risks of artificial feeding Mechanisms of lactation and suckling, Colostrum and milk How to help mothers initiate and sustain breastfeeding How to assess a breastfeed How to resolve breastfeeding difficulties Hospital breastfeeding policies and practices Focus on changing negative attitudes which set up barriers

9. Nutrition for Health and Development, World Health Organization I- During Pregnancy 9 Basic facts on HIV Prevention of mother-to-child transmission of HIV (PMTCT) Voluntary testing and counselling (VCT) for HIV and infant feeding counselling for HIV+ women Antenatal education should not include group education on formula preparation. How to maintain privacy and confidentiality

10. Nutrition for Health and Development, World Health Organization II- Postnatal & After Delivery 10. Set with your patients. Take history : Did she start breast feeding : Did she do as antenataly advised : Any problem with lactation : Any complain : Any thing she want to ask about. Exam both Breasts : Nipple and areola : signs of infection : signs of engorgement. Explain to her mechanism of lactation and suckling. Advices your patient

11. Nutrition for Health and Development, World Health Organization II- Postnatal & After Delivery 10 Early initiation Show mothers how to breastfeed and how to maintain lactation, (even if they should be separated from their infants). Importance of rooming-in (if new concept) Importance of feeding on demand Importance of exclusive breastfeeding How to assure enough breast milk Risks of artificial feeding and use of bottles and pacifiers (soothers, teats, nipples, etc.)

12. Nutrition for Health and Development, World Health Organization II- Postnatal & After Delivery 11 1. Early initiation : Help mothers initiate breastfeeding within a half hour of birth:. Vaginal delivery : Babies breastfed immediately after birth. Caesarean Section: a. General anaesthesia: Babies breastfed within an hour of mother able to respond. b. Regional anaesthesia

13. Nutrition for Health and Development, World Health Organization : How e arly initiation?. Keep mother and baby together. Place baby on mothers chest. Let baby start suckling when ready. Do not hurry or interrupt the process. Delay non-urgent medical routines for at least one hour.

14. Nutrition for Health and Development, World Health Organization II- Postnatal & After Delivery 12 : Why early initiation?. Increases duration of breastfeeding. Allows skin-to-skin contact for warmth and colonization of baby with maternal organisms (Normal flora). Provides colostrum as the babys first immunization. Takes advantage of the first hour of alertness. Babies learn to suckle more effectively. Improved developmental outcomes

15. Nutrition for Health and Development, World Health Organization II- Postnatal & After Delivery 13 Contrary to popular belief, attaching the baby on the breast is not an ability with which a mother is [born…]; rather it is a learned skill which she must acquire by observation and experience. From: Woolridge M. The anatomy of infant sucking. Midwifery, 1986, 2:164-171. 2. Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants.

16. Nutrition for Health and Development, World Health Organization II- Postnatal & After Delivery 14 2. Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants.. One of the causes let mothers stop lactation is failure to know correct position for breastfeeding.. That is why, Teaching of mothers about right positions is one of the 10 steps for successful breastfeeding. (as advised by WHO). This is the Duty of the Obstetrician and midwife.

17. Nutrition for Health and Development, World Health Organization II- Postnatal & After Delivery 15 2. Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants.

18. Nutrition for Health and Development, World Health Organization أولا:- وضع الأم: أولا:- وضع الأم: - يعتبر وضع الأم الصحيح والمريح أمراً ضرورياً لإنجاح الرضاعة الطبيعية: - اجلسي بوضع مريح بحيث أن تسندي ظهرك إلى الحائط أو كرسي أو وسادة - يجب ان تكوني مسترخية ومرتاحة. ثانياً:- ثانياً:- بالنسبة للطفل: ضعي طفلك في حضنك بين ذراعيك من مؤخرة الكتف وليس مؤخرة الرأس بحيث تسندي جسمه كله مع جعل رقبة الطفل مستقيمة أو منحنية قليلا إلى الخلف. اجعلي جسم الطفل كله في مواجهة الثدي وجسم الأم وليس رأسه فقط بحيث تلامس بطن الطفل بطن الأم.

19. Nutrition for Health and Development, World Health Organization 16 اجعلي حلمة ثديك تلمس فم طفلك وعندما يفتح طفلك فمه ضعي الحلمة وهالتها.في فمه وفوق لسانه اجعلي ذقن الطفل يلامس الثدي والفم متسع جداً مع جعل الشفة السفلى منحية للخارج ليكون الجزء الأكبر من هالة الثدي فوق فم الطفل. ثالثاًً:- ثالثاًً:- بالنسبة للمص السليم والفعال: يجب أن يكون مص الطفل بطيء وعميق ويجب أن تري عملية المص لا أن تسمعيها فقط.

20. Nutrition for Health and Development, World Health Organization II- Postnatal & After Delivery 17 Good attachment إمساك صحيح للثدي Poor attachment إمساك غير صحيح للثدي

21. Nutrition for Health and Development, World Health Organization II- Postnatal & After Delivery 18 في نهاية الرضعة، اتركي طفلك يخرج الحلمة بنفسه أو حاولي إخراج الحلمة بإدخال إصبعك الصغير في فم الطفل. بعد إكماله الرضاعة جشئي طفلك وضعيه في فراشه علي جنبه الأيمن أو ظهره للنوم. إذا رغبت يمكنك أن ترضعي طفلك وأنت مستلقية على جانبك خاصة أثناء الليل. في كل مرة ارضعي طفلك من الثديين بالتبادل ولكن ابدي بالثدي غير الذي بدأت به الرضعة السابقة.

22. Nutrition for Health and Development, World Health Organization II- Postnatal & After Delivery 19 3. Importance of Rooming-in (if new concept). A hospital arrangement where a mother/baby pair stay in the same room 24 h, allowing unlimited contact between mother and infant.. Rooming-in Why? a. Reduces costs b. Requires minimal equipment c. Relieve nursing staff d. Reduces infection e. Helps establish and maintain breastfeeding

23. Nutrition for Health and Development, World Health Organization II- Postnatal & After Delivery 20 4. How to assure enough breast milk: Milk removal stimulates milk production. The amount of breast milk removed at each feed determines the rate of milk production in the next few hours. Milk removal must be continued during separation to maintain supply.

24. Nutrition for Health and Development, World Health Organization II- Postnatal & After Delivery 21 5. Importance of exclusive breastfeeding Give newborn infants no food or drink other than breast milk for at least 6 months unless medically indicated.

25. Nutrition for Health and Development, World Health Organization 22 5. Importance of exclusive breastfeeding Acceptable medical reasons for supplementation or replacement feeding. Severe illness: if breastfeeding difficult to achieve. Drugs: anti-metabolites, radioactive iodine, and some anti- thyroid drugs.. Social circumstances: as hard drug use (to be decided on a case-by- case basis), absence of mother.. HIV positive mother (should be counselled about decision). Infectious conditions: as herpes simplex lesions on the breast A. Maternal conditions

26. Nutrition for Health and Development, World Health Organization 23 5. Importance of exclusive breastfeeding Acceptable medical reasons for supplementation or replacement feeding. Very low birth weight (<1500g) or born before 32 wks gestations age – enteral feed should be withheld first 24 hours. Inborn errors of metabolism such as galactosemia, PKU, and maple syrup urine disease. Sick infants in intensive care. Severe dehydration and malnutrition B. Infant conditions

27. Nutrition for Health and Development, World Health Organization 24 6. Importance of feeding on demand. Mothers taught to recognize cues of babies hungry?. Mothers encouraged to feed as often and as long as babies want?. Breastfeeding mothers advised for waking babies that sleep too long or if their breasts overfull. Bbreastfeeding whenever the baby or mother wants, with no restrictions on the length or frequency of feeds.

28. Nutrition for Health and Development, World Health Organization 25 6. Importance of feeding on demand. On demand, unrestricted breastfeeding Why?. Earlier passage of meconium. Lower maximal weight loss. Breast-milk flow established sooner. Larger volume of milk intake on day 3 ( Risk of Engorgement). Less incidence of jaundice

29. Nutrition for Health and Development, World Health Organization 26 7. Risks of artificial feeding and use of bottles and pacifiers (soothers, teats, nipples, etc.). Decreased frequency or effectiveness of suckling. Decreased amount of milk removed from breasts. Delayed milk production or reduced milk supply ( Prolactin). Some infants have difficulty attaching to breast if formula given by bottle

30. Nutrition for Health and Development, World Health Organization 26 7. Risks of artificial feeding and use of bottles and pacifiers (soothers, teats, nipples, etc.) Only then if indicated milk expression. Cup. Spoon. Syringe Retracted nipple, Fissure, Painful Suckling

31. Nutrition for Health and Development, World Health Organization 27 7. Hygiene:. Clean breast before and after each breastfeeding. Clean hands before and after each breastfeeding. No bath, only shower 8. Family planning: lactation can be effective if Breast feeding is. Exclusive. Short interval. Before sleep

32. Nutrition for Health and Development, World Health Organization BFHI Rules of Obstetricians and Midwives II- Postnatal & After Delivery 27 9. When to come back?. Usually we advice patient to come back for follow up and reevaluation in 4 to 6 weeks.. Whenever she or her baby have problem a. Engorgement b. Painful suckling c. Changes in breast

33. Nutrition for Health and Development, World Health Organization