1. 1

2. 2 وضعيت صحيح شيردهي ،مشاهده و ارزيابي شيردهي وگرفتن شرح حال اسماعيل زاده عضو هيات علمي دانشكده پرستاري و مامايي

3. دستورالعمل ترويج تغذيه با شيرمادر 1.سياست ترويج تغذيه باشيرمادر 2.آموزش کليه کارکنان 3.آموزش زنان باردار 4.شروع بموقع تغذيه باشيرمادر 5.آموزش مادران در مورد چگونگی شيردهی 6.تغذيه انحصاری با شيرمادر 7.هم اتاقی مادر ونوزاد 8.تغذيه شيرخوار بر حسب تقاضا 9.عدم استفاده از شيشه و پستانک 10.حمايت از مادران BABY-FRIENDLY HOSPITAL INITIATIVE Revised, Updated and Expanded for Integrated Care 2006

4. 4 به مادران روش تغذيه با شيرمادر وچگونگی حفظ وتداوم شيردهی را حتی در هنگام جدائي از شيرخوار آموزش دهند و برای حل مشکلات شيردهی کمک و حمايت کنند و امکان دوشيدن مکرر شير و ذخيره آن وجود داشته باشد. اقدام 5

5. 5 در صد اقدامات ده گانه بيمارستان های دوستدار کودک کشور 1383 Policy Training Prenatal education Early initiation Teaching mothers how to BF Exclusivebreastfeeding Rooming-in Feeding on demand demand No teats or pacifiers pacifiers Mother support

6. 6 When to assist with breastfeeding 1. The baby is finding the breast in the first hour after birth and may suckle at this time. This should be a relaxed time without emphasis on positioning the mother and baby or assessing a feed. Often the mother and baby will sleep for a few hours after this introduction time. will sleep for a few hours after this introduction time. 1. The baby is finding the breast in the first hour after birth and may suckle at this time. This should be a relaxed time without emphasis on positioning the mother and baby or assessing a feed. Often the mother and baby will sleep for a few hours after this introduction time. will sleep for a few hours after this introduction time. Source: UNICEF.WHO BREASTFEEDING PROMOTION AND SUPPORT IN A BABY-FRIENDLY HOSPITAL SECTION 3. 2: 2006

7. 7 When to assist with breastfeeding 2. When the baby wakes again a few hours later is a good time to help the mother to find a comfortable position and help her to position and attach her baby, if she needs help. Remember to observe first.

8. 8 When to assist with breastfeeding 3. Help the mother to position her baby rather than the health worker positioning the baby. The mother needs to be able to position the baby herself.

9. 9 When to assist with breastfeeding 4. If the baby is a full-term healthy baby there is no need to wake the baby in the first few hours. If the baby was exposed to sedation during labor, is preterm, or small for gestational age, or at risk of hypoglycemia, the baby may need to be woken after 3- 4 hours and encouraged to feed.

10. 10 How to breastfeed get comfortable holding your baby be patient... speed... breastfeeding...

11. 11 Good positioning and attachment are vital to enable the baby to milk the breast effectively

12. 12 Positioning : How to hold the baby in relation to the mother to make attachment and feeding easy and effective

13. 13 Attachment: How the baby’s mouth 'latches-on' or 'attaches' to the mothers breast

14. 14 Positioning for breastfeeding

15. 15 Mother’s position There are many positions that a mother may use – for example, sitting on the floor or the ground, or sitting on a chair, lying down, standing up, or walking. In sitting or lying down, she should be: Comfortable with back supported Feet supported Breast supported, if needed.

16. 16 صندلی مناسب جهت شيردهی پهنای مناسب پهنای مناسب ارتفاع مناسب ارتفاع مناسب دسته مناسب جهت تکيه دست مادر دسته مناسب جهت تکيه دست مادر پشتی مناسب پشتی مناسب زيرپائی (جهت بالانگهداشتن پا) زيرپائی (جهت بالانگهداشتن پا) پهنای مناسب پهنای مناسب ارتفاع مناسب ارتفاع مناسب دسته مناسب جهت تکيه دست مادر دسته مناسب جهت تکيه دست مادر پشتی مناسب پشتی مناسب زيرپائی (جهت بالانگهداشتن پا) زيرپائی (جهت بالانگهداشتن پا)

17. 17 Mother’s position is important Sitting with back and feet supported is more comfortable. Bring the baby level with the breast, Using a rolled up towel or clothes, Cushion or pillow, if needed.

18. 18 PRACTICAL POSITIONS FOR BREATFEEDING 1. Sitting positions  Traditional position:  Cradle Hold Cradle Hold  Cross Cradle Hold Cross Cradle Hold  Underarm position Underarm position 2. Lying-down positions Lying-down positions 3. Others Others

19. 19 Cradle position Useful for babies with good head control: term, healthy babies

20. 20 Cross arm position (Cross Cradle Hold) Useful for small or ill baby with poor head control Sore nipple

21. 21 Underarm position ) "football" hold) Useful for twins, blocked duct, difficulty attaching the baby

22. 22 Lying down on side position A mother cannot sit up and take the weight for the baby in her arms Comfortable after a caesarian section A weary mother! Night feeding A baby with poor head control A baby with cleft lip and/or palate A baby who refuses to breastfeed

23. 23 Dancer position The mother supports her breast with the palm of her hand and the three outer fingers Her finger and thumb are free to support the baby's chin and cheeks

24. 24 Position for abundant milk flow The straddle position ??

25. 25  Babies at Side  V shape  Double Football Hold  Cradle And Football  Cross Cradle Hold  Parallel Twins Position

26. 26 Twins Grow Well on Breastmilk

27. 27

28. 28 Baby’s position The baby also can be in different positions, such as along the mother’s arm, under the mother’s arm, or along her side. The baby’s body needs to be: In line with ear, Close to the mother’s body, Supported at the head, Facing the breast with the baby’s nose to the nipple

29. 29 درارزيابي، مي توان ضمن تشويق به موفقيت و عملكرد خوب مادر و شيرخوار با دادن آگاهي ورفع مشكلات موجود, از مشكلات بعدي پيشگيري نمود. ارزيابي، شامل مشاهده عملكرد مادر و شيرخوار، سئوال و شنيدن پاسخ مادر مي باشد. درارزيابي، مي توان ضمن تشويق به موفقيت و عملكرد خوب مادر و شيرخوار با دادن آگاهي ورفع مشكلات موجود, از مشكلات بعدي پيشگيري نمود. ارزيابي، شامل مشاهده عملكرد مادر و شيرخوار، سئوال و شنيدن پاسخ مادر مي باشد. ارزيابي در تغذيه با شيرمادر

30. BREASTFEED OBSERVATION AID Mother's name _______________________________Date ___________________ Baby's name _________________________________Baby's age ______________ Signs that breastfeeding is going well: Signs of possible difficulty: GENERALMother:  Mother looks healthy  Mother looks ill or depressed  Mother relaxed and comfortable  Mother looks tense and uncomfortable  Signs of bonding between mother and baby  No mother/baby eye contactBaby:  Baby looks healthy  Baby looks sleepy or ill  Baby calm and relaxed  Baby is restless or crying  Baby reaches or roots for breast if hungry  Baby does not reach or root BREASTS  Breasts look healthy  Breasts look red, swollen, or sore  No pain or discomfort  Breast well supported with fingers away from nipple  Breast or nipple painful  Breasts held with fingers on areola BABY’S POSITION  Baby’s head and body in line  Baby’s neck and head twisted to feed  Baby held close to mother’s body  Baby not held close  Baby’s whole body supported  Baby supported by head and neck only  Baby approaches breast, nose to nipple  Baby approaches breast, lower lip/chin to nipple BABY’S ATTACHMENT  More areola seen above baby’s top lip  More areola seen below bottom lip  Baby’s mouth open wide  Baby’s mouth not open wide  Lower lip turned outwards  Lips pointing forward or turned in  Baby’s chin touches breast  Baby’s chin not touching breast SUCKLING  Slow, deep sucks with pauses  Rapid shallow sucks  Cheeks round when suckling  Cheeks pulled in when suckling  Baby releases breast when finished  Mother notices signs of oxytocin reflex  Mother takes baby off the breast  No signs of oxytocin reflex noticed Notes: 7/2

31. 31 How to assessing a breastfeed Observe: The mother and baby in The mother and baby in general The mother’s The mother’s breasts The The position of the baby of the baby Attachment during the feed during the feed The baby’s The baby’s suckling Ask the mother how breastfeeding feels to her.breastfeeding feels Source: UNICEF.WHO BREASTFEEDING PROMOTION AND SUPPORT IN A BABY-FRIENDLY HOSPITAL SECTION 3. 2: 2006

32. BREASTFEED OBSERVATION AID Mother's name _______________________________Date ___________________ Baby's name _________________________________Baby's age ______________ Signs that breastfeeding is going well: Signs of possible difficulty:GENERAL Mother:Mother:  Mother looks healthy  Mother looks ill or depressed  Mother relaxed and comfortable  Mother looks tense and uncomfortable  Signs of bonding between mother and baby  No mother/baby eye contact Baby:Baby:  Baby looks healthy  Baby looks sleepy or ill  Baby calm and relaxed  Baby is restless or crying  Baby reaches or roots for breast if hungry  Baby does not reach or root BREASTS  Breasts look healthy  Breasts look red, swollen, or sore  No pain or discomfort  Breast well supported with fingers away from nipple  Breast or nipple painful  Breasts held with fingers on areola BABY’S POSITION  Baby’s head and body in line  Baby’s neck and head twisted to feed  Baby held close to mother’s body  Baby not held close  Baby’s whole body supported  Baby supported by head and neck only  Baby approaches breast, nose to nipple  Baby approaches breast, lower lip/chin to nipple BABY’S ATTACHMENT  More areola seen above baby’s top lip  More areola seen below bottom lip  Baby’s mouth open wide  Baby’s mouth not open wide  Lower lip turned outwards  Lips pointing forward or turned in  Baby’s chin touches breast  Baby’s chin not touching breast SUCKLING  Slow, deep sucks with pauses  Rapid shallow sucks  Cheeks round when suckling  Cheeks pulled in when suckling  Baby releases breast when finished  Mother notices signs of oxytocin reflex  Mother takes baby off the breast  No signs of oxytocin reflex noticed Notes: 7/2

33. 33 Look at the mother in general: What do you notice about the mother – her age, general appearance, if she looks healthy or ill, happy or sad, comfortable and relaxed or tense? What do you notice about the mother – her age, general appearance, if she looks healthy or ill, happy or sad, comfortable and relaxed or tense? sadtense sadtense Do you see signs of bonding between mother and baby – eye contact, smiling,held securely with confidence, or no eye contact and a limp hold? Do you see signs of bonding between mother and baby – eye contact, smiling,held securely with confidence, or no eye contact and a limp hold?bonding between mother and baby bonding between mother and baby

34. 34 Discouraged mother, Kladanj, Bosnia (1995)

35. 35

36. 36

37. 37 Look at the baby in general: What do you notice about the baby – general health, alert or sleep, calm and relaxed, crying or restless, and any conditions that could affect feeding such as a blocked nose or cleft palate? How does the baby respond – looking for the breast when hungry, close to mother or pulling away?

38. BREASTFEED OBSERVATION AID Mother's name _______________________________Date ___________________ Baby's name _________________________________Baby's age ______________ Signs that breastfeeding is going well: Signs of possible difficulty: GENERALMother:  Mother looks healthy  Mother looks ill or depressed  Mother relaxed and comfortable  Mother looks tense and uncomfortable  Signs of bonding between mother and baby  No mother/baby eye contactBaby:  Baby looks healthy  Baby looks sleepy or ill  Baby calm and relaxed  Baby is restless or crying  Baby reaches or roots for breast if hungry  Baby does not reach or root BREASTS  Breasts look healthy  Breasts look red, swollen, or sore  No pain or discomfort  Breast well supported with fingers away from nipple  Breast or nipple painful  Breasts held with fingers on areola BABY’S POSITION  Baby’s head and body in line  Baby’s neck and head twisted to feed  Baby held close to mother’s body  Baby not held close  Baby’s whole body supported  Baby supported by head and neck only  Baby approaches breast, nose to nipple  Baby approaches breast, lower lip/chin to nipple BABY’S ATTACHMENT  More areola seen above baby’s top lip  More areola seen below bottom lip  Baby’s mouth open wide  Baby’s mouth not open wide  Lower lip turned outwards  Lips pointing forward or turned in  Baby’s chin touches breast  Baby’s chin not touching breast SUCKLING  Slow, deep sucks with pauses  Rapid shallow sucks  Cheeks round when suckling  Cheeks pulled in when suckling  Baby releases breast when finished  Mother notices signs of oxytocin reflex  Mother takes baby off the breast  No signs of oxytocin reflex noticed Notes: 7/2

39. 39 What do you notice about her breasts? How do her breasts and nipples look healthy or red, swollen or sore?red, swollen or sore Does she say that she has pain or act as if she is afraid to feed the baby? How does she hold her breast for a feed? Are her fingers away from nipple or the baby taking a large mouthful of the breast?hold her breast

42. 42 BREASTFEED OBSERVATION AID Mother's name _______________________________Date ___________________ Baby's name _________________________________Baby's age ______________ Signs that breastfeeding is going well: Signs of possible difficulty: GENERALMother:  Mother looks healthy  Mother looks ill or depressed  Mother relaxed and comfortable  Mother looks tense and uncomfortable  Signs of bonding between mother and baby  No mother/baby eye contactBaby:  Baby looks healthy  Baby looks sleepy or ill  Baby calm and relaxed  Baby is restless or crying  Baby reaches or roots for breast if hungry  Baby does not reach or root BREASTS  Breasts look healthy  Breasts look red, swollen, or sore  No pain or discomfort  Breast well supported with fingers away from nipple  Breast or nipple painful  Breasts held with fingers on areola BABY’S POSITION  Baby’s head and body in line  Baby’s neck and head twisted to feed  Baby held close to mother’s body  Baby not held close  Baby’s whole body supported  Baby supported by head and neck only  Baby approaches breast, nose to nipple  Baby approaches breast, lower lip/chin to nipple BABY’S ATTACHMENT  More areola seen above baby’s top lip  More areola seen below bottom lip  Baby’s mouth open wide  Baby’s mouth not open wide  Lower lip turned outwards  Lips pointing forward or turned in  Baby’s chin touches breast  Baby’s chin not touching breast SUCKLING  Slow, deep sucks with pauses  Rapid shallow sucks  Cheeks round when suckling  Cheeks pulled in when suckling  Baby releases breast when finished  Mother notices signs of oxytocin reflex  Mother takes baby off the breast  No signs of oxytocin reflex noticed Notes: 7/2

43. 43 Look at the position of the baby for breastfeeding: How is the baby positioned How is the baby positioned head and body (spine) in line, (straight), head and body (spine) in line, (straight), body held close, body held close, facing the breast, facing the breast, body supported ? body supported ?

44. 44 BREASTFEED OBSERVATION AID Mother's name _______________________________Date ___________________ Baby's name _________________________________Baby's age ______________ Signs that breastfeeding is going well: Signs of possible difficulty: GENERALMother:  Mother looks healthy  Mother looks ill or depressed  Mother relaxed and comfortable  Mother looks tense and uncomfortable  Signs of bonding between mother and baby  No mother/baby eye contactBaby:  Baby looks healthy  Baby looks sleepy or ill  Baby calm and relaxed  Baby is restless or crying  Baby reaches or roots for breast if hungry  Baby does not reach or root BREASTS  Breasts look healthy  Breasts look red, swollen, or sore  No pain or discomfort  Breast well supported with fingers away from nipple  Breast or nipple painful  Breasts held with fingers on areola BABY’S POSITION  Baby’s head and body in line  Baby’s neck and head twisted to feed  Baby held close to mother’s body  Baby not held close  Baby’s whole body supported  Baby supported by head and neck only  Baby approaches breast, nose to nipple  Baby approaches breast, lower lip/chin to nipple BABY’S ATTACHMENT  More areola seen above baby’s top lip  More areola seen below bottom lip  Baby’s mouth open wide  Baby’s mouth not open wide  Lower lip turned outwards  Lips pointing forward or turned in  Baby’s chin touches breast  Baby’s chin not touching breast SUCKLING  Slow, deep sucks with pauses  Rapid shallow sucks  Cheeks round when suckling  Cheeks pulled in when suckling  Baby releases breast when finished  Mother notices signs of oxytocin reflex  Mother takes baby off the breast  No signs of oxytocin reflex noticed Notes: 7/2

45. 45 When latching

46. 46 Teach baby to open wide mouth/gape: Move baby toward breast, touch top lip against nipple Move baby toward breast, touch top lip against nipple Move mouth away slightly Move mouth away slightly Touch top lip against nipple again, move away again Touch top lip against nipple again, move away again Repeat until baby opens wide and has tongue forward Repeat until baby opens wide and has tongue forward Or, better yet, run nipple along the baby’s upper lip, from one corner to the other, lightly, until baby opens wide Or, better yet, run nipple along the baby’s upper lip, from one corner to the other, lightly, until baby opens wide SOURCE: Dr. Jack Newman MD,FRCPC, a consultant with UNICEF's Baby Friendly Hospital Initiative 2005

47. 47 Help the baby to come to the breast and attach by: Touching the baby's lips with the nipple,  Baby opens his or her mouth. Waiting until the baby's mouth is opening wide,  To take a large mouthful of breast. Aiming the baby's lower lip well below the nipple,  His or her chin and lower lip will touch the breast first before the upper lip. Bringing the baby to the breast.  not move herself or her breast to her baby. Source: UNICEF.WHO BREASTFEEDING PROMOTION AND SUPPORT IN A BABY-FRIENDLY HOSPITAL SECTION 2: 2004

48. 48 area drawn into baby’s mouth push base of hand firmly against baby’s shoulders keeping baby “ uncurled ” chin coming in first Move baby not breast SOURCE: Dr. Jack Newman MD,FRCPC, Handout in breastfeeding 2005. WIDE MOUTH / GAPE WATCH LOWER LIP, aim it as far from base of nipple as possible, so tongue draws lots of breast into mouth.

49. 49 area baby draws in mouth -baby’s head tilted slightly back -bring baby in quickly -push with base of hand on shoulders -chin touches first baby’s body close against mother baby’s body close against mother Move baby not breast SOURCE: Dr. Jack Newman MD,FRCPC, Handout in breastfeeding 2005. MOTHER’S VIEW OF NURSING BABY Chin and lower jaw touch breast first

51. 51 MOTHER’S VIEW OF NURSING BABY head tilted slightly back chin well in against breast hold in firmly against shoulders keeping baby uncurled SOURCE: Dr. Jack Newman MD,FRCPC, Handout in breastfeeding 2005.

52. 52 BABY’S ATTACHMENT BABY’S ATTACHMENT

53. 53 Latch-On Sequence Beginning latch-on sequence. Baby’s mouth touching nipple Baby achieving latch-on Baby’s chin pressing into mother’s breast Baby’s chin pressing into mother’s breast. Gently breaking suction seal Gently breaking suction seal.

54. Good Latch-On PLEASE CLIC AND WAIT

55. 55 Signs of Good Latch-On (WHO) Flanged lips Tongue visible when bottom lip is pulled down Ears wiggle Circular movement of jaw Audible swallowing Visible breast movement At least 1 inch of the areola is the baby’s mouth Equal amounts of areola are the top and bottom of baby’s mouth Nose and chin to breast

56. 56 Observe the signs of attachment during the feed: Can you see: more areola above the baby’s mouth than below, mouth open wide, lower lip turned out, and chin touching breast ?

57. 57 Wide Open Mouth

58. 58 Signs of Bad Latch-On (WHO) The baby’s cheeks are sucked in The baby’s mouth moves rapidly, like a flutter The baby’s lips are sucked in (especially the bottom one) The baby’s head moves continuously The baby makes clicking, sucking noises at the breast

59. 59 Positioning, latching on This is no less important for the premature baby than in the full term A good latch allows the baby to get milk better from the breast this teaches the baby to suckle properly babies learn to breastfeed by breastfeeding A good latch prevents nipple soreness

60. 60 31 weeks, 3 days old, and breastfeeding 31 weeks, 3 days old, and breastfeeding Note latch

61. 61

62. 62 28 weeks gestation, two weeks old, latched on, getting milk

63. 63 28 weeks and breastfeeding 28 weeks and breastfeeding

64. 64 Assess Some Breastfeeds some cases study some cases study

65. BREASTFEED OBSERVATION AID Signs that breastfeedin g is going well: Signs of possible difficulty: GENERALMother: Mother looks healthy  Mother looks ill or depressed Mother relaxed and comfortable  Mother looks tense and uncomfortable Signs of bonding between mother and baby  No mother/baby eye contactBaby: Baby looks healthy  Baby looks sleepy or ill Baby calm and relaxed  Baby is restless or crying  Baby reaches or roots for breast if hungry  Baby does not reach or root BREASTS Breasts look healthy  Breasts look red, swollen, or sore  No pain or discomfort  Breast well supported with fingers away from nipple  Breast or nipple painful  Breasts held with fingers on areola BABY’ POSITION Baby’s head and body in line  Baby’s neck and head twisted to feed  Baby held close to mother’s body < Baby not held close  Baby’s whole body supported  Baby supported by head and neck only Baby approaches breast, nose to nipple  Baby approaches breast, lower lip/chin to nipple BABY’S ATTACHMENT > baby not well supported More areola seen above baby’s top lip  More areola seen below bottom lip Baby’s mouth open wide  Baby’s mouth not open wide Lower lip turned outwards  Lips pointing forward or turned in  Baby’s chin touches breast < Baby’s chin not touching breast What positive signs could you point out to the mother? point out to the mother? - Her baby looks thriving and happy breastfeeding - She is looking lovingly at her baby - Baby’s body is held in a line and facing mother - Baby’s body is held in a line and facing mother.

66. 7/5 BREASTFEED OBSERVATION AID Signs that breastfeeding is going well: Signs of possible difficulty: GENERALMother:  Mother looks healthy  Mother looks ill or depressed  Mother relaxed and comfortable  Mother looks tense and uncomfortable  Signs of bonding between mother and baby  No mother/baby eye contactBaby:  Baby looks healthy  Baby looks sleepy or ill  Baby calm and relaxed * Baby is restless or crying  Baby reaches or roots for breast if hungry  Baby does not reach or root BREASTS  Breasts look healthy  Breasts look red, swollen, or sore  No pain or discomfort  Breast well supported with fingers away from nipple  Breast or nipple painful  Breasts held with fingers on areola BABY’S POSITION > support her breast in a scissors hold  Baby’s head and body in line * Baby’s neck and head twisted to feed  Baby held close to mother’s body * Baby not held close  Baby’s whole body sup ported * Baby supported by head and neck only Baby approaches breast, nose to nipple  Baby approaches breast, lower lip/chin to nipple BABY’S ATTACHMENT  More areola seen above baby’s top lip  More areola seen below bottom lip  Baby’s mouth open wide * Baby’s mouth not open wide  Lower lip turned outwards  Baby’s chin touches breast * Lips pointing forward or turned in * Baby’s chin not touching breast What positive signs could you point out to the mother? point out to the mother? - Her baby looks healthy - She is looking lovingly at her baby - Baby’s body is held facing mother.

67. UNICEF/WHO Breastfeeding Promotion and Support in a Baby-Friendly Hospital – 20 hour Course 2006 7/6 BREASTFEED OBSERVATION AID Signs that breastfeeding is going well: Signs of possible difficulty: GENERALMother:  Mother looks healthy  Mother looks ill or depressed  Mother relaxed and comfortable  Mother looks tense and uncomfortable  Signs of bonding between mother and baby  No mother/baby eye contactBaby:  Baby looks healthy * Baby looks sleepy or ill  Baby calm and relaxed  Baby is restless or crying  Baby reaches or roots for breast if hungry  Baby does not reach or root BREASTS  Breasts look healthy  Breasts look red, swollen, or sore  No pain or discomfort  Breast well supported with fingers away from nipple  Breast or nipple painful * Breasts held with fingers on areola BABY’S POSITION Baby’s head and body in line  Baby’s neck and head twisted to feed  Baby held close to mother’s body * Baby not held close  Baby’s whole body supported * Baby supported by head and neck only  Baby approaches breast, nose to nipple  Baby approaches breast, lower lip/chin to nipple BABY’S ATTACHMENT  More areola seen above baby’s top lip  More areola seen below bottom lip  Baby’s mouth open wide * Baby’s mouth not open wide Lower lip turned outwards Lips pointing forward or turned in  Baby’s chin touches breast * Baby’s chin not touching breast What positive signs could you point out to the mother? point out to the mother? - Her baby is being breastfed, which shows her care and love for her baby - In line What positive signs could you point out to the mother? point out to the mother? - Her baby is being breastfed, which shows her care and love for her baby - In line

68. 68 Good position, good latch

69. 69 Nipple points to roof of mouth

70. 70 Well latched on

71. 71 Two errors?

72. 72 Two errors? 1. Nipple is pointing to the lower lip, not upper lip (or has moved baby to much to the side) 2. Mother is squeezing nipple to put it into the baby’s mouth

73. 73 ONE SUCK Open mouth wide Pause Close mouth PAUSEPAUSE

74. 74 BREASTFEED OBSERVATION AID Mother's name _______________________________Date ___________________ Baby's name _________________________________Baby's age ______________ Signs that breastfeeding is going well: Signs of possible difficulty: GENERALMother:  Mother looks healthy  Mother looks ill or depressed  Mother relaxed and comfortable  Mother looks tense and uncomfortable  Signs of bonding between mother and baby  No mother/baby eye contactBaby:  Baby looks healthy  Baby looks sleepy or ill  Baby calm and relaxed  Baby is restless or crying  Baby reaches or roots for breast if hungry  Baby does not reach or root BREASTS  Breasts look healthy  Breasts look red, swollen, or sore  No pain or discomfort  Breast well supported with fingers away from nipple  Breast or nipple painful  Breasts held with fingers on areola BABY’S POSITION  Baby’s head and body in line  Baby’s neck and head twisted to feed  Baby held close to mother’s body  Baby not held close  Baby’s whole body supported  Baby supported by head and neck only  Baby approaches breast, nose to nipple  Baby approaches breast, lower lip/chin to nipple BABY’S ATTACHMENT  More areola seen above baby’s top lip  More areola seen below bottom lip  Baby’s mouth open wide  Baby’s mouth not open wide  Lower lip turned outwards  Lips pointing forward or turned in  Baby’s chin touches breast  Baby’s chin not touching breast SUCKLING  Slow, deep sucks with pauses  Rapid shallow sucks  Cheeks round when suckling  Cheeks pulled in when suckling  Baby releases breast when finished  Mother notices signs of oxytocin reflex  Mother takes baby off the breast  No signs of oxytocin reflex noticed Notes: 7/2

75. 75 Observe the baby’s suckling: Can you see slow deep sucks with pauses? You may hear gentle swallowing or clicks and gulps, and see the baby’s cheeks round when suckling and are not drawn inward during a feed. Notice how the feed finishes - does baby releases the breast by himself or herself and look contented?

76. 76 Ask the mother how breastfeeding feels to her: Can she feel any signs of oxytocin reflex, e.g. leaking or tingling? Is there any discomfort or pain?

77. 77

78. 78 When you are helping a mother: Greet the ‘mother', introduce yourself, and ask her name and her baby's name. Ask her how she is and ask one or two open questions about how breastfeeding is going. Ask her if you may see how her baby breastfeeds, and ask her to put her baby to her breast in the usual way. Sit down yourself, so that you also are comfortable and relaxed, and in a convenient position to help. Observe her breastfeeding for a few minutes.

79. 79 Points when helping a mother: Always observe a mother breastfeeding before you offer help. Always observe a mother breastfeeding before you offer help. Help as much as possible in a “hands off” manner so that the mother attaches her own baby. Help as much as possible in a “hands off” manner so that the mother attaches her own baby. Try to show her by demonstrating with your hand on your own body. if necessary, you may need to use your hand to gently to guide her arm and hand. Try to show her by demonstrating with your hand on your own body. if necessary, you may need to use your hand to gently to guide her arm and hand. Talk about the key points the mother can see when breastfeeding – straight, close, facing, and supported, on her own. Talk about the key points the mother can see when breastfeeding – straight, close, facing, and supported, on her own. Always observe a mother breastfeeding before you offer help. Always observe a mother breastfeeding before you offer help. Help as much as possible in a “hands off” manner so that the mother attaches her own baby. Help as much as possible in a “hands off” manner so that the mother attaches her own baby. Try to show her by demonstrating with your hand on your own body. if necessary, you may need to use your hand to gently to guide her arm and hand. Try to show her by demonstrating with your hand on your own body. if necessary, you may need to use your hand to gently to guide her arm and hand. Talk about the key points the mother can see when breastfeeding – straight, close, facing, and supported, on her own. Talk about the key points the mother can see when breastfeeding – straight, close, facing, and supported, on her own.

80. 80 RECOMMENDATIONS FOR THE MOTHER Mother’s posture  sit with straight, well-supported back  trunk facing forwards, lap flat Baby’s position before feed begins  on pillow can be helpful,  nipple points to the baby’s upper lip or nostril Baby’s body  placed not quite tummy to tummy, but so that baby comes up to breast from below and baby’s eyes make contact with mother’s

81. 81 RECOMMENDATIONS FOR THE MOTHER (continual) Support breast  firm inner breast tissue by raising breast slightly with fingers placed flat on chest wall and thumb pointing up (if helpful, also use sling or tensor bandage around breast) Move baby quickly on to breast  head tilted back slightly, pushing in across shoulders so chin and lower jaw make first contact (not nose) while mouth still wide open, keep baby uncurled, lower lip is aimed as far from nipple as possible so baby’s tongue draws in maximum amount of breast tissue

82. 82 Aim of helping the mother is: She can position and attach her baby by herself. It does not help the mother’s confidence if the health worker can position the baby but she is not able to herself.

83. 83 Many mothers support their breast by: Resting the fingers on the chest wall under the breast, Use the thumb to press the top of the breast slightly, this pressure should be light, and not always in the same spot. Make sure that the fingers are not near the nipple.

84. 84 Breast shape and positioning The mother should not move her breasts from how they naturally fall Positioning her baby should be adapted to take her breast shape, size and position

85. 85 مادران از اين كارها بايد خودداري كنند. دور كردن و كشيدن سينه با سينه حركات شيرخوار را دنبال كردن سينه را به بالا و پايين حركت دادن گرفتن پستان به صورت قيچي سينه را بدون حمايت رها كردن خم كردن بدن به طرف كودك به جاي اينكه او را به بدن نزديك كند وارد كردن نيپل به طرف مركز دهان كودك SOURCE: Dr. Anne Barnes,IBLCLC, Handout in breastfeeding 2005.

86. 86 مادران از اين كارها بايد خودداري كنند پايين كشيدن چانه شيرخوار براي اينكه دهانش باز شود خم كردن سر شيرخوار هنگامي كه به پستان نزديك مي شود حركت دادن پستان به طرف دهان به جاي اينكه شيرخوار را به پستان نزديك كند نزديك كردن شيرخوار به پستان قبل از اينكه به حد كافي دهان را باز كرده باشد عدم حركت دادن سريع كودك به طرف سينه هنگامي كه كاملا دهان را باز كرده است تماس بيني با پستان قبل از اينكه چانه كودك با پستان تماس گيرد دور كردن پستان از بيني كودك

87. 87 LOVES THE BREAST HUMAN MILK FOR: HUMAN INFANT HUMAN INFANT COW’S MILK FOR: CALVE CALVE ARTIFICIAL MILK FOR: ARTIFICIAL BABY ARTIFICIAL BABY BREAST IS BEST

88. 88 باتشكر از جناب آقاي دكتر محمود راوري متخصص اطفال دانشگاه علوم پزشكي اراك عضو كميته كشوري ترويج تغذيه با شيرمادر عضو كميته كشوري ترويج تغذيه با شيرمادر عضو هيئت مديره انجمن علمي تغذيه با شيرمادر عضو هيئت مديره انجمن علمي تغذيه با شيرمادر