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Health Basics: A supplement to Issue no. 37 - June 1989

Dialogue on Diarrhoea Online - Diarrhea, Diarrhoea Control, Prevention, Treatment and Management
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There is much information in this issue that is valuable and useful. Online readers are reminded, however, that treatment guidelines and health care practices change over time. If you are in doubt, please refer to WHO's up-to-date Dehydration Treatment Plans.

Pages 1-6 Breastfeeding
A supplement to Dialogue on Diarrhoea Online Issue 37 - June 1989

DDOnline Breastfeeding supplement to DD37 Page 1 2



Breastfeeding is the best way to feed a new baby: breastmilk is the perfect food for babies, and breastfeeding is safer and cheaper than any milk which can be bought. Babies fed from the breast are more likely to be healthy and free from diarrhoeal diseases. Why breastfeed?

Breast is best - nothing that money can buy is as good for a baby as breastfeeding

  • Breastmilk is the best food there is for babies: it provides all the goodness and energy needed for healthy growth, and is easier for the baby to digest than any other milk
  • Breastfeeding passes on protection from mother to baby against infections; breastmilk is the only milk which contains antibodies to fight diseases such as diarrhoea (bottle-fed babies do not get this protection)
  • Breastfeeding is cleaner and safer than giving milk from a bottle or other container which can be easily contaminated with dirt and germs
Breast is best - nothing that money can buy is as good for a baby as breastfeeding
  • Breastmilk is much cheaper than powdered milk food - all it costs the family is the little extra food needed by the mother. Special baby foods and milk formulae are very expensive and never as good as breastmilk
  • Breastfeeding does not use up valuable fuel and water resources which may have to be gathered or bought and used to boil water for bottle-feeds, and to ensure that feeding bottles and teats are sterilised
  • Breastfeeding is convenient: it can be done whenever the baby is hungry or unhappy, at any time of the day or night. Breastmilk is always available at the right temperature and never goes bad
  • If a mother is breastfeeding a baby frequently by day and night, she is less likely to become pregnant again during this time
  • Breastfeeding helps to stop maternal bleeding after delivery
  • Breastfeeding helps to develop the emotional bond between mother and child

Why does breastfeeding need to be promoted? Most women know that breastfeeding is the natural and best way to feed a baby, but there are many pressures on them not to breastfeed. Traditionally, women have always breastfed: they have seen other babies breastfed and learnt from their mothers and other women in the community. But, increasingly, women are being told that bottle-feeding is the modern way to feed a baby, and must therefore be better. Artificial babymilks are sometimes promoted very aggressively and are even provided in hospitals. Once a mother starts to give milk formula, and stops breastfeeding, it is difficult for her to start breastfeeding again. Women need to feel confident that they can provide the best food for their own babies. Health workers can encourage and support mothers, providing information and practical advice about breastfeeding. This information is not new but, often, it needs to be re-learnt in modern urban communities, especially when mothers are working outside the home, when they have moved away from their extended family, or if they give birth in hospital.

DDOnline Breastfeeding supplement to DD37 1 Page 2 3


Successful breastfeeding Before the birth

  • Tell women about the advantages of breastfeeding
  • Discuss how they fed previous children, and reassure them that difficulties can be overcome
  • Explain what to expect as they start to breastfeed
  • Examine the breasts and nipples - reassure women who think that their nipples are flat or short that a baby feeds from the breast and the shape of the nipple is not important
  • Encourage the mother to eat an adequate mixed diet so that her baby is not too small and her body builds up stores of fat and other tissues which will be used to make milk after the baby is born

After the baby is born

New mothers need information about breastfeeding.

  • The baby should be given to the mother to hold as soon as s/he is born, and she should put the baby straight to the breast. After a normal delivery, most babies want to suck during the first hour after they are born. This is a good time for the baby to learn to suck, and it is important to establish the bond between mother and baby
New mothers need information about breastfeeding.
  • It is important that the baby gets the first breastmilk (called colostrum) because it gives protection against infection. Colostrum is thicker and yellower than later milk, and it comes only in small amounts in the first few days after delivery. Colostrum is all the food needed at this time - no supplements are necessary, not even water or glucose water. A baby is born with enough water in its body to last several days if necessary. Many babies lose a little weight in the first week, but this is normal
  • It is important that the baby learns to suck in a good position - s/he must take enough of the breast into the mouth so that the tongue can express the milk from beneath the areola
  • Breastfeed as often as the baby wants to - frequent suckling helps to make more milk, and helps to prevent problems like engorgement (breasts which are swollen and painful)
  • Each feed should continue for as long as the baby wants to suck; when s/he has finished, s/he will release the nipple spontaneously. A baby should never be pulled off the breast suddenly (if a mother has to stop in the middle of a breastfeed for any reason, she should gently put her finger into the baby's mouth so that it releases the breast)

It is quite safe for mother and baby to sleep together, and night feeding is easier.

  • Even in hospital, a mother and baby should sleep in the same bed, or together in the same room, so that feeding is not restricted in any way. If a baby sleeps with its mother, night feeding can go on without the mother having to wake up or be disturbed more than necessary (the baby will not be crushed by the mother unless she is very ill or drunk or sedated)
It is quite safe for mother and baby to sleep together, and night feeding is easier.
  • Let the baby finish sucking from the first breast, and then offer the other side. Some babies do not want milk from the second side. Do not try to make them take both sides, or they may take more than they need. But it is important to start from the other side next time, to keep the milk flowing. When the baby is bigger, s/he will probably need both sides
  • Breastmilk is always the best food for a baby - if a mother is unable to breastfeed her own baby, expressed breastmilk, or breastfeeding by another mother is better than formula milk
  • In the first four to six months of life, breastmilk provides all the food and drink a baby needs - do not give anything else

Breastfeeding an older child.

  • When a baby is ready for other foods, breastfeeding is still important and should continue until the baby is at least two years old; breastmilk can still provide a third of all the energy and protein a child needs during the second year of life
  • When you decide to stop breastfeeding do it slowly over a period of time; comfort the child and make him or her feel loved in other ways
Breastfeeding an older child.

DDOnline Breastfeeding supplement to DD37 2 Page 3 4


How to help
Mothers of new babies need support and help. They need confidence that they can breastfeed. Reassure mothers who worry about not being able to provide enough milk for their babies. Health workers can provide support and information, as well as helping with problems or sickness. But everyone in the community can help a breastfeeding mother in some way.

  • Other members of the family can help with household tasks and make sure that the mother gets enough to eat and enough time for her baby
  • If a woman has to be away from her baby at any time, she can express milk into a clean cup for a helper to feed to the baby while she is away
  • Other members of the family can also help to look after any other young children and stop them from feeling left out
  • Older women can provide special help and advice from their own experiences of breastfeeding, and help new mothers not to feel embarrassed about breastfeeding

Positioning the baby at the breast
It is important to put a baby onto the breast in the right position. If the baby does not take enough of the breast into his or her mouth, so that s/he sucks on the nipple, it causes pain and damages the nipple, and the baby does not get the milk efficiently.
  • Hold the baby close. facing the breast
  • Offer the whole breast. not just the nipple, to the baby
  • Wait until the baby's mouth is wide open and move him or her quickly onto the breast so that s/he takes a good mouthful. S/he should come onto the nipple from below it, not from on top

Baby sucking in a good position.

A baby in a good position:

  • is close to the mother, and the chin touches the breast
  • has the mouth wide open
  • the lower lip has turned out (and you may be able to see the tongue)
  • takes slow, deep sucks
  • causes no pain to the mother
Baby sucking in a good position.

DDOnline Breastfeeding supplement to DD37 3 Page 4 5


Expressing breast milk If a mother cannot take her baby with her to breastfeed at work, she can express her milk by hand before she goes to work, and leave it for a helper to feed to the baby while she is away. If a mother also expresses milk while she is at work, this helps to keep up her milk supply.

Expressing breast milk

  • Express milk into a clean cup or container. To make sure the cup is clean wash it with soap and water and leave it to dry in the sun; then pour boiling water into the cup. The sun and boiling water will kill most germs.
  • Wash hands thoroughly with soap before expressing milk
  • Lean forward, supporting the breast over the cup or bowl
  • With thumb above and first finger below the nipple, press in towards the body a little way (a)
  • Then bring thumb and finger together, squeezing behind the nipple (b)
  • Release and repeat until milk starts to drip or flow
  • Press the areola (the darker area around the nipple) to the left and right of the nipple in the same way, to make sure that milk is expressed from all sectors of the breast (c)
  • Expressed breastmilk (EBM) should be given to the baby from a clean cup. Feeding bottles should not be used because they are very hard to keep clean and because they make the baby less eager to suck at the breast
  • EBM can be stored during the day (up to six hours if no refrigerator is available, and up to 24 hours if kept refrigerated), but it should be kept covered and as cool as possible. Do not worry if the milk separates; it can be shaken up and is still good to use
  • Using EBM is the best way to feed a baby who is too ill to suck, and expressing milk can relieve very full or leaking breasts

Breastfeeding and diarrhoea

  • Babies who are exclusively breastfed are less likely to get diarrhoea, because breastmilk is free from germs and contains antibodies which protect a baby from infection

When giving oral rehydration solution or expressed breastmilk germs always use a cup and spoon, never a feeding bottle.

  • Bottle-fed babies are more likely to get diarrhoea. Feeding bottles are very difficult to keep clean, and dirty bottles are a major source of illness, especially diarrhoea; bottle-fed babies are also at risk from contaminated water which may be used to mix up powdered milk
When giving oral rehydration solution or expressed breastmilk germs always use a cup and spoon, never a feeding bottle.
  • If a baby has diarrhoea, always continue breastfeeding because a baby still needs food, and especially liquids, to replace what is lost during the diarrhoea. Breastfeeding will also reduce the stool volume and speed recovery
  • When a baby has frequent diarrhoea, oral rehydration fluids may be needed as well. These should be given by cup and spoon. If the baby is too weak to suck at the breast, expressed breastmilk can also be be given by cup
  • Cups used to feed a baby with expressed breastmilk should be carefully washed with boiled water to remove germs

DDOnline Breastfeeding supplement to DD37 4 Page 5 6


Facts about breastfeeding

  • Almost every mother can breastfeed - probably less than one in every hundred cannot

Being able to breastfeed often keeps up the supply of milk.

  • Malnourished women can breastfeed, and the quality of their milk is still good. If they are severely malnourished, they may produce a smaller amount of milk. However, if a woman is undernourished, the milk is made at the expense of her own body tissues, and she may lose weight and have less strength and energy. So it is important for a breastfeeding woman to eat enough to remain strong and healthy herself
Being able to breastfeed often keeps up the supply of milk.
  • Breasts of any size (large or small) are equally good for producing milk
  • The shape of the nipple does not matter - long or short - as long as the baby takes the breast well into the mouth
  • Breastfeeding does not mean that a woman will lose her figure - breastfeeding actually helps a woman to lose weight after pregnancy, and the breasts will return to their former shape after weaning, provided she supports the breasts with a bra or binder when they are heavy with milk. (Some changes occur with pregnancy, and breastfeeding or not breastfeeding does not make any difference)
  • Breastfeeding can continue if a woman becomes pregnant again
  • There is no bad medical effect on a mother's milk if she has sexual intercourse during the months when she is breastfeeding

Problem solving

'My breasts are too full and they hurt'

When the milk first comes in to the breasts, they may feel hard and swollen and painfully full. This is called engorgement, and if engorgement persists it can be relieved by expressing milk from the breasts. The best way to prevent engorgement is to let the baby suck as often and as soon after birth as possible.

'My nipples are sore'

If the baby does not take enough of the breast into the mouth, sucking is painful. If the baby continues to suck in this way, it damages the nipple skin and may cause cracks or fissures. To prevent sore nipples, make sure that the baby sucks in a good position. To treat sore nipples, often all that is needed is to correct the sucking position and continue feeding the baby. Do not put ointments or antiseptics onto the nipples, and do not wash them with soap. Exposure to air, or leaving a little creamy hindmilk on the nipples may help healing. If sucking is impossible for a day or two, express the milk and feed the baby from a cup.

'My baby refuses/finds it difficult to breastfeed'

Occasionally a baby who refuses to suck is seriously ill (e. g. with neonatal tetanus, or an infection) so check his or her general health first and get help if you are worried. Babies may refuse the breast if they have been fed from a bottle or fed in a poor position so that they do not get the milk efficiently, or if they have been separated from their mothers. Usually the problem is simple: the baby may have a blocked nose, which can be cleared before each feed with the tip of a clean cloth. Check also for thrush or other sores in the baby's mouth. A very small baby may find it difficult to suck, and should be fed expressed breastmilk by cup until strong enough to take the breast.

'There is a painful swelling in my breast'

The tubes or ducts which carry milk through the breast may sometimes become blocked causing painful swellings and sometimes infections. To prevent infection, the lump should be gently massaged towards the nipple to unblock the duct, and unrestricted breastfeeding should continue. Feeding should be started with the affected breast for a few days, if possible, to make sure that this breast is emptied.

'I do not have enough milk'

This is the most common reason mothers give for stopping breastfeeding or early supplementation with formula milk. Usually a mother does have enough milk, but needs to be reassured and encouraged. A baby is taking enough milk if s/he gains 125g or more in weight each week, and urinates at least six times a day, with clear or light yellow urine. More frequent breastfeeding usually results in increased milk production. Sometimes the baby is feeding too often anyway and that is why the mother thinks she does not have enough milk.
  • check feeding pattern:
    if infrequent, feed more often, stop supplements, bottles etc.
  • check feeding position:
    if poor, correct and then build up milk

DDOnline Breastfeeding supplement to DD37 5 Page 6


Addresses for organisations supplying books, manuals, audiovisuals and newsletters are listed under sources of information and materials. SOURCES OF INFORMATION AND MATERIALS

  • American Public Health Association. 1015 Fifteenth Street, N W, Washington, D C 20005, USA.
  • The Breastfeeding Information Group. P O Box 59436, Nairobi, Kenya.
  • Center to Prevent Childhood Malnutrition. Suite 204, 7200 Wisconsin Avenue, Bethesda, MD 20814, U S A.
  • IBFAN Africa P O Box 34308. Nairobi, Kenya.
  • IBFAN Europe Regional Office. GIFA, CP 157, 1211 Geneva 19, Geneva.
  • Informative Breastfeeding Service. 16 Gray Street, St. Clair, Port of Spain, Trinidad.
  • Institute for International Studies in National Family Planning. Georgetown University, Washington, D C 20007, U S A.
  • International Baby Food Action Network (IBFAN). 3255 Hennepin Avenue, Suite 230, Minneapolis. MN 55408, U S A.
  • International Organisation of Consumers Unions. Regional Office for Asia and the Pacific, P O Box 1045. 10830 Penang, Malaysia.
  • La Leche League International Inc. 9616 Minneapolis Avenue, Franklin Park, Illinois 60131, U S A.
  • League of Red Cross & Red Crescent Societies. P O Box 372, 1211 Geneva 19, Switzerland.
  • Macmillan Press Ltd. Houndmills, Basingstoke, Hampshire, RG21 2XS, UK.
  • Malaysian Breastfeeding Advisory Association. Persatuan Penaishat Penyusuan Ibu Malaysia, 3rd Floor, 8 JAlan Klyne, Kuala Lumpur 01-21, Malaysia.
  • Nursing Mothers' Association of Australia. P O Box 230, Hawthorn, Victoria 3122, Australia.
  • Nutrition Center of the Philippines. P O Box 653, MCC, Makati, Metro-Manila, The Philippines.
  • Oxford University Press. Walton Street, Oxford OX2 6DP, U K.
  • Pandora Press. 11 Newfetter Lane, London EC4, UK.
  • Singapore Breastfeeding Mothers Group. Consumer Association of Singapore, Trade Union House Annexe, Shenton Way, Singapore 0106.
  • Susu Mamas. P O Box 5857, Boroko, Papua New Guinea.
  • Teaching Aids at Low Cost (TALC). P O Box 49, St Albans, Herts AL1 4AX, UK.
  • UNICEF, 3 UN Plaza, New York, NY 10017, U S A.
  • World Health Organization (WHO). 20 Avenue Appia, 1211 Geneva 27, Switzerland.


Baumslag, N, 1988. Breastfeeding: passport to life. UNICEF/ NCIH conference - summary of technical papers and general recommendations. NGO Committee on UNICEF. UNICEF
Huffman, S, and Combest, C, 1988. Breastfeeding: prevention and treatment necessity for diarrhoea, available in the above and from Center to Prevent Childhood Malnutrition.
Breastfeeding Information Group. Kenya. How to Breastfeed Your Baby. Ebrahim, G, J, 1978. Breastfeeding - the biological option. Macmillan Tropical Community Health Manuals, Macmillan.
Helsing, E, with Savage-King. F, 1982. Breast-feeding in practice: a manual for health workers. Oxford University Press.
Institute for International Studies in Natural Family Planning: Washington, U S A, 1989. Programmatic guidelines for breastfeeding support and promotion and family planning and child survival programs.
International Organisation of Consumers Unions & IBFAN. Malaysia, 1985. Protecting infant health: a health workers' guide to the international code of marketing of breast milk substitutes.
Kyenkya-Isabirye, M, 1988. Resource directory: recommended materials for training and advocacy in breastfeeding programmes. Available from: UNICEF: New York, U S A.
League of Red Cross and Red Crescent Societies, Switzerland. Learn more about breastfeeding and weaning.
Nutrition Center of the Philippines. A manual on infant feeding with emphasis on breastfeeding.
Palmer, G, 1988. The politics of breastfeeding. Pandora Press.
Savage-King, F, 1985. Helping mothers to breastfeed. AMREF. Available from Teaching Aids at Low Cost.
UNICEF, 1985. Bangkok (Regional PSC Officer) Planning a breastfeeding promotion campaign.
WHO, Division of Family Health Breastfeeding and child spacing - what health workers need to know. AUDIOVISUALS Series of slides (200) on infant feeding with emphasis on breastfeeding. Nutrition Center of the Philippines.
Series of slides with script - Breast feeding. Describes advantages to mother and infant, also the prevention and management of common difficulties. Teaching Aids at Low Cost.
Series of slides with script - Breast feeding problems: the common problems of breastfeeding, and how to overcome them. Teaching Aids at Low Cost. NEWSLETTERS TIBS News. Informative Breastfeeding Service. Bi-monthly in English. Free.
Mothers and Children. Bulletin on infant feeding and maternal nutrition. Clearinghouse on Infant Feeding & Maternal Nutrition, American Public Health Association. Quarterly in English. French and Spanish. Free to developing countries.
Breast Briefs. Geneva Infant Feeding Association (GIFA), Switzerland.
IBFAN Africa News. IBFAN Africa. Published in English and French.
IBFAN Action News. IBFAN U S A. Ten issues per year in English. Free to developing countries.

Acknowledgement The information in the insert has been taken from a range of sources. We would especially like to thank Dr. Felicity Savage for her generous help and advice. Line drawings by Sara Kiunga-Kamau and Ivanson Kayaii, from 'Helping Mothers to Breastfeed' by Dr Felicity Savage.


Health Basics - A supplement to Issue no. 37 June 1989

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This edition of Dialogue on Diarrhoea Online is produced by Rehydration Project. Dialogue on Diarrhoea was published four times a year in English, Chinese, French, Portuguese, Spanish, Tamil, English/Urdu and Vietnamese and reached more than a quarter of a million readers worldwide. The English edition of Dialogue on Diarrhoea was produced and distributed by Healthlink Worldwide. Healthlink Worldwide is committed to strengthening primary health care and community-based rehabilitation in the South by maximising the use and impact of information, providing training and resources, and actively supporting the capacity building of partner organisations. - ISSN 0950-0235 Reproducing articles

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updated: 4 March, 2016