1. The Baby Friendly Initiative in Health Services

2. Health Canada Recommendation
Exclusive breastfeeding for the first six months of life for healthy term infant, as breast milk is the best food for optimal growth.
Infants should be introduced to nutrient rich solid foods with particular attention to iron at six months with continued breastfeeding for up to two years and beyond.
What is exclusive breastfeeding?
“Best food for optimal growth” or is it just normal food that baby is programmed to grow normally on?
Supp with 400 IU of Vit D from birth until the infant’s diet includes at least 400 IU per day from food sources or until the breastfed infant reaches 1 yr old.

3. What Is It?
A ten step plan that summarizes the maternity practices necessary to support breastfeeding.
The implementation of RNAO best practices that protect, support and promote breastfeeding.
Endorsement of the WHO/UNICEF International Code of Marketing of Breast-milk Substitutes.
What is Baby Friendly Initiative?

4. The Ten Step Plan

5. 1. Have a written breastfeeding policy that is routinely communicated to all staff and volunteers.
Must address all Ten Steps to Successful breastfeeding.
Included in policy is prohibition of promotion of formula or breastmilk substitutes, including advertising with pens, measuring tapes, etc..

6. 2. Train all health care providers in the knowledge and skills necessary to implement the breastfeeding policy.
Includes a recommended amount of a minimum of 18 hours breastfeeding education for all HCP. (also 3 hours of supervised clinical instruction is recommended)

7. 3. Inform all pregnant women about the benefits and management of breastfeeding.

8. Help mothers initiate breastfeeding within a half-hour of birth. .
Babies are placed sin-to-skin with their mothers. An unhurried environment and unlimited skin contact facilitate a successful first feeding. Mother’s are supported to breastfeed in response to their babies cues.
“Skin to skin means the naked baby is dried after birth and placed on his/her mother’s naked chest. A warm blanket can be place over both mother and baby.”
Mother’s on the maternity unit (from a random sample, at least 80%) should confirm that within a half-hour of birth (or in first hour after c-section) they were given their babies to hold with skin contact, for at least 30 minutes, and offered help by a staff member to initiate breastfeeding.
SOURCE: Breastfeeding Committee for Canada (BCC) “The Ten Steps and Practice Outcome Indicators For Baby-Friendly Hospitals.” edited March 24/04

9. 5. Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants.
Staff will need to be able to teach mother’s techniques for hand expression
(Early Discharge – if breastfeeding not established then written plans that support breastfeeding goals and f/u with appropriate health care provider)

10. 6. Give newborn infants no food or drink other than breastmilk unless medically indicated.
At least 75% of those postpartum breastfeeding mothers (random sample including c-sections) must confirm that their babies have received no food or drink other than breastmilk in the hospital. (BCC ten steps pg. 16)
Staff will have a clear understanding of medical reasons for supplementation (pg. 19)
and recommend supplementing with mothers own breastmilk (or donor milk where available) whenever possible

11.  Allow mothers and infants to remain together 24 hours a day.
Practice rooming-in
 Allow mothers and infants to remain together 24 hours a day.
This includes teaching and examinations occurring at the mother’s bedside or with her present.
Also includes accurate information of the benefits and contraindications to co-sleeping, including bed-sharing.

12. 8. Encourage breastfeeding on demand.
Baby-led or cue based feeding with no restrictions on frequency or lengths of breastfeeds.
Where does 3 hour idea come from?

13. 9. Give no artificial teats or pacifiers to breastfeeding infants.
Applies to babies who are not in a special care nursery. No bottles with artificial nipples or pacifiers.

14. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.
Nursing Mother’s Group – Meetings in Chatham

15. Compliance with The International Code of Marketing of Breast-Milk Substitutes.
Mothers and pregnant women report that they have not received any marketing materials, samples, coupons or gift packs that include human milk substitutes and infant feeding paraphernalia.
Mothers and pregnant women confirm that they have not received group instruction regarding the preparation, storage and feeding of human milk substitutes.
Image taken from:

16. The World Health Organization Code
for the Marketing of Breastmilk Substitutes
Aim: To contribute to the provision of safe and adequate nutrition for all infants.
Scope: All breast-milk substitutes, bottles and nipples and any information concerning their use.
Advertising: no advertising of the above products to the public.

17. The World Health Organization Code
for the Marketing of Breastmilk Substitutes
Labels: Breastmilk substitute labels must clearly state the superiority of breastfeeding with proper instructions and no pictures of infants.
Samples: No free samples to mothers, their families or health care workers.
Facilities: No promotion of products covered under the scope (displays, posters, pamphlets etc.).

18. The World Health Organization Code
for the Marketing of Breastmilk Substitutes
Health Care Workers: Accept no gifts or samples.
Supplies: No free or low-cost supplies of breast milk substitutes to hospitals.
Information: Educational materials must explain the benefits of breastfeeding and the costs associated with formula feeding.
Why WHO code?
Think of the millions spent by formula companies – how does public health compete? Infact Canada Stat
Formula companies know that 90% of mothers that receive formula from the hospital will stay with the brand they were provided with.
In 2006 the formula industry spent 100 million advertising formula in the Philippines. Almost ½ the Philippine's health dept annual budget of 239 Million. The US accounts for ½ of the world 8 Billion annual sales of infant formula.
Dec 2005 Massachusetts became the first state to prohibit formula sample bags in hospital as part of the department of public health regulations. The AAP and CDC supported this. Governor Romney pressured to PH dept to rescind the ban. The council resisted his pressure until he fired and replaced 3 members before a vote on it. They lost the ban in May weeks after this Romney announced a deal with Bristol-Myers-Squibb to build a 66 million dollar pharmaceutical plant in Massachusetts. The Massachusetts Breastfeeding Coalition has launched a national campaign called “Ban the Bags” to rid all US mat wards of formula sample bags. In Massachusetts 11 out of 50 hospital are now bag free without legislation.

19. In February 2010 Chatham-Kent Public Health Unit achieved Baby Friendly Accreditation!
Where Do We Go From Here?
Continue to monitor breastfeeding rates at hospital discharge, 48 hours post-discharge, and 2 weeks
Work to increase exclusive breastfeeding rates to 6 months and develop a method to obtain data
Send in yearly reports to the Breastfeeding Committee for Canada
Continue to work with local agencies to increase breastfeeding awareness, support and practices
Re-assessment in 2015
Chatham-Kent Breastfeeding Coalition
Recert for Baby Friendly every 5 years

20. Who Benefits From Baby Friendly?

21. The woman and her child Consistent care & information Skilled help
Getting off to a good start
Breastfeeding is valued
Mothers are empowered
The woman and her Child
Consistent care, information and advice. Staff in maternity and pediatric units have a written policy, which they understand and follow.
Consistent and skilled help with breastfeeding. Women will receive the same information from all sources whether in the hospital, Dr’s office, community
Early initiation of breastfeeding. Babies are not unnecessarily removed from mothers at birth, thereby encouraging the instinctive seeking and suckling behaviours. When mother and baby need to be separated the mother is helped with expressing her milk and the expressed milk is given to the baby.
Mother's milk is valued. No food or drink other than breastmilk is given.
Breastfeeding is valued. Artificial nipples and soothers are avoided.
Empowerment. The woman has authority for her own resource, breastfeeding.

22. Caregivers for Mothers and Babies
Increased knowledge
Increased skills
Professional competence
Respect for women
Nurses and Dr’s have more knowledge about breastfeeding
Increased knowledge, as evidence for the Global Hospital Assessment Criteria becomes better understood.
Increased skills. Staff are committed to the support of breastfeeding mothers and their babies, even the difficult ones.
Increased professional competence, as practices are investigated and challenged, and changes are made.
A new respect for the woman, the baby, and their ability to breastfeed when given appropriate support. The midwife/nurse is "with woman", rather than providing nursing management of a disease.
As the care becomes "woman-centred" rather than "task centred", all staff respect the woman's need for consistent advice and empowerment, thereby increasing cooperation and collaboration between different staff members.
Care becomes “woman-centred”
not “task-centred”

23. Health Care Facilities
High Standards of care are measured and met
Meets the RNAO Best Practice Standards for care of breastfeeding mothers and babies
Maternity units
A high standard that is measured by the unit and confirmed by a Baby-Friendly™ team representing professional and lay assessors.
A Global Hospital Assessment Criteria, recognised and respected by professionals and consumers.
Valuable in marketing the services provided.
Considerable monetary savings.
In a study done at two centres, Tucson Children’s Hospital and Dundee Scotland Community Centre
For every 1000 infants never breastfed compared with 1000 exclusively breastfed (for only 3 months) infant for the 1st year of life, there were 2033 excess office visits
212 excess days of hospitalization
609 excess prescriptions
For otitis media
Lower respiratory and GI infections
$ /child never breastfed during the first year of life
There are 3 Million babies born that are formula fed every year in the US
This works out to an additional cost of 993,000,000 – 1,425,000,000 in extra health costs for the first year of the child’s life.

24. The Family Health and development of the infant Health of the mother
Saves money
The family
Health and development of infant.
Health of mother.
Cost saving, immediate and long term, breastfeeding is the "Best Investment" a family can make.
Antimicrobial Factors of Breastmilk
John T. May

25. The Community Environmentally Friendly Social programs
Decreased costs for medical care
The community
Flow-on from family.
Environmental considerations. No waste products
Breastfeeding is ecologically benign.
The manufacturing of the packaging of artificial baby milk creates toxins and uses paper, plastic, and tin.  For every 3 million bottle-fed babies, 450 million tins of formula are consumed.
The resulting 70,000 tons of metal in the form of discarded tins is not recycled.
The 550 million tins of artificial baby milk sold each year to bottle feed US babies alone stacked end to end would circle the earth one and a half times;
550 million tins equals 86,000 tons of tin and 1,230 tons of paper labels.

26. BREAST IS BEST FOR FOR MOTHER BABY FOR CHATHAM-KENT
We often say Breast is Best but in reality, Breast is nothing more than normal.
It is the biological norm for infant feeding.
FOR CHATHAM-KENT

27. Breastfeeding Is Normal
It’s done worldwide
Initiation rate 84% at CKHA
Exclusive breastfeeding at discharge is 40-50%
Breastfeeding rates are dropping dramatically until only about 9% are exclusively breastfeeding to 6 months
A practice that is sensitive to cultural and social change
Dramatic turn around in infant feeding practices in North America.
Parents want to do what is best for their baby and the majority are choosing breastfeeding
In Chatham-Kent 84% of mothers are going home breastfeeding their babies.
About 90% have used or are using a formula supplement by the time the baby is 1 month old.
At hospital discharge approx. 50% of babies have received formula

28. Attitudes About Breastfeeding
Attitude affects Behaviour
Important to explore:
Feelings about breastfeeding
Myths about Breastfeeding

29. When Breastfeeding is Normal, Babies Are Protected
Venezuelan President Hugo Chavez talks with people affected by flooding in Araira, 50 km (31 miles) from Caracas this past February.
This is an article in a newspaper.
What do you think the caption under the photo was?
Breasts are considered sex objects in our culture. This can make some men feel uneasy about Bfing or uncomfortable about having their baby use the breasts as a source of nutrition.
When Breastfeeding is Normal, Babies Are Protected

30. Why Should Mothers Breastfeed?

31. Baby Nutritional qualities Anti-infective qualities Physical qualities
Psychological qualities

32. Nutritional Qualities
Nutritionally complete for the first 6 months of life
Ensures adequate infant growth
Just as a mother’s body supplies all the nutrients a baby needs in the uterus, a mother’s breastmilk supplies all the nutrients a baby needs for the first 6 months of life.
Speak to your doctor to see if a vitamin D supplement is recommended
Human milk has the exact fat-to-protein ratio and amino acid composition for your baby
The different nutrients in breastmilk change as your baby grows so that it exactly meets his needs for every stage of his growth.
This is important because not only will your baby’s weight double in the first 6 months, your baby’s brain will double it’s size in the first 6 months of life
The carbohydrates, fats, and proteins in human milk have been shown to be beneficial for brain, nerve growth, improved vision

33. Anti-infective Qualities
Provides anti-bodies
Enhances baby’s immune system
Protection from:
Gastrointestinal illnesses
Respiratory infections
Ear infections
Some childhood cancers
Human Milk sets up the immune system in infants
Babies are born with an immature immune system. Antibodies and other immune factors help to coat the baby’s intestine so that bacteria and viruses are unable to enter into the baby.
Other immune factors hook onto germs and destroy them.
Human Milk also works to trigger the baby’s immune system so the baby starts making his own antibodies.
Small germ fragments in the mothers milk can work as a vaccine in the baby and provide immunity to the baby.
Baby’s who are breastfed are protected from gastrointestinal disease,
Lactoferrin in Human Milk binds to iron, making it available to the baby but unavailable to germs that might be in gut
Protects against respiratory diseases
Protects against infections of the ear, nose and throat.
Protection from childhood cancers such as leukemia and lymphoma

34. Physical Qualities Improved visual development Higher IQ
Protection from:
Diabetes
Obesity
SIDS
Easier to digest
Fatty acids in Human Milk help to develop vision and brain neurons
New studies are showing that breastfed babies have higher IQ’s on average than non-breastfed babies.
In a longitudinal study done in Denmark, it was found that babies who are breastfed for 9 months have the greatest chanced of achieving their IQ potential.
Long term, babies who are fed Human Milk are protected from:
diabetes
Crohn’s disease
Rheumatoid arthritis
asthma
hypertension
The way fat is delivered in breastfeeding, helps the baby to understand and respond to feelings of fullness by recognizing fat in the stomach rather than by stomach distention. This can avoid over-eating later in life.
Preliminary studies indicate that the Cholesterol in Human Milk decreases the baby’s need to produce cholesterol for growth, leading to long term lower cholesterol levels as adults– leads to decrease in Heart disease
Less gas, indigestion because Human Milk is easy to digest.

35. Psychological Qualities
Strong maternal/infant bonding
Greater chance of child developing a secure attachment to mother
Baby’s needs can be met quickly (builds trust)
Humans are a frequent contact species. Bfdg ensures frequent contact so that the baby is able to develop a secure attachment with his mother.
Human Milk is ready instantaneously, this ensures that the baby’s need is met quickly. Meeting a babies needs quickly helps the baby to learn to trust. This will benefit the baby later in life.

36. Mother
Physical qualities
Psychological qualities

37. Physical Qualities Protection from: Helps weight loss
Pre-menopausal Breast and Ovarian cancer
Hemorrhage
Osteoporosis
Helps weight loss
Studies show a decreased risk of breast cancer in women who breastfeed
It is hypothesized that the proteins that are produced in the milk ducts is also responsible for protecting against cancer in the breast duct.
Breastfeeding can delay the return of a woman's menstruation. It is believed that women who have more menstrual cycles are at increased risk of ovarian cancer than those who have less. This is primarily because of estrogen.
Bfing causes the uterus to contract and clamp down decreasing the risk of post-partum hemorrhage.
On average a baby will drink about oz of milk per day. This milk consumption uses about 500 calories a day. This helps the mother to lose her “baby fat”
Studies have shown that Bfing draws calcium out of the bones. This causes the body to make an extra effort to replace lost calcium. As a result, studies have found that women who BF tend to have more calcium in their bones after they wean.

38. Psychological Qualities
Empowering
Food for baby always available
Low cost
“Mothering Hormones”
Breastfeeding is a learned art. Mothers who are able to breastfeed often feel a sense of accomplishment and pride that they are giving their baby the best start in life.
During times of stress, such as war or a natural disaster many mothers find that being able to feed their babies is one less thing to worry about.
Human Milk is free and requires no special utensils or preparation. This can be particularly important to families who have a low income or high bills.
BF releases the hormones Prolactin and Oxytocin that give a mother a feeling of love toward their child and can also help to relax a stressed mother.

39. Anatomy of the Breast
Changes during pregnancy
How milk is made

40. Changes During Pregnancy
Breast grow larger
Skin on breasts appears thinner and veins can be seen
Areola gets larger and darker
Montgomery tubercles get larger

41. Changes During Pregnancy
Hormones cause breast tissue to grow.
More Milk Alveoli
More milk Ducts
Occurs with each pregnancy
Pregnancy hormone of Estrogen and Progesterone cause the milk sacs to increase in size and to increase in number.
The breast grows more milk ducts and more lobes
With each pregnancy a mother grows more breast tissue. Because of this many mothers find that they have more milk with each baby.

42. How Milk Is NOT Made!!!

43. Anatomy Breasts are made up of glandular tissue and fat.
Breasts come in many different sizes and shapes.
The size and shape of a breast usually has very little effect on the ability of the breast to make milk.
The size of the breast has is not r/t to the amount of milk a breast can hold.
The amount of milk that the breast holds may determine whether or not your baby sleeps through the night.

44. This is a new diagram that is now available through use of ultrasound.
The breast is made up of about 4 to 14 lobes.
Each lobes consists of alveoli which contain special cells that make milk called Lactocytes.
The alveoli are surrounded by special cells (myoepethelial cells) which contract to squeeze milk out.
The alveoli are connected to a tube called the Lactiferous Duct.
During a Milk Ejection Reflex, the alveoli are squeezed causing milk to travel down the ducts to just behind the nipple

45. Breast Anatomy Montgomery Tubercles
Baby’s mouth covers 1/2 - 1 inch of areola
Montgomery Tubercles
When the baby nurses, his tongue strips milk from the ducts to the nipple openings and out into the baby’s mouth as seen in the following slide

46. The Action of Breastfeeding
Notice how the tongue moves in paristaltic waves to strip the milk out of the breast tissue. If the baby doesn’t take a mouth full of breast tissue past the nipple, the baby will not be able to take milk out of the breast.

47. The Action of Bottle Feeding
Notice the position of the tongue in this slide. The bottle fed baby does not take the nipple far back in the mouth or he would choke on the liquid as it comes out. Instead, the baby keeps his tongue back in his mouth in order to block off the tip of the nipple when he needs to swallow.

48. How Milk Is Made
When the baby latches onto the breast, the stimulation of the nipple causes oxytocin to be released from the posterior pituitary gland.
Oxytocin causes the cells surrounding the alveoli to contract making the milk to travel down the milk ducts.
The baby then is able to remove the milk from the breast
The removal of the milk from the breast causes the pituitary gland to release prolactin
The breast makes more milk

49. Community Resources Public Health Lactation Consultants Baby Weigh In
As Parent And Baby Grow
Mother Nurture
Talk about use of breastfeeding room in HU.

50. References Riordan & Auerbach Breastfeeding and Human Lactation
The Breastfeeding Atlas - lactpress 2002
Health canada 2002
Breastfeeding Committee for Canada
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La Leche League Canada
Palmer, B. (2001). Otitis Media: An anatomical perspective
Best Start