Sit the baby upright or semi-upright on your lap; support the baby’s back, head and neck. It helps to wrap the baby firmly with a cloth, to help support his or her back, and to keep his or her hands out of the way.
Hold the small cup of milk to the baby's lips.
The cup rests lightly on the baby's lower lip, and the edges of the cup touch the outer part of the baby's upper lip.
Tip or tilt the cup so that the milk just reaches the baby's lips. The baby becomes alert, and opens his or her mouth and eyes.
- A preterm baby starts to take the milk into his or her mouth with his or her tongue. - A full term or older baby sucks the milk, spilling some of it.
DO NOT POUR the milk into the baby's mouth. Just hold the cup to the baby’s lips and let him or her take it himself or herself.
When the baby has had enough, the baby closes his or her mouth and will not take any more. If the baby has not taken the calculated amount, he or she may take more next time, or you may need to feed the baby more often.
Additional information for Session 11
Use of milk from another mother Wet nursing
• In some cultures, a family may look for a wet nurse if the mother dies or is very ill, if the mother will be away from the baby for a long period of time or if the mother is HIV-positive. If the reason for asking another woman to breastfeed a baby is to reduce the risk of the baby acquiring HIV, the wet nurse needs to be counselled, tested and shown to be HIV-negative.
• The wet nurse, if sexually active, also needs to be counselled about safer sex practices so that she does not acquire the virus during the breastfeeding period. The wet nurse needs access to
breastfeeding support and assistance to establish good breastfeeding.
• It is important for the mother to stay close to the baby, and to care for him or her as much as possible herself, so that she bonds with her baby.
Donor milk and heat-treated milk
• Heat-treating destroys the HIV in the breast milk. A mother who is HIV-positive can also heat-treat her milk at home to reduce the risk of transmitting HIV to her baby. Breast milk should not be heat- treated unless necessary. Breast milk from an HIV-negative or untested mother does not need to be heat treated if the milk is for her own baby. Heating reduces some anti-infective components of breast milk and enzymes in the milk. However, heat-treated breast milk remains superior to breast- milk substitutes. Do not heat-treat the baby’s own mother’s milk just 'in case' the mother is HIV- positive.
• Information on using the milk from another mother and how to heat-treat breast milk to destroy HIV can be found in Chapter 3 of HIV and Infant Feeding Counselling Tools: Reference Guide.
Feeding expressed breast milk to the baby
• Tube feeding - Fat can stick to the side of the tube thus reducing the energy level of the feed
received. If breast milk is fed continuously, angle the milk container and place the outlet tube at the highest point in the container so that the creamy part of the milk is fed first.
• Bottle and artificial teats come in a wide variety of sizes and shapes. There is not one teat that is
‘best’ or most like a mother’s breast. Babies who use the bottle and teat method may lose interest in breastfeeding. A baby can progress from tube feeding, to cup feeding to fully feeding at the breast. The baby does not need to ‘learn’ to feed from a bottle and teat as part of his or her development.
• Clean water and extra fuel are not always available to clean bottles and teats. This places the baby's health at risk. If a mother plan to use bottles and teats, then the mother must be instructed on the health and safety issues associated with their use.
A Breastfeeding Supplementer
• A breastfeeding supplementer can be useful to ensure that the baby receives enough milk while encouraging the baby to suckle for longer or if the baby has a weak suck. To use a nursing supplementer the baby must be able to attach to the breast and suckle.
- Show slide 11/2:Breastfeeding supplementer
• A breastfeeding supplementer is a device to allow extra milk to be given while the baby is at the breast, thus stimulating milk production, encouraging suckling, and enabling closeness of mother and baby. If the baby cannot attach to the breast and suckle, this method cannot be used.
• A breastfeeding supplementer device can be purchased or home-made. Read the instructions for using a purchased device.
• To use a home-made supplementer: The supplement is put into a cup, and a fine tube passes from the cup along the mother’s breast to the baby’s mouth. As the baby suckles on the breast, the baby draws up the supplement through the tube50.
50 See additional information in RELACTATION: A review of experience and recommendations for practice. WHO/CHS/CAH/98.14 http://www.who.int/child-adolescent-health/NUTRITION/infant.htm
• The tube of the supplementer needs to be thoroughly rinsed with water immediately after use, and then sterilised each time it is used, especially if the baby is ill or preterm; or rinsed and then washed well in very hot soapy water for an older, healthy baby. Cleaning the tube makes extra work for the mother or hospital staff. The mother may need help to use this method. Consider if a simpler method such as cup feeding would be suitable.
- Discuss this method more and show a supplementer if they are used in your hospital. Breast pumps
- Demonstrate the use of breast pumps that are available to mothers in your community.
Explain both the positive and negative sides of their use.
• Breast pumps are not always practical, affordable or available, so it is preferable for mothers to learn how to express milk by hand. If breast pumps are available to mothers in your area and if a particular mother needs to use one, help her choose an effective pump, show her how to use the pump and go through the manufacturer's instructions with her.
• It is usually helpful to stimulate the oxytocin reflex before pumping by sitting comfortably with support for the back and the arm holding the pump, relaxing, massage and other techniques as described for hand expressing.
• It is possible with some large electric pumps to pump both breasts at the same time. Double pumping increases the mother’s prolactin level. It can help when large volumes of milk are needed or the mother has only a short time to pump.
• With all pumps use only a comfortable level of suction – more suction does not remove more milk and may damage the breasts. Mimic the baby’s action – short quick initial sucks followed by longer, slower suction. With a cylinder hand pump, extend the cylinder to create a comfortable level of suction and hold that suction until the milk flow slows. The mother does not need to keep pumping if the milk is flowing.
• If the mother is getting little or no milk from pumping, check that the pump is working and check her pumping technique (including stimulating the oxytocin reflex). Do not conclude that she “has no milk”.
• Ensure that the mother is able to sterilise the pump if she intends to feed the milk to her baby.
• Avoid the rubber bulb type hand pumps. These damage mother’s nipples, are difficult to clean and the milk cannot be used for feeding a baby.
Check list for choosing a pump
o Does the mother find it works well? o Is it easily available at an affordable price?
o Is it comfortable to use – arm position, weight, adjustable suction?
o Is the size of the breast cup/funnel and insert if available, suitable for the size of the nipple and breast?
o Can milk be stored in a collection container, in standard thread containers, or is there a need to purchase special containers?
o What is the noise level when in use?
o Is it safe to use and easy to clean and sterilise? o Is it easy to assemble with few parts?
Storing expressed breast milk
• Choose a suitable container made of glass or plastic that can be kept covered. Clean it by washing in hot soapy water, and rinsing in hot clear water. If the mother is hand expressing, she can express directly into the container.
• If storing several containers, each container should be labelled with the date. Use the oldest milk first.
• The baby should consume expressed milk as soon as possible after expression. Feeding of fresh milk (rather than frozen) is encouraged.
• Frozen breast milk may be thawed slowly in a refrigerator and used within 24 hours. It can be defrosted by standing in a jug of warm water and used within one hour, as it is warm. Do not boil milk or heat it in a microwave as this destroys some of its properties and can burn the baby’s mouth.
Breast milk Storage
Healthy baby at home
Fresh Milk
• At 25-37oC for 4 hours. At 15-25oC for 8 hours. Below 15oC for 24 hours.
Milk should not be stored above 37o C.
• Refrigerated (2-4oC): up to 8 days.
Place the container of milk in the coldest part of the refrigerator or freezer. Many refrigerators do not keep a constant temperature. Thus, a mother may prefer to use milk within 3-5 days or freeze milk that will not be used within 5 days, if she has a freezer.
Frozen Milk
• In a freezer compartment inside refrigerator: 2 weeks.
• In a freezer part of a refrigerator-freezer: 3 months.
• In a separate deep freeze: 6 months.
• Thawed in a refrigerator: 24 hours (do not re-freeze), or place the container in warm water to thaw quickly.
Ill baby in hospital
Fresh Milk
• At room temperature (up to 25oC): 4 hours.
• Refrigerated (2-4oC): 48 hours. Frozen milk
• In a freezer compartment inside refrigerator: 2 weeks.
• In a freezer part of a refrigerator-freezer or a separate deep freeze (-20oC): 3 months.