The Ministry of Health employs a “no bottle” policy at all Government hospitals and Community Health Clinics. (In specific instances where parents refuse or in instances where breastfeeding may be contra-indicated, alternatives are then offered.) All mothers in the Maternity Wards of both the Princess Margaret and the Rand Memorial Hospitals are encouraged to breastfeed almost immediately post delivery- this aids in the bonding between, as well as the overall well-being of, both mother and baby.

The Ministry of Health seeks to train all staff who come in contact with mothers and infants, in proper breastfeeding techniques and the importance of breastfeeding. In this way, they are further helped to promote, protect and support breastfeeding. An 18 hours course for maternity staff for Breastfeeding Management and Promotion was prepared by UNICEF (1993), and has been adopted by the Ministry of Health. Development of the course was a collaborative effort of UNICEF, WHO, Wellstart and breastfeeding support consultants. This course has been accepted as an integral part of achieving the long term goals of the Baby Friendly Hospitals Initiative. One of the overarching themes of the course is to equip maternity staff with the knowledge base necessary to make lasting policy changes. The Foundation for the Baby Friendly Initiative was laid forth in the Innocenti Declaration in 1990, and was subsequently adopted by the World Summit for Children:

“All women should be enabled to practise exclusive breastfeeding and all babies should be fed exclusively on breast milk from birth to 6 months of age. Thereafter, children should continue to be breastfed while receiving appropriate and adequate complementary foods, up to 2 years and beyond.”

Session 1: Breastfeeding Recommendations and Breast Care

At the end of session, participants will be able to:

1. List current breastfeeding recommendations.
2. Discuss the dangers of using artificial teats such as bottles and pacifiers.
3. Discuss the consequences of early introduction of supplementary foods.

Duration: 40 minutes

Introduction
Studies overwhelmingly indicate that most babies who are exclusively breastfed for the first 6 months are generally healthier than those that are not breastfed.

Session 2: The Anatomy and Physiology of the Breast & Role of Colostrum

At the end of session, participants will be able to:

1. Identify parts of the breast.
2. Describe how breastfeeding works.
3. Discuss breast changes.
4. Discuss the role of Colostrum.

Duration: 40 minutes

Handouts

• “How Breastfeeding Works”
• “Structure of the Breast”

Introduction
Breastfeeding is a special gift only a mother can give her baby. Two elements are necessary for getting milk to the baby:

• A breast that produces and releases milk.
• A baby who is able to remove the milk from the breast, with effective suckling.

The manner in which the baby is attached to the breast will determine how successfully these 2 elements come together. There are many variations in the size and shape of a woman’s breast. However, milk production does not depend on breast size. (Be sure to tell every mother that her breast is good for breastfeeding and avoid frightening words like “problem”.)

Content

Structures involved in Breastfeeding
The diagram shows a cross section of the breast. In the diagram, you can see 7 “units”. Each woman has 15 to 20 “units” in each breast. As soon as the placenta is delivered, the brain sends a stimulus, in the form of a hormone called PROLACTIN, to the alveoli cells in the breast. Another hormone then comes into play, OXYTOCIN. Oxytocin is responsible for “squeezing” the milk out of the alveoli into the ducts to be deposited into the lactiferous sinuses. The lactiferous sinuses are sacs immediately under areola, where the milk is stored.

The nipple should contain no milk and only acts as the passageway to allow the milk to flow through. The nipple should be at the back of the baby’s throat. It "tickles" the throat and makes the baby swallow. This is said to be the sexual behaviour of the baby, seen as he rolls his eyes. The baby should never be allowed to have only the nipple in his mouth. When properly attached, the baby should "bite" on the areola (darkened area around the nipples). The areola with the little fat glands enables the baby to fix onto the breast.

Prolactin

• Makes the alveoli produce milk.
• Makes the mother feel sleepy and relaxed.
• Prolactin levels need to stay high in order for the alveoli to produce milk.
• Even when prolactin is high, if suckling is inefficient, and milk is not removed from parts of the breast, milk production will shut down in those parts.

How Mothers can help keep Prolactin Levels High

• The baby is attached effectively at the breast and is not given any artificial dummies or treats that would confuse his sucking.
• The baby breastfeeds as frequently as he wants, usually every 1-3 hours.
• The baby breastfeeds as long as he wants.
• The baby breastfeeds at night, when prolactin release in response to sucking is greatest.

Oxytocin

• Oxytocin contracts the cells around the alveoli and sends milk down the ducts to the milk sinuses, where it is available for the baby to remove. The process is called the milk ejection reflux, or "let-down".
• Early postpartum, when the milk ejects, the mother may feel uterine contractions or sudden thirst. She may see milk leaking from the other breast. However, mothers do not always feel a physical sensation.
• When the milk ejects, the rhythm of the baby’s sucking will change from rapid to regular deep, slow sucks (approximately, once per second).

Oxytocin release can be inhibited temporarily by:

• Extreme pain (such as a fissured nipple)
• Stress hormones resulting from doubt, embarrassment, or anxiety
• Nicotine, alcohol, and caffeinated drinks

The mother can reduce this inhibition by:

• Relaxing and getting comfortable for feeds.
• Avoiding embarrassing or stressful situations for feeds.
• Expressing a little milk and gently stimulating the nipple.
• Asking someone to gently massage her upper back, especially along the sides of the back bone.

How Breastfeeding Works

• Once the baby’s lower lip is stimulated, he will open his mouth wide, bringing his tongue forward.
• The tongue draws the nipple, areola and breast tissue well back into the mouth, forming a longer nipple.
• The tongue cups and sweeps the nipple from front to back in a wave like manner, pressing it up against the roof of the baby’s mouth. The baby’s gum gently squeezes the milk sinuses using his jaw and cheek muscles.
• The rhythmical movements of the tongue and jaw together cause milk to flow from the breast into the baby's mouth, making him swallow. The mother will notice her baby’s rhythm: suck, swallow, breathe; suck, swallow, breathe.

The teat formed by the breast and nipple fills the baby’s mouth, leaving no room for movement of the breast within the baby’s mouth. After a feed, the nipple should not look flattened or compressed if the baby was attached correctly. It is important to note that the baby does not get milk from the breast by suction.

Breast Changes

The breasts double in size and may become more sensitive. The nipple and areola may darken in colour. Montgomery glands, 9 small, pimple-like bumps, may appear on the areolas. These help to keep the nipples soft and give off a faint scent that helps the baby find the nipples.

Role of Colostrum

Colostrum is the perfect first food for the baby. It can be found in the breast from the seventh month of pregnancy.

Important for:

• The development of strong teeth and bones
• Finishing off brain development of the baby
• Aiding the development of good eye sight
• Preventing jaundice
• Protecting the baby against bacterial infections, allergies and viruses. In other words, it is the baby’s first immunisation.

Summary
The more a woman breastfeeds, the more milk her breasts will produce. With correct positioning and attachment, the breast will be stimulated to make more than enough milk for the baby. Advise mothers to eat healthy foods and drink plenty of fluids, especially water, to quench thirst.

Conclusion
Breast milk production is a MIRACLE! Where else can you find a complete baby food that is manufactured, transported, stored and delivered to the consumer, and is not touched by human hands?

Questions/Answers

Session 3: Technique of Breastfeeding

1. Discuss the importance of putting the baby to the breast within the first half hour of delivery.
2. Describe the “latching-on” process.
3. Discuss the procedures for continued breastfeeding on Postnatal Ward, home, work and despite separation.
4. Describe the “cup and spoon” method.
5. Demonstrate breastfeeding positions.
6. Discuss hand expression and breast milk storage.

Duration: 40 minutes
Materials: Handouts, Video and Dolls.

Introduction
It is important for mothers to know their baby’s signs of hunger. How frequently and how long to breastfeed is determined by the baby’s demand. Frequent suckling and milk removal helps to keep milk production high. Therefore, mothers and babies should be kept together while in hospital with no more than 1 hour separation for hospital procedures.

Content

The importance of putting baby to the breast within the first half hour of delivery as soon as the baby’s lusty cry is heard cannot be overstated. The mother should request that her baby be bought to her so that she may commence “skin-to-skin” contact, as well as start breastfeeding within the first half hour - the suckling reflex of the infant is strongest at this time. The “skin-to-skin” contact causes the baby’s gut to get “colonised” to the mother’s germs. Suckling on the breast also releases a hormone, oxytocin, which assists in controlling postpartum bleeding (in the mother).

The “latching-on” Process

For proper attachment, the baby’s body should be facing the mother, mouth open wide, bottom lip curled outwards with the chin touching the breast. Most or all of the areola should be in the baby’s mouth. You should not put a crying baby to the breast! Always quiet the baby for easy attachment.

Postnatal Ward

On Maternity Ward, “rooming-in” for all mothers who are able to is routinely done. In this way, they can give immediate care to their babies. Each cubicle has a bed for the mother and a crib for her baby. This allows your baby to breastfeed on demand when hungry. This also reinforces bonding and closeness, which should continue at home.

Premature Infants

If the baby is born before expected, the mother can maintain lactation by carrying out the following procedure:
Start expressing milk as soon after delivery as possible and refrigerate it until the baby is ready for feeds by mouth.
Express at least 7 times every 24 hours, using extreme sanitation precautious. The mother may be required to take the expressed breast milk (EBM) to the hospitalised baby. Over a long period your milk production may decrease, however, full lactation should resume when the baby is discharged. If the baby is given cup-fed liquids, it will be relatively easy to commence breastfeeding at home.

At Home

Mothers are encouraged to breastfeed in a quiet, comfortable environment. This fosters increased confidence and comfort in the practice of breastfeeding. Caffeinated drinks should be avoided. The baby should be kept very close to the mother so that she is able to observe nonverbal cues for feeding on demand.

At Work

Should the mother return to work and is separated from the baby at feeding time, the best solution, for the specific circumstance, need to be used.

This might include:

• The mother might visit her baby during work-breaks so as to engage in breastfeeding.
• Some work situations may allow a mother to bring a small infant to the job site. (All work hazards should be taken into account.)
• The mother may express milk during the time she is away. The expressed breast milk could, in turn, be used by the caregiver to feed the baby in the mother’s absence.

Cup and Spoon Feeding
 

• Use a small, ordinary cup (A cup with a spout should be avoided).
• Hold the baby closely, sitting a little upright with its back against the abdomen.
• Hold the small cup or glass to the baby’s lips. He may make sucking movements. Pour in a little milk at a time, very slowly.
• Give the baby time to swallow. Let him rest between sips.
• If you are worried about giving too much, try using a spoon.
• Spoon feeding is quite safe but it takes longer. If a baby is very ill, for example, with difficult breathing, it may be better to feed the baby with a spoon.

Expressing Breast Milk

A mother’s own expressed breast milk is more appropriate for her baby than any other woman’s breast milk because no other woman’s milk is being made in response to this particular baby’s suckling, and in this baby’s environment.

In preparation for expressing, the following procedure is recommended.

1. Wash hands with soap and hot water, rinse and dry.
2. Apply a warm, moist cloth a few minutes before expressing to help milk flow.
3. Gently massage the breast towards the nipple and continue to massage the breast during milk expression to stimulate the milk ejection reflex.
4. Lean forward and support the breast with the hand.
5. Position the thumb on the areola, above the nipple, and the first finger on the areola, below the nipple.
6. Press the thumb and first finger inwards towards the chest wall a little way.
7. Firmly press on the milk sinuses beneath the areola, between finger and thumb.
8. Press and release the thumb and forefinger several times until milk starts to drop out. Milk may drip at the beginning, progressing to a spray after the milk “lets down”.
9. Rotate the thumb and forefinger around the areola so that milk is removed from all the milk sinuses.
10. Do not squeeze the nipple itself and do not move the fingers along the skin of the breast. Pressing or pulling the nipple cannot express milk – it only damages the nipple.

Storing Expressed Breast Milk

1. Prepare a clean container that can be covered for storing the milk. (The container should not be of glass which can cause the nutrients from the milk to stick on to it.) The container should be washed in hot, soapy water and rinsed with hot water. If the mother is hand expressing, she can express directly into the container.
2. Use 1 container for the amount of milk that the baby will take in 1 feeding.
3. If the mother is storing several containers in one place, each container should be labelled with a date. The oldest milk should be used first.
4. Breast milk left at room temperature is safe to use for up to 8 hours.
5. Breast milk stored in the refrigerator is safe to use for 72 hours.
6. Frozen breast milk can be stored for up to 3 months in refrigerator freezer.
7. Breast milk stored in an upright freeze is safe to use for up to 1 year.

Ending a Feed

Allow the baby to end the feed. Place your baby to rest on his side or back, never on the stomach.

Summary/Conclusion

A mother and her baby should always be kept together. Should separation occur, the mother needs to know about the different methods of feeding the baby that will not interfere with breastfeeding. Proper positioning of the baby at the breast is very important for satisfying the baby’s appetite and sustaining milk supply. The various positions for holding the baby make it a flexible situation for both mother and baby. The mother’s prolactin hormone level is highest at night, which enables the baby to feed continuously at this time, should he desire. Avoid putting the baby on a schedule.

Session 4: The Importance of Breastfeeding

1. List the benefits of breastfeeding for the mother.
2. List benefits to the baby.
3. Discuss the benefits to the father from breastfeeding.
4. Discuss the benefits society derives from supporting a breastfeeding campaign.

Duration: 40 minutes.
Handouts: “The Benefits of Breastfeeding”

Content
Benefits to the mother

• Reduces the risk of breast and ovarian cancer.
• Allows internal organs to return to normal more quickly.
• When exclusive breastfeeding is practiced, it can become a natural family planning method, known as the Lactation Amenorrhoea method.
• There is no menstruation or loss of blood which will prevent anaemia.
• The mother regains her pre- pregnancy weight quicker.
• Post partum depression is reduced.
• Less visits to “Sick Baby Clinic”.
• The workload of caring for your child is reduced, and the mother is able to receive more rest.
• Night feeds and travel are more convenient – no utensils to clean, no excess load to carry.
• The risk of osteoporosis (softening of the bones) is decreased.

Benefits to the baby

Breast milk provides many health benefits for the baby. When babies are exclusively breastfed, these benefits are highest. Overall there is less illness requiring healthcare among exclusively breastfed babies. Exclusive breastfeeding provides the best infant nutrition for development until 6 months of age.

Other benefits

1. Breastfed babies have less diarrhoea and gastrointestinal (GI) and respiratory infections than “artificially” fed babies.
2. Breast milk helps “friendly” bacteria to grow in the baby’s intestine, thus preventing other harmful bacteria from growing.
3. Living cells in breast milk helps to prevent disease and inflammation.
4. Each mother’s milk is specially suited to her baby’s needs, in order to protect him from disease-causing germs that are in their environment.
5. Breast milk contains growth factors that boosts a baby’s ability to fight disease, aids the development of the brain, spinal cord and other organs.
6. Lactose, in the breast milk, helps prevents Rickets (which can cause crooked legs) through calcium absorption. This substance also aids brain development.
7. Protects from allergies.
8. Protects the baby from allergies, such as gastrointestinal disturbances, skin rashes, wheezing and runny nose. Giving babies even a single bottle of artificial formula in the first days of life can increase the rate of these allergic conditions. All formulas, including soy formulas, carry a risk of allergy.
9. Protection from Jaundice. Babies who are breastfed immediately after birth and on demand have reduced risk of developing jaundice, which can be caused by the free passage of meconium (the baby’s first stools which is black) and prevents re-absorption of bile into the baby’s system.
10. A lower incidence of Sudden Infant Death Syndrome.
11. A lower risk of childhood diabetes, cancer and ear infections.
12. A better response to vaccinations and a faster ability to fight disease.
13. Fewer orthodontic and dental problems (for twisted and uneven teeth).
    No bottle associated tooth decay.
14. Better psycho-motor, emotional and social development - the child should be better behaved and more controllable. Breastfed babies are generally more sociable and cry less.

Benefits to father

1. As fathers are very often assigned to changing diapers they are happy to know that the baby’s stools have less odour.
2. Economics of breastfeeding cause fathers to have more money as they do not have to buy items such as bottles, milk and formula.
3. When it is time to care for the baby, he often finds that the baby is content and happy and thus more manageable.

Benefits to Society

• Schools should have more controllable children.
• The workforce will be more productive with less absenteeism due to illness.
• Less illness make fewer demands on the healthcare system.
• Breastfeeding results in good health and longevity, benefiting insurance companies - reducing claims and increasing premiums.
• Breastfeeding is environmentally safe. No bottles or tins to discard!

SUMMARY/CONCLUSION

Breastfeeding not only benefits the baby but also the mother, father and society as a whole. The benefits are derived when babies are breastfed exclusively for the first 6 months.

Frequently Asked Questions:

1. How long will the workshop last?
   18 hours.
2. Will I receive a certificate?
   Yes.
3. Can I receive college Credits?
   Yes.
4. Would information be forwarded to my supervisor regarding the workshop?
   Yes, this is available upon request.