Helpful Resources

Mar; 123(3): e40610. 15. Mitchell, A. Results from the first year of the New Zealand count death study. The New Zealand Medical Journal. 1991; 104: 7176. 16. McVea, K.L. et al. The role of breastfeeding in sudden infant death syndrome. Journal of Human Lactation. 2000 Feb; 16(1): 1320. 17. Scariati, P.D. et al. A longitudinal analysis of infant morbidity and the extent of breastfeeding in the United States. Pediatrics. 1997 Jun; 99(6): E5. 18. Dewey, K.G. et al. Differences in morbidity between breast-fed and formula-fed infants. Journal of Pediatrics. 1995 May; 126(5 Pt 1): 696702.

of sibling pairs to reduce confounding. Epidemiology. 2005 Mar; 16(2): 24753. 38. Harder T, et al. Duration of breastfeeding and risk of overweight: a meta-analysis. American Journal of Epidemiology 2005; 162: 97403. 39. Owen, C. G., Martin, R. M., Whincup, P. H. et al. Effect of infant feeding on the risk of obesity across the life course: A quantitative review of published evidence. Pediatrics. 2005; 115(5): 136777. 40. Toschke, A.M., et al. Overweight and obesity in 6- to 14-year-old Czech children in 1991: Protective effect of breastfeeding. Journal of Pediatrics. 2002; 141: 7649 December 2002. 41. Armstrong, J., Reilly, J.J. Breastfeeding and lowering the risk of childhood obesity. The Lancet. 2002 Jun 8; 359 (9322): 20032004. 42. Gillman, M.W. et al. Risk of overweight among adolescents who were breastfed as infants. Journal of the American Medical Association. 2001 May 16; 285 (19): 24612467. 43. von Kries, R. Breast feeding and obesity: cross sectional study. British Medical Journal. 1999; 319: 147150. 44. Tulldahl, J., Pettersson, K., Andersson, S.W., Hulthen, L. Mode of infant feeding and achieved growth in adolescence: early feeding patterns in relation to growth and body composition in adolescence. Obesity Research. 1999 Sep; 7(5): 4317. 45. Arenz, S., et al. Breastfeeding and childhood obesitya systematic review. International Journal of Obesity and Related Metabolic Disorders. 2004 Oct; 28(10): 124756.

61. Titus-Ernstoff, L. Menstrual and reproductive factors in relation to ovarian cancer risk. British Journal of Cancer. 2001 Mar 2; 84 (5): 714721. 62. Ness, R.B. et al. Factors related to inflammation of the ovarian epithelium and risk of ovarian cancer. Epidemiology. 2000 Mar; 11 (2): 111117. 63. Siskind, V. et al. Breastfeeding, menopause, and epithelial ovarian cancer. Epidemiology. 1997 Mar; 8 (2): 18891. 64. John, E.M. et al. Characteristics relating to ovarian cancer risk: collaborative analysis of seven U.S. case-control studies. Epithelial ovarian cancer in black women. Journal of the National Cancer Institute. 1993 Jan 20; 85(2): 1427. 65. Gwinn, M.L. et al. Pregnancy, breast feeding, and oral contraceptives and the risk of epithelial ovarian cancer. Journal Clinical Epidemiology. 1990; 43(6): 55968. 66. Schneider, A.P. Risk factor for ovarian cancer. New England Journal of Medicine. 1987.

84. Chantry, C.J., Auinger, P., Byrd, R.S. Lactation among adolescent mothers and subsequent bone mineral density. Archives of Pediatrics and Adolescent Medicine. 2004 Jul; 158(7): 6506. 85. Huo, D.Z.; Lauderdale, D.S., Li, L.M. Influence of reproductive factors on hip fracture risk in Chinese women. Osteoporosis International. 2003 Aug; 14 (8): 694700. 86. Blaauw, R. et al. Risk factors for development of osteoporosis in a South African population. South African Medical Journal. 1994; 84: 32832. 87. Melton, L. et al. Influence of breastfeeding and other reproductive factors on bone mass later in life. Osteoporosis International. 1993 Mar; 3(2): 7683.

Useful websites for families include:

La Leche League International: http://www.llli.org/ Kellymom Breastfeeding and Parenting: http://www.kellymom.com/index.html Dr. Jack Newman, Newman Breastfeeding Clinic and Institute: http://www. breastfeedinginc.ca/content. php?pagename=information

Useful websites for healthcare professionals include:

World Health Organization: http://www. who.int/topics/breastfeeding/en/ American Academy of Pediatrics: http:// www.aap.org/healthtopics/breastfeeding. cfm American The American Congress of Obstetricians and Gynecologists: http://www. acog.org/departments/dept_notice. cfm?recno=18&bulletin=3197 Canadian Pediatric Society: http://www. cps.ca/english/index.htm NHS: http://www.nhs.uk/Planners/ breastfeeding/Pages/breastfeeding.aspx UNICEF: http://www.unicef.org.uk/ BabyFriendly/About-Baby-Friendly/

Otitis media:
19. Duncan, B. et al. Exclusive breast-feeding for at least four months protects against otitis media. Pediatrics. 1993 May; 91(5): 86772. 20. Alho, O., Risk factors for recurrent acute otitis media and respiratory infection in infancy. International Journal of Pediatric Otorhinolaryngology. 1990; 19: 15161. 21. Teele, D.W., epidemiology of otitis media during the first seven years of life in greater Boston: a prospective, cohort study. Journal of Infectious Diseases.1989.

WHO code:
88. http://www.who.int/nutrition/publications/ infantfeeding/9241541601/en 89. World Health Assembly Resolutions have further clarified or extended certain provisions of the Code: http://www.who. int/nutrition/topics/wha_nutrition_iycn/ en/2

Breast Cancer:
67. Stuebe, A.M., Willett, W.C., Xue F., Michels, K.B. Lactation and incidence of premenopausal breast cancer: a longitudinal study. Archives of Internal Medicine. 2009 Aug 10; 169(15): 136471. 68. Clarke, C.A., Purdie, D.M., Glaser, S.L. Population attributable risk of breast cancer in white women associated with immediately modifiable risk factors. BMC Cancer, 2006 Jun 27; 6: 170170. 69. Becher, H., Schmidt, S., Chang-Claude, J. Reproductive factors and familial predisposition for breast cancer by age 50 years. A case-control-family study for assessing main effects and possible geneenvironment interaction. International Journal of Epidemiology. 2003 Feb; 32 (1): 3848. 70. Gammon, M.D. The Long Island breast cancer study project: description of a multi-institutional collaboration to identify environmental risk factors for breast cancer. Breast Cancer Research and Treatment. 2002 Aug; 74 (3): 235254. 71. Beral, V. et al. Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50,302 women with breast cancer and 96,973 women without the disease. The Lancet. 2002 Jul 20; 360 (9328): 187195. 72. Zeng, T. et al. Long-term breastfeeding lowers mothers breast cancer risk. American Journal of Epidemiology. 2001; 152: 11291135. 73. Millikan, R. et al. International Journal of Epidemiology 1999; 28: 396402. 74. Marcus, P.M., Baird, D.D., Millikan, R.C., Moorman, P.G., Qaqish, B., Newman, B. Adolescent reproductive events and subsequent breast cancer risk. American Journal of Public Health. 1999 Aug; 89(8): 12447. 75. Newcomb, P.A. et al. Lactation in relation to postmenopausal breast cancer. American Journal of Epidemiology. 1999 Jul 15; 150(2): 17482. 76. Newcomb, P. et al. Lactation and reduced risk of premenopausal breast cancer. New England Journal of Medicine. 1994; 330(2): 8187. 77. Layde, P.M., The independent associations of parity age at first full term pregnancy, and duration of breast feeding with the risk of breast cancer. Journal of Clinical Epidemiology. 1989. 78. McTieman, A., Evidence of protective effect of lactation on risk of breast cancer in young women. American Journal of Epidemiology.1986.

Water:
90. Shrago, L. Glucose water supplementation of the breastfed infant during the first three days of life. Journal Human Lactation. 1987; 3: 8286, [Abstract/Free Full Text] 91. http://www.who.int/mediacentre/ news/statements/2011/ breastfeeding_20110115/en/ 92. Rempel, Lynn A and John K. The Breastfeeding Team: The Role of Involved Fathers in the Breastfeeding Family Journal Human Lactation, May 2011 27: 115121 93. http://www.who.int/features/qa/21/en/ 94. Naylor, Audrey J., MD, DrPH, Morrow, Ardythe L., PhD, Developmental Readiness of Normal Full Term Infants to Progress from Exclusive Breastfeeding to the Introduction of Complementary Foods Linkages: A Worldwide Project April 2001 95. http://www.unicef.org.uk/BabyFriendly/ Health-Professionals/Care-Pathways/ Breastfeeding/First-days/Baby-ledfeeding/. 96. http://www.unicef.org.uk/Documents/ Baby_Friendly/Leaflets/3/introducingsolid-foods.pdf

References for further reading by topic

Diarrhea:
1. Scariati, P.D. et al. A longitudinal analysis of infant morbidity and the extent of breastfeeding in the United States. Pediatrics. 1997 Jun; 99 (6): E5. 2. Coppa, G.V., et al. Human milk oligosaccharides inhibit the adhesion to Caco-2 cells of diarrheal pathogens: Escherichia coli, Vibrio cholerae, and Salmonella fyris. Pediatric Research. 2006 Mar; 59(3): 37782. 3. Quigley, M.A. et al. How protective is breast feeding against diarrhoeal disease in infants in 1990s England? A case-control study. Archives of Disease in Childhood. 2006 Mar; 91(3): 24550. 4. Newburg, D.S. et al. Innate protection conferred by fucosylated oligosaccharides of human milk against diarrhea in breastfed infants. Glycobiology. Mar 2004; 14(3): 253263. 5. Dewey, K.G. et al. Differences in morbidity between breast-fed and formula-fed infants. Journal of Pediatrics. 1995 May; 126 (5 Pt 1): 696702.

Asthma:
22. Kuiper, S. et al. Interactive effect of family history and environmental factors on respiratory tract-related morbidity in infancy. Journal of Allergy and Clinical Immunology. 2007 9 May. 23. Oddy, W.H., Peat J.K., de Klerk, N.H. Maternal asthma, infant feeding, and the risk of asthma in childhood. Journal of Allergy and Clinical Immunology. Jul 2002; 110 (1): 6567. 24. Dell S., To, T. Breastfeeding and asthma in young children Findings from a population-based study. Archives of Pediatrics and Adolescent Medicine. Nov 2001; 155 (11): 12611265. 25. Gdalevich M., Mimouni D., Mimouni, M. Breast-feeding and the risk of bronchial asthma in childhood: a systematic review with meta-analysis of prospective studies. Journal of Pediatrics. 2001 Aug; 139(2): 2616. 26. Haby, M.M. et al. Asthma in preschool children: prevalence and risk factors. Thorax. 2001 Aug; 56 (8): 589595.

Cardiac disease:
46. Owen, C.G., Whincup, P.H., Kaye, S.J., Does initial breastfeeding lead to lower blood cholesterol in adult life? A quantitative review of the evidence. American Journal of Clinical Nutrition. 2008 Aug; 88(2): 30514. 47. Singhal, A. The early origins of atherosclerosis. Advances in Experimental Medicine and Biology. 2009; 646: 518. 48. Martin, R.M., Ebrahim, S., Griffin, M. et al. Breastfeeding and atherosclerosis Intima-media thickness and plaques at 65-year follow-up of the Boyd Orr cohort. Arteriosclerosis Thrombosis and Vascular Biology, 2005 Jul 25; (7): 14821488. 49. Singhal, A. et al. Breastmilk feeding and lipoprotein profile in adolescents born preterm: follow-up of a prospective randomised study. The Lancet. 2004 May 15; 363(9421): 15711578.49.509. 50. Owen, C.G., et al. Infant feeding and blood cholesterol: A study in adolescents and a systematic review. Pediatrics. 2002 Sep; 110 (3): 597608. 51. Singhal, A., Cole, T.J., Lucas, A. Early nutrition in preterm infants and later blood pressure: two cohorts after randomised trials. The Lancet. 2001 Feb 10; 357(9254): 4139. 52. Ravelli, A.C.J., et al. Infant feeding and adult glucose tolerance, lipid profile, blood pressure, and obesity. Archives of Disease in Childhood. 2000 Mar; 82 (3): 248252. 53. Plancoulaine, S., et al. Infant-feeding patterns are related to blood cholesterol concentration in prepubertal children aged 511y. European Journal of Clinical Nutrition. 2000 Feb; 54 (2): 114119.

Bermuda Breastfeeding Guidelines for Healthy Infants

Diabetes type 1:
27. Monetini, L. Bovine beta-casein antibodies in breast- and bottle-fed infants: their relevance in Type 1 diabetes. Diabetes Metabolism Research and Reviews. 2001 JanFeb; 17 (1): 5154. 28. Kimpimaki, T., et al. Short-term exclusive breastfeeding predisposes young children with increased genetic risk of Type I diabetes to progressive beta-cell autoimmunity. Diabetologia. 2001 Jan; 44 (1): 6369. 29. Kuehne, V.S., et al. Longer breastfeeding is an independent protective factor against development of type 1 diabetes mellitus in childhood. Diabetes Metabolism Research and Reviews. 2004 MarApr; 20(2): 150157. 30. McKinney, et al. Perinatal and neonatal determinants of childhood type 1 diabetes. A case-control study in Yorkshire, U.K. Diabetes Care. 1999 Jun; 22(6): 92832. 31. Pettitt, D.J., Knowler, W.C. Long-term effects of the intrauterine environment, birth weight, and breast-feeding in Pima Indians. Diabetes Care. 1998 Aug; 21 Suppl 2: B13841. 32. Diabetes Care. 1994; 17:13811389, 14881490.

Skin to skin
97. http://www.unicef.org.uk/BabyFriendly/ Health-Professionals/Care-Pathways/ Breastfeeding/Birth/

Supplementation:
98. http://www.unicef.org.uk/BabyFriendly/ Health-Professionals/Going-BabyFriendly/Maternity/Ten-Steps-toSuccessful-Breastfeeding/Step-6---Avoidsupplementation/ 99. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Care of the neonate. In: Gilstrap, L.C., Oh, W., eds. Guidelines for Perinatal Care. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2002: 222. 100. Shrago, L. Glucose water supplementation of the breastfed infant during the first three days of life. Journal of Human Lactation. 1987; 3 :8286 [Abstract/Free Full Text] 101. Goldberg, N.M., Adams, E. Supplementary water for breast-fed babies in a hot and dry climatenot really a necessity Archives of Disease in Childhood. 1983;58 :73 74[Abstract/ Free Full Text] 102. Eidelman, A.I. Hypoglycemia in the breastfed neonate. Pediatric Clinics of North America. 2001; 48 :377387 [Web of Science][Medline]

Pneumonia:
7. Cesar, J.A. et al. Impact of breastfeeding on admission for pneumonia during postneonatal period in Brazil: nested casecontrol study. British Medical Jounal. 1999 May 15; 318(7194): 13161320. 8. Hylander, M.A. et al. Human milk feedings and infection among very low birth weight infants. Pediatrics. 1998 Sep; 102(3): E38.

Hypertension:
54. Lawlor, D.A., et al. Associations of parental, birth, and early life characteristics with systolic blood pressure at 5 years of age: findings from the Mater University study of pregnancy and its outcomes. Circulation. 2004 Oct 19; 110(16): 241723. 55. Martin, R.M., et al. Breastfeeding in infancy and blood pressure in later life: systematic review and meta-analysis. American Journal of Epidemiology 2005,161:1526. 56. Martin, R.M., et al. Does breast-feeding in infancy lower blood pressure in childhood? The Avon Longitudinal Study of Parents and Children (ALSPAC). Circulation. 2004 Mar 16; 109(10): 125966.

Meningitis:
9. Silfverdal, S.A. et al. Long-term enhancement of the IgG2 antibody response to Haemophilus influenzae Type B by breastfeeding. Pediatric Infectious Disease Journal. Sep 2002; 21 (9): 816821. 10. Harabuchi, Y. et al. Human milk secretory IgA antibody to nontypeable Haemophilus influenzae: possible protective effects against nasopharyngeal colonization. Journal of Pediatrics. 1994 Feb; 124(2):1938. 11. Arnold, C. et al. Day care attendance and other risk factors for invasive Haemophilus influenzae Type B disease. American Journal of Epidemiology. 1993 Sep 1; 138(5): 33340. 12. Petersen, G.M. Effects of age, breast feeding, and household structure on Haemophilus influenzae Type B disease risk and antibody acquisition in Alaskan Eskimos. American Journal of Epidemiology. 1991 Nov 15; 134(10): 121221. 13. Cochi, S.L. Primary invasive Haemophilus influenza Type B disease, a populationbased assessment of risk factors. Journal of Pediatrics. 1986 Jun; 108(6): 88796.

Heart disease:
79. Schwarz, E.B. et al. Duration of lactation and risk factors for maternal cardiovascular disease. Obstetrics and Gynecology. 2009 May; 113(5): 97482. 80. Stuebe, A.M., Michels, K.B., Willett, W.C., et al. Duration of lactation and incidence of myocardial infarction in middle to late adulthood. American Journal of Obstetrics and Gynecology. 2009 Feb; 2009 (2): 138.e18. 81. Mezzacappa, E.S. et al. Breast-feeding and maternal cardiovascular function. Psychophysiology, 2001 Nov; 38 (6): 988997. 82. Knip, M., Virtanen, S.M., Becker, D., Dupre, J., Krischer, J.P., Akerblom, H.K., Early feeding and risk of Type 1 diabetes: experiences from the trial to reduce insulin dependant diabetes mellitus in the genetically at-risk (TRIGR). American Journal of Clinical Nutrition. 2011 Jun 8.

Diabetes type 2:
33. Young,T.K. et al. Type 2 diabetes mellitus in children Prenatal and early infancy risk factors among native Canadians. Archives of Pediatrics and Adolescent Medicine 2002 Jul; 156 (7): 651655. 34. Owen, C.G., et al. Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence. American Journal of Clinical Nutrition. 2006 Nov; 84(5): 104354.

Presented to healthcare professionals by the Department of Health, Well Bermuda, Bermuda Hospitals Board and La Leche League of Bermuda, August 2011

Pacifiers:
103. http://www.unicef.org.uk/Documents/ Baby_Friendly/Statements/4/dummy_ statement_08.pdf?epslanguage=en

Engorgement:
104. The Breastfeeding Answer Book La Leche League 3rd Revised Edition : Nikodem, V. et al. Do Cabbage leaves prevent breast engorgement? A randomized, controlled study. Birth 1993; 20:6164 105. Roberts, K. et al. Effects of cabbage leaf extract on breast engorgement. Journal of Human Lactation 1998; 14(3):23136

Ovarian cancer:
57. Zhang, M., Xie, X, Lee, A.H.; Binns, C.W. Prolonged lactation reduces ovarian cancer risk in Chinese women. European Journal of Cancer-Prevention. 2004 Dec; 13(6): 499502. 58. Zhang, M., Lee, A.H., Binns, C.W. Reproductive and dietary risk factors for epithelial ovarian cancer in China. Gynecologic Oncology. Jan 2004; 92(1): 320326. 59. Tung, K.H., et al. Reproductive factors and epithelial ovarian cancer risk by histologic type: a multiethnic case-control study. American Journal of Epidemiology. 2003 Oct 1; 158(7): 62938. 60. Greggi, S. et al. Risk factors for ovarian cancer in central Italy. Gynecologic Oncology. 2000 Oct; 79 (1): 5054.

Obesity:
35. Krameru, M., Matush L., Vanilovich I., et al. Effects of prolonged and exclusive breastfeeding on child height, weight, adiposity, and blood pressure at age 6.5 y: evidence from a large randomized trial. American Journal of Clinical Nutrition, Vol. 86, No. 6, 17171721, 2007 Dec. 36. Weyermann, M., Rothenbacher, D., Brenner, H. Duration of breastfeeding and risk of overweight in childhood: a prospective birth cohort study from Germany. International Journal of Obesity. 2006 Aug; 30(8): 12817. 37. Nelson, M.C., Gordon-Larsen, P., Adair, L.S. Are adolescents who were breast-fed less likely to be overweight? Analyses

Osteoporosis:
83. Akkus, Z. et al. Determination of osteoporosis risk factors using a multiple logistic regression model in postmenopausal Turkish women. Saudi Medical Journal. 2005 Sep; 26(9): 13519.

SIDS:
14. Vennemann, M.M. et al. Does breastfeeding reduce the risk of sudden infant death syndrome? Pediatrics. 2009

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Bermuda Breastfeeding Guidelines for Healthy Infants

Healthcare professionals and lay counsellors should guide and encourage women by recommending the following practices for successful breastfeeding. These practices follow recommendations by the World Health Organization (WHO) and guidelines produced by medical professional organizations involved in the care of women and children in the US, the United Kingdom and Canada, including the American Academy of Pediatrics, American College of Obstetricians and Gynecologists, NHS, Canadian Pediatric Society and Health Canada.

2. Perform all initial assessments on a healthy infant while infant is with the mother, preferably while infant is in contact with mothers skin. 3. Allow newborn to remain with the mother during the recovery period, unless the mothers or infants medical condition precludes this. 4. Encourage frequent feeds in first few days (eight to 12 times in 24 hours) after birth and inform mother about the benefits of colostrum and suckling. Identify a few measures of adequate feeding: WET DIAPERS: Expect one on day one and increasing by one for each day of life, until days three to five when they reach six urinations per day. STOOLING: After day four, expect three to four stools in a 24-hour period. Normal breastfed stools are yellow and loose (soft to watery, may be seedy or curdy) and there should be no meconium after day five. WEIGHT GAIN: Regain birth weight by two weeks. Educate mother about the early signs of hunger (increased alertness, mouthing or rooting, noting that crying is a late sign). 5. Mother should offer both breasts at every feed and allow the newborn to nurse as long as desired. The first breast offered at each feed should be alternated. 6. Supplements should not be given to a breastfeeding infant, including water, glucose water, formula or other fluids, unless medically indicated98102, and they rarely are. In the event supplements are medically indicated, efforts should be made to avoid bottle-feeding and artificial nipples. Alternate feeding methods such as cup, spoon, syringe or tube feeding are preferred. 7. Pacifiers and all artificial nipples should be avoided in healthy-term infants until breastfeeding is well established, approximately four weeks after birth103

11. If mother and baby need to be separated or if baby is not yet latching, educate mother on how to protect her milk supply by using a breast pump or hand expression. Provide a care plan that includes frequent pumping sessions. 12. Encourage mother to stay well hydrated and to rest when infant sleeps. Encourage mother to eat a healthy diet that includes a variety of foods. 13. Encourage mother to seek early advice on breastfeeding difficulties from a healthcare professional or breastfeeding support person such as a Community Health Nurse at the Department of Health (292-3095), the Maternity Unit (239-1325), an International Board Certified Lactation Consultant or La Leche League (2361120 or 541-6455)

WHO recommends infants be exclusively breastfed for the first six months of life to achieve optimal growth, development and health and recommends infants continue breastfeeding, along with nutritious, complementary foods, up to the age of two years91.
In addition, the Department of Health and Bermuda Hospitals Board support the International Code of the Marketing of Breastmilk Substitutes and its subsequent resolutions and encourage healthcare providers in Bermuda to adhere to these provisions 88-89.

Prenatally

Educate women about the benefits of breastfeeding for mother and child. Breastfeeding provides ideal food to support the healthy growth and development of infants. Breast milk promotes sensory and cognitive development, and protects against acute and chronic disease. Exclusive breastfeeding for about the first six months reduces the incidence of many illnesses in infants, including diarrhea15, pneumonia78, meningitis913, sudden infant death syndrome (SIDS)1418, otitis media1921 and diabetes mellitus Type 1 27-32. Children who were breastfed according to WHO guidelines have decreased risk for illness, including asthma2226 and Type 2 diabetes3334, and adults who were breastfed according to WHO guidelines have decreased rates of obesity3544, hypertension5456 cardiac disease4653 and Type 2 diabetes. Breastfeeding contributes to the health and well-being of mothers by reducing their risk of ovarian5766 and breast cancers6778, heart disease7981, diabetes7982 and osteoporosis8387. Provide information on the basic principles and techniques of breastfeeding: Proper latch-on and positioning techniques; supply helpful literature with photographs. Recognizing the earliest signs of hunger in baby (such as increased alertness, rooting and mouthing); encourage mother to follow babys cues. Emphasize the importance of breastfeeding frequently (eight to 12 times in a 24-hour period) in the first few weeks to establish milk supply and prevent engorgement. Avoid artificial nipples, bottles and pacifiers in the first month of breastfeeding.

Inform women about the normal variations in babies breastfeeding habits and about the individual experiences of breastfeeding. Assure mother that with information, encouragement and support from healthcare professionals, families and the community, she can successfully breastfeed. Particularly elicit the support of dads in encouraging breastfeeding. Encourage women to breastfeed exclusively for the first six months of life. Clarify that the maximum health benefits are conferred by exclusive breastfeeding, meaning breast milk onlyno water90, juice or other foods for about the first six months91. Vitamins or supplements are allowed as per the advice of the babys doctor. Inform women that medical professionals recommend breastfeeding continue after the introduction of solids at around six months and until baby is at least one year and longer, if mutually desired. Educate women about the many benefits of continued nursing for mothers and babies. Provide information on introducing complementary foods at around six months of age93 or when baby show several signs he/she is ready for solids9496. Such signs include: Baby can sit up without any support. Baby continues to be hungry despite more frequent nursing, which is unrelated to illness or teething. Baby has lost the tongue-thrusting reflex and does not push solids out of his/her mouth.

Avoiding Common Early Breastfeeding Difficulties: Prevention is the key!

Sore nipples: Slight soreness is normal initially and during the first few sucks of each feed in the early days of breastfeeding. Degree of soreness relates to many factors including hormonal issues, positional and latchon technique. Observation of technique and nipple health is essential to assist with this problem. Correct positioning and latch-on techniques are the cornerstones of initial management. Avoiding artificial nipples reduces chances of nipple confusion and improper latch-on habits, which can lead to soreness. In general, applying breast milk to nipples and allowing them to air dry is soothing to breasts in the early days. Lansinoh brand lanolin cream may be useful if soreness persists. Many other over-the-counter creams may not be safe for baby or helpful. Engorged breasts: Early, unrestricted breastfeeding reduces the chances of painful breast engorgement. It is especially important to promote babies breastfeeding as frequently as they desire in the first 48 hours of life, before the natural fullness and enlargement of breasts occurs due to milk production. The value of frequent, early feeds cannot be overstated (multiple health benefits for mother and baby). Allow baby to come off the breast naturally, before offering the second breast. This practice appears to reduce the incidence of painful engorgement. After day three or four, when milk production begins to transition from colostrum to mature milk, some initial discomfort is natural. If breasts become painfully engorged, assure proper latch-on and positioning by observing breastfeeding technique. Make adjustments as needed and encourage frequent feeding. Manually expressing a small amount of breast milk as needed may provide some relief. Applying cool compresses or raw cabbage leaves to the breasts between feeds also helps reduce discomfort. Leave cabbage leaves on for 20 minutes and use no more than three times per day; discontinue use after engorgement/oversupply subsides104.

8. Remind mother that some babies are sleepy and uninterested in feeding in the first few days. Encourage mother to check for wet diapers and whether baby is passing the meconium. If baby is sleeping and not feeding often and not producing wet diapers and/or passing the meconium, mothers should be encouraged to gently arouse the newborn to feed. 9. Formally evaluate breastfeeding technique at the bedside and document observations each day during hospital stay. Any problems identified should be addressed in hospital prior to discharge.

At Birth And Early Postpartum Period (First Two Weeks)

Baby can pick up things with his/her finger and thumb (pincer grasp).

1. Allow direct skin-to-skin contact97 with mother immediately after delivery and until first feeding has been accomplished.

First Weeks Of Life And Postpartum (Weeks Three To 12)

10. Reassure mother that fatigue and individual variations in breastfeeding patterns are normal. Remind her that it is not unusual for newborns to have a fussy period each day and that crying is babys way of communicating a variety of needs, not just hunger.

B E RM U DA B R E A STFEEDI N G GUI DELI N ES FO R HEALTHY I N FA N T S

BE RMUDA BR E ASTFE E D ING G UID E LINE S FOR H E ALTH Y INFANTS

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