World Breastfeeding Week is celebrated every 1-7 August with annual themes including healthcare systems, women and work, the community support, ecology, economy, science and education. This year, for World Breastfeeding Week 2021, World Alliance for Breastfeeding Action (WABA) has selected the theme: Protect Breastfeeding: A Shared Responsibility. The theme is aligned with thematic area 2 of the WBW-SDG 2030 campaign which highlights the links between breastfeeding and survival, health and wellbeing of women, children and nations.

WABA states that this year’s objectives are to:

• Inform people about the importance of protecting breastfeeding.
• Anchor breastfeeding support as a vital public health responsibility.
• Engage with individuals and organizations for greater impact. 
• Galvanize action on protecting breastfeeding to improve public health.

Pregnancy and lactation are an especially vulnerable time for working women and their families. Expectant and nursing mothers require special protection to prevent harm to their or their infants' health, and they need adequate time to give birth, to recover, and to nurse their children. At the same time, they also require protection to ensure that their jobs are not jeopardized because of pregnancy or maternity leave.

 Maternity Protection is key to enable breastfeeding and empower parents for a successful implementation of recommended breastfeeding practices. PAHO/WHO recommends that countries must implement and reinforce the International Code of Marketing of Breast-milk Substitutes at all levels. It is vital to ensure that breastfeeding mothers do not get targeted by the industry, marketing or public health professional who want to jeopardize their breastfeeding by promoting formula-feeding.

Seeing Maiduguri Project as Nutrition Project, Breastfeeding plays important roles as this was concerned observed when the HP team did assessment in December 2020: When respondent were asked if they exclusively breastfeed for 6 months, 64% said they exclusively breastfeed while 36% said they don’t breastfeed exclusively for six months.

It was also observed from the assessment that most caregivers stopped breastfeeding as soon as they get pregnant leaving the breastfeeding child at risk of not feeding well, Birth spacing is very poor in Borno state in general as almost all the caregivers are either breastfeeding or pregnant.

As soon as the mother is pregnant or given birth to child, attention is being shifted to the pregnancy or the new born baby, no wonder most of the our patients are either last born or the second to the last born, 69% are last born where most of the mothers are pregnant, 17% are the second to the last born, while 14% are the other order of birth. 86% of the patients are either last born or second to the last which might be attributed to less care from the mother due to lack of birth spacing and improper breastfeeding coupled with lack of food.

The HP team chose 3^rd of August as the major day of celebration as other days until 7^th will continue celebration at mini level stressing on the below messages on breastfeeding.

The celebration took place in Nilefa Kiji, Kushari Community and Outreach respectively.

 

-         Messages for Under 6 Months -

Importance of exclusive breastfeeding during the first 6 months

·      Exclusive breastfeeding means feeding your baby only with breast milk for the first 6 months

o   It is important to breastfeed on demand, both day and night, which means feeding your baby every time he cries or shows other signs of being hungry such as sucking on your fingers or clothes. If a baby does not “demand” the breast, he should be fed at least every three hours.

o   Breast milk provides all the food and water that your baby needs during the first 6 months of life if you feed on demand. Even during very hot weather, breast milk will satisfy your baby’s thirst if you feed your baby on demand

o   Do not give anything else, not even water, during your baby’s first 6 months. Other food and liquids can make your baby sick in a way breast milk will not. You can give medicines if they are recommended by your health provider.

o   This constant suckling will keep a steady supply of breast milk (it is a supply and demand system)

o   Exclusive breastfeeding for the first 6 months protects your baby from many illnesses, such as diarrhea and respiratory infections

o   Breastfeeding encourages mother-child bonding

o   Breastfeeding can help stop or reduce bleeding which may occur from the vagina after birth

·      Mixed feeding means feeding your baby both breast milk and any other foods or liquids, including infant formula, animal milks, or water

o   Giving your baby anything else other than breast milk before 6 months will cause him to suckle less and will reduce the amount of breast milk that you produce

o   Water, other liquids and foods can make the baby sick, especially with diarrhea which can be very dangerous for young babies

o   Mixed feeding increases the chances that your baby will suffer from illnesses such as diarrhea and pneumonia, and from malnutrition

o   Mixed feeding reduces the protection that exclusive breastfeeding gives, and all of the benefits that your baby gets from your breast milk

What can you do to get more breast milk? 

·      Try to have, as much as possible, a balanced diet

·      Drink a lot of water (minimum 3 liters per day, even more when very hot weather)

·      Allow your baby to nurse as often as possible on both breasts for at least 20 minutes. The fact that the child is sucking will improve the milk production

Feeding the sick baby less than 6 months of age

·      Breastfeed more frequently during illness, including diarrhea, to help the baby fight illness, reduce the chances of weight loss and recover more quickly

·      Breastfeeding also provides comfort to your sick baby. If your baby refuses to breastfeed, encourage your baby until he takes the breast again

·      Give only breast milk and medicines recommended by your health care provider

·      After each illness, increase the frequency of breastfeeding to help your baby regain health and weight

·      When you are sick, continue to breastfeed your baby. It will help the baby to be protected against your infection. It will never make the baby fall sick. If the baby gets sick it is not because of the breast milk but because of transmission through air or dirty hands. You may need extra food and support during this time.

 

Messages Starting at 6 Months -

Starting complementary feeding when baby reaches 6 months

·      At 6 months, your baby needs other foods in addition to breast milk (now breast milk alone is not enough to keep the baby healthy and strong)

·      Continue breastfeeding your baby on demand both day and night

·      6 - 7 months:

o   You should continue breastfeeding while feeding your baby complementary food like mashed vegetables and fruit

o   No salt, spices, onions or garlic in your baby’s food

·      7 - 10 months:

o   Continue breastfeeding your baby and giving him mashed vegetables and fruit

o   Introduce semi solid food like rice, potatoes (well cooked) bread in your baby’s diet

o   No salt, spices, onions or garlic in your baby’s food

·      10 - 24 months:

o   Continue breastfeeding your baby and giving him vegetables/fruit + semi solid foods

o   Introduce animal food (eggs, chicken, fish, meat) in your baby’s diet

o   Give your baby a variety of food (from the 3 groups of food: energy giving, body building and protective) every day

·      You should continue breastfeeding until your child is two years old if possible

·      Breast milk continues to be the most important part of your baby’s diet : breastfeed first before giving other foods

 

-         General Breastfeeding Messages -

 

Benefits of Breastfeeding and Breast Milk:

• Contains all the nutrients that a child of 6 month’s needs (after 6 months, breast milk is not enough but still good to develop the immunity)
• Contains antibody: protection against infections
• Always available
• Always at the great temperature
• Free
• Clean
• Easier to digest
• Creates bond between mom and baby

We can still breastfeed:

·         If we are sick (exception of HIV)*  (see PMCTC section)

·         If pregnant

 

Not enough milk? Probably problem of aspiration:

·         Malformation of the mouth

·         Wrong position

·         Baby too weak 

 

What to do to increase the production of the milk?

·                     To have a balanced diet

·                     Drink a lot of water

·                     Enough rest

• To put the baby the maximum on the breast (kangaroo care)

 

Breast Feeding Positions:

• There are different ways to position your baby:
• Cradle position (most commonly used).
• Cross-cradle position (good for small babies).
• Side-lying position (use to rest while breastfeeding and at night).
• Under-arm position (use after caesarean section, if your nipples are painful, or if you are breastfeeding twins or a small baby).
• It is important to find the position that is comfortable for you and your baby
• If a position is painful, stop and try again in a new position
• Stimulate your baby by touching his feet or hands if he stops sucking
• After feeding the baby, don't let him lie on the bed but take him in your arms to digest. On the bed he will be vomiting.
• Avoid jiggling the baby, but give little rubs and pats on the shoulder

 

Balanced Diet- Nutrition of the Mother (essential diet and liquid in-take while breastfeeding):

Keep a healthy diet

•          Eat at least 3 meals a day (morning, noon and evening).

•          Eat lot of energy food (bread, rice,...) and protection food (vegetable and fruits).

•          Eat also but in smaller quantity body building food (meat, eggs,...).

•          Avoid eating too much sugar and oil (fried food, biscuits,...)

 

Drink lots of clean water everyday

•          Drink at least 2 liters of water per day

•          Drinking lots of water helps to produce breast milk

 

Take your child immediately to a trained health worker or clinic if any of the following symptoms are present:

• Refusal to feed and being very weak.

• Vomiting (cannot keep anything down).

• Diarrhoea (more than three loose stools a day for two days or more and/or blood in the stool, sunken eyes).

• Convulsions (rapid and repeated contractions of the body, shaking).

• The lower part of the chest sucks in when the child breathes in, or it looks as though the stomach is moving up and down (respiratory infection).

• Fever (possible risk of malaria).

• Malnutrition (loss of weight or swelling of the body).

 

Danger Signs of Malnutrition

·         Malnutrition is a serious medical condition that develops if a child is given food that lacks adequate nutrients – insufficient proportion of carbohydrates, vitamins, proteins and fats.  Kwashiorkor and Marasmus are two forms of severe malnutrition

 

·         SIGNS OF KWASHIORKOR

o   Oedema, - swelling of the body with pitting on both feet, is a sign that a child is developing a condition called Kwashiorkor.

o   Thin, sparse and pale hair which easily falls out

o   Dry, scaly skin especially on the arms and legs; skin of the child  may start peeling off.

o   A puffy or "moon" face.

o   A child who has Kwashiorkor doesn't like to eat or play.

 

·         SIGNS OF MARASMUS

• A child who has Marasmus is wasted (low weight for height); very thin with no fat, “skin and bones”
• Little or no fat on buttocks; in extreme cases there are many folds of skin on the buttocks and thighs which looks like baggy pants
• The face of a child who has Marasmus looks like that of an old person.
• A child who has Marasmus has a distended or protruding stomach.

 

 

-         Specific Breast Feeding Methods & Techniques–

Double Suckling Technique

• What: Some babies need supplementary milk because the mother is not currently producing enough OR the baby is too weak to suck the milk out of the mother’s breast.  In this case, you should ALWAYS use the double suckling technique.
• HOW? To perform this technique, the tip of an NG tube is placed at the caregiver’s nipple, and the other end of tube is placed in a cup with therapeutic milk.  The cup is placed 20 cm below infant’s mouth (to make the baby suck to get milk to flow).
• WHY? Gives the baby enough milk, stimulates the breast milk production and stimulates proximity between mother and child

 

Kangaroo Mother Care

• What: Kangaroo Mother Care (KMC) is a medical method of skin-to-skin care because it provides warmth, safety and food
• WHO?  KMC is for babies with low birth weight (LBW), preterm infants, and/or sick term infants
• KMC is made up of 4 separate components; position, nutrition, discharge and support
• Position: Place the baby between breasts in an upright position.  Turn the head to the side; in a slightly extended position (mother should sleep slightly elevated).  Avoid forward flexion and hyperextension of the neck.  The infant should be in a flexed position – legs and arms. Secure the baby with a binder/wrap, additional blanket covering if needed.  The baby should wear a nappy, socks and hat.
• Support: Health care staff support in hospital to encourage and motivate mother and from Family at home to continue KMC
• Discharge:  Helps speed up discharge (less time spent in hospital).  Less dependency on technology, more efficient use of staffing for sicker children, improved morale and quality of care, and better survival.
• Benefits: KMC benefits both baby and mother. 
• Baby: The baby benefits because of effective thermal control, and a thermal synchrony develops between mother and baby.  The infant is also much less stressed and this provides neurological protection to the infant; less impact of painful procedures, improved neurodevelopment, better organizes sleep patterns, and more mature and organized electrical brain activity.
• Mother: The mother gains confidence in caring for her infant, there is an improvement in mother and infant bonding due to physical closeness, the mother is empowered to play an active role in infant’s care, enables the mother to become primary care giver, and promotes breast feeding.

 

 Re-lactating mothers or wet nurses (in case of orphan babies)

• What: For establishing lactation in woman who is not currently lactating

• Who: any woman who has been pregnant in the past
• How: suckling 8-10 times per day
• How long: several days / even 2 weeks or more
• Infants can be initially fed with a breast milk substitute using supplementary suckling technique

 

-         Prevention of Mother-to-Child Transmission (PMTCT) of HIV -

[For Mothers who ask about risks of breast feeding][i]

• Risks for a woman is HIV-infected to pass HIV to her baby if NO preventative actions are taken:
• A woman infected with HIV can pass HIV to her baby during pregnancy, labour, delivery, or through breastfeeding.
•  However, not all babies born to women with HIV become infected with HIV.
• If NO preventive actions are taken to prevent or reduce HIV transmission, out of every

100 HIV-infected women who become pregnant, deliver, and breastfeed for up to two years, about 35 of them will pass HIV to their babies:

®     25 babies may become infected with HIV during pregnancy, labour, and delivery.

®     10 babies may become infected with HIV through breastfeeding, if the mothers breastfeed their babies for up to two years. 

o   The other 65 women will NOT pass HIV to their babies.

• All women with HIV should prevent HIV re-infection by practising safer sex. This means

using condoms during pregnancy and during breastfeeding. Becoming re-infected with HIV while pregnant or breastfeeding greatly increases the risk of mother-to-child transmission of HIV.

• All breastfeeding mothers infected with HIV should seek immediate help or treatment at their nearest health facility if they have any infections or breast problems.
• They should not feed from a breast with a cracked or bleeding nipple until the problem is resolved, but should feed from the other breast. If a mother sees redness in or around her baby’s mouth, or white spots, she should take her baby to the health facility immediately.
• Breastfeeding mothers who are HIV-positive should eat an extra meal a day to give them extra energy.

 

• Risks of a woman who is HIV-infected  passing HIV to her baby if both take ARVs and practise exclusive breastfeeding during the first 6 months:[ii]

o   A woman infected with HIV should be given special medicines (called antiretroviral drugs or ARVs) to decrease the risk of passing HIV to her infant during pregnancy, birth, or breastfeeding.

o   A baby born to a woman who is HIV-infected should also receive special medicines (ARVs) to decrease the risk of getting HIV during the breastfeeding period.

o   Throughout the entire period of breastfeeding, antiretroviral drugs are strongly recommended for either the HIV-infected mother or her HIV-exposed infant.

o    If an HIV-infected mother and her baby practice exclusive breastfeeding during the first 6 months and either the mother or baby takes ARVs throughout the breastfeeding period, the risk of infection greatly decreases.

o   If these preventive actions are taken, out of every 100 HIV-infected women who become pregnant, deliver, and breastfeed for at least one year, fewer than five of them will pass HIV to their babies:

®     Two babies may become infected with HIV during pregnancy, labour, and delivery.

®     Three babies may become infected with HIV through breastfeeding.

o  More than 95 of these women will NOT pass HIV to their babies.

 

·         Exclusively breastfeed and take ARVs[iii]

o   An HIV-infected mother should talk with a health worker at her health facility about how to feed her baby.

o   Exclusive breastfeeding (giving ONLY breastmilk) for the first 6 months together with special medicines (ARVs) for either mother or baby greatly reduces the chance of HIV passing from an HIV-infected mother to her baby.

o   When an HIV-infected mother exclusively breastfeeds, her baby receives all the benefits of breastfeeding, including protection from diarrhoea and other illnesses.

o   Mixed feeding (feeding baby both breastmilk and any other foods or liquids, including infant formula, animal milks, or water) before 6 months greatly increases the chances of an HIV-infected mother passing HIV to her baby.

o   Mixed feeding can cause damage to the baby’s stomach. This makes it easier for HIV and other diseases to pass into the baby.

o   Mixed feeding also increases the chance of the baby dying from other illnesses such as diarrhoea and pneumonia because he or she is not fully protected through breastmilk and the water and other milks or food can be contaminated.

o   If an HIV-infected mother develops breast problems, she should seek advice and treatment immediately. She may be encouraged to express and heat-treat her breastmilk so that it can be fed to her baby while she is recovering.

o   HIV-exposed babies should be tested when they are about 6 weeks old.

o   All babies who test positive at 6 weeks should breastfeed exclusively until 6 months, even in the absence of ARV interventions, and then continue to breastfeed for up to 2 years or longer. Complementary foods should be introduced at 6 months, as recommended.

o   All breastfeeding babies who test negative at 6 weeks should continue to exclusively breastfeed until 6 months and continue to breastfeed until 12 months. Complementary foods should be introduced at 6 months, as recommended.

o   After 12 months, breastfeeding should stop. However, abrupt stopping of breastfeeding should be avoided. It should be gradually stopped over the course of one month.

 

• For a woman who decides not to follow the national recommendation to breastfeed[iv]

o   Infant feeding recommendations are given to the mother at health facility.

o   Exclusive replacement feeding (giving ONLY infant formula) for the first 6 months

eliminates the chance of passing HIV through breastfeeding.

o   Replacement feeding is also accompanied with provision of ARVs for the mother (at least

one week after birth) and the infant (for six weeks after birth).

o   Maintaining the mother’s central role in feeding her baby is important for bonding and

may also help to reduce the risks in preparation of replacement feeds.

o   Mixed feeding (feeding baby both breastmilk and any other foods or liquids, including infant formula, animal milks, or water) before 6 months greatly increases the chances of an HIV-infected mother passing HIV to her baby.

o   Mixed feeding is always dangerous for babies less 6 months. A baby less than 6 months has immature intestines. Other food or drinks than breastmilk can cause damage to the baby’s stomach. This makes it easier for HIV and other diseases to pass to the baby.

o   Support the mother to feed her child:

®     No mixed feeding.

®     No dilution of formula.

®     Help mother read instructions on formula tin.

®     Feed the baby with a cup.

o   Discard additional commercial infant formula left over after one meal.

o   Baby should be given clean water in addition to commercial infant formula.

o   Refer to health facility if her baby gets sick with

 

• Conditions needed to use commercial infant formula[v]

[For mothers who decided at the health facility to opt out of breastfeeding + ARVs]

o   Talk with a health worker at your health facility about how to feed your baby.

o   Wash hands with soap and water before preparing formula and feeding baby.

o   Make sure to get enough supplies for the baby’s normal growth and development until he or she reaches at least 6 months.

®     A baby needs about 44 tins of 450 g in formula for the first 6 months.

®     A baby needs about 50 tins of 400 g in formula for the first 6 months.

o   Always read and follow the instructions that are printed on the tin very carefully. Ask for more explanation if you do not understand.

o   Use clean water to mix with the infant formula. If you can, prepare the water that is

needed for the whole day. Bring the water to a rolling boil for at least two minutes and then pour into a flask or clean, covered container specially reserved for boiled water.

o   Keep or carry boiled water and infant formula powder separately to mix for the next feeds, if the mother is working away from home or for night feeds.

o   Wash the utensils with clean water and soap, and then boil them to kill the remaining germs.

o   Use only a clean spoon or cup to feed the baby. Even a newborn baby learns quickly how to drink from a cup. Do not use bottles, teats, or spouted cups.

o   Store the formula tin in a safe, clean place.           

o   Only prepare enough infant formula for one feed at a time, and use the formula within one hour of preparation.

o   DO NOT reintroduce breastfeeding: avoid any mixed feeding.

 

 

• Non-breastfed child from 6 up to 24 months[vi]

[Only for non-breastfed children who are between 6 and 24 months]

o   A minimum of two cups of milk each day is recommended for all children under 2 years of age who are no longer breastfeeding.

o   This milk can be either commercial infant formula, that is prepared according to directions, or animal milk, which should always be boiled for children who are less than 12 months old. It can be given to the baby as a hot or cold beverage, or can be added to porridge or other foods.

o   Fresh animal milk should always be boiled for children who are less than 12 months old.

o   All children need complementary foods from 6 months of age.

o   The non-breastfed child from 6 up to 9 months needs the same amount of food and snacks as the breastfed child of the same age plus one extra meal plus two cups of milk each day (one cup = 250 ml).

o   The non-breastfed child from 9 up to 12 months needs the same amount of food and snacks as the breastfed child of the same age plus two extra meals plus two cups of milk each day.

o   The non-breastfed child from 12 up to 24 months needs the same amount of food and snacks as the breastfed child of the same age plus two extra meals plus two cups of milk each day.

o   After 6 months, also give two to three cups of water each day, especially in hot climates.

 

 

-         Wet Nursing (Under 6 Months)  -

-        ONLY for orphans less than 6 months of age is admitted in the TFC who is not being breastfed OR a child less than 6 months of age that is admitted in the TFC and medical staff confirms that the caregiver cannot breastfeed.    

Note: Fori Criteria is 2 months – 10 years.  Staff will not focus on wet nursing for children 6 months and above.

 

-          There are circumstances which make breastfeeding difficult, for instance in cases of orphans where the mother is absent, or mother’s medical inability to provide breast milk to her child. In these situations, an alternative feeding plan must be arranged for the child to receive optimal nourishment; wet nursing or artificial milk.

 

-          If caregiver is willing to wet nurse, she will first do HIV Counseling and Testing.  If she is found eligible by the medical staff for breastfeeding, the Caregiver breastfeeds child (with support of HP, Nutritional assistant, Nurse, Doctor)

 

• Messages for Caregiver Positive/Child Negative Cases:
• Messages for Caregiver Positive/Child Positive Cases:
• Messages for Caaregiver Negative/Child Positive
• Messages for Caregiver Negative/Child Negative Cases:

 

References