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      <h1 id="top">6.2 Breastfeeding messages</h1>
      <div class="section" id="Baby_Friendly_Step_8"><h2>Baby Friendly Step 8</h2>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><h3></h3>
      <div><span style="font-weight: bold;"> Step 8 </span> of the Ten Steps to Successful Breastfeeding summarizes the basis of breastfeeding management in recognising an infant's total needs. It states:</div>
      <blockquote>
        <div>
          <span style="font-style: italic;">Encourage breastfeeding on demand.</span>
        </div>
      </blockquote>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
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      <div class="section" id="How_often_should_my_baby_breastfeed_"><h2>How often should my baby breastfeed?</h2>
    <div class="columns"><div class="column" style="width: 50%">
        <div>
          <p class="listTitle">Teach parents to recognize and respond promptly to early feeding cues:</p>
          <ul>
            <li>Early cues
						<ul><li>wriggling, moving arms or legs</li><li>rooting, fingers to mouth</li></ul>
					</li>
            <li>Mid cues
						<ul><li>fussing, squeaky noises</li><li>restless, crying intermittently</li></ul>
					</li>
            <li>Late cues
						<ul><li>full cry, aversive screaming pitch, turns red</li></ul>
					</li>
          </ul>
        </div>
      </div><div class="column" style="width: 50%">
        <div class="captionBox"><img width="300" height="193" src="images/baby_crying_bbc_web.jpg" alt="Newborn exhibiting a late feeding cue" /><p>Newborn exhibiting a late feeding cue</p></div>
      </div></div><br style="clear: both" />
    <div><p> A mother's unique breast capacity and rate of milk synthesis dictates how much milk she has available in the breast at each feed, and infant hunger dictates how much the baby will take at each feed. Neither of these factors are amenable to manipulation. </p><p> Kent et al (2006) <sup><a href="#note1">1</a></sup> in their study of 71 thriving, exclusively breastfed babies ranging in age from 1 to 6 months, found: </p><ul><li> they averaged 11 feeds (range 6 - 18) per 24 hrs. <br /> </li><li> 10 of the babies always fed from both breasts per feed; </li><li> 19 babies always fed from one breast per feed; </li><li> the <span style="font-weight: bold;"> majority </span> of babies sometimes fed from one and sometimes fed from both breasts; </li><li> 2/3 of babies fed at night, and consumed 20% of their total daily intake at this time. <br /> </li></ul> These researchers concluded that all mothers and babies are unique and mothers should respond to their babies' cues rather than striving to be <strong>average.</strong> <br /><br /></div>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/tip.png" class="icon" alt="" /><h3>What should I tell a mother?</h3>
      <div>Responding to her baby's early feeding cues will ensure baby is fed as often as necessary for her baby.</div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
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      <div class="section" id="Is_my_baby_getting_enough_breastmilk_"><h2>Is my baby getting enough breastmilk?</h2>
    <div>
      <p> Before you can answer this question you need to know how much breastmilk is normal at the various stages of lactation. The average is as follows:<sup><a href="#note1">1</a></sup> <sup><a href="#note2">2</a></sup> <sup><a href="#note3">3</a></sup> </p>
      <table class="grid">
        <thead>
          <tr>
            <th>Age of baby</th>
            <th>24hr volume</th>
            <th>Infant intake</th>
          </tr>
        </thead>
        <tfoot>
          <tr>
            <td colspan="3">Approximate conversion: divide millitres by 30 to obtain volume in ounces</td>
          </tr>
          <tr>
            <td colspan="3">
              <span style="font-weight: bold;">Note:</span>
              <br />
              <span style="font-style: italic;">Individual breastmilk intake (and therefore production) does not significantly change from Week 4 to 6 months of age</span>
            </td>
          </tr>
        </tfoot>
        <tbody>
          <tr class="row0">
            <th>Day One</th>
            <td>37ml (7 - 123ml)</td>
            <td>few drops - 5ml/feed</td>
          </tr>
          <tr class="row1">
            <th>Day Two</th>
            <td>84ml (44 - 335ml)</td>
            <td>5 - 15ml/feed</td>
          </tr>
          <tr class="row0">
            <th>Day Three</th>
            <td>408ml (98 - 775ml)</td>
            <td>15 - 30ml/feed</td>
          </tr>
          <tr class="row1">
            <th>Day Five</th>
            <td>705ml (452 - 876ml)</td>
            <td>depends on feeding frequency, volume available and infant appetite<br /></td>
          </tr>
          <tr class="row0">
            <th>1 - 6 months</th>
            <td>780ml (500 - 1350ml)</td>
            <td>30ml - 135ml/feed (6 - 18 feeds/day)</td>
          </tr>
        </tbody>
      </table>
    </div>
    <div>
      <p> The colostrum received by the baby in the first few days contains highly concentrated immunoglobulins and other protective factors (<a href="topic_1-2.html">1.2 Breastmilk Immunology</a>). Also, babies are usually born somewhat 'waterlogged' and therefore a few days of low oral intake assists the infant to clear the excess fluids. The baby is in more need of immunological protection than nutrition in the first few days. </p>
      <p> Physiologically the newborn's stomach is not able to hold volumes larger than this. At birth the gastric wall is non-compliant and non-relaxing, which, when combined with the hypomotility of the duodenum, results in early satiety and frequent regurgitation in the first few days.<sup><a href="#note4">4</a></sup> </p>
      <br />
    </div>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/books.png" class="icon" alt="" /><h3>Workbook Activity 6.3</h3><p>Complete Activity 6.3 in your workbook.</p></td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    <div><p> In the first 3 days postpartum it can be assumed that the intake is adequate if the baby is positioned well, latches well and suckling actively. After lactogenesis II (average range of clinical onset is 50-73 hrs postpartum <sup><a href="#note5">5</a></sup> ) it is essential that mothers know how to recognize signs that their baby is feeding well. <br /> </p> Teach mothers to: <ul><li> observe the sucking pattern. Baby should be seen to move from a quick suck:suck:suck pattern <span class="aside"> (a stimulation pattern) </span> to a slower suck:swallow:breathe:suck:swallow:breathe pattern <span class="aside"> (the nutritive pattern) </span> which is sustained for 2 to 3 minutes. Baby may pause after this and repeat the pattern again. Observation of this pattern confirms milk transfer is occurring. </li><li> after most feeds the baby will appear satiated </li><li> baby's mucous membranes will be moist </li><li> urine and stool output will indicate adequate intake (If it's coming out, it must have gone in!) <strong></strong> </li></ul> <table class="grid"><thead><tr><th> Age </th><th> Urine output </th><th> Stool output </th></tr></thead><tbody><tr class="row0"><th> 0 - 24 hours </th><td> one wet nappy/diaper </td><td> one or more meconium stools </td></tr><tr class="row1"><th> 24 - 48 hours </th><td> two wet nappies/diapers </td><td> one or more meconium stools/possible transitional stool <br /> </td></tr><tr class="row0"><th> 48 - 72 hours </th><td> three wet nappies/diapers </td><td> transitional stool </td></tr><tr class="row1"><th> from Day 4 onwards </th><td> 6 - 8 thoroughly wet nappies/diapers, with clear urine </td><td> soft, yellow, curdy (at least daily until about 6 weeks) </td></tr></tbody></table> <br /></div>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/tip.png" class="icon" alt="" /><h3>#1 Rule of infant output - If it's coming out it must have gone in!</h3>
      <div><span style="font-weight: bold;">It is important for parents to understand this concept</span>. Teach them that the volumes going in as intake will be reflected in output of urine and bowels. Describe the amounts that are displayed in the chart so that parents have a realistic expectation.<br /><p></p><p><span class="aside">Exception: the baby is being given fluids other than breastfeeding</span></p></div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/group.png" class="icon" alt="" /><h3>How do mothers receive this information?</h3>
      <div>
        <p> Is this information routinely given to ALL mothers? It is critical to the well-being of her baby. If you aren't able to identify when a mother has had this information discussed with her, form a group to develop a protocol to ensure this safeguard is put in place as soon as possible. </p>
      </div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>Is it the same for bottle-fed babies?</h3>
      <div>Yes, on the whole it is. All babies should be fed when they cue to feed, and be allowed to finish the feed when they choose to, ie. not forced to finish all the formula or breastmilk in the bottle.<br />Urine and stool output is also an excellent guide to intake sufficiency for babies fed with a bottle, though those receiving breastmilk substitutes will have a firmer stool and be prone to constipation.<br /></div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    <div class="section" id="Twins_or_more_"><h3>Twins, or more!</h3>
      <div>Like most mothers, mothers of multiples choose to breastfeed because breastmilk is known to provide better nutrition and health for their babies. Prenatal counseling of mothers of multiples significantly increases the initiation and duration of breastfeeding.<sup><a href="#note6">6</a></sup> Attendance at 'mothers of multiples' support group meetings is also associated with increasing the duration of breastfeeding.</div>
      <div class="section" id="Can_mothers_produce_enough_milk_for_multiples_"><h4>Can mothers produce enough milk for multiples?</h4>
        <div>Yes. The more often and effectively breastmilk is removed from the breast, the more milk will be produced. All mothers should be taught this principle, but it is even more relevant to the mother of multiples.<br /><br />Studies<sup><a href="#note7">7</a></sup> of milk production in mothers of multiples found that the mothers of exclusively breastfed three-month-old twins were producing between 2.2 - 3.4 litres (73 - 113oz.) of breastmilk per 24 hours, while a mother of exclusively breastfed 2½ month old triplets produced 3.08 litres (~103 oz). This compares with studies of breastmilk production for singletons of 750 to 1100 ml (25 - 36oz.) per 24 hours.<sup><a href="#note8">8</a></sup><br /></div>
      </div>
      <div class="section" id="Assisting_breastfeeding"><h4>Assisting breastfeeding</h4>
        <div>
          <p> There are several issues that should be addressed, namely education about breastfeeding, working with the mother to find the positions that work for her, discussing how she will cope with fatigue and the extra workload, and increasing her food intake to maintain her health. </p>
          <ul>
            <li> Find an appropriate long couch or bed that provides space on each side of the mother for her to place essentials or place a baby down while she is attending to another baby. </li>
            <li> Use a firm pillow or foam that will not sink during feeds. </li>
            <li> The newborn may perform better with breastfeeding if the mother feeds each baby individually during the early learning phase. This allows her the opportunity to bond and learn about each baby's breastfeeding needs and abilities. </li>
            <li> When breastfeeding two babies at the same time <ul><li> initially the mother will require competent assistance to help with positioning her babies, ensuring correct latch and effectiveness of feedings </li><li> the mother can first position and attach the baby who requires the most assistance, supporting him with one hand, then assist the more competent baby to attach </li><li> should one baby have a weaker suck, the milk ejection reflex will be stimulated by the other baby </li></ul> </li>
            <li> For triplets, two babies can be fed at the same time, then the third baby feeds from both breasts. At subsequent feeds the babies are rotated. </li>
            <li> Encourage the mother to ask for and accept help from family and friends who have offered assistance so she can concentrate on her task of breastfeeding and caring for the babies, and herself. </li>
          </ul>
        </div>
      </div>
      <div class="captionBox"><img width="396" height="284" src="images/twins_blog_lge.png" alt="Breastfeeding twins" /><p>Breastfeeding twins</p></div>
    </div>
  </div>
      <div class="section" id="When_should_I_begin_giving_baby_other_foods_"><h2>When should I begin giving baby other foods?</h2>
    <div class="section" id="Baby_Friendly_Point_5"><h3>Baby Friendly Point 5</h3>
      <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><h3></h3>
        <div><span style="font-weight: bold;">Point 5</span> of the Seven-Point Plan is concerned with maintaining <strong>exclusive</strong> breastfeeding until 6 months, and continued breastfeeding with the addition of appropriate complementary foods after 6 months of age. <br /></div>
        <blockquote>
          <div>
            <span style="font-style: italic;">Encourage exclusive and continued breastfeeding (beyond six months)(to two years), with appropriately timed introduction of (adequate and safe) complementary foods.</span>
            <br />
          </div>
        </blockquote>
      </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    </div>
    <div>The nutrient requirement of well, full term infants is met by exclusive breastfeeding for the first 6 months after birth. <p> Growth is generally not improved by complementary feeding before six months, even under optimal conditions, i.e., nutritious, microbiologically safe foods. Complementary foods introduced before six months displace the nutritionally superior breastmilk. Replacing even just some breastmilk too soon leads to nutritional deficits and growth faltering, as does not commencing appropriate complementary foods at the appropriate time for his needs. <sup><a href="#note9">9</a></sup> <br /> </p> <p> At around 6 months of age, most infant's energy needs for growth and development are beyond the provision of breastmilk alone and appropriate complementary foods will provide additional calories and nutrient for future growth. <br /> </p> <p> Also, developmental milestones also determine that the infant is not <span style="font-style: italic;"> functionally </span> ready to take complementary foods earlier than 6 months of age. At, or soon after 6 months, strengthening of the infant's musculature allows him to independently control his head and sit up. The development of fine motor coordination of more distal muscles, including the tongue and lips and their function of bringing in and manipulating more solid food in preparation for swallowing, is indicative of his ability to handle these foods at this age. <sup><a href="#note9">9</a></sup> </p> <p> Between 6 and 24 months of age is a critical time for promotion of optimal growth, health and behavioral development with longitudinal studies demonstrating this is the peak age for growth faltering, deficiencies of certain micronutrients, and common childhood illnesses. </p> <p class="listTitle"><span style="font-style: italic;"> The World Health Organisation <sup><a href="#note10">10</a></sup> </span> recommends the following guiding principles for appropriate complementary feeding to ensure nutritional wellbeing continues once complementary feeding begins: </p> <ul><li> continue frequent, on demand breastfeeding until two years old or beyond; </li><li> practise responsive feeding (e.g. feed infants directly and assist older children. Feed slowly and patiently, encourage them to eat but do not force them, talk to the child and maintain eye contact); </li><li> practise good hygiene and proper food handling; </li><li> start at six months with small amounts of foods and increase gradually as the child gets older; </li><li> gradually increase food consistency and variety; </li><li> increase the number of times that the child is fed, 2-3 meals per day for infants 6-8 months of age, and 3-4 meals per day for infants 9-23 months of age, with 1-2 additional snacks as required; </li><li> feed a variety of nutrient rich foods; </li><li> use fortified complementary foods or vitamin-mineral supplements, as needed; and </li><li> increase fluid intake during illness, including more breastfeeding, and offer soft, favourite foods. </li><br /> Eat daily: <ul><li> Meat, poultry, fish or eggs </li><li> Vitamin A-rich fruits and vegetables </li><li> Adequate fat content </li></ul> <p> A well-planned vegetarian diet that incorporates all macro- and micro-nutrients would be suitable. <sup><a href="#note11">11</a></sup> </p> <p> Avoid giving drinks with low nutrient value, such as tea, coffee and sugary drinks. Limit the amount of juice offered to avoid displacing more nutrient-rich breastmilk. </p> <table style="width: 573px; height: 263px;" class="grid"><thead><tr><th> Age </th><th> Texture </th><th> Frequency </th><th> Amount each meal </th></tr></thead><tfoot><tr><td colspan="4"> Adapted from: WHO 2005 </td></tr></tfoot><tbody><tr class="row0"><th> From 6 months </th><td> soft porridge, well mashed vegetables, fruit, meats </td><td> 2 times/day + frequent breastfeeds </td><td> 2 - 3 tablespoonfuls </td></tr><tr class="row1"><th> 7 - 8 months </th><td> mashed foods </td><td> 3 times/day + frequent breastfeeds </td><td> Increase gradually to 2/3 of a 250ml cup each meal </td></tr><tr class="row0"><th> 9 - 11 months </th><td> finely chopped or mashed foods &amp; foods baby can pick up </td><td> 3 meals + 1 snack between meals + breastfeeds </td><td> 3/4 of 250ml cup or bowl </td></tr><tr class="row1"><th> 12 - 24 months </th><td> Family foods, mashed if necessary </td><td> 3 meals + 2 snacks + continued breastfeeding </td><td> A full 250ml cup or bowl </td></tr></tbody></table> </ul></div>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/tip.png" class="icon" alt="" /><h3>Baby-led or mother-led eating?</h3>
      <div>Developed countries approach to complementary foods tends to be in a structured fashion of food preparation (puree or mash), mother-directed using a spoon. <br />This is not possible or practical in traditional cultures - the infant is directly involved in food time with the family.<br /><br />Finger foods can be offered to babies so that they can choose their own intake according to ability and needs. This is called <span style="font-style: italic;">Baby-led weaning</span>. A recent study<sup><a href="#note12">12</a></sup> showed significantly low levels of food restriction, no association with weight and reported to possibly have a positive effect on later eating habits and weight.<br /></div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
  </div>
      <div class="section" id="When_should_I_wean_my_baby_from_the_breast_"><h2>When should I wean my baby from the breast?</h2>
    <div>
      <p> Breastfeeding and breastmilk continues to provide protection and growth factors as well as being a quality food source for as long as the child is breastfed. There is no stage of lactation where breastmilk stops having these beneficial effects. </p>
      <p> The introduction of complementary foods from 6 months of age is the beginning of the weaning process. The weaning process can take as long as the mother and baby want it to take. The American Academy of Pediatrics recommends breastfeeding continue for at least the first 12 months of life and beyond with the addition of appropriate complementary foods from 6 months.<sup><a href="#note13">13</a></sup> The World Health Organisation recommends babies continue to receive breastmilk until at least their second birthday and beyond, with the addition of appropriate complementary foods from 6 months of age.<br /></p>
      <p> Despite this knowledge, the number of babies who are being exclusively breastfed at 6 months of age, and the number of babies receiving any breastmilk at 12 months of age is much less than it should be in most countries. </p>
    </div>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Weaning too early</h3>
      <div>Have you thought about how you could influence mothers in your area? <p> Brainstorm some ideas with your colleagues and implement them. Examples could be a poster that simply states &ldquo;<q>Breastmilk only to 6 months; Breastmilk plus family foods to 2+ years.</q>&rdquo; Sometimes a simple statement such as that is all the mother needs to know. However, you could also address education about artificial feeding and talk to mothers about the barriers they may see to continuing to provide breastmilk. </p></div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
  </div>
      <div class="section" id="What_should_I_remember_"><h2>What should I remember?</h2>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/remember.png" class="icon" alt="" /><h3></h3>
      <div>
        <ul>
          <li>The infant feeding cues.</li>
          <li>The variation in milk production and infant intake in the first 5 days.</li>
          <li>The expected infant output which indicates adequate intake.<br /></li>
          <li>How to teach mothers to recognise milk transfer.</li>
          <li>Expectations for mothers about the frequency of breastfeeding.</li>
        </ul>
      </div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
  </div>
      <div class="section" id="Self-test_quiz"><h2>Self-test quiz</h2>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><h3></h3>
      <div></div><div class="activity" id="activity_rr">
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	new MCQ('A mother of a healthy, thriving two week old baby asks you how often her baby should be breastfeeding. Which of the following is the best response?', [{text:'Just keep doing what you\'re doing. Baby is growing well.',feedback:'While that is reassuring to the mother, she has asked you because she wants some further guidance.',score:0},{text:'Babies of this age should be breastfeeding about 8 to 10 times in 24 hours.',feedback:'Really? But that doesn\'t take into consideration her breastmilk storage capacity, or the baby\'s individual needs.',score:0},{text:'Listen to your baby. Babies will indicate a need to breastfeed by crying.',feedback:'This cue is much too late - the mother should respond before the baby gets to this stage.',score:0},{text:'Every baby and mother is different. Follow your baby\'s feeding cues, feeding him as soon as you see him wriggling or bringing his hand to his mouth.',feedback:'Yes, that encourages the mother to observe her baby, getting to know his needs. You\'d also describe normal output so that she is reassured he is getting plenty of breastmilk.',score:1}]),
	new MCQ('Several weeks later the mother tells you she must be separated from her baby for 24 hours when he is two months old. She wants to know how much breastmilk she should leave for him. What will you tell her?', [{text:'Bring baby in to the clinic just before you go away. We\'ll weigh him then work out how much he should have.',feedback:'No. This is outdated thinking. Breastfed babies don\'t significantly increase their intake of breastmilk between the first and sixth months despite gaining lots of weight in that time.',score:0},{text:'Well, if he was artificially feeding he\'d be having about 120 ml (4 ounces) 6 or 7 times a day. Use that as a guide.',feedback:'This suggestion is unhelpful and probably harmful.',score:0},{text:'Breastfed babies average about 800ml (27 ounces) in 24 hours. Aim for that amount and a little extra. If you can express another 30 - 60ml (ounce or two) it should be plenty.',feedback:'That\'s correct. And it\'s only for one day, so it\'s not critical that she gets it exactly right.',score:1},{text:'Express as much milk as you can between now and then. We don\'t know how much breastfed babies take, so have some artificial infant formula for back-up.',feedback:'This suggestion is unhelpful and portrays health provider approval of artificial feeding which is likely to influence her long-term breastfeeding intention.',score:0}]),
	new MCQ('Many mothers are concerned they don\'t know if their baby is getting enough breastmilk. Which one of the following points is likely to hinder a mother\'s confidence and knowledge about her baby\'s adequate intake?', [{text:'bringing the baby to the clinic to be weighed frequently',feedback:'Frequent weighing is more likely to worry the mother than reassure her; and only tells her in retrospect if baby is receiving enough breastmilk and doesn\'t teach her about making her own observations.',score:1},{text:'watching the baby\'s feeding pattern move from a quick suck/suck to the slower sucking and swallowing which is sustained for a couple of minutes every breastfeed',feedback:'This is a good point. The mother can see and hear that the baby is swallowing breastmilk.',score:0},{text:'the infant will appear settled, with moist mucous membranes after most breastfeeds',feedback:'Infants who have breastfed well appear calm and sleep well. Moist mucous membranes is good to look for but if they\'re not it\'s a late sign that breastfeeding is not going well.',score:0},{text:'the infant\'s output will be plentiful - nappies/diapers soaked with clear urine, frequent copious stool output.',feedback:'You\'ll definitely discuss this. This sign is evident at every nappy/diaper change (...what comes out, must have gone in). A deviation away from this is the first sign that intake is inadequate.',score:0}]),
	new MCQ('The father of a 3-month old breastfed baby mentions he\'s looking forward to being able to feed the baby too and asks when he can start. How will you respond?', [{text:'Your baby is not old enough for food yet. You could help by changing diapers/nappies or giving him a bath.',feedback:'Perhaps not an exciting proposition for him and perhaps this comment indicated that he may not be capable of participating in the feeding.',score:0},{text:'Yes it is fun to give the baby other foods. You could do it now if you like, but he\'ll only push the food out with his tongue as he isn\'t ready yet.',feedback:'This advice is wrong and dangerous as it could cause the baby to aspirate food.',score:0},{text:'Yes that\'s a great way for you to help by being involved in the feeding, and you will also have fun with your baby. At around 6 months, he\'ll be able to sit well and be developed enough to be ready for foods.',feedback:'This is the best of the responses, but you could probably think of better ways to phrase it to maintain the father\'s enthusiasm.',score:1},{text:'Babies shouldn\'t be started on solids until they are 6 months old. How would you feel about giving your baby a bottle of breastmilk to let his mother sleep longer some nights?',feedback:'While this suggestion does maintain the desired exclusive breastfeeding until 6 months, the unnecessary introduction of a bottle could cause some babies suck confusion, and the mother will still need to wake up to pump her milk to prevent engorgement. Other ways for the father to be involved in baby care are preferred.',score:0}]),
	new MCQ('For how long is the mother\'s breastmilk of benefit to her child? How long will you recommend that mothers continue to breastfeed their baby?', [{text:'Breastmilk no longer meets an infant\'s needs after 6 months and weaning can occur any time after that.',feedback:'No, that\'s wrong. Breastmilk will provide nutritional and immunological protection to the baby for as long as he receives it, and he needs it until at least his second birthday.',score:0},{text:'Breastmilk continues to provide nutritional and immunological protection to the baby for as long as he receives it. Breastfeeding should continue with the addition of complementary foods from 6 months until at least the end of baby\'s second year.',feedback:'Yes, that\'s correct. The timing of weaning is recommended by the World Health Organisation.',score:1},{text:'The first 3 months of breastfeeding is the most important, but even to encourage the mother to give colostrum is better than nothing.',feedback:'Breastmilk NEVER becomes unimportant, or \'less\' important. The breastfed child should be in a nutritionally and immunologically sound position by two years of age and healthy enough to maintain his condition without breastmilk.',score:0},{text:'Breastmilk is the best milk for babies. The duration of breastfeeding is a decision she should make according to how it fits into her lifestyle.',feedback:'Does the baby have any rights in this decision? It\'s the baby\'s health that will be MOST affected by the mother\'s decision. Most mothers want to do what is best for their babies and therefore you should discuss with her the effects of premature weaning.',score:0}])
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    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
  </div>
      <div id="footnotes">
        <h3>Notes</h3>
        <ol>
          <li id="note1"><a href="references.html#kent06" title="See full details">#</a> Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day</li>
          <li id="note2"><a href="references.html#rior05" title="See full details">#</a> Riordan J (2005) Breastfeeding and Human Lactation</li>
          <li id="note3"><a href="references.html#sain84" title="See full details">#</a> Saint L et al. (1984) The yield and nutrient content of colostrum and milk of women from giving birth to 1 month post-partum</li>
          <li id="note4"><a href="references.html#zang01" title="See full details">#</a> Zangen S et al. (2001) Rapid maturation of gastric relaxation in newborn infants</li>
          <li id="note5"><a href="references.html#pere01" title="See full details">#</a> Perez-Escamilla R et al. (2001) Validity and public health implications of maternal perception of the onset of lactation: an international analytical overview</li>
          <li id="note6"><a href="references.html#frie04a" title="See full details">#</a> Friedman S et al. (2004) The effect of prenatal consultation with a neonatologist on human milk feeding in preterm infants.</li>
          <li id="note7"><a href="references.html#sain86" title="See full details">#</a> Saint L et al. (1986) Yield and nutrient content of milk in eight women breast-feeding twins and one-woman breast-feeding triplet.</li>
          <li id="note8"><a href="references.html#kent04" title="See full details">#</a> Kent JC et al. (2004) Frequency, volume and fat content of breastfeeds of exclusively breastfed babies</li>
          <li id="note9"><a href="references.html#whor01" title="See full details">#</a> World Health Organization (2001) Report of the expert consultation of the optimal duration of exclusive breastfeeding</li>
          <li id="note10"><a href="references.html#who10" title="See full details">#</a> World Health Organisation (2010) Infant and young child feeding - Fact sheet N,.342</li>
          <li id="note11"><a href="references.html#amit10" title="See full details">#</a> Amit M (2010) Vegetarian diets in children and adolescents.</li>
          <li id="note12"><a href="references.html#brow10" title="See full details">#</a> Brown A et al. (2010) Maternal Control of Child Feeding During the Weaning Period: Differences Between Mothers Following a Baby-led or Standard Weaning Approach.</li>
          <li id="note13"><a href="references.html#aapp05" title="See full details">#</a> AAP Policy Statement, Section on Breastfeeding (2005) Breastfeeding and the Use of Human Milk</li>
        </ol>
      </div>
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    <div id="menu">
      <h1>Breastfeeding Essentials</h1>
      <ol>
        <li>1.0 <a href="topic_1-0.html">Why Breastfeeding is Important</a><ol><li>1.1 <a href="topic_1-1.html">Biochemistry</a></li><li>1.2 <a href="topic_1-2.html">Immunology</a></li><li>1.3 <a href="topic_1-3.html">Relative risks</a></li></ol></li>
        <li>2.0 <a href="topic_2-0.html">Communication Skills</a><ol><li>2.1 <a href="topic_2-1.html">Non-verbal</a></li><li>2.2 <a href="topic_2-2.html">Listening skills</a></li><li>2.3 <a href="topic_2-3.html">Building confidence</a></li><li>2.4 <a href="topic_2-4.html">An example</a></li></ol></li>
        <li>3.0 <a href="topic_3-0.html">Pregnancy Care</a><ol><li>3.1 <a href="topic_3-1.html">The feeding decision</a></li><li>3.2 <a href="topic_3-2.html">The barriers</a></li><li>3.3 <a href="topic_3-3.html">Physical preparation</a></li></ol></li>
        <li>4.0 <a href="topic_4-0.html">The Birth Experience</a><ol><li>4.1 <a href="topic_4-1.html">The first hours</a></li><li>4.2 <a href="topic_4-2.html">Labor interventions</a></li><li>4.3 <a href="topic_4-3.html">Postnatal interventions</a></li></ol></li>
        <li>5.0 <a href="topic_5-0.html">Breastfeeding the Baby</a><ol><li>5.1 <a href="topic_5-1.html">Positioning Principles</a></li><li>5.2 <a href="topic_5-2.html">Breastmilk transfer</a></li><li>5.3 <a href="topic_5-3.html">Assessing breastfeeding</a></li></ol></li>
        <li>6.0 <a href="topic_6-0.html">A time to learn</a><ol><li>6.1 <a href="topic_6-1.html">Practical skills</a></li><li class="current">6.2 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><a href="topic_6-2.html">Breastfeeding messages</a></li><li>6.3 <a href="topic_6-3.html">Normal growth</a></li><li>6.4 <a href="topic_6-4.html">Sleep</a></li><li>6.5 <a href="topic_6-5.html">Psychological support</a></li><li>6.6 <a href="topic_6-6.html">Discharge planning</a></li></ol></li>
        <li>7.0 <a href="topic_7-0.html">Infant Challenges</a><ol><li>7.1 <a href="topic_7-1.html">Late preterm infant; Non-latching</a></li><li>7.2 <a href="topic_7-2.html">Hypoglycemia; Jaundice</a></li><li>7.3 <a href="topic_7-3.html">Supplementation</a></li><li>7.4 <a href="topic_7-4.html">Crying baby</a></li><li>7.5 <a href="topic_7-5.html">Inadequate weight gain</a><ol><li>7.5.1 <a href="topic_7-5-1.html">Feeding-line device at the breast</a></li><li>7.5.2 <a href="topic_7-5-2.html">Cup feeding</a></li><li>7.5.3 <a href="topic_7-5-3.html">Finger Feeding</a></li><li>7.5.4 <a href="topic_7-5-4.html">Bottle feeding</a></li></ol></li></ol></li>
        <li>8.0 <a href="topic_8-0.html">Maternal Challenges</a><ol><li>8.1 <a href="topic_8-1.html">Engorgement</a></li><li>8.2 <a href="topic_8-2.html">Nipple Pain</a></li><li>8.3 <a href="topic_8-3.html">Breast Problems</a></li><li>8.4 <a href="topic_8-4.html">Insufficient breastmilk</a></li><li>8.5 <a href="topic_8-5.html">Medical, Surgical Issues</a></li></ol></li>
        <li>9.0 <a href="topic_9-0.html">Promotion, Protection and Support</a><ol><li>9.1 <a href="topic_9-1.html">The International Code of Marketing of Breastmilk Substitutes</a></li><li>9.2 <a href="topic_9-2.html">The Baby Friendly Initiative</a></li><li>9.3 <a href="topic_9-3.html">Young Child Feeding</a></li><li>9.4 <a href="topic_9-4.html">Local initiatives</a></li><li>9.5 <a href="topic_9-5.html">Infant feeding in emergencies</a></li></ol></li>
        <li>10.0 <a href="topic_10-0.html">Closing session</a><hr /></li>
        <li class="appendix"> <a href="references.html">List of references</a></li>
        <li class="appendix"> <a href="contents.html">Course contents</a></li>
        <li class="appendix"> <a href="full.html">Print version</a></li>
      </ol>
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