Criteria for the 10 Steps and other components
The Global Criteria for the Baby-friendly Hospital Initiative serve as the standard for measuring adherence to each of the Ten Steps for Successful Breastfeeding and the International Code of Marketing of Breast-milk Substitutes. The criteria listed below for each of the Ten Steps and the Code are the minimum global criteria for baby-friendly designation. Additional criteria are provided for “mother-friendly care” and “HIV and infant feeding”. It is recommended that the criteria for “mother-friendly care” be implemented gradually, after maternity staff has received necessary training on this topic. Relevant decision-makers in each country should decide whether the criteria on HIV and infant feeding should be required, depending on the prevalence of HIV among women using the maternity facilities.
The BFHI Self-Appraisal Tool, presented in Section 4 of this series, gives maternity facilities a tool for making a preliminary assessment of whether they are fully implementing the Ten Steps, adhering to the International Code of Marketing, and meeting criteria related to mother-friendly care and HIV and infant feeding. The Global Criteria actually describe how “baby-friendliness” will be judged during the external assessment, and thus can be very useful for maternity staff to study as they work to get ready for assessment. The Global Criteria are listed both here and after the respective sections of the Self Appraisal Tool, for easy reference during self-appraisal.
It is important that the hospital consider adding the collection of statistics on infant feeding and implementation of the Ten Steps into its maternity record-keeping system, if it has not done so already. It is best if this data collection process be integrated into whatever information gathering system is already in place. If the hospital needs guidance on how to gather this data and possible forms to use, responsible staff can refer to the sample data-gathering tools available in Section 4.2: Guidelines and Tools for Monitoring BFHI.
STEP 1. Have a written breastfeeding policy that is routinely communicated to all health care staff
Global Criteria - Step One
The health facility has a written breastfeeding or infant feeding policy that addresses all 10 Steps and protects breastfeeding by adhering to the International Code of Marketing of Breast-milk Substitutes. It also requires that HIV-positive mothers receive counselling on infant feeding and guidance on selecting options likely to be suitable for their situations. The policy should include guidance for how each of the “Ten Steps” and other components should be implemented (see Section 4.1, Annex 1 for suggestions).
The policy is available so that all staff members who take care of mothers and babies can refer to it. Summaries of the policy covering, at minimum, the Ten Steps, the Code and subsequent WHA Resolutions, and support for HIV-positive mothers, are visibly posted in all areas of the health care facility which serve pregnant women, mothers, infants, and/or children. These areas include the labour and delivery area, antenatal care in-patient wards and clinic/consultation rooms, post partum wards and rooms, all infant care areas, including well baby observation areas (if there are any), and any special care baby units. The summaries are displayed in the language(s) and written with wording most commonly understood by mothers and staff.
STEP 2. Train all health care staff in skills necessary to implement the policy
Global Criteria - Step Two
The head of maternity services reports that all health care staff members who have any contact with pregnant women, mothers, and/or babies, have received orientation on the breastfeeding/infant feeding policy. The orientation that is provided is sufficient.
A copy of the curricula or course session outlines for training in breastfeeding promotion and support for various types of staff is available for review, and a training schedule for new employees is available.
Documentation of training indicates that 80% or more of the clinical staff members who have contact with mothers and/or infants and have been on the staff 6 months or more have received training at the hospital, prior to arrival, or though well-supervised self-study or on-line courses that covers all 10 Steps, the Code and subsequent WHA resolutions, mother-friendly care. It is likely that at least 20 hours of targeted training will be needed to develop the knowledge and skills necessary to adequately support mothers. At least three hours of supervised clinical experience are required.
Documentation of training also indicates that non-clinical staff members have received training that is adequate, given their roles, to provide them with the skills and knowledge needed to support mothers in successfully feeding their infants.
Training on how to provide support for non-breastfeeding mothers is also provided to staff. A copy of the course session outlines for training on supporting non-breastfeeding mothers is also available for review. The training covers key topics such as:
the risks and benefits of various feeding options;
helping the mother choose what is acceptable, feasible, affordable, sustainable and safe (AFASS) in her circumstances;
the safe and hygienic preparation, feeding and storage of breast-milk substitutes;
how to teach the preparation of various feeding options, and
how to minimize the likelihood that breastfeeding mothers will be influenced to use formula.
The type and percentage of staff receiving this training is adequate, given the facility’s needs
Out of the randomly selected clinical staff members*:
At least 80% confirm that they have received the described training or, if they have been working in the maternity services less than 6 months, have, at minimum, received orientation on the policy and their roles in implementing it.
At least 80% are able to answer 4 out of 5 questions on breastfeeding support and promotion correctly.
At least 80% can describe two issues that should be discussed with a pregnant woman if she indicates that she is considering giving her baby something other than breast milk.
Out of the randomly selected non-clinical staff members**:
At least 70% confirm that they have received orientation and/or training concerning the promotion and support of breastfeeding since they started working at the facility.
At least 70% are able to describe at least one reason why breastfeeding is important.
At least 70% are able to mention one possible practice in maternity services that would support breastfeeding.
At least 70% are able to mention at least one thing they can do to support women so they can feed their babies well.
- *
These include staff members providing clinical care for pregnant women, mothers and their babies.
- **
These include staff members providing non-clinical care for pregnant women, mother and their babies or having contact with them in some aspect of their work.
STEP 3. Inform all pregnant women about the benefits and management of breastfeeding
Global Criteria - Step Three
If the hospital has an affiliated antenatal clinic or an in-patient antenatal ward:
A written description of the minimum content of the breastfeeding information and any printed materials provided to all pregnant women is available.
The antenatal discussion covers the importance of breastfeeding, the importance of immediate and sustained skin-to-skin contact, early initiation of breastfeeding, rooming-in on a 24 hour basis, feeding on cue or baby-led feeding, frequent feeding to help assure enough milk, good positioning and attachment, exclusive breastfeeding for the first 6 months, the risks of giving formula or other breast-milk substitutes, and the fact that breastfeeding continues to be important after 6 months when other foods are given.
Out of the randomly selected pregnant women in their third trimester who have come for at least two antenatal visits:
At least 70% confirm that a staff member has talked with them individually or offered a group talk that includes information on breastfeeding.
At least 70% are able to adequately describe what was discussed about two of the following topics: importance of skin-to-skin contact, rooming-in, and risks of supplements while breastfeeding in the first 6 months.
STEP 4. Help mothers initiate breastfeeding within a half-hour of birth
This Step is now interpreted as:
Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour. Encourage mothers to recognize when their babies are ready to breastfeed and offer help if needed.
Global Criteria - Step Four
Out of the randomly selected mothers with vaginal births or caesarean sections without general anaesthesia in the maternity wards:
At least 80% confirm that their babies were placed in skin-to-skin contact with them immediately or within five minutes after birth and that this contact continued without separation for an hour or more, unless there were medically justifiable reasons.
(Note: It is preferable that babies be left even longer than an hour, if feasible, as they may take longer than 60 minutes to breastfeed).
At least 80% also confirm that they were encouraged to look for signs for when their babies were ready to breastfeed during this first period of contact and offered help, if needed.
(Note: The baby should not be forced to breastfeed but, rather, supported to do so when ready. If desired, the staff can assist the mother with placing her baby so it can move to her breast and latch when ready).
If any of the randomly selected mothers have had caesarean deliveries with general anaesthesia, at least 50% should report that their babies were placed in skin-to-skin contact with them as soon as the mothers were responsive and alert, with the same procedures followed.
At least 80% of the randomly selected mothers with babies in special care report that they have had a chance to hold their babies skin-to-skin or, if not, the staff could provide justifiable reasons why they could not.
Observations of vaginal deliveries, if necessary to confirm adherence to Step 4, show that in at least 75% of the cases babies are placed with their mothers and held skin-to-skin within five minutes after birth for at least 60 minutes without separation, and that the mothers are shown how to recognize the signs that their babies are ready to breastfeed and offered help, or there are justified reasons for not following these procedures.
STEP 5. Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants
Global Criteria - Step Five
The head of maternity services reports that mothers who have never breastfed or who have previously encountered problems with breastfeeding receive special attention and support both in the antenatal and postpartum periods.
Observations of staff demonstrating how to safely prepare and feed breast-milk substitutes confirm that in 75% of the cases, the demonstrations were accurate and complete, and the mothers were asked to give “return demonstrations”.
Out of the randomly selected clinical staff members:
At least 80% report that they teach mothers how to position and attach their babies for breastfeeding and are able to describe or demonstrate correct techniques for both or, if not, can describe to whom they refer mothers on their shifts for this advice.
At least 80% report that they teach mothers how to hand express and can describe or demonstrate an acceptable technique for this, or, if not, can describe to whom they refer mothers on their shifts for this advice.
At least 80% can describe how non-breastfeeding mothers can be assisted to safely prepare their feeds, or can describe to whom they refer mothers on their shifts for this advice.
Out of the randomly selected mothers (including caesarean):
At least 80% of those who are breastfeeding report that someone on the staff offered further assistance with breastfeeding within six hours of birth.
At least 80% of those who are breastfeeding report that someone on the staff offered them help with positioning and attaching their babies for breastfeeding.
At least 80% of those who are breastfeeding are able to demonstrate or describe correct positioning of their babies for breastfeeding.
At least 80% of those who are breastfeeding are able to describe what signs would indicate that their babies are attached and suckling well.
At least 80% of those who are breastfeeding report that they were shown how to express their milk by hand or given written information and told where they could get help if needed.
At least 80% of the mothers who have decided not to breastfeed report that they have been offered help in preparing and giving their babies feeds, can describe the advice they were given, and have been asked to prepare feeds themselves, after being shown how.
Out of the randomly selected mothers with babies in special care:
At least 80% of those who are breastfeeding or intending to do so report that they have been offered help to start their breast milk coming and to keep up the supply within 6 hours of their babies’ births.
At least 80% of those breastfeeding or intending to do so report that they have been shown how to express their breast milk by hand.
At least 80% of those breastfeeding or intending to do so can adequately describe and demonstrate how they were shown to express their breast milk by hand.
At least 80% of those breastfeeding or intending to do so report that they have been told they need to breastfeed or express their milk 6 times or more every 24 hours to keep up their supply.
STEP 6. Give newborn infants no food or drink other than breast milk, unless medically indicated
Global Criteria - Step Six
Hospital data indicate that at least 75% of the babies delivered in the last year have been exclusively breastfed or exclusively fed expressed breast milk from birth to discharge or, if not, that there were documented medical reasons.
Review of all clinical protocols or standards related to breastfeeding and infant feeding used by the maternity services indicates that they are in line with BFHI standards and current evidence-based guidelines.
No materials that recommend feeding breast milk substitutes, scheduled feeds or other inappropriate practices are distributed to mothers.
The hospital has an adequate facility/space and the necessary equipment for giving demonstrations of how to prepare formula and other feeding options away from breastfeeding mothers.
Observations in the postpartum wards/rooms and any well baby observation areas show that at least 80% of the babies are being fed only breast milk or there are acceptable medical reasons for receiving something else.
At least 80% of the randomly selected mothers report that their babies had received only breast milk or expressed or banked human milk or, if they had received anything else, it was for acceptable medical reasons, described by the staff.
At least 80% of the randomly selected mothers who have decided not to breastfeed report that the staff discussed with them the various feeding options and helped them to decide what was suitable in their situations.
At least 80% of the randomly selected mothers with babies in special care who have decided not to breastfeed report that staff has talked with them about risks and benefits of various feeding options.
STEP 7. Practice rooming-in - allow mothers and infants to remain together – 24 hours a day
Global Criteria - Step Seven
Observations in the postpartum wards and any well-baby observation areas and discussions with mothers and staff confirm that at least 80% of the mothers and babies are together or, if not, have justifiable reasons for being separated.
At least 80% of the randomly selected mothers report that their babies have been in the same room with them without separation or, if not, there were justifiable reasons.
STEP 8. Encourage breastfeeding on demand
Global Criteria - Step Eight
Out of the randomly selected breastfeeding mothers:
At least 80% report that they have been told how to recognize when their babies are hungry and can describe at least two feeding cues.
At least 80% report that they have been advised to feed their babies as often and for as long as the babies want or something similar.
STEP 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants
Global Criteria - Step Nine
Observations in the postpartum wards/rooms and any well baby observation areas indicate that at least 80% of the breastfeeding babies observed are not using bottles or teats or, if they are, their mothers have been informed of the risks.
Out of the randomly selected breastfeeding mothers:
At least 80% report that, as far as they know, their infants have not been fed using bottles with artificial teats (nipples).
At least 80% report that, as far as they know, their infants have not sucked on pacifiers.
STEP 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic
Global Criteria - Step Ten
The head/director of maternity services reports that:
Mothers are given information on where they can get support if they need help with feeding their babies after returning home, and the head/director can also mention at least one source of information.
The facility fosters the establishment of and/or coordinates with mother support groups and other community services that provide breastfeeding/infant feeding support to mothers, and can describe at least one way this is done.
The staff encourages mothers and their babies to be seen soon after discharge (preferably 2–4 days after birth and again the second week) at the facility or in the community by a skilled breastfeeding support person who can assess feeding and give any support needed and can describe an appropriate referral system and adequate timing for the visits.
A review of documents indicates that printed information is distributed to mothers before discharge, if appropriate, on how and where mothers can find help on feeding their infants after returning home and includes information on at least one type of help available.
Out of the randomly selected mothers at least 80% report that they have been given information on how to get help from the facility or how to contact support groups, peer counsellors or other community health services if they have questions about feeding their babies after return home and can describe at least one type of help that is available.
Compliance with the International Code of Marketing of Breast-milk Substitutes
Global Criteria – Code compliance
The head/director of maternity services reports that:
No employees of manufacturers or distributors of breast-milk substitutes, bottles, teats or pacifiers have any direct or indirect contact with pregnant women or mothers.
The hospital does not receive free gifts, non-scientific literature, materials or equipment, money, or support for in-service education or events from manufacturers or distributors of breast-milk substitutes, bottles, teats or pacifiers.
No pregnant women, mothers or their families are given marketing materials or samples or gift packs by the facility that include breast-milk substitutes, bottles/teats, pacifiers, other infant feeding equipment or coupons.
A review of the breastfeeding or infant feeding policy indicates that it uphold the Code and subsequent WHA resolutions by prohibiting:
The display of posters or other materials provided by manufacturers or distributors of breast-milk substitutes, bottles, teats and dummies or any other materials that promote the use of these products.
Any direct or indirect contact between employees of these manufacturers or distributors and pregnant women or mothers in the facility.
Distribution of samples or gift packs with breast-milk substitutes, bottles or teats or of marketing materials for these products to pregnant women or mothers or members of their families.
Acceptance of free gifts (including food), literature, materials or equipment, money or support for in-service education or events from these manufacturers or distributors by the hospital.
Demonstrations of preparation of infant formula for anyone that does not need them.
Acceptance of free or low cost breast-milk substitutes or supplies.
A review of records and receipts indicates that any breast-milk substitutes, including special formulas and other supplies, are purchased by the health care facility for the wholesale price or more.
Observations in the antenatal and maternity services and other areas where nutritionists and dieticians work indicate that no materials that promote breast-milk substitutes, bottles, teats or dummies, or other designated products as per national laws, are displayed or distributed to mothers, pregnant women, or staff.
Observations indicate that the hospital keeps infant formula cans and pre-prepared bottles of formula out of view unless in use.
At least 80% of the randomly selected clinical staff members can give two reasons why it is important not to give free samples from formula companies to mothers.
Mother-friendly care
Global Criteria – Mother-friendly care
(Note: These criteria should be required only after health facilities have trained their staff on policies and practices related to mother-friendly care).
A review of the hospital policies indicates that they require mother-friendly labour and birthing practices and procedures including:
Encouraging women to have companions of their choice to provide continuous physical and/or emotional support during labour and birth, as desired.
Allowing women to drink and eat light foods during labour, as desired.
Encouraging women to consider the use of non-drug methods of pain relief unless analgesic or anaesthetic drugs are necessary because of complications, respecting the personal preferences of the women.
Encouraging women to walk and move about during labour, if desired, and assume positions of their choice while giving birth, unless a restriction is specifically required for a complication and the reason is explained to the mother.
Care that does not involve invasive procedures such as rupture of the membranes, episiotomies, acceleration or induction of labour, instrumental deliveries, or caesarean sections unless specifically required for a complication and the reason is explained to the mother.
Out of the randomly selected clinical staff members:
At least 80% are able to describe at least two recommended practices and procedures that can help a mother be more comfortable and in control during labour and birth.
At least 80% are able to list at least three labour or birth procedures that should not be used routinely, but only if required due to complications.
At least 80% are able to describe at least two labour and birthing practices and procedures that make it more likely that breastfeeding will get off to a good start
Out of the randomly selected pregnant women:
At least 70% report that the staff has told them women can have companions of their choice with them throughout labour and birth and at least one reason it could be helpful.
At least 70% report that they were told at least one thing by the staff about ways to deal with pain and be more comfortable during labour, and what is better for mothers, babies and breastfeeding.
HIV and infant feeding (optional)
(Note: The national BFHI coordination group and/or other appropriate national decision-makers will determine whether or not maternity services should be assessed on whether they provide support related to HIV and infant feeding).
Global Criteria – HIV and infant feeding
The head/director of maternity services reports that:
The hospital has policies and procedures that seem adequate concerning providing or referring pregnant women for testing and counselling for HIV, counselling women concerning PMTCT of HIV, providing individual, private counselling for pregnant women and mothers who are HIV positive on infant feeding options, and insuring confidentiality.
Mothers who are HIV positive or concerned that they are at risk are referred to community support services for HIV testing and infant feeding counselling, if they exist.
A review of the infant feeding policy indicates that it requires that HIV-positive mothers receive counselling, including information about the risks and benefits of various infant feeding options and specific guidance in selecting the options for their situations, supporting them in their choices.
A review of the curriculum on HIV and infant feeding and training records indicates that training is provided for appropriate staff and is sufficient, given the percentage of HIV positive women and the staff needed to provide support for pregnant women and mothers related to HIV and infant feeding. The training covers basic facts on:
the risks of HIV transmission during pregnancy, labour and delivery and breastfeeding and its prevention;
the importance of testing and counselling for HIV;
local availability of feeding options;
the dangers of mixed feeding for HIV transmission;
facilities/provision for counselling HIV positive women on advantages and disadvantages of different feeding options; assisting them in exclusive breastfeeding or formula feeding (note: may involve referrals to infant feeding counsellors);
how to assist HIV positive mothers who have decided to breastfeed; including how to transition to replacement feeds at the appropriate time
how to minimize the likelihood that a mother whose status is unknown or HIV negative will be influenced to replacement feed.
A review of the antenatal information indicates that it covers the important topics on this issue. (these include the routes by which HIV-infected women can pass the infection to their infants, the approximate proportion of infants that will (and will not) be infected by breastfeeding; the importance of counselling and testing for HIV and where to get it; and the importance of HIV positive women making informed infant feeding choices and where they can get the needed counselling).
A review of documents indicates that printed material is available, if appropriate, on how to implement various feeding options and is distributed to or discussed with HIV positive mothers before discharge. It includes information on how to exclusively replacement feed, how to exclusively breastfeed, how to stop breastfeeding when appropriate, and the dangers of mixed feeding.
Out of the randomly selected clinical staff members:
At least 80% can describe at least one measure that can be taken to maintain confidentiality and privacy of HIV positive pregnant women and mothers.
At least 80% are able to mention at least two policies or procedures that help prevent transmission of HIV from an HIV positive mother to her infant during feeding within the first six months.
At least 80% are able to describe two issues that should be discussed when counselling an HIV positive mother who is deciding how to feed her baby.
Out of the randomly selected pregnant women who are in their third trimester and have had at least two antenatal visits or are in the antenatal in-patient unit:
At least 70% report that a staff member has talked with them or given a talk about HIV/AIDS and pregnancy.
At least 70% report that the staff has told them that a woman who is HIV-positive can pass the HIV infection to her baby.
At least 70% can describe at least one thing the staff told them about why testing and counselling for HIV is important for pregnant women.
At least 70% can describe at least one thing the staff told them about what women who do not know their HIV status should consider when deciding how to feed their babies.
Section 1.3 - Annex 1. Acceptable medical reasons for use of breast-milk substitutes
Preface
A list of acceptable medical reasons for supplementation was originally developed by WHO and UNICEF as an annex to the Baby-friendly Hospital Initiative (BFHI) package of tools in 1992.
WHO and UNICEF agreed to update the list of medical reasons given that new scientific evidence had emerged since 1992, and that the BFHI package of tools was also being updated. The process was led by the departments of Child and Adolescent Health and Development (CAH) and Nutrition for Health and Development (NHD). In 2005, an updated draft list was shared with reviewers of the BFHI materials, and in September 2007 WHO invited a group of experts from a variety of fields and all WHO Regions to participate in a virtual network to review the draft list. The draft list was shared with all the experts who agreed to participate. Subsequent drafts were prepared based on three inter-related processes: a) several rounds of comments made by experts; b) a compilation of current and relevant WHO technical reviews and guidelines (see list of references); and c) comments from other WHO departments (Making Pregnancy Safer, Mental Health and Substance Abuse, and Essential Medicines) in general and for specific issues or queries raised by experts.
Technical reviews or guidelines were not available from WHO for a limited number of topics. In those cases, evidence was identified in consultation with the corresponding WHO department or the external experts in the specific area. In particular, the following additional evidence sources were used:
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The Drugs and Lactation Database (LactMed) hosted by the United States National Library of Medicine, which is a peer-reviewed and fully referenced database of drugs to which breastfeeding mothers may be exposed.
- -
The National Clinical Guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn, review done by the New South Wales Department of Health, Australia, 2006.
The resulting final list was shared with external and internal reviewers for their agreement and is presented in this document.
The list of acceptable medical reasons for temporary or long-term use of breast-milk substitutes is made available both as an independent tool for health professionals working with mothers and newborn infants, and as part of the BFHI package. It is expected to be updated by 2012.
Acknowledgments
This list was developed by the WHO Departments of Child and Adolescent Health and Development and Nutrition for Health and Development, in close collaboration with UNICEF and the WHO Departments of Making Pregnancy Safer, Essential Medicines and Mental Health and Substance Abuse. The following experts provided key contributions for the updated list: Philip Anderson, Colin Binns, Riccardo Davanzo, Ros Escott, Carol Kolar, Ruth Lawrence, Lida Lhotska, Audrey Naylor, Jairo Osorno, Marina Rea, Felicity Savage, María Asunción Silvestre, Tereza Toma, Fernando Vallone, Nancy Wight, Anthony Williams and Elizabeta Zisovska. They completed a declaration of interest and none identified a conflicting interest.
Introduction
Almost all mothers can breastfeed successfully, which includes initiating breastfeeding within the first hour of life, breastfeeding exclusively for the first 6 months and continuing breastfeeding (along with giving appropriate complementary foods) up to 2 years of age or beyond.
Exclusive breastfeeding in the first six months of life is particularly beneficial for mothers and infants.
Positive effects of breastfeeding on the health of infants and mothers are observed in all settings. Breastfeeding reduces the risk of acute infections such as diarrhoea, pneumonia, ear infection, Haemophilus influenza, meningitis and urinary tract infection (1). It also protects against chronic conditions in the future such as type I diabetes, ulcerative colitis, and Crohn’s disease. Breastfeeding during infancy is associated with lower mean blood pressure and total serum cholesterol, and with lower prevalence of type-2 diabetes, overweight and obesity during adolescence and adult life (2). Breastfeeding delays the return of a woman’s fertility and reduces the risks of post-partum haemorrhage, pre-menopausal breast cancer and ovarian cancer (3).
Nevertheless, a small number of health conditions of the infant or the mother may justify recommending that she does not breastfeed temporarily or permanently (4). These conditions, which concern very few mothers and their infants, are listed below together with some health conditions of the mother that, although serious, are not medical reasons for using breast-milk substitutes.
Whenever stopping breastfeeding is considered, the benefits of breastfeeding should be weighed against the risks posed by the presence of the specific conditions listed.
INFANT CONDITIONS
Infants who should not receive breast milk or any other milk except specialized formula
Infants with classic galactosemia: a special galactose-free formula is needed.
Infants with maple syrup urine disease: a special formula free of leucine, isoleucine and valine is needed.
Infants with phenylketonuria: a special phenylalanine-free formula is needed (some breastfeeding is possible, under careful monitoring).
Infants for whom breast milk remains the best feeding option but who may need other food in addition to breast milk for a limited period
- □
Infants born weighing less than 1500 g (very low birth weight).
- □
Infants born at less than 32 weeks of gestation (very preterm).
- □
Newborn infants who are at risk of hypoglycaemia by virtue of impaired metabolic adaptation or increased glucose demand (such as those who are preterm, small for gestational age or who have experienced significant intrapartum hypoxic/ischaemic stress, those who are ill and those whose mothers are diabetic (5) if their blood sugar fails to respond to optimal breastfeeding or breast-milk feeding.
MATERNAL CONDITIONS
Mothers who are affected by any of the conditions mentioned below should receive treatment according to standard guidelines.
Maternal conditions that may justify permanent avoidance of breastfeeding
HIV infection
15: if replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS) (
6). Otherwise, exclusive breastfeeding for the first six months is recommended.
Maternal conditions that may justify temporary avoidance of breastfeeding
- □
Severe illness that prevents a mother from caring for her infant, for example sepsis.
- □
Herpes simplex virus type 1 (HSV-1): direct contact between lesions on the mother’s breasts and the infant’s mouth should be avoided until all active lesions have resolved.
- □
Maternal medication:
- –
sedating psychotherapeutic drugs, anti-epileptic drugs and opioids and their combinations may cause side effects such as drowsiness and respiratory depression and are better avoided if a safer alternative is available (7);
- –
radioactive iodine-131 is better avoided given that safer alternatives are available - a mother can resume breastfeeding about two months after receiving this substance;
- –
excessive use of topical iodine or iodophors (e.g., povidone-iodine), especially on open wounds or mucous membranes, can result in thyroid suppression or electrolyte abnormalities in the breastfed infant and should be avoided;
- –
cytotoxic chemotherapy requires that a mother stops breastfeeding during therapy.
Maternal conditions during which breastfeeding can still continue, although health problems may be of concern
- □
Breast abscess: breastfeeding should continue on the unaffected breast; feeding from the affected breast can resume once treatment has started (8).
- □
Hepatitis B: infants should be given hepatitis B vaccine, within the first 48 hours or as soon as possible thereafter (9).
- □
Hepatitis C.
- □
Mastitis: if breastfeeding is very painful, milk must be removed by expression to prevent progression of the condition(8).
- □
Tuberculosis: mother and baby should be managed according to national tuberculosis guidelines (10).
- □
Substance use16(11):
- –
maternal use of nicotine, alcohol, ecstasy, amphetamines, cocaine and related stimulants has been demonstrated to have harmful effects on breastfed babies;
- –
alcohol, opioids, benzodiazepines and cannabis can cause sedation in both the mother and the baby.
Mothers should be encouraged not to use these substances, and given opportunities and support to abstain.
References
- 1.
Technical updates of the guidelines on Integrated Management of Childhood Illness (IMCI) Evidence and recommendations for further adaptations. Geneva: World Health Organization; 2005.
- 2.
Evidence on the long-term effects of breastfeeding: systematic reviews and meta-analyses. Geneva: World Health Organization; 2007.
- 3.
- 4.
Resolution WHA39.28. Infant and Young Child Feeding; Thirty-ninth World Health Assembly; Resolutions and records. Final; Geneva. 5–16 May 1986; Geneva: World Health Organization; 1986. pp. 122–135. (WHA39/1986/REC/1), Annex 6.
- 5.
- 6.
HIV and infant feeding: update based on the technical consultation held on behalf of the Inter-agency Task Team (IATT) on Prevention of HIV Infection in Pregnant Women, Mothers and their Infants; Geneva. 25–27 October 2006; Geneva: World Health Organization; 2007. [accessed 23 June 2008].
http://whqlibdoc.who.int/publications/2007/9789241595964_eng.pdf.
- 7.
Breastfeeding and maternal medication: recommendations for drugs in the Eleventh WHO Model List of Essential Drugs. Geneva: World Health Organization; 2003.
- 8.
- 9.
Hepatitis B and breastfeeding. Geneva: World Health Organization; 1996. (Update No. 22)
- 10.
Breastfeeding and Maternal tuberculosis. Geneva: World Health Organization; 1998. (Update No. 23)
- 11.
Background papers to the national clinical guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn. NSW Department of Health; North Sydney, Australia: 2006. Commissioned by the Ministerial Council on Drug Strategy under the Cost Shared Funding Model.
http://www.health.nsw.gov.au/pubs/2006/bkg_pregnancy.html.
