1.5BABY-FRIENDLY EXPANSION AND INTEGRATION POSSIBILITIES

Publication Details

Over the last 15 years of work on BFHI, many lessons have been learned. Perhaps the clearest lesson is the need for more attention to Step 10 and the community. A second pressing issue has been the need to rectify the misunderstandings concerning the appropriateness of BFHI in the context of the HIV pandemic. Other issues that have arisen and have been addressed in some countries include:

  • the need to ensure mother-friendly care;
  • breastfeeding supportive paediatric care;
  • mother and baby-friendly NICUs;
  • mother and baby-friendly physician’s offices;
  • and last, but by no means least, the need for the mother of the exclusively breastfed child to be supported to understand the need for the age-appropriate addition of complementary foods after 6 months.

Current trends in health system and related planning indicate the need for increased flexibility, integration, and complementarity among interventions. For this reason, and to aid countries in creating synergy in their programmes and in actively addressing identified issues, a variety of alternative approaches are now included in the BFHI materials. These expansion and integration options are intended to create the possibility for more creative and supportive mother and baby-friendly care.

Presented below are a few of the many variations that have been tried around the world in order to bring truly baby-friendly care to all.

Baby-friendly communities: Creating Step Ten

Step 10, of all of the Ten Steps, has not achieved full implementation in a wide variety of settings, although many options are suggested, including mother-to-mother or peer groups, organised support by certified lactation consultants, regular outreach by the maternity staff especially in the first days postpartum, referral to community-based primary health care centres with specialized training, hotlines, etc. Efforts to date have not been optimal due to a variety of factors, not the least of which is that facility-based personnel may simply not have the skills to create community mobilization. In addition, often there is reliance on volunteers to carry out ongoing activities, so it is necessary to have regular refreshers and support activities for ongoing motivation and communication.

Perhaps of most relevance to reaching the most vulnerable populations is the reality that most deliveries in developing countries occur in the communities and even the initial baby-friendly care may not be in place.

A new initiative – Baby-friendly Communities – has been developed in some countries, and can serve as a model

  1. for expanding BFHI practices and criteria into community health services,
  2. for expanding BFHI practices into delivery settings where there are no community health services, and
  3. for strengthening the vital tenth step in ensuring best practices and support for every mother.

Suggestions for development and content of national criteria that could be applied in these three situations are presented below:

Suggested National Baby-friendly Community components: provided for community discussion, reflecting on all applicable Global Criteria for the BFHI (the Ten Steps)

The development of the criteria should include the participation and commitment of:

  1. Community political and social leadership, both male and female, who are committed to making a change in support of optimal infant and young child feeding.
  2. All health facilities that include maternity services, or local health care provision, especially those that are already designated “baby-friendly” and actively support both early and exclusive breastfeeding (0–6 months).
  3. If home deliveries are the norm, all who assist in these deliveries.

Locally developed criteria should specify that :

  1. All who assist in facility-based or home deliveries are informed concerning mother-friendly labour and birthing practices such as encouraging mothers to have companions to provide support, minimizing invasive procedures unless medically necessary, encouraging women to move about and assume positions of their choice during labour, etc. (see “mother-friendly” section) and are informed concerning the importance of delayed cord cutting, immediate skin-to-skin continued for at least 60 minutes, and no prelacteal feeds.
  2. Community access to referral site(s) with skilled support for early, exclusive and continued breastfeeding is available.
  3. Support is available in the community for age-appropriate, frequent, and responsive complementary feeding with continued breastfeeding. This will generally mean that there is availability of micronutrients or animal-based foods and adequate counselling to assist mothers in making appropriate choices.
  4. Mother-to-mother support system, or similar, is in place.
  5. No practices, distributors, shops or services violate the International Code (as applicable) in the community.
  6. Local government or civil society has convened, created and supports implementation of at least one political or social normative change and/or additional activity that actively supports mothers and families to succeed with immediate and exclusive breastfeeding practices (e.g. time-sharing of tasks, granting authority to transport breastfeeding mothers for referral if needed, identification of “breastfeeding advocates/protectors” among community leaders, breastfeeding supportive workplaces, etc.).

In addition, simplified job-aids for assisting and for assessing home deliveries (including those performed by skilled midwives and, if possible, traditional birth attendants), should be developed, are available and are in use.

Example from Gambia

An excellent example of an innovative approach to this problem and its solution is found in the “The Baby Friendly Community Initiative (BFCI) – An Expanded Vision for Integrated Early Childhood Development in the Gambia”. The full text of this document will be available on the UNICEF website.

In summary, BFHI was used as the model for the development of the Baby-friendly Community Initiative (BFCI). The BFCI includes 10 steps to successful infant feeding incorporating maternal nutrition, infant nutrition, environmental sanitation and personal hygiene. In other settings, safe delivery or child and maternity protection might have greater relevance. In Gambia, communities identified 5 women and 2 men each, to be trained and certified “Village Support Groups on Infant Feeding”. When the 10 steps developed by the community are implemented, the community is designated a “Baby-friendly Community”.

Training of community representatives as Village Support Groups on infant feeding was considered the most important element of the BFCI. Men’s involvement in the BFCI both as members of the Support Groups and as part of the target population may also be a crucial element for success and sustainability of the intervention. Their involvement in an area, which in the past targeted only women, sent out a clear and strong message that maternal and infant nutrition concerned both men (fathers) and women (mothers).

World Breastfeeding Week may be used as an entry point to bring together targeted politicians, Senior Government and NGO officials, as well as international Agencies for sensitization to create better understanding of the importance of breastfeeding, what has already occurred in country, and what may be possible, and create a cadre of high level support.

In Gambia, such a meeting led to recommendations:

  1. intensified information, education and communication (IEC) activities to eradicate taboos and other traditional practices, which affect the practice of optimal breastfeeding;
  2. inclusion of breastfeeding in the curricula of schools and training institutions;
  3. setting up of support groups on breastfeeding;
  4. extended maternity leave for working mothers;
  5. development of breastfeeding policies;
  6. similar seminars at the regional and community levels;
  7. the implementation of the Baby-friendly Hospital Initiative; and
  8. ensuring community involvement.

The results of this approach in Gambia were an increase from 60% to 100% in initiation of breastfeeding in the first day of life, and a decline in introduction of complementary feeding at four months of age from 90% to nearly 0%.

In Gambia, the BFHI also helped introduce other community based services that meet the needs of infants and young children are vital to many health, growth and development intervention approaches, including bed nets, HIV/AIDS awareness, immunization support, and reproductive health care. The approach promotes and protects the rights of the child to survival, growth and development.

The Ten Steps to Successful Breastfeeding in the Community: The Gambia’s Baby-friendly Community Initiative

Every village should have an enabling environment for mothers to practice optimal breastfeeding. Therefore, a trained Village Support Group on infant feeding:

  1. Informs and advises all pregnant and lactating women and their spouses on the importance of an adequate maternal diet using locally available foods by explaining the benefits to both maternal and infant health.
  2. Informs all pregnant women and their spouses about the benefits of breast milk including colostrum.
  3. Advises and encourages mothers to initiate breastfeeding within an hour after birth and not to give any prelacteal feeds unless on the advice of a medical personnel.
  4. Informs both mothers and fathers about the benefits of exclusive breastfeeding and encourages all mothers of healthy newborns to breastfeed exclusively for six months.
  5. Informs both mothers and fathers about the hazards and cost of bottle-feeding, the use of formula and the use of pacifiers (comforters).
  6. Ensures that orphans get breast milk by encouraging the traditional practice of wet nursing for babies who have lost their mothers at birth.
  7. Advises and encourages mothers to introduce locally available complementary foods when the infant is six months of age.
  8. Advises and encourages all mothers to use fermented cereal in the preparation of the complementary feeding by telling them about the benefits.
  9. Teaches all mothers and caregivers about the benefits of adequate personal hygiene and environmental sanitation to infant health, including the basic principles for the preparation of safe foods for infants and young children.
  10. Encourages mothers to support each other to practice optimal breastfeeding by forming their own informal support groups on infant feeding.

BFHI and Prevention of Mother-to-Child Transmission (PMTCT) of HIV/AIDS

The WHO/UNICEF guidance on infant feeding support for HIV-positive mothers strongly suggest that training on support for exclusive breastfeeding precede training on feeding options for HIV-positive mothers. For this reason, Malawi, among other countries, has decided that BFHI must be in place at the same time as the initiation of counselling for the HIV-positive mothers.

The rationale is at least 3-fold:

  1. Since exclusive breastfeeding is an option for all mothers, the establishment of excellence in support of exclusive breastfeeding will benefit all.
  2. For HIV-positive mothers for whom replacement feeding in not acceptable, feasible, affordable, sustainable and safe, exclusive breastfeeding is the recommended option.
  3. If all counsellors understand the importance of exclusive breastfeeding, spill over and over use of artificial foods will be reduced.
  4. Recent research findings indicate that exclusive breastfeeding may reduce the passage of HIV via breast milk, when compared to mixed feeding.

If this last item is proven to be consistent in additional studies, then exclusive breastfeeding among the greater population of HIV-infected women who have not been diagnosed as yet will provide a double benefit.

Mother-baby-friendly facilities

The Mother-friendly Childbirth Initiative includes the “Ten Steps of the Mother-friendly Childbirth Initiative for mother-friendly Hospitals, Birth Centres, and Home Birth Services” and can be initiated in concert with baby-friendly initiatives and as an integrated mother-baby aspect of a maternal-child care continuum.

The Mother-friendly Childbirth Initiative was initially developed in 1996 by the Coalition for Improving Maternity Services (CIMS) with the First Consensus Initiative. CIMS is a coalition of individuals and national organizations with concern for the care and well-being of mothers, babies, and families. The mission is to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs. This evidence-based mother-, baby-, and family-friendly model focuses on prevention and wellness as the alternatives to high-cost screening, diagnosis, and treatment programs. The suggested “Ten steps” is based on the recognition that some current maternity and newborn practices both contribute to high costs and inferior outcomes, such as inappropriate application of technology and routine procedures that are not based on scientific evidence. The principles of this approach is respect for the normalcy (i.e., non-medical) of the birthing process, the autonomy and empowerment of the woman, caregiver responsibility and doing “no harm”.

The Mother-baby-friendly Ten Steps presented here are modified to allow integration with current continuum of care approaches.

Suggested Mother-baby-friendly Ten Steps for consideration in developing national criteria in coordination with baby-friendly

A mother-baby-friendly hospital, birth centre, or home birth:

  1. Provides or refers for antenatal care, including vitamin/iron/folate supplementation, malaria prophylaxis, HIV-testing, monitoring for danger signs, and referral where appropriate.
  2. Offers all birthing mothers:
    -

    Unrestricted access to the birth companions of her choice, including fathers, partners, children, family members, and friends.

    -

    Unrestricted access to continuous emotional and physical support from a skilled woman-for example, a doula or labour-support professional.

    -

    Access to the best available care, preferably skilled assistance and access to timely referral as needed.

    -

    The freedom to walk, move about, and assume the positions of her choice during labour and birth (unless restriction is specifically required to correct a complication), and discourages the use of the lithotomy18 position.

  3. Maintains records to allow for external and self-assessment and reporting purposes.
  4. Provides culturally competent care - that is, care that is sensitive and responsive to the specific beliefs, values, and customs of the mother’s ethnicity and religion.
  5. Has clearly defined policies and procedures for:
    -

    Clean birthing techniques.

    -

    Delayed cord clamping.

    -

    Placenta removal and disposal.

    -

    Collaboration, consultation and referral with other maternity services, including maintaining communication with all caregivers when referral/transfer is necessary.

    -

    Linking the mother and baby to appropriate community resources, including prenatal and post-discharge follow-up and breastfeeding support.

  6. Does not routinely employ practices and procedures that are unsupported by scientific evidence, including but not limited to the following:
    -

    Shaving; enemas; IVs (intravenous drip); withholding nourishment; early rupture of membranes; electronic fetal monitoring.

    Other interventions are limited as follows:
    -

    Has an induction rate of 10% or less.

    -

    Has an episiotomy rate of 20% or less, with a goal of 5% or less.

    -

    Has a total caesarean rate of 10% or less in community hospitals, and 15% or less in tertiary care (high-risk) hospitals.

    -

    Has a VBAC (vaginal birth after caesarean) rate of 60% or more with a goal of 75% or more.

  7. Educates staff in non-drug methods of pain relief and does not promote the use of analgesic or anaesthetic drugs not specifically required to correct a complication.
  8. Encourages all mothers and families, including those with sick or premature newborns or infants with congenital problems, to touch, hold, breastfeed, and care for their babies to the extent compatible with their conditions.
  9. Has training in haemorrhage control, both manual and medical.
  10. Strives to achieve the WHO-UNICEF Ten Steps of the Baby-friendly Hospital Initiative to promote successful breastfeeding.
18

To lie flat on back with legs elevated

Key aspects of “mother-friendly care” have been integrated into the revised 20-hour course, Global Criteria and assessment process for BFHI, as an optional module. This provides countries with an easy way to begin the process of integrating mother-friendly childbirth practices into their maternity services, if they do not yet have a full-fledged initiative of the type described above.

Baby-friendly neonatal intensive care and paediatric units

Whereas BFHI is maternity based, its impact in support of post-discharge breastfeeding is limited to its community outreach – Step Ten. Therefore, the concept of baby-friendly paediatrics was considered. The following 10 steps are derived from the suggested 11 Steps developed in Australia19 and are built upon the BFHI:

10 Steps to Optimal Breastfeeding in Paediatrics

  1. Have a written breastfeeding policy and train staff in necessary skills.
  2. When an infant is seen, for either a well visit or due to illness, ascertain the mother’s infant feeding practices, and assist in establishment or management of breastfeeding as needed.
  3. Provide parents with written and verbal information about breastfeeding.
  4. Facilitate unrestricted breastfeeding or, if necessary, milk expression for mothers regardless of the child’s age.
  5. Give breastfed children other food or drink only when age appropriate or when medically indicated, and if medically indicated, use only alternative feeding methods most conducive to return to breastfeeding.
  6. If hospitalization is needed, ensure facility allows 24-hours mother/child rooming in.
  7. Administer medications and schedule procedures so as to cause the least possible disturbance of feeding.
  8. Maintain a human milk bank, according to standards.
  9. Provide information and contacts concerning community support available.
  10. Maintain appropriate monitoring and records/data collection procedures to permit quality assurance assessment, progress rounds or staff meetings, and feedback.

The issue of transitioning the baby from an NICU setting to home is also extremely important. Items to include in consideration of baby-friendly treatment of the premature or ill infant should include criteria or standards for care, discharge planning, post-discharge assessment, and special support for mothers.

The Academy for Breastfeeding Medicine, International, in cooperation with US Department of Health and Human Services, WHO and UNICEF, has developed many protocols that may serve as a basis for national development of criteria for Baby-friendly Paediatrics or Baby-friendly NICUs. These protocols are posted and updated regularly. ABM is dedicated to continuing the development and dissemination of these standards for practice on their website: http://www.bfmed.org/protocols.html.

Baby-friendly physician’s office: Optimizing care for infants and children

This guidance is derived from the ABM draft protocol which is available in full on their website. This is presented for consideration in the development of criteria for Baby-friendly Physician Offices.

Issues to consider in developing criteria for Baby-friendly physician offices20

  1. Establish a written breastfeeding friendly office policy and inform all new staff about the policy.
  2. Encourage breastfeeding mothers to exclusively breastfeed. Instruct mother not to offer bottles or a pacifier till breastfeeding is well established.
  3. Offer culturally and ethnically competent care.
  4. Offer a prenatal visit and show your commitment to breastfeeding during this visit.
  5. Collaborate with local hospitals and maternity care professionals in the community. Convey to delivery rooms and newborn units your office policies on breastfeeding initiation.
  6. Schedule a first follow-up visit 48–72 hours after hospital discharge or earlier if breastfeeding related problems, such as excessive weight loss (>7%) or jaundice are present at the time of hospital discharge.
  7. Ensure availability of appropriate educational resources for parents. Educational material should be non-commercial and not advertise breast milk substitutes, bottles and nipples.
  8. Do not interrupt or discourage breastfeeding in the office. Allow and encourage breastfeeding in the waiting room. Ensure an office environment that demonstrates breastfeeding promotion and support.
  9. Develop and follow triage protocols to address breastfeeding concerns and problems.
  10. Commend breastfeeding mothers during each visit for choosing and continuing breastfeeding.
  11. Encourage mothers to exclusively breastfeed for 6 months and continue breastfeeding with complementary foods until at least 24 months and thereafter as long as mutually desired. Discuss introduction of solid food at 6 months of age, emphasizing the need for high-iron solids and assess for need for vitamin D supplementation.
  12. Have a written breastfeeding policy and provide a lactation room with supplies for your employees who breastfeed or express breast milk at work. Encourage community employers and day care providers to support breastfeeding.
  13. Acquire or maintain a list of community resources and support local breastfeeding support groups.
  14. Work with insurance companies to encourage coverage of breast pump costs and lactation support services.
  15. All clinicians and physicians should receive education regarding breastfeeding. Volunteer to let medical students and residents rotate in your practice. Participate in medical student and resident physician education. Encourage establishment of formal training programs in lactation for future and current healthcare providers.
  16. Monitor breastfeeding initiation and duration rates in your practice, and analyse what additional changes can be made to enhance your support for optimal infant and young child feeding.
20

Modified from ABM Protocol.

Baby-friendly complementary feeding

Breastfeeding and complementary feeding are a continuum; consideration of one must include consideration of the other. As the name indicates, “complementary” feeding is a complement to breastfeeding. Complementary feeding is essential for continued growth after 6 months of age. New recommendations for the addition of first foods into the diet emphasize protein and micronutrients in addition to energy needs.

The Ten Guiding Principles of Complementary Feeding serve as a guide for feeding behaviours, and as BFHI is integrated with other programmes, there will be an increasing number of opportunities to build on its messages.

TEN GUIDING PRINCIPLES FOR COMPLEMENTARY FEEDING21

  1. DURATION OF EXCLUSIVE BREASTFEEDING AND AGE OF INTRODUCTION OF COMPLEMENTARY FOODS. Practice exclusive breastfeeding from birth to 6 months of age, and introduce complementary foods at 6 months of age (180 days) while continuing to breastfeed.
  2. MAINTENANCE OF BREASTFEEDING. Continue frequent, on-demand breastfeeding until 2 years of age or beyond.
  3. RESPONSIVE FEEDING. Practice responsive feeding, applying the principles of psychosocial care. Specifically: a) feed infants directly and assist older children when they feed themselves, being sensitive to their hunger and satiety cues; b) feed slowly and patiently, and encourage children to eat, but do not force them; c) if children refuse many foods, experiment with different food combinations, tastes, textures and methods of encouragement; d) minimize distractions during meals if the child loses interest easily; e) remember that feeding times are periods of learning and love - talk to children during feeding, with eye to eye contact.
  4. SAFE PREPARATION AND STORAGE OF COMPLEMENTARY FOODS. Practice good hygiene and proper food handling by a) washing caregivers’ and children’s hands before food preparation and eating, b) storing foods safely and serving foods immediately after preparation, c) using clean utensils to prepare and serve food, d) using clean cups and bowls when feeding children, and e) avoiding the use of feeding bottles, which are difficult to keep clean.
  5. AMOUNT OF COMPLEMENTARY FOOD NEEDED. Start at 6 months of age with small amounts of food and increase the quantity as the child gets older, while maintaining frequent breastfeeding. The energy needs from complementary foods for infants with “average” breast milk intake in developing countries are approximately 200 kcal per day at 6–8 months of age, 300 kcal per day at 9–11 months of age, and 550 kcal per day at 12–23 months of age. In industrialized countries these estimates differ somewhat (130, 310 and 580 kcal/d at 6–8, 9–11 and 12–23 months, respectively) because of differences in average breast milk intake.
  6. FOOD CONSISTENCY. Gradually increase food consistency and variety as the infant gets older, adapting to the infant’s requirements and abilities. Infants can eat pureed, mashed and semi-solid foods beginning at six months. By 8 months most infants can also eat “finger foods” (snacks that can be eaten by children alone). By 12 months, most children can eat the same types of foods as consumed by the rest of the family (keeping in mind the need for nutrient-dense foods, as explained in #8 below). Avoid foods that may cause choking (i.e., items that have a shape and/or consistency that may cause them to become lodged in the trachea, such as nuts, grapes, raw carrots).
  7. MEAL FREQUENCY AND ENERGY DENSITY. Increase the number of times that the child is fed complementary foods as he/she gets older. The appropriate number of feedings depends on the energy density of the local foods and the usual amounts consumed at each feeding. For the average healthy breastfed infant, meals of complementary foods should be provided 2–3 times per day at 6–8 months of age and 3–4 times per day at 9–11 and 12–24 months of age, with additional nutritious snacks (such as a piece of fruit or bread or chapatti with nut paste) offered 1–2 times per day, as desired. Snacks are defined as foods eaten between meals-usually self-fed, convenient and easy to prepare. If energy density or amount of food per meal is low, or the child is no longer breastfed, more frequent meals may be required.
  8. NUTRIENT CONTENT OF COMPLEMENTARY FOODS. Feed a variety of foods to ensure that nutrient needs are met. Meat, poultry, fish or eggs should be eaten daily, or as often as possible. Vegetarian diets cannot meet nutrient needs at this age unless nutrient supplements or fortified products are used (see #9 below). Vitamin A-rich fruits and vegetables should be eaten daily. Provide diets with adequate fat content. Avoid giving drinks with low nutrient value, such as tea, coffee and sugary drinks such as soda. Limit the amount of juice offered so as to avoid displacing more nutrient-rich foods.
  9. USE OF VITAMIN-MINERAL SUPPLEMENTS OR FORTIFIED PRODUCTS FOR INFANT AND MOTHER. Use fortified complementary foods or vitamin-mineral supplements for the infant, as needed. In some populations, breastfeeding mothers may also need vitamin mineral supplements or fortified products, both for their own health and to ensure normal concentrations of certain nutrients (particularly vitamins) in their breast milk. [Such products may also be beneficial for pre-pregnant and pregnant women].
  10. FEEDING DURING AND AFTER ILLNESS. Increase fluid intake during illness, including more frequent breastfeeding, and encourage the child to eat soft, varied, appetizing, favourite foods. After illness, give food more often than usual and encourage the child to eat more.
21

Guiding principles for complementary feeding of the breastfed child. Washington DC, Panamerican Health Organization, 2003. The whole document can be downloaded from http://www​.who.int/nutrition​/publications​/infantfeeding/guiding​_principles_compfeeding_breastfed.pdf

The two figures that follow, emphasis the need to support continued breastfeeding from 6 months to 2 years or longer to meet the baby’s growing needs in addition to suitable complementary foods.

Figure 1. Percentage of nutrients from 550cc of breast milk, and needs remaining to be supplied by complementary foods in the second year of life.

Figure 1

Percentage of nutrients from 550cc of breast milk, and needs remaining to be supplied by complementary foods in the second year of life.

Figure 2. Minimum dietary energy density required to attain the level of energy needed from complementary foods in one to five meals per day, according to age group and level (low, average, or high) of breast milk energy intake (BME).

Figure 2

Minimum dietary energy density required to attain the level of energy needed from complementary foods in one to five meals per day, according to age group and level (low, average, or high) of breast milk energy intake (BME). a Assumed functional gastric (more...)

This figure conveys the necessity of maintaining high volumes of milk for energy while adding a sufficient number of meals, dependent on their nutrient density.

How might complementary feeding be addressed in baby-friendly care? There are many options.

  • If BFHI has expanded into the paediatrics areas, it may include the “guiding principles” of complementary feeding and use of the new growth charts.
  • If baby-friendly communities are in place, locally available foods may be identified for best feeding at this age.
  • If BFHI Step Ten has reached out to community workers, whether from the health, agricultural, educational, or lay sectors, their training and efforts can include the “guiding principles”.

In all cases, collection of data on feeding patterns and content by age of child, whether ongoing or periodic, will provide invaluable feedback for programme improvement.

Mother-baby friendly health care - everywhere!

The principles of mother-child centred care, protection of optimal mother and child conditions, and the recognition that maternal-child dyad deserves respect and support, are the underlying principles of all of these mother and baby-friendly expansion possibilities, and can be translated to a wide variety of environments, including:

  • Hospitals, including all paediatric and women’s health care units, as well as general medicine and surgery.
  • Other health care facilities such as clinics, MCH centres, etc.
  • Community outreach and mobilization programs.
  • Faith based communities.
  • Physician’s offices.
  • International initiatives, such as Community IMCI, partnership activities, Accelerated Child Survival and others.

The mother and baby-friendly activity may be added into one of these other efforts, or vice versa. The priority must be to ensure a comprehensive approach to support for Infant and Young Child Feeding, including legislating the International Code of Marketing, BFHI in the health system, and mother and baby-friendly community activities, as well as any of the above synergistic activities.

Footnotes

19

Donohue L, Minchin M, Minogue C. 11 Step approach to Optimal Breastfeeding in the Paediatric Unit. Breastfeeding Review. 1996;4(2):88.

22

From the WHO/UNICEF Infant and Young Child Feeding Counselling: An Integrated Course.

23

From Dewey K, Brown K. Update on technical issues concerning complementary feeding of young children in developing countries and implications for intervention programs. Daelmans B, Martines J, Saadeh R, editors. Food and Nutrition Bulletin. Special Issue Based on a World Health Organization Expert Consultation on Complementary Feeding. 2003;24(1):8. [PubMed: 12664525]