INTRODUCTION:

Baby Friendly Hospital Initiative (BFHI) was launched in 1992 in India, is an effort by
UNICEF and the World Health Organisation to ensure that all maternities, whether free
standing or in a hospital become centers of breastfeeding support.
BFHI is A successful movement to promote breastfeeding through hospitals.
• The Baby Friendly Hospital Initiative (BFHI), also known us Baby Friendly Initiative
(BFI), is a worldwide programme of the World Health Organization and UNICEF, launched
in 1992 in India following the adoption of the Innocenti Declaration on breastfeeding
promotion in 1990. The initiative is a global effort for improving the role of maternity
services to enable mothers to breastfeed babies for the best start in life. It aims at improving
the care of pregnant women, mothers and newborns at health facilities that provide maternity
services for protecting, promoting and supporting breastfeeding, in accordance with the
International Code of Marketing of Breastmilk Substitutes.
• The GLOBAL initiative was co-sponsored by USAID and SIDA.
• The Baby Friendly Hospital Camping was launched by the WHO/UNICEF in Mid 1991 in
Ankara to boost the breastfeeding practices and to counter the trends of bottle feeding.
UNICEF, the World Health Organization, and many national government health agencies
recommend that babies are breastfed exclusively for their first six months of life. Studies
have shown that breastfed babies are less likely to suffer from serious illnesses, including
gastroenteritis, asthma, eczema, and respiratory and ear infections.
•Adults who were breastied as babies may be less likely to develop risk factors for heart
disease such as obesity and high blood pressure. There are benefits for mothers too: women
who don't breastfeed have increased risk of developing heart disease, hypertension, diabetes,
high cholesterol, breast cancer, ovarian cancer and hip fractures in later life.
Why focus on BBHFI ? :
The MOHFW-Government of India, WHO and UNICEF recommend i) initiation of
breastfeeding within one hour of birth, ii) exclusive breastfeeding (only breastfeeding,
nothing else) for the first six months of life and iii) continued breastfeeding till 2 years of age
or beyond along with appropriate complementary feeding after six months of age.
Optimal feeding has the potential to simultaneously reduce the burden of under-nutrition and
overweight, obesity or diet-related non communicable diseases (NCDs) including type 2
diabetes, cardiovascular disease and some cancers. An international study [i] on cost of not
breastfeeding estimates that in India inadequate breastfeeding results in 100,000 preventable
child deaths (mainly due to diarrhoea and pneumonia), 34.7 million cases of diarrhoea, 2.4
million cases of pneumonia, and 40,382 cases of obesity in India. Health impact on mothers
is more than 7000 cases of breast cancer, 1700 of ovarian cancer and 87000 of type- 2
diabetes and India spends US$ 106.05 million on health care due to illness.
Despite the unparalleled value, the breastfeeding rates remain low in India. According to the
World Health Organisation, there is substantial evidence that implementing the ‘Ten Steps’in
maternity hospitals significantly improves breastfeeding rates. A systematic review of 58
studies [ii] on maternity and newborn care published in 2016, clearly showed that observance
of the ‘Ten Steps’ impacts early initiation of breastfeeding immediately after birth, exclusive
breastfeeding and total duration of breastfeeding.
GOALS OF BFHI :
1. To transform hospitals and maternity facilities through implementation of the "Ten steps"
2. To end the practice of distribution of free and low-cost supplies of breast-milk substitutes
to maternity wards and hospitals.
Baby friendly hospitals are required to adopt breast- feeding policy and to follow the 'Ten
steps of successful breastfeeding' as recommended by code of practice of WHO/UNICEF.
Key Dates In The History Of Breastfeed and BFHI :-
Year History
1991 Launching of Baby-Friendly Hospital Initiative

1992 BFHI launched in India

2000 WHO Expert Consultation on HIV and Infant Feeding

2001 WHO Consultation on the optimal duration of exclusive Breastfeeding.

2002 Endorsement of the global Strategy for infant and Child feeding by the WHO

2006& Revision of BFHI

2018
Ten steps to successful breastfeeding are :
STEP 1:
1. Have a written breastfeeding policy, that is routinely communicated to all health care
staff.
Breastfeeding policy: Why?
• Requires a course of action and provides guidance.
• Helps establish consistent care for mothers and babies.
• Provides a standard that can be evaluated.
Breastfeeding policy: What should it cover?
At a minimum, it should include
 The 10 steps to successful breastfeeding
 An Institutional ban on acceptance of free or low cost supplies of breast-milk
substitutes, bottles, and teats and its distribution to mothers.
 A framework for assisting HIV positive mothers to make informed infant feeding
decisions that meet their individual circumstances and then support for their
decision.
Breastfeeding policy: How should it be presented?
It should be:
• Written in the most common languages understood by patients and staff
 • Available to all staff caring for mothers and babies
• Posted or displayed in areas where mothers and babies are cared for.

Step 1a: Comply fully with the International Code of Marketing of Breast-milk Substitutes
and relevant World Health Assembly resolutions.
Families are most vulnerable to the marketing of breast-milk substitutes during the entire
prenatal, perinatal and postnatal period when they are making decisions about infant
feeding. The WHA has called upon health workers and health-care systems to comply
with the International Code of Marketing of Breast-milk Substitutes and subsequent
relevant WHA resolutions (the Code), in order to protect families from commercial
pressures. Additionally, health professionals themselves need protection from commercial
influences that could affect their professional activities and judgement. Compliance with
the Code is important for facilities providing maternity and newborn services, since the
promotion of breast-milk substitutes is one of the largest undermining factors for
breastfeeding . Companies marketing breast-milk substitutes, feeding bottles and teats are
repeat/edly found to violate the Code . It is expected that the sales of breast-milk
substitutes will continue to increase globally, which is detrimental for children’s survival
and well-being . This situation means that ongoing concerted efforts will be required to
protect, promote and support breastfeeding, including in facilities providing maternity and
newborn services.
Implementation: The Code lays out clear responsibilities of health-care systems to not
promote infant formula, feeding bottles or teats and to not be used by manufacturers and
distributors of products under the scope of the Code for this purpose. This includes the
provision that all facilities providing maternity and newborn services must acquire any
breast-milk substitutes, feeding bottles or teats they require through normal procurement
channels and not receive free or subsidized supplies (WHA Resolution 39.28 (62)).
Furthermore, staff of facilities providing maternity and newborn services should not
engage in any form of promotion or permit the display of any type of advertising of
breast-milk substitutes, including the display or distribution of any equipment or materials
bearing the brand of manufacturers of breast-milk substitutes, or discount coupons, and
they should not give samples of infant formula to mothers to use in the facility or to take
home.
Infant feeding policy
Step 1b: Have a written infant feeding policy that is routinely communicated to staff and
parents.
Policy drives practice. Health-care providers and institutions are required to follow
established policies. The clinical practices articulated in the Ten Steps need to be incorporated
into facility policies, to guarantee that appropriate care is equitably provided to all mothers
and babies and is not dependent on the preferences of each care provider. Written policies are
the vehicle for ensuring patients receive consistent, evidence-based care, and are an essential
tool for staff accountability. Policies help to sustain practices over time and communicate a
standard set of expectations for all health workers.
 Implementation: Facilities providing maternity and newborn services should have a clearly
written breastfeeding policy that is routinely communicated to staff and parents. A facility
breastfeeding policy may stand alone as a separate document, be included in a broader infant
feeding policy, or be incorporated into a number of other policy documents. However
organized, the policy should include guidance on how each of the clinical and care practices
should be implemented, to ensure that they are applied consistently to all mothers. The policy
should also spell out how the management procedures should be implemented, preferably via
specific processes that are institutionalized.
Step 1c: Establish ongoing monitoring and data-management systems.
Facilities providing maternity and newborn services need to integrate recording and
monitoring of the clinical practices related to breastfeeding into their
quality-improvement/monitoring systems.
Implementation: Two of the indicators, early initiation of breastfeeding and exclusive
breastfeeding, are considered “sentinel indicators”. All facilities should routinely track these
indicators for each mother–infant pair. Recording of information on these sentinel indicators
should be incorporated into the medical charts and collated into relevant registers. The group
or committee that coordinates the BFHI- related activities within a facility needs to review
progress at least every 6 months. During concentrated periods of quality improvement,
monthly review is needed. The purpose of the review is to continually track the values of
these indicators, to determine whether established targets are met, and, if not, plan and
implement corrective actions. In addition, if the facility has an ongoing system of maternal
discharge surveys for other quality-improvement/quality- assurance assessments, and it is
possible to add question(s), one or both indicators could be added for additional verification
purposes or periodic checks.
STEP 2:
2. Train all health care staff in skills necessary to implement this policy.
Timely and appropriate care for breastfeeding mothers can only be accomplished if
staff have the knowledge, competence and skills to carry it out. Training of health
staff enables them to develop effective skills, give consistent messages, and
implement policy standards. Staff cannot be expected to implement a practice or
educate a patient on a topic for which they have received no training.
Breastfeeding training:
• Advantages of breastfeeding
• Risks of artificial feeding
• Mechanisms of lactation and suckling
• How to help mothers initiate and sustain breastfeeding
• How to assess a breastfeed
• How to resolve breastfeeding difficulties
• Hospital breastfeeding policies and practices
• Focus on changing negative attitudes which set up barriers.

STEP 3:
3. Inform all pregnant women about the benefits of breastfeeding.
 All pregnant women must have basic information about breastfeeding, in order to
make informed decisions. A review of 18 qualitative studies indicated that mothers
generally feel that infant feeding is not discussed enough in the antenatal period and
that there is not enough discussion of what to expect with breastfeeding . Mothers
want more practical information about breastfeeding. Pregnancy is a key time to
inform women about the importance of breastfeeding, support their decision- making
and pave the way for their understanding of the maternity care practices that facilitate
its success. Mothers also need to be informed that birth practices have a significant
impact on the establishment of breastfeeding
Antenatal education should include:
• Benefits of breastfeeding
• Early initiation
• Importance of rooming-in
• Importance of feeding on demand
• Importance of exclusive breastfeeding
• How to assure enough breastmilk
• Risks of artificial feeding and use of bottles and pacifiers (soothers, teats, nipples,
etc.)
•Basic facts on HIV
•Prevention of mother-to-child transmission of HIV (PMTCT)
• Voluntary testing and counselling (VCT) for HIV and infant feeding counselling for
HIV+ women
• Antenatal education should not include group education on formula preparation
STEP 4:
4. Help mothers initiate breastfeeding within a half-hour of birth.
Immediate skin-to-skin contact and early initiation of breastfeeding are two closely
linked interventions that need to take place in tandem for optimal benefit. Immediate
and uninterrupted skin- to-skin contact facilitates the newborn’s natural rooting reflex
that helps to imprint the behaviour of looking for the breast and suckling at the breast.
Additionally, immediate skin to-skin contact helps populate the newborn’s
microbiome and prevents hypothermia. Early suckling at the breast will trigger the
production of breast milk and accelerate lactogenesis. Many mothers stop
breastfeeding early or believe they cannot breastfeed because of insufficient milk, so
establishment of a milk supply is critically important for success with breastfeeding.
In addition, early initiation of breastfeeding has been proven to reduce the risk of
infant mortality
 “Place babies in skin-to-skin contact with their mothers immediately following birth
for at least an hour and encourage mothers to recognize when their babies are ready to
breastfeed, offering help if needed."
Implementation: Early and uninterrupted skin-to skin contact between mothers and
infants should be facilitated and encouraged as soon as possible after birth .Skin-to-skin
contact is when the infant is placed prone on the mother’s abdomen or chest with no
clothing separating them. It is recommended that skin-to-skin contact begins immediately,
regardless of method of delivery. It should be uninterrupted for at least 60 minutes.
I. Early initiation of breastfeeding for the normal newborn. Why?
• Increases duration of breastfeeding
• Allows skin-to-skin contact for warmth and colonization of baby with maternal
organisms
• Provides colostrum as the baby's first immunization
• Takes advantage of the first hour of alertness
• Babies learn to suckle more effectively
• Improved developmental outcomes
II. Early initiation of Breastfeeding: How?
• Keep mother and baby together
• Place baby on mother's chest
• Let baby start suckling when ready
• Do not hurry or interrupt the process
• Delay non-urgent medical routines for at least one hour
STEP 5:
5. Show mothers how to breastfeed and how to maintain lactation, even if they should be
separated from their infants.
“Contrary to popular belief, attaching the baby on the breast is not an ability with which a
mother is [born.]; rather it is a learned skill which she must acquire by
observation and experience.”
While breastfeeding is a natural human behaviour, most mothers need practical help in
learning how to breastfeed. Even experienced mothers encounter new challenges with
breastfeeding a newborn. Postnatal breastfeeding counselling and support has been shown
to increase rates of breastfeeding up to 6 months of age. Early adjustments to position and
attachment can prevent breastfeeding problems at a later time. Frequent coaching and
support helps build maternal confidence.
Implementation: Mothers should receive practical support to enable them to initiate and
maintain breastfeeding and manage common breastfeeding difficulties . Practical support
 includes providing emotional and motivational support, imparting information and
teaching concrete skills to enable mothers to breastfeed successfully. The stay in the
facility providing maternity and newborn services is a unique opportunity to discuss and
assist the mother with questions or problems related to breastfeeding and to build
confidence in her ability to breastfeed.
A number of topics should be included in teaching mothers to breastfeed. It is essential to
demonstrate good positioning and attachment at the breast, which are crucial for
stimulating the production of breast milk and ensuring that the infant receives enough
milk. Direct observation of a feed is necessary to ensure that the infant is able to attach to
and suckle at the breast and that milk transfer is happening. Additionally, facility staff
need to educate mothers on the management of engorged breasts, ways to ensure a good
milk supply, prevention of cracked and sore nipples, and evaluation of milk intake.
Supply and demand
• Milk removal stimulates milk production.
• The amount of breast milk removed at each feed determines the rate of milk production
in the next few hours.
• Milk removal must be continued during separation to maintain supply.
STEP 6:
6. Give newborn infants no food or drink other than breast milk unless medically
indicated.
Giving newborns any foods or fluids other than breast milk in the first few days after
birth interferes with the establishment of breast-milk production. Newborns’ stomachs
are very small and easily filled. Newborns who are fed other foods or fluids will
suckle less vigorously at the breast and thus inefficiently stimulate milk production,
creating a cycle of insufficient milk and supplementation that leads to breastfeeding
failure. Babies who are supplemented prior to facility discharge have been found to be
twice as likely to stop breastfeeding altogether in the first 6 weeks of life. In addition,
foods and liquids may contain harmful bacteria and carry a risk of disease.
Supplementation with artificial milk significantly alters the intestinal microflora.
Impact of routine formula supplementation :

Decreased frequency or effectiveness of suckling

Decreased amount of milk removed from breasts

Delayed milk production or reduced milk supply

Some infants have difficulty attaching to breast if formula given by bottle.

Acceptable medical reasons for supplementation or replacement are:
 Infant conditions:
• Infants who cannot be breastfeed but can receive breastmilk include those who are
very weak, have sucking difficulties or oral abnormalities or are separated from their
mothers.
• Infants who may need other nutrition in addition to BM include very low birth
weight or preterm infants, infants at risk of hypoglycaemia, or those who are
dehydrated or malnourished, when BM alone is not enough.
• Infants with galactosemia should not receive BM or the usual BMS. They will need
a galactose free formula.
• Infants with phenylketonuria may be BF and receive some phenylalanine
free formula.

Maternal conditions:

• Breastfeed should stop during therapy if a mother is taking anti-metabolites,

radioactive iodine, or some anti-thyroid medications.
• Some medications may cause drowsiness or other side effects in infants and should
be substituted during Breastfeeding.
• Breastfeed remains the feeding choice for the majority of infants even with tobacco,
alcohol and drug use. If the mother is an intravenous drug user Breastfeed is not
indicated.
• Avoidance of all Breastfeed by HIV+ mothers is recommended when replacement
feeding is acceptable, feasible, affordable, sustainable and safe. Otherwise exclusive
breastfeeding is recommended during the first months, with Breastfeed discontinued
when conditions are met. Mixed feeding is not recommended.
• If a mother is weak, she may be assisted to position her baby so she can breastfeed.
•Breastfeeding is not recommended when a mother has a breast abscess, but
Breastmilk should be expressed and Breastfeeding resumed once the breast is drained
and antibiotics have commenced. Breastfeeding can continue on the unaffected breast.
• Mothers with herpes lesions on their breasts should refrain from Breastfeeding until
active lesions have been resolved.
• Breastfeeding is not encouraged for mothers with Human T-cell leukaemia virus, if
safe and feasible options are available.
• BF can be continued when mothers have hepatitis B, TB and mastitis, with
appropriate treatments undertaken.
STEP 7:
7. Practice rooming-in. Allow mothers and infants to remain together 24 hours a day.
Rooming-in is necessary to enable mothers to practise responsive feeding, as mothers
cannot learn to recognize and respond to their infants’ cues for feeding if they are
separated from them. When the mother and infant are together throughout the day and
night, it is easy for the mother to learn to recognize feeding cues and respond to them.
This, along with the close presence of the mother to her infant, will facilitate the
establishment of breastfeeding.
 Implementation: Facilities providing maternity and newborn services should enable
mothers and their infants to remain together and to practise rooming-in throughout the
day and night .Rooming-in involves keeping mothers and infants together in the same
room, immediately after vaginal birth or caesarean section, or from the time when the
mother is able to respond to the infant, until discharge. This means that the mother and
infant are together throughout the day and night.
When a mother is placed in a dedicated ward to recover from a caesarean section, the
baby should be accommodated in the same room with her, close by. She will need
practical support to position her baby to breastfeed, especially when the baby is in a
separate cot or bed.
Rooming-in : A hospital arrangement where a mother/baby pair stay in the same
room day and night, allowing unlimited contact between mother and infant
Rooming-in : Why?
• Reduces costs
• Requires minimal equipment
• Requires no additional personnel
• Reduces infection
• Helps establish and maintain breastfeeding
• Facilitates the bonding process
STEP 8.
8. Encourage breastfeeding on demand.
Breastfeeding involves recognizing and responding to the infant’s display of hunger and
feeding cues and readiness to feed, as part of a nurturing relationship between the mother
and infant. Responsive feeding (also called on-demand or baby- led feeding) puts no
restrictions on the frequency or length of the infant’s feeds, and mothers are advised to
breastfeed whenever the infant is hungry or as often as the infant wants. Scheduled
feeding, which prescribes a predetermined, and usually time- restricted, frequency and
schedule of feeds is not recommended. It is important that mothers know that crying is a
late cue and that it is better to feed the baby earlier, since optimal positioning and
attachment are more difficult when an infant is in distress.
Breastfeeding on demand:
Breastfeeding whenever the baby or mother wants, with no restrictions on the length
or frequency of feeds
On demand, unrestricted breastfeeding Why?
• Earlier passage of méconium
• Lower maximal weight loss
• Breast-milk flow established sooner
• Larger volume of milk intake on day 3
• Less incidence of jaundice
STEP 9.
9. Give no artificial teats or pacifiers (also called dummies and soothers) to
breastfeeding infants.
Proper guidance and counselling of mothers and other family members enables them to
make informed decisions on the use or avoidance of pacifiers and/or feeding bottles and
teats until the successful establishment of breastfeeding. While WHO guidelines do not
call for absolute avoidance of feeding bottles, teats and pacifiers for term infants, there
are a number of reasons for caution about their use, including hygiene, oral formation and
recognition of feeding cues.
Implementation: If expressed milk or other feeds are medically indicated for term
infants, feeding methods such as cups, spoons or feeding bottles and teats can be used
during their stay at the facility. However, it is important that staff do not become reliant
on teats as an easy response to suckling difficulties instead of counselling mothers and
enabling them to attach babies properly and suckle effectively. It is important that the
facility staff ensure appropriate hygiene in the cleaning of these utensils, since they can be
a breeding ground for bacteria. Facility staff should also inform mothers and family
members of the hygiene risks related to inadequate cleaning of feeding utensils, so that
they can make an informed choice of the feeding method.
STEP 10.
10. Foster the establishment of breastfeeding support groups and refer mothers to them
on discharge from the hospital or clinic.
Mothers need sustained support to continue breastfeeding. While the time in the facility
providing maternity and newborn services should provide a mother with basic
breastfeeding skills, it is very possible her milk supply has not been fully established until
after discharge. Breastfeeding support is especially critical in the succeeding days and
weeks after discharge, to identify and address early breastfeeding challenges that occur.
She will encounter several different phases in her production of breast milk, her infant’s
growth and her own circumstances (e.g. going back to work or school), in which she will
need to apply her skills in a different way and additional support will be needed.
Receiving timely support after discharge is instrumental in maintaining breastfeeding
rates. Maternity facilities must know about and refer mothers to the variety of resources
that exist in the community.
" The key to best breastfeeding practices is continued day-to-day support for the
breastfeeding mother within her home and community.”

Link mothers to trained ANM in the community on discharge from the hospital or clinic.

Support can include:

• Early postnatal or clinic checkup
• Home visits
• Telephone calls
• Community services
- Outpatient breastfeeding clinics
- Peer counselling programmes
• Mother support groups
- Help set up new groups
- Establish working relationships with those already in existence
• Family support system
Implementation: As part of protecting, promoting and supporting breastfeeding, discharge
from facilities providing maternity and newborn services should be planned for and
coordinated, so that parents and their infants have access to ongoing support and receive
appropriate care .Each mother should be linked to lactation-support resources in the
community upon discharge. Facilities need to provide appropriate referrals to ensure that
mothers and babies are seen by a health worker 2–4 days after birth and again in the second
week, to assess the feeding situation.
Facilities providing maternity and newborn services need to identify appropriate community
resources for continued and consistent breastfeeding support that is culturally and socially
sensitive to their needs. The facilities have a responsibility to engage with the surrounding
community to enhance such resources. Community resources include primary health-care
centres, community health workers, home visitors, breastfeeding clinics, nurses/midwives,
lactation consultants, peer counsellors, mother-to mother support groups, or phone lines (“hot
lines”). The facility should maintain contact with the groups and individuals providing the
support as much as possible, and invite them to the facility where feasible. Follow-up care is
especially crucial for preterm and low birth-weight babies. In these cases, the lack of a clear
follow-up plan could lead to significant health hazards. Ongoing support from skilled
professionals is needed.
Indian hospitals are till in early stages of joining this movement. The National BFHI task
force was formed in 1992, towards the efforts to improve the breastfeeding practices. The
task force comprising of Government of India, UNICEF, WHO and professional
organizations (TNAI, BPNI, NNF, IMA, FOGSI, IAP, CMAI, CHAI, IBFAN, ACASH) is
working for evaluation of breastfeeding practices in the hospitals and appropriate certification
as 'Baby Friendly Hospital'. The certificate needs re-recognition on every two years to ensure
the standard and quality for successful breastfeeding.
Besides promotion of breastfeeding, baby friendly hospital initiative in India also proposes to
provide:
 Improved antenatal care
 Mother friendly delivery services
 Standardized institutional support of immunization
 Diarrhea management
 Promotion of healthy growth and good nutrition
 Widespread availability and adoption of family planning.
Government of India has made significant efforts to promote and protect breastfeeding by
enacting a law 'The Infant Milk Substitutes, Feeding Bottles and Infant Food Act, 1992'. The
act prohibits advertising of infant milk substitutes (IMS) and feeding bottles to public, free
sampling, hospital promotion and gifts of samples of IMS to health workers. Violation of the
act can lead to fine or imprisonment.
Challenges reported in this study include:
 Lack Of Ownership And Funding Of BFHI,
 Inadequate Human Resources, Overburdened Health Facilities,
 Weak Monitoring And Evaluation Mechanisms,
 Inability To Involve Private Hospitals,
 Ineffective Implementation Of The International Code Of Marketing Of Breastmilk
Substitutes (The Code) And
 Lack Of Proper Mechanisms To Provide Technical Support And Leadership.
Barriers :
At the maternity hospital level, separation of babies from mothers especially in cesarean
section births, more so in the private sector; inadequately trained health staff; unnecessary use
of infant formula due to commercial influence of baby food industry on health facilities; and
inadequate counselling and support to mothers during antenatal and postnatal periods were
found to be some of the additional barriers to success of BFHI implementation. In India,
cesarean sections have increased substantially in last 5 years, now at 47.4% in private and
14.3% in public sector (NFHS 5 2019-2021), which certainly leads to failure of breastfeeding
as mothers do not get the support they need to succeed.
Both the MAA programme of MOHFW Government of India and the WHO guidance with
the revised “Ten Steps to Successful Breastfeeding” urge hospitals implement the Infant Milk
Substitutes Feeding Bottles and Infant Foods (Regulation of Production, Supply and
Distribution) Act 1992, and Amendment Act 2003 (IMS Act), and have a written feeding
policy, data management system, competent staff (by training in breastfeeding counselling),
provision of antenatal counselling on breastfeeding and support at birth to initiate
breastfeeding, breastfeeding friendly practices like rooming-in, avoiding foods other than
breastmilk unless medically indicated etc. However, the MAA program does not reach out to
private sector hospitals.
EXCLUSIVE BREASTFEEDING
Public health organisations, including the World Health Organisation recommend 6 months of
exclusive breastfeeding for optimal growth, cognitive development and health. Exclusive
breastfeeding for 6 months is the optimal method of infant feeding (WHO, 2001).
The WHO recommends exclusive breastfeeding for 6 months and continued breastfeeding
until 2 years of age along with complementary foods (Kramer & Kakuma, 2001).
Although the health benefits of exclusive breastfeeding are widely acknowledged, opinions
and recommendations are strongly divided on the optimal duration of exclusive breastfeeding
and the practice of exclusive breastfeeding in different cultures and regions. This has led to
many lactating women not practicing exclusive breastfeeding. (UNICEF, 2012).
TERMINOLOGY :
Exclusive breastfeeding If an infant is fed no other food or drink except breastmilk, it is
exclusive breastfeeding. The baby should not have been given even water or a pacifier.
Predominant breastfeeding If a breastfed infant is fed small amounts of another food or
drink, such as water, or tea but is predominantly breastfed, it is almost exclusively
breastfeeding or predominantly breastfeeding.
Partial breastfeeding If a baby has some breastfeeds and some artificial milk feeds, or other
drinks; or has started supplementary feeds but continues to be breastfed, it is called partial
breastfeeding.
Token breastfeeding If an infant mostly has other food, but still breastfeeds occasionally, it
is called token breastfeeding.
Bottle-feeding This means feeding a baby from a bottle even if the feed is expressed
breastmilk.
DEFINITION OF BREASTFEEDING :
• WHO has defined breastfeeding as the normal method to provide infants with the nutrients
they need for healthy growth and development. (WHO,2013)
• Breastfeeding: the method of feeding a baby with milk directly from the mother's breast
(Bristow, 2012)
• Breastfeeding is the normal way of providing young infants with nutrients they need for
healthy growth and development (WHO, 2013)
DEFINITION OF EXCLUSIVE BREASTFEEDING
• Exclusive breastfeeding: breast milk only, excluding water, other liquids, and solid foods
(WHO, 2013).
• Exclusive breastfeeding means that the infant receives only breast milk. No other liquids or
solids are given not even water - with the exception of oral rehydration solution, or
drops/syrups of vitamins, minerals or medicines. (WHO, 2013).
Different Composition of Breast Milk :-
Not all of breast milk's properties understood, but its nutrient content is relatively consistent.
Breast milk is made from nutrients in the mother's bloodstream and bodily stores. It has an
optimal of fat, sugar water and protein that is needed for a babv's growth and development.
Breastfeeding triggers biochemical reactions which allows for the enzymes, hormones,
growth factors and immunologic substances to effectively defend against infectious diseases
for the infant. The breast milk also has long-chain polyunsaturated fatty acids which help
with normal retinal and neural development.
The composition of breast milk changes depending on how long the baby nurses at each
session, as well as on the child's age. The first type produced during the first days after
childbirth, is called colostrum. Colostrum is easy to digest although it is more concentrated
than mature milk. It has a laxative effect that helps the infant to pass early stools, aiding in
the excretion of excess bilirubin, which helps to prevent jaundice. It also helps to seal the
infants gastrointestinal tract from foreign substances, which may sensitize the baby to foods
that the mother has eaten. Although the baby has received some antibodies through the
placenta, colostrum contains a substance which is new to the newborn, secretory
immunoglobulin A (IgA). IgA works to attack germs in the mucous membranes of the throat,
lungs, and intestines, which are most likely to come under attack from germs.
COLOSTRUM
•Zinc-20 mg/l
•Contains immune cells and many antibodies such as IgA, IgG, IgM.
•Antibodies in colostrum provide passive immunity & fight against viral diseases such as
small pox, polio, measles & influenza
•Contains B12 binding protein which make unavailability of E.Coli. & other bacteria
•Cell maturation enzymes like lysozyme, peroxidases & xanthin oxidases are present.
Composition of colostrum

NUTRIENT AMOUNT

Energy (Kcal) 58

Fat g 2.9
Calcium mg 31

Phosphorus mg 14

Iron mg 0.09

Protein g 2.7

Lactose g 5.3

Vitamin A IU 296

Although colostrum is secreted in small quantities, it is sufficient to meet the caloric needs of
a normal newborn in the first few days of life. It enhances the development and maturation of
the baby’s gastro-intestinal tract. The anti-infective proteins and white cells provide the first
immunization against the diseases that a baby encounters after delivery. Colostrum also has a
mild purgative effect, which helps to clear baby’s gut of meconium and helps to prevent
jaundice by clearing the bilirubin from the gut. Being rich in growth factors, it stimulates the
baby’s immature intestine to develop in order to digest and absorb milk and to prevent the
absorption of undigested protein. If a baby is given any other milk or food before colostrum,
it can damage the intestinal mucosa and cause allergies.
Transitional Milk
It follows the colostrum and secretes during first two weeks of postnatal period. It has
increased fat and sugar content and decreased protein and immunoglobulin content.
Mature Milk
It is secreted usually from 10 to 12 days after delivery. It is thin and watery but contains all
nutrients for optimal growth of the baby.
Preterm Milk
The breast milk secreted by a mother who has delivered a preterm baby is different from milk
of a mother who has delivered a full term baby. This milk contains more proteins, sodium,
iron, immunoglobulins and calories appropriate for the requirements of the preterm neonates.
Fore Milk
It is secreted at the starting of the regular breastfeeding. It is more watery to satisfy the baby's
thirst and contains more proteins, sugar, vitamins and minerals.
Hind Milk
It is secreted towards the end of regular breastfeeding and contains more fat and energy. The
mother should feed the baby allowing one breast to empty to provide both fore milk and hind
milk, before offering other breast. For optimum growth and to fulfill adequate fluid and
nutritional requirements, both fore milk and hind milk are needed for the baby. Hence, baby
should be allowed to empty one breast before moving to the other breast.
ADVANTAGES OF BREASTFEEDING :
Breastfeeding is safest, cheapest and best protective food for infants. Superiority of human
milk is due to its superior nutritive and protective value. It is perfect food for infants and
provides total nutrient requirements for the first six months of life. When combined with
appropriate weaning foods, it is an invaluable source of nourishment until past the second
birth day. It prevents malnutrition and allow the child to develop fully
Nutritional superiority:
Breast milk contains all the nutrients a baby needs for normal growth and development, in an
optimum proportion and in a form that is easily digested and absorbed. Breast milk contains
all the nutrients in the right proportion which are needed for optimum growth and
development of the baby up to 6 months. It is essential for brain growth of the infant because
it has high percentage of lactose and galactose which are important components of
galactocerebroside.
Carbohydrates: Lactose is in a high concentration (6-7 g/ dL) in breast milk. The galactose
is necessary for formation of galactocerebrosides. Lactose helps in absorption of calcium and
enhances the growth of lactobacilli, the good bacteria, in the intestine.
Proteins: The protein content of breast milk is low (0.9-1.1 g/dL) compared to animal milk.
Most of the protein is in form of lactalbumin and lactoglobulin (60%), which is easily
digested. Human milk contains amino acids like taurine and cysteine which are necessary for
neuro-transmission and neuromodulation. These are lacking in cow milk and formula.
Fats: Breast milk is rich in polyunsaturated fatty acids, necessary for the myelination of the
nervous system. It also contains omega 2 and omega 6 (very long chain) fatty acids, which
are important for the formation of prostaglandins and cholesterol.
Vitamins and minerals: The quantity and bioavailability of vitamins and minerals is
sufficient to the needs of the baby in the first 6 months of life.
Water and electrolytes: Breast milk has a water content of 88% and hence a breastfed baby
does not require any additional water in the first few months of life even during summer
months.
• It facilitates absorption of calcium which helps in bony growth.
• Breast milk fats are polyunsaturated fatty acids which are necessary for the myelination of
the nervous system.
•It has vitamins, minerals, electrolytes and water in the right proportion for the infant which
are necessary for the maturation of the intestinal tract.
• It provides 66 calories per 100 mL and contains 1.2 g protein, 3.8 g fat, 7 g lactose and
vitamin 'A' 170 to 670 IU, vitamin 'C' 2 to 6 mg, vitamin 'D' 2.2 IU, calcium 35 mg,
phosphorus 15 mg in 100 mL. The total amount of milk secretion per day is about 600 to 700
mL, which is sufficient for the baby. Its composition is ideal for an infant.
•It provides specific nutrition for preterm baby in preterm delivery.
Nutrients Colostrum Mature milk Preterm milk
Calories 58 cal/100ml 70cal/100ml 70-76cal/100ml
Fat 2.9g/100ml 4.2g/100ml 2g/100ml
Protein 3.7g/100 ml 1.1g/100ml 2g/100ml
Carbohydratelactos 5.3g/100ml 7g/100ml 6g/100ml
e
Table 1: breast milk composition
Digestibility
Breast milk is easily digestable. The protein of breast milk are mostly lactoalbumin and
lactoglobulin which form a soft curds that is easy to digest. The enzyme lipase in the breast
milk helps in the digestion of fats and provides free fatty acids.

Protective Value
Breast milk contains IgA, IgM, macrophages, lymphocytes, bifidus factors, unsaturated
lactoferrin, lysozyme, complement and interferon. Thus breastfed body less likely to develop
infections especially gastrointestinal and respiratory tract infections, e.g. diarrhea and ARI.
Secretory IgA helps to protect against E.Coli and possibly allergies.
It also provides protection against malaria and various viral and bacterial infections like skin
infections, septicemia etc.
Breastfeeding protects the infant from allergy and bronchial asthma. It also protects against
neonatal hypocalcemia, tetany, necrotizing enterocolitis, deficiencies of vitamin E and zinc,
neonatal convulsions and sudden infant death syndrome.
Exclusive breastfeeding baby has less chance of developing malnutrition, hypertension,
diabetes mellitus, coronary artery disease, arteriosclerosis, ulcerative colitis, appendicitis,
childhood lymphoma, liver disease; celiac disease and dental caries.

IMMUNOGICAL
BENEFITS
Immunoglobulins (IgA ,IgM, IgE, IgD) Protective against bacterial and virus
infections

Bifidus Factors Promotes formation of healthy bacterial

colonization in infant's lower GI

Lactoferrin Iron binding protein that reduces the

availability of iron to bacteria in the GIT

Lacto peroxidase Destroys bacteria

Lysozyme Kills bacteria by destroying the cell wall,

promotes the growth of healthy intestinal
flora and has anti-inflammatory
functions.

Enzymes

like amylase, lipoprotein lipase, oxidases, Increases digestibility and also act as defense
lactoperxidases and leucocyte against microbes.
mycloperoxidase

Macrophages Destroy bacteria by phagocytosis,

synthesizes lactoferin and lyzozyme

Interferon Interferes with viral replication in host cells

Psychological Benefits
•Breastfed babies are better bonded with mother than formula fed babies.
• Benefits to the preterm babies.
• It significantly shortens length of hospital stay.
• It minimizes hospital costs.
•Breastfeeding enhances brainstem maturation.
• It reduces the risk of life-threatening disease of the gastrointestinal system and other
infectious diseases.
• They have future IQs that are 8-15 points higher than those who receive formula.
Benefits to the Mother:
I. Breastfeeding mothers experience a quicker recovery after childbirth, with less chance of
postpartum bleeding.
II. Mothers who breastfeed are more likely to return to their prepregnancy weight than
mothers who formula feed.Breastfeeding reduces the risk for long-term obesity.
III. Exclusive breastfeeding minimizes the risk of anemia by delaying the return of the
menstrual cycle for 20-30 weeks.
IV. Exclusive breastfeeding for the first 6 months postpartum, in the absence of
menstruation, is 98% effective in preventing pregnancy.
V. Women who do breastfeeding to their babies are less likely to develop ovarian and
premenopausal breast cancers.
VI. Breastfeeding reduces osteoporosis.
VII. Breastfeeding mothers are reported to be more confident and less anxious than bottle-
feeding mothers.

Benefits to the Society:

i. Breastfeeding saves money and time and conserves energy. The estimated cost of
artificial feeding is four times than that of breastfeeding. Concentrated and ready- to-feed
formulas are even more expensive than powdered formula.
ii. Breastfeeding reduces the number of sick days that families have to spend to care for
their sick children.
iii. Breastfeeding is the cheapest source of optimum nutrition and reduces the cost of health
services that must be paid for by insurers, government, agencies, or families.

Anatomy of Breast:
Breast is composed of glandular tissue, supporting tissue and ft Glandular tissue contains
milk producing sacs which are surrounded by myoepithelial cells helping drainage of milk
through lactiferous ducts. These ducts form lactiferous sinuses, which lie below the junction
of the areola and remaining breast tissue to store milk. Areola and nipples are rich in nerve
supply. Montgomery's glands are present in the areola and they produce oily substance to
keep the nipple soft.
Breast Anatomy The breast is made up of glandular tissue, supporting tissue and fat. The
glandular tissue consists of small clusters of sac-like spaces which produce milk. Each sac is
lined by network of myoepithelial cells that propel the milk into lactiferous ducts towards
nipple. Before reaching the nipple, the ducts widen to form lactiferous sinuses which store
milk. The lactiferous sinuses lie beneath the junction of areola and rest of breast. The areola
and nipples are extremely sensitive as they are supplied by a rich network of nerve endings.
On the areola, there are small swellings of glands which produce an oily fluid to keep the
nipple skin soft. Since the lactiferous sinuses lie beneath the areola, a baby must suck at the
nipple and areola. The gum line of the baby should rest at the junction of areola and rest of
breast tissue in order to express milk stored in lactiferous sinuses.

Physiology :
Lactogenesis is a complex phenomenon involving many hormones and reflexes. Two
hormones are most important, prolactin and oxytocin.
Prolactin reflex (milk secretion reflex): Prolactin produced by the anterior pituitary gland is
responsible for milk secretion by the alveolar epithelial cells When the baby sucks, the nerve
ending in the nipple carry impulse to the anterior pituitary which in turn release prolactin and
that acts on the alveolar glands in the breast to stimulate milk secretion. This cycle from
stimulation to secretion is called the prolactin reflex or the milk secretion reflex. The more
the baby sucks at the breast, the greater is the milk production. The earlier the baby is put to
the breast, the sooner this reflex is initiated. The greater the demand more is the production. It
is, therefore, important for mothers to feed early, frequently and empty out the breasts
completely at each feeding session. Since prolactin is produced during night-time,
breastfeeding during night is very important for maintenance of this reflex.
Oxytocin reflex (milk ejection reflex): Oxytocin is a hormone produced by the posterior
pituitary. It is responsible for ejection of the milk from the glands into the lactiferous sinuses.
This hormone is produced in response to stimulation to the nerve endings in the nipple by
suckling as well as by the thought, sight, or sound of the baby. Since this reflex is affected by
the mother's emotions, a relaxed, confident attitude helps the milk ejection reflex. On the
other hand, tension and lack of confidence hinder the milk flow.

Factors which reduce milk production are:

• Using dummies, pacifiers and bottles not only interfere with breastfeeding but also
predispose the baby to diarrhea.
• Giving supplements such as sugar water, gripe water, honey, breast milk substitutes or
formula, either as prelacteal (before initiation of breastfeeding) or supplemental (concurrent
to breastfeeding) feeds. Studies have reported that even 1 or 2 supplemental feeds reduce the
chances of successful breastfeeding.
• Painful breast conditions like sore or cracked nipples and engorged breast.
• Lack of night feeding, as the prolactin reflex is not adequately stimulated.
• Inadequate emptying of breast such as when baby is sick or small and the mother does not
manually express breast milk or when baby is fed less frequently.
Reflexes In the Baby :
A baby is born with certain reflexes which help the baby to feed. These include rooting,
suckling and swallowing reflexes.
The rooting reflex: When cheek or the side of the mouth is touched, the baby opens her
mouth and searches for the nipple. This is called rooting reflex. This reflex helps the baby to
find the nipple and in proper attachment to the breast.
The suckling reflex: When baby's palate is touched with nipple, the baby starts sucking
movements. This reflex is very strong immediately after birth. The suckling reflex consists
of:
• Drawing in the nipple and areola to form an elongated teat inside the mouth.
• Pressing the stretched nipple and areola with the jaw and tongue against the palate.
• Drawing milk from the lactiferous sinuses by wave like peristaltic movement of the tongue
underneath the areola and the nipple and compressing them against the palate above.
To suckle effectively, the baby has to attach (latch) well. Obtaining good attachment at breast
is a skill, which both the mother and the baby have to learn.
The method of suckling at the breast and bottle is entirely different. Suckling on a bottle
filled with milk is a passive process and the baby has to control the flow of milk into the
mouth with her tongue. While breastfeeding requires active efforts by the baby. A bottlefed
baby develops nipple confusion and refuses to feed on the breast. Single session of bottle-
feeding lessens the chances of successful breastfeeding. Bottle-feeding of babies is fraught
with risk of serious infections and consequent ill-health.
The swallowing reflex: When the mouth is filled with milk, the baby reflexly swallows the
milk. It requires a couple of suckles before baby can get enough milk to trigger swallowing
reflex. It requires coordination with breathing. The suckle-swallow-breathe cycle lasts for
about one second.
Technique of Breastfeeding
Mothers require substantial assistance to learn the technique of breastfeeding. With correct
technique, breastfeeding is natural and a pleasurable experience for the mother. However, a
variety of breastfeeding problems do occur in large proportion of mothers that require
counseling and support from the health providers for their prevention and appropriate
treatment.
Positioning
Position of the mother: The mother can assume any position that is comfortable to her and
the baby. She can sit or lie down. Her back should be well supported and she should not be
leaning on her baby.
Position of baby: Make sure that baby is wrapped properly in a cloth
i. Baby's whole body is supported not just neck or shoulders.
ii. ii. Baby's head and body are in one line without any twist in the neck.
iii. iii. Baby's body turned towards the mother (abdomens of the baby and the mother
touching each other). iv. Baby's nose is at the level of the nipple.
Attachment (Latching)
After proper positioning, the baby's cheek is touched and that initiates rooting reflex. Allow
the baby to open his mouth widely and at that point, the baby should be latched onto the
breast ensuring that the nipple and most of the areola are within baby's mouth .It is important
that the baby is brought on the mother's breast and mother should
not lean onto baby.
Signs of Good Attachment
i. The baby's mouth is wide open.
ii. Most of the nipple and areola in the mouth, only upper
areola visible, not the lower one.
iii. The baby's chin touches the breast.
iv. The baby's lower lip is everted.
Effective Suckling
• Baby suckles slowly and pauses in between to swallow (suck, suck, suck.. and
swallow). One may see throat cartilage and muscles moving and hear the gulping sounds
of milk being swallowed.
• Baby's cheeks are full and not hollow or retracting during sucking.

Effective suckling is when the infant shows slow deep sucks, sometimes pausing. If the infant
is not sucking well, then look for ulcers and white patches in the mouth (Thrush).
It is very important to ensure good attachment because poor attachment results in
 Pain or damage to nipple leading to sore nipples.
 Breast is not emptied thus causing breast engorgement.
 Poor milk supply hence baby is not satisfied and is irritable after feeding.
 Mother produces less milk resulting in a frustrated baby who refuses to suck. This leads to
poor weight
gain.
Positions of Breastfeeding :
Positions Characteristics
Proper position of baby while
breastfeeding
 Supporting whole baby’s body
 Ensure baby's head, neck and back
are in same plane
 Baby's abdomen touches mother's ,
abdomen
 Entire baby's body should face
mother.
Correct vs Incorrect position
This allows mothers to rest or sleep while
baby nurses especially who have had
cesarean births.
 Mother lies on her side using pillows
under head and back.
 Head and neck should be
comfortably propped up.
 Put a small rolled blanket behind the
baby's back.
 Pull baby close and guide his/her
Side lying position mouth to the nipple.

This is a commonly used comfortable

position
 Mother holds her baby with his head
on her forearm and his/her whole
body facing her.
 Place baby across her stomach, with
her face and knees close-in facing
mother's body.

Cradle position

This is good for premature babies or

babies who are having trouble latching
on.
 Mother holds her baby along the
opposite arm from the breast she is
using.
 Support baby's head with the palm of
her hand at the base of his/her head.

Cross-cradle position
 Good for mothers with large breasts or
inverted nipples.
 Mother holds her baby at her side,
lying on his/her back, with his/her
head at the level of your nipple.
 Support baby's head with the palm of
mother's hand at the base of his/her
Clutch or football position head.
Nursing in the football/clutch hold is
common for twins.
 Each baby is nursing while his
stomach wraps around mother's and
feet extend around her body to the
side.
 With supportive pillows underneath
babies, it is easy to use her hands to
help babies latch.

Twin football or clutch position

Support one baby's head in each of
mother's arms.
Babies' heads may rest in the bend of her
arm near her elbow.
• Babies' bodies will be in her lap turned
toward her abdomen.
• Mother holds one baby using the
football hold and the other baby using the
cradle hold.

Twin cross cradle position

•Mother holds one baby usingthe football
hold and the other baby using the cradle
hold

Football and cradle hold combination

Problems in Breastfeeding:
Breast Engorgement:
The milk production increases during the second and third day after delivery. If feeding is
delayed or infrequent or the baby is not well-positioned at the breast, milk accumulates in the
alveoli. Such a breast becomes swollen, hard, warm and painful and is termed as an engorged
breast.
Signs and symptoms include pain and tenderness in one or both the breasts, low rise of
temperature, edematous and flushed nipples and general malaise.
Treatment: Breast engorgement can be prevented by early and frequent feeding and correct
attachment of the baby to the breast. Treatment consists of local warm water packs and
analgesics (Paracetamol) to the mother to relieve pain. Milk should be gently expressed to
soften the breast and then the mother must be helped to correctly attach the baby to the breast.
Inverted Nipple and Flat Nipple:
Flat nipple can be pulled out easily and does not cause any difficulty in breastfeeding.
Inverted nipple causes difficulty in attachment. This condition should be diagnosed in the
antenatal period. Treatment includes stretching and rolling out the nipple many times a day
soon after birth of the baby. Plastic syringe is put into the nipple and milk is drawn out to
correct the nipple before putting the baby to breast.
Sore Nipple:
A sore nipple is caused by incorrect attachment of the baby to the breast. A baby who only
sucks at the nipple does not get enough milk so he sucks more vigorously resulting in a sore
nipple. Frequent washing with soap and water as well as pulling the baby off the breast while
he is still sucking may also result in a sore nipple. Candida infection of the nipple can also be
a cause of a sore nipple.
Treatment consists of correct positioning and attachment of the baby to the breast. Hind milk
should be applied to the nipple after a feed and the nipples should be aired, to allow healing
in between feeds. If fungal infection is suspected, treat with antifungal medication
Breast Abscess:
If a congested, engorged breast, an infected cracked nipple, or a blocked duct and mastitis
are not treated in the early stages, then an infected breast segment may form a breast abscess.
The mother may also have high grade fever and a raised blood count.
Treatment: Mother must be treated with analgesics and antibiotics. The abscess is to be
incised and drained. Breastfeeding must be continued from the other breast
Not Enough Milk:
If indications of adequate feeding are not seen, mother may perceive about not enough milk.
There are various reasons for insufficient milk supply as following:
•Breastfeeding factor: Delayed start, feeding at fixed times, infrequent feeds, no night feeds,
short feeds, poor attachment, use of bottles, pacifiers, offering other fluids (water, tea).
• Maternal factor: Lack of confidence, illness, unwilling for breastfeeding worries, stress,
pain, smoking, tiredness.
Reason should be identified and treated accordingly.
Encourage rooming in, relieve mother's stress and provide adequate rest and fluids. Teach the
mother appropriate technique as well as frequency and duration of feeding her baby.
Breast milk expression
It is useful for all mothers to know how to express and store their milk. Mother should
express milk at least 8-10 times a day to maintain lactation.
 To maintain milk production and for feeding the baby who is premature, low birth weight or
sick and cannot breast feed.
 Working mothers, who plan to return to work can express the milk in advance and store it to
ensure exclusive breastmilk feeding for their babies.
 To relieve breast engorgement.
Breast milk can be expressed by hand ,hand held breast pump, electric breast pump.
Storing expressed breast milk
 Expressed breast milk (EBM) should be stored in covered sterile container
 Wash the container with lid thoroughly with soap and water
 Boil the container and the lid in boiling water for at least 20 minutes
 Allow the container to be cool before pouring milk
 Store the breast milk in covered container in room temperature for eight (8) hours and
in the household refrigerator for 24 hours
Conclusion:
Breastfeeding is safest, cheapest, and best protective food for infants. Superiority of human
milk is due to its superior nutritive and protective value. It is perfect food for infants and
provides total nutrient requirements for the first six months of life. When combined with
approaches weaning foods, it is an invaluable source of nourishment until past the second
birth day.it prevents malnutrition and allow the child to develop fully.
BIBLIOGRAPHY:
1. Hockenberry Marlyn J., Wilson David, Wong’s Essential of Pediatric Nursing, First
South Asian Edition, Barhakhamba , New Delhi, Reed Elsevier India Pvt. Ltd,
Reprint 2013, Page No.853-855
2. Gupta Piyush, PG Textbook of Pediatrics General Pediatrics And Neonatology, Care
Of Normal Newborn. Volume 1. New Delhi: Jaypee Brothers Medical Publishers (P)
Ltd; 2015. Page no 408-410.
3. Dutta Parul, Pediatric Nursing, Newborn Infant. 3 rd Edition. New Delhi: JAYPEE
Brothers;2014. Page no 70-72.
4. Singh Meherban, Essential Pediatrics for Nurse, Daryaganj, New Delhi, CBS
Publishers & Distributors Pvt.Ltd, 2014, Page no 169-178
5. Paul.K.Vinod Bagga Arvind. Ghai Essential Pediatrics. CBS Publishers &
Distribution pvt.Ltd.New Delhi. Page no-245-261

WEBSITES:
1. https://www.who.int/teams/nutrition-and-food-safety/food-and-nutrition-actions-
in-health-systems/ten-steps-to-successful-breastfeeding
2. https://www.unicef.org/documents/baby-friendly-hospital-initiative
3. https://www.bpni.org/wp-content/uploads/2022/07/WBW-Action-Folder-2022.pdf
4. https://bfhi-india.in/home.php