Breastfeeding

Breast milk is the best food you can offer your new baby. The Canadian Paediatric Society
recommends exclusive breastfeeding for the first 6 months of life. At about 6 months, your
baby will be ready for other foods, but you can continue breastfeeding as long as it is
comfortable for you and your baby, even well into the toddler years.

Breast milk:

 Is naturally and uniquely produced—by each mother for her own baby. So your baby is less
likely to be exposed to foreign allergenic material.
 Contains antibodies and other immune factors that help prevent illness.
 Has the right amount and quality of nutrients to meet your baby’s first food needs.
 Is easy on your baby’s digestive system, so there is less chance of constipation or diarrhea.

Breastfeeding offers your baby the best start, but it’s not always easy. Problems are common.
Don’t be afraid to ask for help and support—it’s out there (see “Who should I ask if I have
questions about breastfeeding?).

What should breastfeeding mothers eat?

Breastfeeding burns calories, so it is important that you eat a variety of nutritious foods and
drink plenty of fluids. You don’t need to avoid milk, egg, peanut or other foods while
breastfeeding. There is no evidence that avoiding certain foods will prevent allergy in your
child.

You should avoid dieting while you are breastfeeding.

What is colostrum?

Colostrum is the first milk produced in the early days after your baby is born. It is sometimes
thick and yellowish, but it can also be thin and watery. Colostrum is very rich in proteins,
vitamins, minerals and infection-fighting antibodies that are found only in breast milk.

You will know that your colostrum is changing into breast milk when it becomes milky white
in colour. Your breasts may also feel full. This is known as your milk “coming in”. The
amount of time it takes for milk to “come in” varies from mother to mother. If your milk hasn’t
come in within 72 hours of your baby’s birth, it is a good idea to talk to your doctor.

How do I know when it’s time for a feeding?

You should always feed a baby on demand, which means feeding her whenever she’s hungry.
However, in the first few days of life, it is not uncommon for babies to need to be woken up
for a feed. If this behavior persists into the second week of life, talk to your doctor. In the first
few weeks, babies need to be breastfed 8 to 12 times over a 24-hour period. Let your baby set
the pace.

Sometimes babies ask to feed for short periods of time but more frequently. This is called
“cluster feeding” and often happens in the evening. “Cluster feeding” is normal and
might mean your baby is going through a growth spurt. This is your baby’s way of stimulating
your milk production.

How will I know if my baby is feeding well?

Feed your baby from each breast for as long as she wants and alternate the breast you begin
with at each feeding.

Your baby is feeding well when:

 You hear short swallowing sounds (making a “K” sound) which gradually become longer and
deeper as your milk is released.
 He is content after feeding.
 The nursing process isn’t painful.
 Six or more wet diapers in a 24-hour period.
 Stools that are yellow, soft and seedy. Early on, these may come after every feeding. After the
first month, stools may not be as frequent (1 bowel movement every 2 to 7 days), but they
should be soft and yellow.
 Your baby is gaining weight.

How will I know if my baby isn’t feeding well?

Your baby isn’t feeding well when:

 She isn’t content after a feeding.

  The nursing process is painful.
 Your baby is not gaining weight.

What else should I know about breastfeeding?

 Wash your hands before breastfeeding.

 If you experience cracked or sore nipples, try exposing them to the air after each feeding,
allowing them to dry naturally. You can also apply lanolin cream. You can buy a lanolin
product at your local pharmacy. Cracked or sore nipples are often a sign that a baby’s latch is
not optimal. Talk to your doctor or a lactation specialist about this.
 Avoid using soap on your nipples. Soap will wash away your breasts’ natural lubricants.
 Some women get mastitis, a serious bacterial infection which causes painful swelling of the
breasts, and sometimes fever. If you have these symptoms, see your doctor. Mastitis is treated
with antibiotics. It is advised to keep breastfeeding during treatment.

When should I express breast milk?

If your breasts are engorged (large, sore, and feeling extremely full), your newborn may have
difficulty latching on. Express some milk by gently massaging or pushing on your breast with
your hand. This may help your baby latch on.

If you will be away from your baby during feeding time, you can express your breast milk.
This will allow your baby to drink breast milk from a cup or a bottle when you are not
available.

Expressed breast milk is also a way to keep breastfeeding while your baby is in child care.
Make sure the centre or home has a refrigerator. Breast milk has to be kept chilled until
feeding time.

How should expressed breast milk be stored?

Expressed breast milk should be kept in a clean container, such as a glass bottle or milk bags
for breast milk, with the date marked on it. Plastic polyethylene bags, such as commercial
bottle liners, and containers made of bisphenol A (BPA) are not recommended because they
can affect the quality of your milk.

Breast milk can be stored for:

 6 to 8 hours at room temperature (no warmer than 25°C [77°F]),

 up to 5 days in the refrigerator (at a temperature of below 4°C [<39°F]),
 2 weeks in your refrigerator freezer (not in the door),
 3-6 months in the freezer compartment of a refrigerator with separate doors, or
 6-12 months in a separate chest-type freezer (at a temperature below -20°C [-4°F]).

Never mix fresh breast milk with chilled or frozen breast milk because it can cause bacteria to
grow and lead to food poisoning.
How do I prepare expressed breast milk for a feeding?

 Thaw frozen milk in the refrigerator and keep it there until you’re ready for it. Do not use a
microwave to thaw or warm frozen expressed milk because it can affect the quality of the milk.
 Prepare clean bottles and nipples.
 Put the thawed milk into a feeding bottle or cup. You can warm the milk by placing the bottle
of expressed milk into a container of warm water before the feeding.
 Shake the bottle of breast milk well to mix any separated layers.
 After each feeding, throw away any leftover milk.
 Do not refreeze breast milk once it has been thawed or partially thawed.

Does my baby need anything else besides breast milk?

Because of our northern latitude, Canadian infants are at risk of vitamin D deficiency. Since
breast milk has only small amounts of vitamin D, babies who are breastfed should receive a
daily supplement, which is available as drops.

Are there ever reasons not to breastfeed?

Rarely are there reasons not to breastfeed.

If you are receiving chemotherapy (especially cyclosporine, methotrexate, bromocriptine,

cyclophosphamide, doxorubicin), have HIV disease, or take street drugs (especially PCP), talk
to your doctor. You may be advised not to breastfeed.

If you have a medical condition or take prescription medications, always talk to your doctor
before nursing your baby. Breastfeeding is safe to continue with most prescription medications
because only small amounts will pass through your breast milk.

What do I feed my baby when I cannot breastfeed?

If breastfeeding is not an option, use a store-bought iron-fortified infant formula for the first 12
months.

 Formula should be cow milk-based.

 Homemade formulas made from canned, evaporated, whole milk (cow or goat) are not
recommended as a breast milk substitute.
 Rice or other plant-based beverages, even when fortified, are not appropriate as a breastmilk
substitute as they are nutritionally incomplete for infants. There is no evidence that soy-based
formula will prevent your child from developing an allergy.
 Soy-based infant formulas should only be used as an alternative to cow milk-based formula if
your baby has galactosemia (a rare disorder that will affect how your baby’s body processes
simple sugar) or if your baby cannot consume dairy-based products for cultural or religious
reasons.
 Talk to your doctor if you are unsure which formula is best for your child.
Since vitamin D is already added to infant formula, most full-term babies who are formula-fed
don’t need a supplement. However, formula-fed babies in northern communities should receive
a supplement of 400 IU/day from October to April to ensure they have enough vitamin D.

At about 6 months, you can begin to introduce solids to your baby’s diet.

Who should I ask if I have questions about breastfeeding?

Although breastfeeding is the natural way to feed your baby, you may find it hard in the
beginning. This is normal and like most aspects of motherhood, you’ll learn through
experience. Don’t be afraid to ask for help or advice from health professionals or experienced
friends and relatives.

Your doctor or midwife can counsel you about the principles and practice of breastfeeding.
Many community-based programs also support breastfeeding families, such as La Leche
League Canada. Call their toll-free breastfeeding line for a referral to someone in your
community: 1-800-665-4324.

You may also contact a lactation consultant, public health nurse, and/or breastfeeding
coordinator.

More information from the CPS:

 Feeding your baby in the first year

 Vitamin D
 Weaning your child from breastfeeding

Additional resources:

 La Leche League Canada

 Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months
 Nutrition for Healthy Term Infants: Recommendations from Six to 24 Months
 Breastfeeding Resources Ontario

Reviewed by the following CPS committees:

 Nutrition and Gastroenterology Committee

Last Updated: July 2018

© 2019 - Canadian Paediatric Society
www.cps.ca - info@cps.ca

This site complies to the HONcode standard for trustworthy healthinformation: verify
here

INTRODUCTION

Human milk is widely recognized as the optimal source of nutrition for all infants. Breast milk
promotes development of the infant's immune system and meets the nutritional needs of a full
term infant until approximately six months of age, when complementary foods and fluids are
usually added to the diet. (See "Patient education: Starting solid foods during infancy (Beyond
the Basics)".)
Most national and international groups recommend exclusive breastfeeding without the use of
infant formula or other foods or liquids for the first six months, and partial breastfeeding for at
least 12 months. Despite the overwhelming evidence in favor of breastfeeding, in the United
States about 83 percent of women breastfeed immediately after birth and only about 58 percent
of women are still breastfeeding at six months [1]. The United States has set a goal for further
increases in breastfeeding rates by 2020, such that at least 82 percent of mothers initiate
breastfeeding, and at least 61 percent are still breastfeeding at six months [2]. There are many
reasons that women choose not to breastfeed, including embarrassment, lack of knowledge about
the benefits of breast milk, belief that formula is equal to breast milk, and myths about the "ease"
of formula feeding compared with breastfeeding.

This topic discusses how to breastfeed, including positioning, latch on, frequency and length of
feeding, pacifiers, and the need for supplements and vitamins. Additional breastfeeding topics
are available separately:

WHEN TO START BREASTFEEDING

Breastfeeding should begin within the first few hours of delivery, by allowing the baby to rest or
nurse, skin-to-skin, on the mother's chest. During this time, most infants are alert and interested
in nursing. However, there is no evidence that it will be more difficult or impossible to
breastfeed if the infant cannot nurse within this time period.

In the first few days after delivery, the woman produces a small amount of thick yellowish milk
called colostrum. Colostrum is rich in nutrients and provides all the calories a baby needs for the
first few days.

Many women worry that their infant is not getting enough milk immediately after delivery, when
only small amounts of colostrum are normally produced. Infants are born with an excess of fluid
and sugar stores that they are able to use as the woman's milk supply increases.

It is normal to produce small amounts of milk in the beginning. With continued frequent
breastfeeding, a larger amount of milk will be produced within three to five days. Infants
normally lose weight during the first few days of life and gradually regain this weight by two
weeks after delivery.

POSITIONING

A woman may use one of several positions to hold her infant while breastfeeding. There is no
one "best" position for every infant and woman; the best position is one that is comfortable for
the woman and allows the infant to latch-on, suckle, and swallow easily. A woman may have
several preferred positions depending upon the baby's size, the baby or mother's medical
condition(s), and feeding location (eg, in bed versus in a chair).

In all positions, the baby should not have to turn his or her head to nurse; the baby's nose should
be aligned with the mother's nipple (figure 1). Turning the head in any direction makes it more
difficult to coordinate suckling and swallowing, and can potentially make it more difficult for the
baby to latch correctly. (See 'Latch on' below.)

Pillows or nursing supports can help to ensure that both the woman and the infant are
comfortable. When the mother is sitting in a chair, a foot stool or ottoman is helpful in
supporting the infant's weight and preventing fatigue in the mother's arms, shoulders, and neck.

After feeding, the infant should be placed back in their own bed, which is the safest sleeping
environment and minimizes the risk for sudden infant death syndrome (SIDS) [3]. (See "Patient
education: Sudden infant death syndrome (SIDS) (Beyond the Basics)".)

Cradle hold — The cradle hold can be done while the mother sits in a chair. To feed from the
left breast, the infant's head and body are supported by the mother's left forearm (figure 2). The
mother's left hand usually supports the baby's buttocks or upper thighs. Some women use a
pillow to support this arm. The baby's stomach should be flat against the mother's chest and the
baby's head should be in line with the body (not turned). The mother's free hand (the right hand
in this example) supports and guides the breast to the infant's wide-open mouth. The thumb on
the free hand may be placed on top of the areola and the breast supported with the cupped
fingers. Care should be taken to position the hand away from the nipple so that the thumb and
fingers do not interfere with latching.

Cross-cradle hold — The cross-cradle hold can also be done while the mother sits in a chair. To
feed from the left breast, the infant's head and body are supported by the mother's right hand and
forearm. Some women use a pillow to support this arm (figure 3). The baby's stomach should be
flat against the mother's chest and the baby's head should be in line with the body (not turned).
The mother's free hand (the left hand in this example) supports and guides the breast to the
infant's wide-open mouth. The thumb on the free hand may be placed on top of the areola and the
breast supported with the cupped fingers. Care should be taken to position the hand away from
the nipple so that the thumb and fingers do not interfere with latching.

Football hold — The football position allows a woman to easily see the baby at her breast. It is
often preferred by women who have an abdominal incision, after a Cesarean section, or by
women with large breasts or a small or premature baby. The baby is supported by a pillow as the
mother sits, which should allow the baby's head to be at the level of the mother's breast.

To feed from the left breast, the baby's body and legs are under the left arm, with the head
supported by the mother's left hand (figure 4). The mother's free hand (the right hand in this
example) supports and guides the breast to the infant's wide-open mouth.

Side-lying hold — The side-lying hold allows the mother to nurse while lying down. When
using this position, there should be no excess bedding around the infant. The side-lying hold
should not be used on a waterbed, a couch, or a recliner because this poses a suffocation hazard
to the infant.
To nurse from the left breast, the woman lies on her left side. The baby's head and body lie
parallel to the woman's body, with the baby's mouth close to and facing the woman's left breast
(figure 5). The woman may prefer to have a pillow under her head, with her left hand between
her head and the pillow. The mother's free hand (the right hand in this example) supports and
guides the breast to the infant's wide-open mouth. The thumb on the free hand may be placed on
top of the areola and the breast supported with the cupped fingers. Care should be taken to
position the hand away from the nipple so that the thumb and fingers do not interfere with
latching.

Laid-back or "biological nursing" — In the laid-back or "biological nursing" position, the

mother is semi-reclined with her arms and torso well supported, and the baby is placed on her
stomach between the mother's breasts (figure 6). Infants may be able to latch more easily, as the
baby is securely positioned against the mother's body and the baby's reflexes assist in latching
on. Mothers also may find that they do not have to work as hard supporting their infants and tire
less.

LATCH ON

Latching on refers to the infant's formation of a tight seal around the nipple and most of the
areola with his or her mouth. A correct latch-on allows the infant to obtain an adequate amount
of milk and helps to prevent nipple soreness and trauma.

Signs of a good latch-on include:

●The top and bottom lips should be open to at least 120° (figure 1)
●The lower lip (and, to a lesser extent, the upper lip) should be turned outward against the
breast
●The chin should be touching the breast, while the nose should be close to the breast
●The cheeks should be full
●The tongue should extend over the lower lip during latch-on and remain below the areola
during nursing (visible if the lower lip is pulled away)

When an infant is latched correctly, the woman may feel discomfort for the first 30 to 60
seconds, which should then decrease. Continued discomfort may be a sign of a poor latch-on. To
prevent further pain or nipple trauma, the woman should insert her clean finger into the infant's
mouth to break the seal. She can then reposition the infant and assist with latch-on again.
Information about painful or sore nipples is available separately. (See "Patient education:
Common breastfeeding problems (Beyond the Basics)".)

Signs of poor latch-on include:

●The upper and lower lip are touching at the corners of the mouth
●The cheeks are sunken
●Clicking sounds are heard, corresponding to breaking suction
●The tongue is not visible below the nipple (if the lower lip is pulled down)
 ●The nipple is creased after nursing

A video that describes how to latch a baby correctly is available here.

Suckling and swallowing — An infant must be able to suckle and swallow correctly to consume
an adequate amount of milk. It should be possible to hear the infant swallow. These early
swallows may sound like the letter "C" in cat, and are heard infrequently in the first day or two
of nursing. The infant's jaw should move quickly to start the flow of milk, with a swallow heard
after every one to three jaw movements [4] once the milk supply has increased significantly after
the first few days.

FREQUENCY AND LENGTH OF FEEDING

Women are encouraged to attempt breastfeeding as soon as the infant begins to show signs of
hunger. Early signs of hunger include awakening, searching for the breast (called rooting), or
sucking on the hands, lips, or tongue. Most infants do not cry until they are very hungry; waiting
to breastfeed until an infant cries is not recommended.

In the first one to two weeks, most infants will breastfeed 8 to 12 times per day. Some infants
will want to nurse frequently, as often as every 30 to 60 minutes, while others will have to be
awakened and encouraged to nurse. A baby may be awakened by changing the diaper or tickling
the feet. During the first week of life, most clinicians encourage parents to wake a sleeping infant
to nurse if four hours have passed since the beginning of the previous feeding. Some babies will
cluster feed, meaning that they feed very frequently for a number of feedings and then sleep for a
longer period.

Caring for an infant can be an exhausting experience. However, it may be comforting to know
that breastfeeding is no more time consuming than formula feeding, which often requires
additional time to purchase and prepare the formula and wash bottles and nipples.

The length of time an infant needs to finish breastfeeding varies, especially in the first few weeks
after delivery; some infants require as little as 5 minutes while others need 20 minutes or more.
Most experts recommend that the infant be allowed to actively breastfeed for as long as desired;
timing the feeding (ie, watching the clock) is not recommended. "Active" breastfeeding means
that the infant is regularly suckling and swallowing.

It is not necessary to switch sides in the middle of a nursing session. Thorough emptying of one
breast allows the baby to consume milk from deeper in the breast, which has a higher fat content
than milk available at the start of a nursing session.

Most infants signal that they are finished nursing by releasing the nipple and relaxing the facial
muscles and hands. Infants younger than two to three months often fall asleep during nursing,
even before they are finished. In this case, it is reasonable to try and awaken the child and
encourage him/her to finish nursing. After finishing one breast, offer the other side with the
understanding that the infant (especially an older infant) may not be interested.
Growth spurts — It is common for an infant to occasionally nurse more frequently or for longer
periods during the first year. However, every infant is different, and increases in appetite may
occur at different times. Parents are encouraged to allow their infant to nurse more frequently
when the infant shows interest.

How much is enough? — Many parents are concerned that their infant is not getting enough
milk because it is not possible to see how much milk the baby consumes. There are a few clues
that parents can use to estimate whether the baby is getting enough breast milk.

Monitor diapers — Keep a written record of the number of wet and dirty diapers per day. Many
parents keep a written record of wet and dirty diapers for the first week or two.

Normally, by the fourth to fifth day after birth, an infant should have at least six wet diapers per
day with clear or pale yellow urine. Fewer than six wet diapers, or dark yellow or orange urine in
the diaper are signs of inadequate intake and should be reported to the child's clinician.

Meconium is the sticky dark-colored stool that infants normally produce for the first few days
after birth. An infant's stool should become mustard yellow to light brown, often with visible
milk curds, by the fourth to fifth day. Most infants have four or more stools per day by day four.

Monitor weight — It is normal for infants to lose weight after delivery, with the average infant
losing four to five ounces within the first few days of life. Normally, infants stop losing weight
by five days of age and typically regain their birth weight by two weeks of age.

Infants who lose more than this amount may be at risk for becoming
dehydrated and/or developing jaundice. If this occurs, the healthcare provider will try to
determine the cause of the infant's weight loss and whether supplementation with banked human
milk, pumped milk, or infant formula is needed. (See "Patient education: Jaundice in newborn
infants (Beyond the Basics)".)

The American Academy of Pediatrics recommends that all healthy breastfeeding newborns are
weighed and examined by a healthcare provider three to five days after birth and again two to
three weeks after birth; this allows the provider to monitor for signs of jaundice, dehydration,
weight loss, or other complications, and to answer parents' questions.

Maintaining milk supply — Milk continues to be produced in the breast based upon how
frequently and thoroughly milk is removed. Regularly nursing an infant triggers the release of
two hormones, prolactin and oxytocin. Milk production is reduced if milk is not removed
regularly or if the breast is incompletely emptied. In addition, the breasts are more likely to
become uncomfortably full and leak milk if a feeding is delayed or skipped.

For this reason, breastfeeding women are encouraged to nurse their baby as often as the baby
shows signs of hunger. Most experts recommend allowing the baby to nurse until finished with
one side, then switching to the other side. (See 'Frequency and length of feeding'above.)
PACIFIERS

Parents often use a pacifier to soothe their infant, although pacifiers should not be used to delay
feedings. If an infant appears hungry he or she should be offered the breast. If parents desire to
use a pacifier, pacifiers should not be introduced until breastfeeding is well established, usually
around two weeks of age.

IS BREAST MILK ALL MY BABY NEEDS?

It is not necessary to give formula, bottled water, or glucose water supplements to a full term
infant who gains weight appropriately and who has an adequate number of wet and dirty diapers.
Providing formula can potentially reduce a woman's supply of breast milk, especially if formula
is given in place of breastfeeding (eg, before bedtime or during the night).

Even in hot climates, parents do not need to give water or fruit juice to a breastfed infant until he
or she is approximately six months old.

Nutritional supplements — A vitamin or mineral supplement may be recommended for some

full term breastfeeding infants. Nutritional supplements are usually given as a liquid with a
medicine dropper or mixed into pumped breast milk.

Vitamin B12 — The body requires a source of vitamin B12 to maintain blood cells. Low levels
of vitamin B12 can lead to anemia, developmental delay, and other problems. A multivitamin
supplement that includes B12 is recommended for breastfeeding infants of strict vegetarian
(vegan) mothers. Adequate B12 is available in most nonprescription infant vitamin drops.

Vitamin D — The body requires vitamin D to absorb calcium and phosphorus, which are
essential in the formation of bones. Inadequate levels of vitamin D in children can lead to a
condition known as rickets, which causes bones to be fragile and to break easily.

Breast milk contains vitamin D, although usually not in adequate amounts to meet an infant's
needs. The only other source of vitamin D for exclusively breastfed infants is sunlight. However,
the potential risk of sunburn is greater than the potential benefit of sun exposure, especially
considering that a safe source of vitamin D is available.

All breastfed infants should be given a supplement containing 400 int. units of vitamin D per
day, starting within days of birth.

Iron — Iron is an essential nutrient that the body requires to produce and maintain red blood
cells. Infants with a low iron level are at risk for a number of problems, including a low blood
count (anemia). Iron deficiency has also been associated with mild impairment of the immune
system and developmental delays. Breast milk contains iron that is easily absorbed. Exclusively
breastfed infants who are preterm or low birth weight are usually given a multivitamin
supplement that contains iron. Specific recommendations about an infant's iron needs should be
discussed with the child's healthcare provider.
WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to
your medical problem.

This article will be updated as needed on our Web site (www.uptodate.com/patients). Related
topics for patients, as well as selected articles written for healthcare professionals, are also
available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a
patient might have about a given condition. These articles are best for patients who want a
general overview and who prefer short, easy-to-read materials.

Patient education: Breastfeeding (The Basics)

Patient education: Deciding to breastfeed (The Basics)
Patient education: Jaundice in babies (The Basics)
Patient education: Health and nutrition for women who breastfeed (The Basics)
Patient education: Pumping breast milk (The Basics)
Patient education: Weaning from breastfeeding (The Basics)
Patient education: Having twins (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are best for patients who want in-depth
information and are comfortable with some medical jargon.

Patient education: Starting solid foods during infancy (Beyond the Basics)
Patient education: Deciding to breastfeed (Beyond the Basics)
Patient education: Maternal health and nutrition during breastfeeding (Beyond the Basics)
Patient education: Common breastfeeding problems (Beyond the Basics)
Patient education: Pumping breast milk (Beyond the Basics)
Patient education: Jaundice in newborn infants (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and
other health professionals up-to-date on the latest medical findings. These articles are thorough,
long, and complex, and they contain multiple references to the research on which they are based.
Professional level articles are best for people who are comfortable with a lot of medical
terminology and who want to read the same materials their doctors are reading.

Breastfeeding: Parental education and support

Common problems of breastfeeding and weaning
Infant benefits of breastfeeding
Maternal nutrition during lactation
Nutritional composition of human milk for full-term infants
 The impact of breastfeeding on the development of allergic disease
Safety of infant exposure to antidepressants and benzodiazepines through breastfeeding

The following organizations also provide reliable health information.

●National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)
●The Center for Disease Control and Prevention
(www.cdc.gov/breastfeeding)
●American Academy of Pediatrics
(www.healthychildren.org/english/ages-stages/baby/breastfeeding)
●Massachusetts Breastfeeding Coalition
(www.massbreastfeeding.org)
●Breastfeeding Online
(www.breastfeedingonline.com)

Finding a lactation consultant — International Board Certified Lactation Consultants, or

IBCLCs, are available at most hospitals as well as privately, and can be an invaluable resource
for instructions about breastfeeding, pumping, milk storage, and bottle feeding breast milk. The
websites listed below have information about finding a lactation consultant or breastfeeding
counselor.

●La Leche League

(www.lalecheleague.org)
●International Board of Lactation Consultant Examiners
(www.iblce.org)
phone: 703-560-7330
●International Lactation Consultant Association
(www.ilca.org)
phone: 919-861-5577

[1,4-7].

REFERENCES

1. Centers for Disease Control, Breastfeeding report card, 2018. Avaialble at:
https://www.cdc.gov/breastfeeding/pdf/2018breastfeedingreportcard.pdf (Accessed on October
15, 2018).
2. Healthy People 2020. Available at: https://www.healthypeople.gov/2020/topics-
objectives/topic/maternal-infant-and-child-health/objectives (Accessed on April 10, 2018).
3. American Academy of Pediatrics announces new safe sleep recommendations to protect against
SIDS, sleep-related infant deaths, 2016. Available at: https://www.aap.org/en-us/about-the-
aap/aap-press-room/Pages/American-Academy-of-Pediatrics-Announces-New-Safe-Sleep-
Recommendations-to-Protect-Against-SIDS.aspx (Accessed on April 06, 2018).
4. Qureshi MA, Vice FL, Taciak VL, et al. Changes in rhythmic suckle feeding patterns in term
infants in the first month of life. Dev Med Child Neurol 2002; 44:34.
5. Biological nurturing. Laid back breastfeeding. http://www.biologicalnurturing.com/ (Accessed
on January 21, 2013).
6. Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2012; 129:e827.
7. World Health Organization. Global Strategy for Infant and Young Child Feeding. 2002.
Available at: www.who.int/nut/documents/gs_infant_feeding_text_eng.pdf (Accessed on June
01, 2007).

Topic 1196 Version 28.0

Signs of Correct Nursing

 Your baby’s mouth is open wide with lips turned out.
 His chin and nose are resting against the breast.
 He has taken as much of the areola as possible into his mouth.
 He is suckling rhythmically and deeply, in short bursts separated by pauses.
 You can hear him swallowing regularly.
 Your nipple is comfortable after the first few suckles.

Signs of Incorrect Nursing

 Your baby’s head is not in line with his body.
 He is sucking on the nipple only, instead of suckling on the
areola with the nipple far back in his mouth.
 He is sucking in a light, quick, fluttery manner rather than taking deep, regular sucks.
 His cheeks are puckered inward or you hear clicking noises.
 You don’t hear him swallow regularly after your milk production has increased.
 You experience pain throughout the feed or have signs of nipple damage (such as cracking or
bleeding).

Benefits of Breastfeeding for Mom

Breastfeeding is a wonderful gift for you as well as your baby.

Release of Good Hormones

Many mothers feel fulfillment and joy from the physical and emotional communion they
experience with their child while nursing. These feelings are augmented by the release of
hormones, such as:

 Prolactin: Produces a peaceful, nurturing sensation that allows you to relax and focus on
your child.

 Oxytocin: Promotes a strong sense of love and attachment between the two of you.

These pleasant feelings may be one of the reasons so many women who have breastfed their first child
choose to breastfeed the children who follow.

Health Benefits
Breastfeeding provides health benefits for mothers beyond emotional satisfaction.

 Mothers who breastfeed recover from childbirth more quickly and easily. The hormone
oxytocin, released during breastfeeding, acts to return the uterus to its regular size more
quickly and can reduce postpartum bleeding.

 Studies show that women who have breastfed experience reduced rates of breast and
ovarian cancer later in life.

 Some studies have found that breastfeeding may reduce the risk of developing type 2
diabetes, rheumatoid arthritis, and cardiovascular disease, including high blood pressure
and high cholesterol.

 Exclusive breastfeeding delays the return of the mother’s menstrual period, which can
help extend the time between pregnancies. (Note: Exclusive breastfeeding can provide a
 natural form of contraception if the mother’s menses have not returned, the baby is
breastfeeding day and night, and the baby is less than six months old.)

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 Counselling for Maternal and Newborn Health Care: A Handbook for Building Skills.

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13BREASTFEEDING
Go to:

What is in this session?

Breastfeeding plays a crucial role in the health, growth and development of babies and has
benefits for the mother too. Women may need some help to successfully feed their babies. They
need support and reassurance as they learn this skill. This session focuses on the initiation of
breastfeeding following birth and when and how to refer women who are experiencing
difficulties.

IMPORTANT
If necessary and where possible, you should refer women to see a trained breastfeeding
counsellor and/or use support materials, such as “the WHO and UNICEF training materials”.
Breastfeeding counselling, a training course
(1993) http://www.who.int/child_adolescent_health/documents/who_cdr_93_3/en/index.html
Infant and young child feeding counselling, an integrated course
(2006) http://www.who.int/nutrition/publications/infantfeeding/9789241594745/en/

Go to:

What skills will I develop?

 Providing information and demonstrating breastfeeding techniques
 Encouragement and support
 Shared problem-solving
Go to:

What am I going to learn?

By the end of this session you should be able to:
1. Communicate the advantages and benefits of breastfeeding for both mother and baby
2. Demonstrate how to breastfeed a baby, including positioning and attachment
3. Assess actual and potential difficulties and how to work with women on ways to
overcome them
4. Explain the opportunities for HIV-infected mothers to breast feed and improve HIV-free
survival of their baby
Go to:
Breastfeeding
During pregnancy and after the birth it is important to discuss with women the importance of
exclusive breastfeeding for six months. Try to include the partner or other family members and
communicate to them all about the benefits of breastfeeding for the mother and baby, the process
of breastfeeding and when and how long to feed for. You should also discuss continued
breastfeeding after six months and introduction of other foods in addition to breast milk. You
might find it useful to refer to more specialized breastfeeding tools and materials to support your
discussion.

What is so good about breastfeeding?

 Breast milk provides all the nutrients that a baby needs for the first six months of life to
grow and develop.
 Breast milk continues to provide high-quality nutrients and helps protect against infection
up to two years of age or more.
 Breast milk protects babies from infections and illnesses.
 Babies find breast milk easy to digest.
 The baby's body uses breast milk efficiently.
 Breastfeeding can contribute to birth spacing.
 Breastfeeding helps the mother's uterus to contract reducing the risk of bleeding after
birth.
 Breastfeeding lowers the rate of breast and ovarian cancer in the mother.
 Breastfeeding promotes a faster return to mother's pre-pregnancy weight.
 Breastfeeding promotes the emotional relationship, or bonding, between mother and
infant.

REMINDER
As well as benefits for the baby in terms of survival, breastfeeding has other advantages. It is
easier to carry out than feeding formula; it takes no preparation; is always at the correct
temperature, it is always clean and is always available. It is the perfect nutrition for babies.
Communicate information on the advantages of breastfeeding (including health benefits,
economic benefits, etc.), to help women decide which method of feeding they will choose. Be
sure to also discuss the risks of not breastfeeding. Answer any questions or concerns the woman
may have. For example, some women do not realize that it is normal for the baby to lose weight
in the first three or four days after birth and that this is not a reflection of how she is
breastfeeding or the quality of her breast milk. Women can still breastfeed while taking most
medications, such as antibiotics, antiretroviral or TB medication.
Some women may choose not to breastfeed. You should respect this decision, even if you
disagree with it and support her to replacement feed safely.
Women need support to help them decide and carry out their infant feeding choice

RISKS OF NOT BREASTFEEDING

 Babies may get sick more often with diarrhoea, malnutrition and pneumonia and are at
increased risk of dying.
 Babies do not get natural protection to illnesses.

Initiating skin-to-skin contact and breastfeeding

After birth, dry the baby. Place him/her on the mother's chest, preferably with skin-to-skin
contact. Use a blanket to cover both baby and the mother, to keep the baby warm. When the baby
seems ready, encourage the mother to help the baby to her breast. Babies show they are ready to
take the breast when they start “rooting”, or looking for the breast. Some babies need
encouragement to latch-on at this stage.
It is important for all mothers to start skin-to-skin contact from birth as soon as possible
following birth – preferably in the first hour. They should let their baby suckle when they appear
to be ready. Some babies may take longer to start breastfeeding. As a health worker you have an
important role in helping the mother to do this. Early contact will help a mother to bond with her
baby - that is, to develop a close, loving relationship. It also makes it more likely that she will
start to breastfeed.
SKIN-TO-SKIN CONTACT HELPS
 to keep the baby warm
 to establish breastfeeding
 to encourage mother-child bonding.

Positioning and attachment

To help a mother learn how to breastfeed first encourage her to get herself into a comfortable
position. Show her how to hold the baby straight, with both the baby's head and body turned to
face her breast and with the baby's nose opposite her nipple. She should hold the baby close
supporting the whole body, not just the neck and shoulders. Refer to breastfeeding aids and
materials to help you become more familiar with correct positioning and attachment.

Encourage and support women as they learn to breastfeed

Observe the mother breastfeeding her baby and offer help and assistance if needed. Look for
signs of good attachment and effective suckling (slow deep sucks with pauses). If the attachment
is not good, encourage the mother to reposition the baby. Show the mother how to take the baby
off the breast, by inserting her little finger into the corner of the baby's mouth. Keep encouraging
and reassuring the mother the whole time. Encourage her to reposition the baby until she feels
comfortable and the baby is sucking well. Reassure her that there is no need to rush, even if the
baby is crying.
REMINDER
Correct breastfeeding positioning occurs when the baby's:
 head and whole body are well supported and held close to mother
 face and stomach face the mother
 ear and shoulder are in one straight line, neck is not twisted.
Good attachment occurs when the baby's:
 mouth covers most of areola (dark part of the nipple) with some of the areola visible
above the mouth
 mouth is wide open
 chin touches the breast
 lower lip is turned outwards.
Effective suckling occurs when:
 slow, deep firm sucks alternate with bursts of suckling
 no other sounds except swallowing sounds are heard.

Exclusive breastfeeding
All mothers should be encouraged to exclusively breastfeed their babies until they are six months
old. Exclusive breastfeeding means that the baby is not given any other food or drink, not even
water. They are only given breast milk. Make sure that you or others in the facility do not give
the baby anything that will interfere with exclusive breastfeeding.

REMINDER
To encourage and support exclusive breastfeeding there are key things you can do:
1. Encourage breastfeeding frequently, day and night, and advise the mother to allow the
baby to feed for as long as he/she wants. Tell her it is quite normal for a baby to feed up
to eight times a day. Explain to her the signs a baby will show when he/she needs to be
fed (such as “rooting”, looking for the nipple, sucking on the hand).
2. Reassure the parents that there is no need to give the baby any other drink or food, not
even water – breast milk has all a baby needs.
3. Help the mother whenever she needs assistance and especially if she is a first time or
adolescent mother or a mother with other special needs.
4. Explain to the mother she should let the baby finish the first breast and come off on its
own before offering the second breast.
5. Encourage the mother to start each feed with a different breast. For example, if the left
breast is used to start one feed, at the next feeding start with the right breast.
 6. If it is necessary to express breast milk, show the mother how to do this and show her
how to feed expressed breast milk by cup. You may need to refer her to a trained infant
feeding counsellor for this.
7. Reassure the mother that her body will make enough breast milk to satisfy her baby's
needs. Just because a baby is crying, it does not mean that she does not have enough
breast milk. A baby who is demanding more breast feeds may be growing. By allowing
the baby to suckle more often, her body will produce more breast milk to meet her baby's
needs.
8. Explain that the mother can provide all the breast milk her baby needs for the first 6
months and beyond.
9. Explain that the mother can continue breastfeeding if she has to return to work or school,
either by expressing breast milk or feeding more often when she is at home.
10. Advise her to seek help (or come back to see you) if the baby is not feeding well or if she
has any difficulties or concerns with breastfeeding, sore nipples or painful breasts. If
needed, refer her to a trained infant feeding counsellor.

Activity 1

variable

To examine ways to improve how breastfeeding is supported and

communicated to mothers.
In many health facilities breastfeeding is supported in a number of different ways. This activity is
designed to get you and your colleagues to assess how you provide breastfeeding counselling and
support, and what could be improved or strengthened.
1. Gather the following information from ten women who have recently given birth. If you
are working in a group, each group member should do the same.
o At what point in pregnancy did the health worker discuss breastfeeding with
them?
o Do they think these discussions should have started earlier in pregnancy or later,
or was this the right time?
o Do they remember what was discussed with them? (Make a list of the different
points discussed.)
o Did they feel the information was clear and easy for them to understand?
 o After birth, what advice and support was given to them to breastfeed their babies?
When was this given?
o Was skin-to-skin contact promoted after birth (the baby placed on the mother's
upper abdomen)? How soon after birth was it started?
o Was ongoing support, advice and reassurance given to them? How was this
given?
o Who gave them support and advice once they were home? Did they feel they had
enough support and advice or did they need more? What additional support and
advice did they think would be helpful?
o What are some of the barriers women face to exclusive breastfeeding and how can
the health staff help them to solve these?
o Ask women for suggestions on how staff could better respond to their needs.
2. Discuss the responses with the rest of the group working through this handbook if
applicable. Do you need to do anything differently? How can you as a team better
respond to the support women need to successfully breastfeed? With the manager, make a
plan for any changes that should be introduced, including reviews to check on how you
are progressing. For example, you could carry out this activity again, six months after
making changes to evaluate whether you have made any improvements.

Our View
Discussion of breastfeeding should start during pregnancy by asking women how they plan to
feed the baby. At this time you do not need to overload women with too much information. Stick
to the basic facts about the benefits of breastfeeding for the baby and for the mother. Talk to
women about the benefits of initiating skin-to-skin contact as soon as possible following the birth
(preferably within one hour) to facilitate early initiation of breastfeeding. You should help the
mother with the first breastfeed to show her how to position and attach the baby. Demonstrations
are important as breasfeeding is a skill that mothers learn. Have dolls available to demonstrate
position. Remember to provide as much support and reassurance as each woman needs - it will
vary according to the woman.
Consider how you might be able to provide support and reassurance to women once they have
left the health facility and are at home. Once home many women experience feeding problems
such as engorged breasts or cracked nipples. Others may be pressured by family members to
offer supplementary foods or drinks. How can you work with women to overcome some of these
problems? One way is to talk with all family members on the importance of exclusive
breastfeeding. You can also make sure you assess breastfeeding at any visit or meeting during
the postnatal period. Also consider holding a special session for breastfeeding problems.
Often in the community, groups exist to support women who are breastfeeding. Find out what
support exists, or contact women who have successfully breastfed and see if they would be
available to support women after birth.
Before discharge and if the mother returns to the health facility during the postnatal period you
need to assess how breastfeeding is going. You should also assess breastfeeding and provide
relevant information during routine visits and at any time if there is feeding difficulty or the
mother is concerned about feeding.
Go to:

Supporting breastfeeding
Women need extra support, encouragement and reassurance while breastfeeding. Although we
view breastfeeding as a natural process, it is still a skill that has to be learned. Initially
breastfeeding can seem demanding, as the baby may have a desire to feed/suck frequently.
Babies however, begin to establish their own pattern over time, and the mother will begin to feel
more comfortable and at ease.
Some women also find that the initial ‘let down’ reflex is very strong which causes them pain or
they get strong after-pains as their wombs contract. Reassure them that this will pass. The ‘let
down’ reflex may also cause them to leak milk when they have sexual intercourse. Reassure
them that this is normal and that they may need to tell their husband or partner that this is
normal.
Sometimes husbands or partners may feel excluded from the breastfeeding process. Encourage
them to be involved in other ways. This may ease the situation and help men to provide more
support for breastfeeding; for example, by asking him to fetch the baby for the feed, helping
make the woman comfortable, or looking after the other children while she is feeding. Massaging
the baby, and humming to calm a crying baby are other very useful ways of involving men.
Many women find breastfeeding difficult due to problems such as engorgement or sore nipples.
Engorgement may happen a few days after birth or at any time when the baby's feeding pattern
changes. The breasts become overfull with milk and tissue fluid; milk does not flow well and the
skin is tight (especially the nipple). This makes it difficult for the baby to latch on. Sometimes
the skin looks red and the woman has a fever which usually disappears in 24 hours. To prevent
engorgement, help women to start breastfeeding soon after birth, ensure good attachment and
encourage unrestricted breastfeeding. To treat engorgement, recommend that the mother puts
warm compresses on her breasts or takes a warm shower and expresses enough milk to reduce
discomfort which helps make attachment easier. After expressing milk she can use cold
compresses to reduce the inflammation. Cracked or sore nipples occur mainly because the baby
is not attaching properly. Help the mother to make sure the baby is attaching properly.

Support for feeding preterm and/or low birth weight babies

Low birth-weight or preterm babies should be fed their mother's own breast milk. The mother
may need extra support to initiate breastfeeding or expressing breastmilk as soon as possible
after birth. Because low birth-weight babies can sometimes get easily tired when feeding, it is
particularly important that the mother feeds her baby as often as possible, responding to demand
and at least 8 feeds during 24 hours, during the day and night
If a mother cannot feed her own baby, it is still best for a low birth-weight baby to be fed human
breast milk. Another woman could feed the baby, so long as she is not HIV-infected. Some
facilities have established breast milk banks, where breast milk from healthy donor women is
collected, pasteurised and kept frozen. If your facility does not have a breast milk bank, maybe
the local referral hospital can put you in contact with a breast milk bank. Try to find out about
breast milk banks in your area and keep this information available for mothers who cannot
breastfeed for a while due to health problems. If the low birth-weight or preterm baby cannot be
fed breast milk, either by the mother, a wet nurse or from a breast milk bank, then the baby can
be given standard infant formula by cup. Look at Session 26 of the WHO Breastfeeding
Counselling: A training course
(http://www.who.int/maternal_child_adolescent/documents/who_cdr_93_3/en/), for further
information on how to help a mother breastfeed a low birth-weight baby.

Encouraging continuous skin-to-skin contact can help low birth weight babies keep warm and
support breastfeeding on demand. Make sure parents are aware of all the newborn danger signs
and that they understand it is especially important to bring a low birth-weight newborn to a
health facility if they have any worries, as these small babies are at particular risk from infections
and feeding difficulties.

Support for the mother who is not yet breastfeeding

If the mother or baby is ill or the baby is too small to suckle you need to give extra support and
help. First teach the mother how to express milk and feed the baby by cup. If you have not been
trained to do this, you should refer to an infant feeding counsellor where possible. If the mother
and baby are separated for any reason then reassure the mother about the baby's progress
whenever she asks. Encourage the mother to start breastfeeding the baby as soon as she or the
baby is able.
Support for breastfeeding twins
Many mothers who give birth to two or more babies are worried they will not have enough milk.
Reassure her that she will have enough milk for both babies. Encourage the mother to feed one
baby at a time until breastfeeding is established. You can then show her different ways she can
feed the babies and work with her to find out which method she is most comfortable with. If one
twin is weaker or smaller than the other, make sure that the weaker twin also gets enough milk.

Advice to women who are not breastfeeding

Some women may not be able to breastfeed and others may choose not to. A woman's right to
take an informed decision should be supported and respected. If after discussing the benefits of
breastfeeding and the risks of not breastfeeding the mother decides not to breastfeed, she should
be shown alternative methods.
These mothers need to learn how to safely prepare and feed formula to their babies. You may
also have other women whose babies have died or who have had a stillbirth. These women may
experience discomfort in their breasts for a period of time. Advise them not to stimulate the
breasts or nipples. Show them how to support the breasts with a firm well fitting bra or a cloth.
Teach the mother how to express just a little milk to relieve discomfort but not enough to
stimulate more milk production.

REMINDER
Advise all women to seek care if their breasts become painful, swollen, and red or if they feel ill.
Go to:

Mothers who are HIV-positive

Babies of HIV-positive mothers can benefit from breastfeeding for all the same reasons outlined
above. HIV may pass from an HIV-infected mother to her baby during pregnancy, childbirth and
breastfeeding. Antiretroviral treatments can dramatically reduce the risk of mother-to-child
transmission during breastfeeding and increase the chance of HIV-free survival of the baby (that
is, staying free of HIV infection and also staying alive). Although there is still a small chance
that the baby could become HIV positive even when the mother is being treated with
antiretroviral drugs, babies who are not breastfed, but given replacement feeds, are more likely to
die from infections.
National health authorities should have a policy to indicate whether health services should
promote and support breastfeeding or replacement feeding among HIV-infected mothers. You
need to be aware of this recommendation and you should develop the skills to support women to
achieve this. However, it is a mother's right to choose how to feed her baby and you will need to
support her choice. Mothers who are aware they are HIV infected should be counselled on safe
infant feeding by a trained infant feeding counsellor. Where specialist help is not available, you
should support women as best you can.
Ask her to repeat back to you in her own words to make sure she has understood the information
correctly. Work together to make a plan that she can implement in order to carry out safe infant
feeding.
Women who are HIV-positive and plan to breastfeed need support, particularly in the early
stages when breastfeeding is being initiated. Try to help the women to avoid getting mastitis or
nipple damage, as these difficulties increase the risk of transmission to the baby. Advise the
woman to return if she has any problems with her breasts.
Women who have chosen replacement feeding for their babies must have regular follow-up to
ensure that the baby is growing and to support replacement feeding. These women need extra
support and reassurance, especially if they are from a community where breastfeeding is the
norm. Many communities may stigmatize or shun a woman who chooses replacement feeding.
Work with families and communities to support women in their choice of infant feeding.

WHO RECOMMENDATIONS FOR INFANT FEEDING FOR HIV-POSITIVE WOMEN

Mothers known to be HIV positive should be provided with lifelong antiretroviral therapy or
antiretroviral prophylaxis (preventative treatment) to reduce HIV transmission to the baby during
pregnancy, childbirth and breastfeeding.
National health authorities should decide whether health services in that country should
principally promote and support breastfeeding or promote and support replacement feeding
among HIV-infected mothers.
In settings where national authorities recommend breastfeeding, HIV infected mothers and/ or
their babies should be given antiretroviral treatment or prophylaxis to reduce the risk of
transmission throughout the breastfeeding period.
These mothers should exclusively breastfeed their babies for the first 6 months of life, then
introduce appropriate complementary foods with continued breastfeeding for the first 12 months
of life. Mothers should stop breastfeeding only when they can provide a safe and adequate diet.
If a mother decides to stop breastfeeding, she should do so gradually within one month.
HIV infected mothers should only give commercial infant formula milk as a replacement feed to
their baby when specific conditions of safety and hygiene, affordability and supply of formula,
access to health care and family support for replacement feeding are met.
Guidelines on HIV and infant feeding 2010. Principles and recommendations for infant feeding
in the context of HIV and a summary of evidence
http://www.who.int/maternal_child_adolescent/documents/9789241599535/en/
What did I learn?

Breastfeeding should be encouraged and supported for all women. In this session you examined
how to explain the importance of exclusive breastfeeding for six months and continued
breastfeeding up to two years or beyond. You learned how to support women and how to
demonstrate ways to effectively breastfeed soon after the birth. You also learned that mother
who are HIV-infected can also breastfeed and give their baby all the benefits of breast milk with
very little risk of transmitting HIV.
Take some time to reflect on how you can improve your own skills in communicating
breastfeeding and demonstrating how to position and attach the baby. You could use your
notebook to write down tips or advice you can give to women who are experiencing problems.
Encourage women to learn from one another; often women have helpful home remedies or
suggestions for alleviating some of the discomforts associated with breastfeeding in the early
stages. Determine what support exists in the community. Make contacts with these groups.
Finally, remember that it is important for successful breastfeeding that the woman has the
support of her partner and her family.
Copyright © World Health Organization 2013.
 All rights reserved. Publications of the World Health Organization can be obtained from WHO
Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22
791 3264; fax: +41 22 791 4857; e-mail: tni.ohw@sredrokoob). Requests for permission to
reproduce or translate WHO publications – whether for sale or for noncommercial distribution –
should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-
mail: tni.ohw@snoissimrep).

Bookshelf ID: NBK304199

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Table 3
Mothers’ attitudes towards breastfeeding on IIFA Scale

Variables Disagree Neutral Agree Mean

(SD)

f % f % F %

The benefits of breast milk last only as long as 73 59.8 13 10.7 36 29.5 3.43 ± 1.05
the baby is breast fed*
Variables Disagree Neutral Agree Mean
(SD)

f % f % F %

Formula feeding is more convenient than 102 83.6 8 6.6 12 9.8 3.90 ± 0.78
breastfeeding

Breastfeeding increases mother infant bonding 16 13.1 16 13.1 90 73.8 3.58 ± 0.89

Breast milk is lacking in iron* 32 26.2 61 50 29 23.8 3.12 ± 1.04

Formula fed babies are more likely to be 81 66.3 14 11.5 27 22.2 2.49 ± 0.98
overfed than breastfed babies

Formula feeding is the better choice if the 69 56.5 8 6.6 45 36.9 3.40 ± 1.19
mother plans to go back to work*

Mothers who formula feed miss one of the great 35 28.7 17 13.9 70 57.4 3.25 ± 1.07
joys of motherhood
Variables Disagree Neutral Agree Mean
(SD)

f % f % F %

Women should not breastfeed in public places 92 75.4 6 4.9 24 19.7 3.77 ± 1.05
such as restaurants

Breastfed babies are healthier than formula fed 27 22.1 3 2.5 92 75.4 3.60 ± 1.08
babies

Breastfed babies are more likely to be overfed 28 23 19 15.6 75 61.4 2.59 ± 0.99
than formula fed babies

Fathers feel left out if a mother breast feeds* 99 81.2 13 10.7 10 8.2 3.84 ± 0.72

Breast milk is the ideal food for babies 11 9.1 2 1.6 109 89.3 3.93 ± 0.89

Breast milk is more easily digested than formula 18 14.8 2 1.6 102 83.6 3.77 ± 0.91
Variables Disagree Neutral Agree Mean
(SD)

f % f % F %

Formula is as healthy for an infant as breast 101 82.8 4 3.3 17 13.9 3.99 ± 0.94
*
milk

Breastfeeding is more convenient than formula 25 20.5 0 0 97 79.5 3.60 ± 1.08

Breast milk is cheaper than formula 12 9.8 3 2.5 107 87.7 3.82±0.85

A mother who occasionally drinks alcohol 28 23 32 26.2 62 50.8 2.62±1.11

should not breastfeed her baby*

Mean attitude score 58.77 ±

4.74

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*
Reverse scored items
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ASSESS THE KNOWLEDGE ATTITUDE AND PRACTICE REGARDING
BREASTFEEDING AMONG PRIMI MOTHERS

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ASSESS THE KNOWLEDGE ATTITUDE AND PRAC

T I C E REGARDING BREASTFEEDING AMONG PRIMI MOTHERS

S . N o .
C O N T E
N T
1 . I N T R O D U C T I O N

Need for the study

Statement of the problem

Objectives

Operational Definitions

Hypothesis

Assumption

Projected
OutcomeI I . R E V I E W O F L I T E R A T U R E I I I . R E
S E A R C H M E T H O D D L O G Y

Research Design

Setting of the Study

Population

Sample and Sampling Technique

Criteria for sample selection

Instrument

Validity of the Tool

Data collection procedure

Plan for data analysisI V . D A T A ANALYSIS AND

INTERPRETATIONV . D I S C U S S I O N V I
. S U M M A R Y , C O N C L U S I O N , I
M P L I C A T I O N RECOMMENDATION AND
LIMITATIONV I I . B I B L I O G R A P H Y
RESEARCH CHAPTER – IINTRODUCTION
Breastfeeding is the ideal from of feeding in the neonate.Artifical feedingexposes
the infant to infection and results in over a million death annually world wide due to
its illeffects.World breast feeding week is August first week(1-7days)T h e C a r e f o r a
c h i l d n e e d s t o b e g i n i s t h e f i r s t f e w h o u r s o f l i f e w i t h exclusive breast
feeding and appropriate interventions at 4-6 months in the form of timely complementary
feeding.Exclusive breast feeding for 6 months means that the infant receives
only breast milk from her mother on expressed breast milk who other foods or
drinksw i t h t h e e x c e p t i o n o f d r o p s o r m e d i c a t i o n s , d u r i n g t h i s t i m e a n d
after 6
months b r e a s t f e e d i n g s h o u l d c o n t i n u e f o r 2 4 h r s o r m o r e a l o
n g w i t h a p p r o p r i a t e complementary feedings.Good nutrition is one of the basic
components of health and as particulars of optimal child development survival and maintenance
of health through our life.The nutritional and health status of infants depends mainly on
the feeding practices of the community. Early life is a period of rapid growth with the weight
of infant doubling by 6 months and tripling by one year of age
(Dr.Riten Kumar, 2004)
Infants constitute 3% of India’s population and through their chances
o f s u r v i v a l h a v e i m p r o v e d b y n e a r l y 5 0 % i n t h e l a s t 2 0 ye a r s t h e i n f a n t
mortalityr a t e ( I M R ) o f I n d i a i s 7 4 / 1 0 0 0 l i v e b i r t h s , m u c h h i g h e r t h a
n t h e I M R o f t h e development world which stands at 8/1000 live births. Many low cost
measures likeimmunization exclusive breast feeding growth monitoring.All New born who
cry soon after birth and do not show any signs of illnessmust be kept close to their
mother and put to the breast soon after birth. This willensure warmth initiation of
breast feeding and emotional bonding-Breast feedingshould be initiated within the first
hour after birth .Exclusive breast feeding will saves lives of many babies by preventing
malnutritioninfection like diarrhoea
(S.S.PRABHVDEVA)

Breast feeding Promotion Network of India(BPNI) 2002,

says, infantsaged (0-5)months who are not breastfed have seven fold and five fold increased
risk of death from diarrhoea compared with infants who are exclusively breastfeed.
Atthe same age, non exclusive breast feeding results in more than two fold creased risk of
dying from diarrhea .Infants aged 6-11 months who are not breast fed also have been
an increased risk of such deaths.
The 10
th
five year plan of Government of India (2003 -2007)
h a d s e t a target to increase exclusive breast feeding rate to 80% during first
6 months fromthe current level of around 40.5% and increased rate initiation of
breast feedingwithin one hour to 50% from the current level of about 15% and
increased rate of complementary feeding from 33.5%to75% to reduce infant and childhood
mortalityand improve health and development of infants and young children.There is a crucial
window of opportunity provide the support and informationn e c e s s a r y f o r b r e a s t
f e e d i n g . O n e o f t h e m o r e c o m m o n l y u s e d b r e a s t f e e d i n g assessment tool is
called the
“ LATCH”
tool .This tool is utilized to assess them o t h e r a n d i n f a n t b y f u r t h e r i d e n t i f yi n g
a r e a s w h e r e a s s i s t a n c e i s n e e d e d . T h e components of this tools assess.
L
: T h e i n f a n t s L a t c h
A
: A v a i l a b l e s w a l l o w i n g
T
: T h e m o t h e r ’ s t y p e o f n i p p l e
C
: C o m f o r t w i t h b r e a s t f e e d i n g
H
: I n f a n t h o l d (Dr.Mrs.S.KAMALA,Dr.Mrs.JEYAG
OWRI,Dr.Mrs.KALAVATHI,Dr.Mrs.GANDHIMATHI ,2008)They have A to Z about breast
feedingThe following will give complete array of information about breast milk andits benefits
to babies
A
-
A
naemia
B
-
B
onding
C
-
C
olostrum
D
-
D
ehydration
E
-
E
asiness
F
-
F
eed

G
-
G
rowth
H
-
H
igh risk babies
I
-
I
mmunological
J
-
J
aw development
K
-
K
ids problems
L
-
L
ong term benefits
M
-
M
ental development
N
-
N
utritional advantages
O
-
O
besity
P
-
P
ain
Q
-
Q
uicker brain growth
R
-
R
espiratory infections
S
-
S
udden death syndrome
T
-
T
ype II diabetes
U
-
U
rinary Tract infections
V
-
V
accine
W
-
W
arm chain
X
-E
x
actly
Y
-
Y
our baby
Z
-
Z
ero wasteE n s u r e e x c l u s i v e b r e a s t f e e d i n g d u r i n g f i r s t 6 m o n t h s o f l i f e ,
a d d i t i o n a l water is not necessary even in summer.Breast feeding should be continued during
diarrhea as well as other illnessesIt help’s the baby to get optimal nutrition and recover from the
illness faster.
NEED FOR THE STUDY
Currentl y only 31% of Indian mothers practices demand feeding must
be practised by educating mothers regarding breast feeding inorder to
i m p r o v e t h e health of the mother and the baby.The mother of today has adopted to the
recent trends of life style replacingt r a d i t i o n a l o n e s . T h e r e a r e
m a n y c h a n g e s o n e o f w h i c h i s c h a n g e s i n c u l t u r a l diversity and the majority
of mothers (68.3%) breast feed on the day of delivery

while 31.6% of mothers rejected colostrums as bad for the child, whe reas
81.3%considered it is good.Recent study from Ghana found that 22% of deaths new
borns would have b e e n p r e v e n t e d o f n e w b o r n s s t a r t e d b r e a s t f e e d i n g , w i t h
i n o n e h o u r o f b i r t h ,irrespective of whether they were exclusively breast feed later or not.
Extrapolatingthe data to other countries, the same researches estimated that if 99% of
infantsstarted breast feeding on the first day of Life a total of 867,000 lives could be
savedworldwide and if they started breastfeeding within one hour of birth, then 31% of all
neonatal death could the prevented, which amounts to 1,117,000. India can saveits 2,50,000
babies annually by just one action..
STATEMENT OF PROBLEM
:A S t u d y t o a s s e s s t h e k n o w l e d g e , a t t i t u d e a n d p r a c t i c e r e g
a r d i n g breastfeeding among primi mothers in Government Hospital at Dharapuram.
OBJECTIVES :
To assess the demographic variables of primi mothers .To assess the knowledge regarding breast
feeding among primi mothersTo assess the attitude regarding breast feeding among primi
mothers.To assess the practice regarding breast feeding among primi mothers.To correlate the
knowledge attitude regarding breast feeding among primi mothers.To find out the
association between the knowledge regarding breast feedingamong primi mothers with
their demographic variables.
OPERATIONAL DEFINITIONS
:
ASSESS :
It means the process of collecting, organizing,validating and recording data.In the study, the
knowledge of primi mothers regarding breast feeding is assessed.
KNOWLEDGE :
Information gained through experience on education. It refers to correctre
sponse of the primi mothers regarding breast
f e e d i n g w h i c h i s m e a s u r e d b ystructured questionairre.

ATTITUDE :
It means mental stance that is composed of different beliefs, usual
l y involving a positive or negative judgements towards a person, object or idea . In
thiss t u d y i t r e f e r s t o t h e
a t t i t u d e o f b r e a s t f e e d i n g a m o n g p r i m i m o t h e r s w h i c h i s measured by 3
point likert scale.
PRACTICE:
It means the way of doing something. In this study if refers to the practice of breast feeding
among primi mothers which is measured by observational check list.
BREASTFEEDING:
Breastfeeding is the feeding of an infant or young child with breast milk directly
from human breasts.
PRIMI MOTHERS:
Primi mothers is the one who has given birth for the first time.
ASSUMPTIONS:

Primi mothers have inadequate knowledge regarding breast feeding

Primi mothers are not aware of proper techniques of breast feeding.

Primi mothers will vary in breast feeding practice according to socio culturalfactors.
LIMITATIONS:

Sample size is limited to 30

The study is limited to the primi mothers admitted in Government Hospital,Dharapuram.

PROJECTED OUTCOME:
This study helps to assess the knowledge about breast feeding of the primi mothers in
Government Hospital at Dharapuram.This study will help the primi mothers to analyse
the importance of breastfeeding and it techniques.It helps to improve the level of
knowledge, attitude and practice of breast feeding among primi mothers in Government
Hospital, Dharapuram.
CHAPTER – IIREVIEW OF LITERATURE
This Chapter includes review of literature for this study which is organized under the
following headings.
PART – I
Overview of breast feeding
PART –II
Studies related to breast feeding
PART- IOVERVIEW OF BREASTFEEDING:
It is the ideal form of infant feeding and is crucial for life long health andwell
being. Breast feeding is the birth right of every baby .Nature has so designedthat
when a baby is born a readymade food in the form of breast milk flows
liked i v i n e n e c t a r . B r e a s t f e e d i n g i s n a t u r a l a n d i n s t i n c t i v e e v e r y m
o t h e r w a n t t o breastfeed her baby and she must the
p r o v i d e d w i t h n e c e s s a r y g u i d a n c e e v e r y mother can successfully breastfeed and
provide a best start in life to her baby.
DEFINITION OF EXCLUSIVE BREASTFEEDING
:Only breast milk is given no other food or drink not even water is given an infant
should be exclusively breast feed for 6 months of life.
COMPONENTS OF THE BREAST MILK
:
FAT:
Provides the baby with more than 50% of his caloric requirements.
LACTOSE:
There is more lactose in human milk than in any other mammalian milk,
PROTEIN
:Human milk contains has than half the amount of protein contained in cow’sm i l k . , b u t
b e c a u s e o f i t s e a s y d i g e s t i b i l i t y i t p r o v i d e s t h e b a b y w i t h t h e i d e a l quantity.
VITAMIN –A
Mature human milk contains 280 international units(IU) of vitamin A if vitamin A
and colostrums contains twice that amount cow’s milk contains only 180IU

VITAMIN –D
It is now believed that both water soluble and for soluble vitamin D
a r e present in human milk.
VITAMIN –E
Human colostrument is rich in vitamin E and the levels in mature
h u m a n milk are higher than in cow’s milk.
VITAMIN-K
T h i s v i t a m i n i s e s s e n t i a l f o r t h e s yn t h e s i s o f b l o o d c l o t t i n g f a c t o r s . I t
i s present in human milk and absorbed efficiently.
VITAMIN B COMPLEX:
All of the B Vitamins are present at levels which believed to provide
t h e baby with his necessary daily requirements.
VITAMIN –C
Human milk contains 43mg/100ml is vitamin C compared with 21 mg/100mlin fresh cow’s milk.
IRON
Normal full term babies are usually born with a high hemoglobin level (16-22g/dl ) which
decreases rapidly after birth.
ZINC
This trace mineral is essential to humans. A deficiency may result in failureto thrive and typical
skin lesions.
OTHER MINERALS
Human milk has significantly lower levels of calcium, phosphorus ,sodiumand potassium than
cow’s milk.
OTHER IMPORTANT PROPERTIESIMMUNOGLOBULINS:
IgA ,IgG, IgM, and IgD are all found in human milk.
LYSOZYME:LYSOZYME
Is present in breast milk in concentrations 5000 times greater than in cow’s milk.
LACTOFERRINLACTOFERRIN
I s a b u n d a n t i n h u m a n m i l k b u t i s n o t p r e s e n t i n c o w ’ s milk

THE BIFIDUS FACTOR

:
THE BIFIDUS FACTOR
in human milk promotes the growth of gram -
positive bacilli in the gut –
f l o r a , p a r t i c u l a r l y L a c t o b a c c i l l u s b i f i d u s , w h i c h discourages the
multiplication of pathogens.
ANTI-ALLERGIC FACTORS
:Allergic problems occur less frequently in breastfeed babies than in bottle fed babies.
TECHNIQUES OF BREASTFEEDING:

Mother should take bath daily and wear clean cloths.

Mother should clean her breast and hands before starting the feed.

Mother should sit comfortable position .The baby head should be elevated.

Identify cues for breastfeeding (Rooting, Sucking, hand to

m o u t h movement).

Hold the infant close facing the breast with chest.

Start feeding the baby before becomes hungry.

Support the breasts in the palm of her hands allowing the nipple to
p a y through the index and the middle fingers into the infants mouth.

The infant should drawn both the nipple and areola in to her mouth.

The baby’s nose should not be obstructed the breast tissues.

Change the breast with each feed

Allow him to suckle at one breast for 10-15 minutest or more.

End the feed by introducing a finger in between corner of the mouth of infant breast tissues to
break the suction to avoid injury the nipple.

Do not keep the baby in supine position. Burp the baby immediately after feeding.

Burp is keep the baby on the shoulders and gently tap the back to
e n s u r e release of air from the stomach and digestion.
ADVANTAGES OF BREASTFEEDING:
BENEFITS TO THE BABY:
o
Breast milk is a complete food and it provides all the nutrients a baby needsduring first 6 months
of life.
o
Breast milk contains a number of anti-infective substances and antibodies

o
Breast fed babies are less likely to suffer from allergic disorder like asthmaand
eczema
o
Breast feeding provides immunological benefits to the baby for the life time.
o
Breast feeding provides emotional security.
BENEFITS TO THE MOTHER:

During breast feeding there is a release of oxytocin to eject the m

i l k , oxytocin helps to contract the uterus.

Breast feeding delays ovulation and onset of menstruation.

Breast feeding is convenient

Breast feeding helps to maintain and regain the pre pregnancy body weight.

Mothers who breast feed their babies have a reduced risk of development of breast
and ovarian cancer.
SORE AND DAMAGED NIPPLES:
It is due to trauma from the bab y’s mouth and tongue which results
f r o m incorrect positioning baby’s mouth to the breast
ENGORGEMENT:
The breasts are hard ,painful and sometimes flushed.
MASTITIS:
It means inflammation of the breast
BREAST ABSCESS:
A fluctuant swelling develop in a previously inflammed area.
LONG NIPPLE:
It leads to poor feeding
INVERTED AND FLAT NIPPLE
Initiates lactation by expressing the milk.
PART – IISTUDIES RELATED TO BREAST FEEDING
Okolo S.N(1999)
conducted on current breast feeding knowledge , attitude a n d p r a c t i c e s o f
m o t h e r s i n f i v e r u r a l c o m m u n i t i e s i n t h e s a v a n n a h r e g i o n o f Nigeria.
The knowledge attitude and practice regarding breast feeding among 310m o t h e r s i n f i v e
r u r a l c o m m u n i t i e s i n T o t o l o c a l G o v e r n m e n t i n N a s s a r w a s t a t e . ‘Nigeria
were investigated using a questionnaire.162(52.3%) were illiterate while

148(47.7%) had either primary or secondary school education. Apart

from giving b a b i e s c o l o s t r u m s , w h i c h w a s s e e n a m o n g s t w i t h h i g h e r l e v e l s
o f e d u c a t i o n s (P<0.001) other practices investigated such as exclusive breast
feeding, demandfeeding” rooming in” and time of first breast feeding and time of
breast feed werenot influenced by the mothers level of education. All mothers attended the
antenatalclinic but only 103(33.3%) received instructions from t he health worker on
breastfeeding and 46.8% delivered at home. Only 28.6% of babies were breast feed
within 24 hours of birth.A mean time after birth for the first breast feeding was 47.7 hours.
Although breastfeeding is widely practiced, none of the babies was
exclusively breasted and prelacteal feeds ranging from water. formula. The practice of
discarding colostrumsand replacing if with a wide range of prelacteal feeds and late
initiation of
breastf e e d i n g h a s i m p l i c a t i o n f o r h e a l t h e d u c a t i o n p r o g r a m m e s a n d n e o n a t
a l f e e d i n g strategies.
Nanthine Subbaish

(2000)
c o n d u c t e d a s t u d y t o a r r e a r s t h e k n o w l e d g e attitudes, practice and problems of post
natal mothers regarding breast feeding in aselected hospital at Madurai, revealed that
majority of the samples had sufficientknowledge of breastfeeding like importance
of breast milk, benefits feeding from both the breasts , diet of lactating mother’s prevention
of breast engorgement, etc.,They have positive attitude towards breast feeding practices.
Bellegio guidelines (2000),
summarises that the maximum spacing effect of b r e a s t f e e d i n g i s a c h i e v e d w h e n a
m o t h e r f u l l y b r e a s t f e e d s a n d t h e s e r e m a i n s amenorrhic, that is she does not
menstruate. Full breast feeding entails providing aninfant with no other food or liquid but
breast milk. when these two conditions aremet, breast feeding provides more than 98%
protection from pregnancy during thef i r s t 6 m o n t h s b r e a s t f e e d i n g n o t o n l y d e l a ys
o v u l a t i o n b u t a l s o r e d u c e s t h e likelihood of conception
Worldege brief. A (2002)
“Mother’s knowledge and brief on breast feeding.A c r o s s s e c t i o n a l s u r v e y w a s
c o n d u c t e d t o a s s e s s t h e k n o w l e d g e a n d b e l i e f o f mothers towards breast feeding
the study was carried out on 317 mothers with new born. The conventional cluster
sampling technique was utilized to select the studysubjects. Almost all mothers 308
(92%) of them considered human milk is best milk for good child growth compared to cow’s
milk.

A higher population proportion 253(80%) mothers considered breast milk alone

sufficient enough to feed a baby up to the age of six months. The majority 310(97%) suggested
not to breast feed when a mother gets pregnant . Three quarters of mother’s prefer red hot to
breast feed when the mother’s get sick. Concluded that though mother’s value breast
milk as the best child fed. Their knowledge and breasttowards breast feeding the child
when the baby / mother gets sick and the mothers gets pregnant is very poor. These are
potentially harmful effects, which could
leadt o t h e d a n g e r o u s p r a c t i c e o f a b r u p t c e s s a t i o n . T h e s e h a r m f u l s h
o u l d w e w e l l addressed and minimized though continues health education
Rinda John (2003)
conducted descriptive study on knowledge, attitudes and practice of employed mothers about
breast feeding. The main objective of the studyto determine knowledge, attitudes and practice of
breast feeding. The major resultss h o w e d t h a t t h e l e v e l
o f k n o w l e d g e s h o w s t h a t 2 8 % o f t h e s a m p l e h a d p o o r knowledge ,57%
of the mothers had average knowledge and only 15% had goodknowledge regarding
breast feeding. The mothers has higher means. percentage73% knowledge score in the
area of benefits of breast feeding. Which is essential
Gulbin G. etal in Turkey (2002)
conducted a study aimed at comparing thefirst year growth of infants who had received different
feeding regimens throughoutthe first 4 months. Anthropometric measurements of 332
infant during a well
babyc l i n i c w o r e a n a l y z e d . T h e i n f a n t s w e r e d i v i d e d i n t o 4 g r o u p s e
x c l u s i v e l y breastfeed, predominantly breastfeed, practically brea stfeed and non
breast feed.Exclusively breast feed infant were significantly healthier in the first two months
of life compared to partially breastfeed or non -breastfeed infants. Weight and
lengthmeasurement of the predominantly breastfeed infant were almost identical to thoseof the
exclusively breast fed group at all ages.
Ogbonna C, Daboer, J.C. (2007),
c o n d u c t e d c r o s s s e c t i o n a l s t u d y o n knowledge and practice of exclusive breast feeding
among mother’s in Jos, Nigeria.The target population of interest was nursing mothers who have
infants aged 6-12months,pretested structured closed ended interviewer questionnaire was used..
Four hundred and seventy nursing mothers consented were recruited for the study througha
house to house visit. 2 female and 1 male were recruited and trained on
t h e questionnaire administration. Results showed that out of the 470 nursing
motherss t u d i e d 3 8 7 w e r e a b l e t o d e f i n e c o r r e c t l y e x c l u s i v e b r e a s t f e e d i n g .
Targeting
adolescents for exclusive breast feeding education and sensitization is necessary in preparing
them for motherhood
Shilaja. K.G. (2008)
c o n d u c t e d s t u d y t o a s s e s s t h e k n o w l e d g e a n d confidence of prim
Para mothers regarding exclusive breast feeding in post natal units of selected hospitals.

CHAPTER – III
RESEARCH METHODOLOGY
RESEARCH METHODOLOGY:
T h i s c h a p t e r d e a l s w i t h m e t h o d o l o g y a d o p t e d f o r t h e s t u d y. I f i n c l u d e s r e s
earch approach, research design, setting sample and sampling tech
n i q u e , instrument, data collection procedure and plan for data analysis
RESEARCH APPROACH:
The research approach adopted for the study was survey approach
RESEARCH DESIGN
The research design for the present study is a descriptive design which is oneof the non-
experimental design.
SETTING OF THE STUDY
The study was conducted in Government Hospital.
D h a r a p u r a m . I t i s a Government Hospital. The samples were selected from the maternity
ward.
POPULATION
The population of the study is 30 primi mothers.
CRITERIA FOR SAMPLE SELECTION
INCLUSION CRITERIA
1.
Primi mothers2 . M o t h e r s w h o k n o w s t a m i l l a n g u a g e 3.Mothers who are willing
to participate in the study
EXCLUSION CRITERIA
1.Multi mothers
2.
Mothers who are not willing to participate
SAMPLING TECHNIQUE
Convenient Sampling techniques used to select the samples.
SAMPLE SIZE:
The sample size included for the study consist of 30 primi mothers
INSTRUMENT AND SCORING PROCEDURE
DESCRIPTION OF THE TOOLS
The tool consist of 4 sections;

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