BREASTFEEDING FREQUENTLY ASKED QUESTIONS

Breastfeeding Q & A Guide 2012

CONTENTS 1. BACKROUND 2. BENEFITS OF BREASTFEEDING 3. THE ART OF BREASTFEEDING 4. PRACTICES, BARRIERS AND MISCONCEPTIONS 5. BREASTFEEDING BEYOND SIX MONTHS 6. MOST COMMON DIFFICULTIES RESULTING IN BREASTFEEDING FAILURE 7. BREASTFEEDING IN THE CONTEXT OF HIV 8. POLICY RELATED MATTERS 9. BREASTFEEDING SUPPORT 10 11 12 5 6 7 3 4

Breastfeeding Q & A Guide 2012 1. BACKROUND This question and answer guide provides accurate, easy-to-understand answers to the most commonly asked questions about breastfeeding. The importance of breastfeeding, including in the context of HIV, cannot be overstated. One of the reasons for poor breastfeeding practices is a lack of information on the benefits to both the mother and the baby and how to master the art of successful breastfeeding. The answers in this guide are based on the latest evidence and international recommendations.

2. BENEFITS OF BREASTFEEDING 2.1 What is exclusive breastfeeding? Exclusive breastfeeding means giving your baby only breast milk with no supplementary feeding of any type (no water, juice, animal milk, and solid foods) except for vitamins, minerals, and medications prescribed by a doctor or healthcare worker when medically indicated. How does breastfeeding benefit my baby? Breastfeeding contributes significantly to the survival and good health of babies. Key benefits of breastfeeding are: Your baby gets all the nutrients he/she needs to grow and develop healthily for the first six months. From six months up to a year breast milk continues to provide most of the nutrients your baby needs. Breast milk contains antibodies that help strengthen your babys immune system providing protection against common illnesses such as diarrhoea and pneumonia. Breastfed babies are less likely to have respiratory and middle-ear infections than formula fed babies. Breast milk contains special properties that keep the gut lining strong which helps in reducing chances of infection. Colostrum (the first milk the breast produces)) is regarded as the first immunisation. This milk is rich in protective substances and is vital to protect your baby from various infections. Your baby cannot get these protective substances from any other food (even from the most expensive infant milk formula). Breast milk is readily available and does not need to be prepared. Breastfeeding promotes bonding between you and your baby. Breastfeeding is the natural way to feed your baby and the best gift you can give your baby. Breastfeeding contributes to a lifetime of good health. Adults who were breastfed as babies have a lower risk of developing chronic diseases of lifestyle such as obesity, coronary heart disease and Type 2 diabetes. Breastfeeding contributes to child survival. Globally, malnutrition has been responsible, directly and indirectly, for up to 60% of the 10.9 million deaths annually among children under five. Over two3

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Breastfeeding Q & A Guide 2012 thirds of these deaths are associated with inappropriate feeding practices and lack of optimal breastfeeding. 2.3 Does breastfeeding benefit the mother? Yes, breastfeeding is known to reduce the risks of breast and ovarian cancer later in life and helps women return to their prepregnancy weight a lot quicker. Mothers who breastfeed exclusively and whose menstrual cycle has not resumed, have about 98% protection against falling pregnant soon after delivery. This is, however, only achieved if the mother feeds on demand day and night. It is important for mothers to know that contraceptives may safely be used while breastfeeding and will give the mother an opportunity to regain her optimal health after delivery.

NB The mother needs to discuss contraception with a healthcare provider.

3. THE ART OF BREASTFEEDING 3.1 When should mothers start breastfeeding? To enable early production of milk, breastfeeding should start immediately after delivery, within the first hour of birth, and the babymother pair should be left together for at least an hour. Why is it important to breastfeed immediately after birth or within the first hour? early breastfeeding helps stimulate of the production of milk just after birth babies are alert and most eager to feed early initiation of breastfeeding helps regulate the babys temperature and blood sugar level early breastfeeding helps the mother and baby to start bonding. How often and for how long should mothers breastfeed? Your baby needs to be fed often both day and night. Letting the baby feed as frequently as he/she wants helps the body to produce more breast milk. This is called demand feeding. Your baby needs to be left to feed for as long as he/she wants. At the beginning of each feed the early milk, called the foremilk, contains enough water to satisfy the babys thirst, even in hot weather. The milk that follows, called the hind milk, is produced when the baby feeds for long. It is concentrated at the end of a feed and provides higher amounts of important fats, it is feeding and promotes growth. The baby should finish the first breast before being offered the second breast, if he/she still wants more. A baby may feed between 8-12 times per day. This is, however, not an indication that breastfeeding should be scheduled.

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Breastfeeding Q & A Guide 2012 4. PRACTICES, BARRIERS AND MISCONCEPTIONS Lack of support and negative statements from health workers and family members may cause a mother to lose confidence or interest in breastfeeding. Some of the issues that mothers raise include: difficulty in leaving expressed breast milk at home with grandmothers not feeling comfortable about feeding the baby in front of family members and friends Sometimes fluids are given to newborn babies to clean their systems before breastfeeding. This is unnecessary and may damage the babys stomach. Sometimes solid foods are introduced too early because the family or the mother believes the baby is not getting enough from the breast. 4.1 Is it safe for my baby to be breastfed by someone else? This practice, called wet nursing, is not advisable. If wet nursing is considered, the following steps are important to follow. The wet-nurse must understand the implications of HIV and agree to take an HIV test before commencing wet nursing and 68 weeks after starting The wet nurse should receive counselling on HIV infection and how to avoid infection during breastfeeding The babys mother should know all about the wet nurses lifestyle. THIS DECISION SHOULD BE DISCUSSED WITH A HEALTH PROFESSIONAL 4.2 Is it necessary for mothers to take milk-stimulating products or supplements? No, generally milk-stimulating products are unnecessary. Before the mother considers using these products (often called lactagogues) she should: ensure that the baby is properly latched to the breast and feeding adequately ensure that she is relaxed and not stressed ensure she breastfeeds as often as possible Does the mother needs extra fluids when breastfeeding? Yes, a mother will need extra fluid to replace fluid used to produce breast milk. Taking extra fluid will not increase milk supply if breastfeeding is not frequent. Do breastfed babies get constipated? It is unusual for an exclusively breastfed baby to suffer from constipation. A baby who is exclusively breastfed usually has stools which are bright yellow, sweet-smelling and the consistency of scrambled eggs. When formula or solids are introduced to a baby, then the stools usually change and become more brown, solid and foul smelling and the child may start suffering from constipation. When do babies sleep through the night? 5

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Breastfeeding Q & A Guide 2012 All babies are different, however breastfeeding at night is important and may even help both mother and baby to sleep better. Older babies are able to regulate their feeds and their sleep patterns. There is no specific age at which children sleep through the night, children are different. 4.6 What are the dangers of smoking, use of alcohol and recreational drugs during breastfeeding? Cigarette smoking can affect your milk supply which may upset the babys stomach. You are advised to give up smoking and recreational drugs. If this is not possible, reduce your smoking as much as possible and avoid smoking an hour before feeding and during feeding to reduce the harmful effects. No one should smoke in the same room as a baby because of the dangers of passive smoking. Smoking is also linked to lower milk production. As a breastfeeding mother you should avoid alcohol completely. Alcohol passes into the milk and is subsequently taken in by the breastfeeding baby. 4.7 Can all mothers breastfeed? Almost all mothers can breastfeed irrespective of their breast size and shape. Statistics show that only one percent of mothers are unable to produce breast milk. With adequate knowledge and support most mothers can breastfeed successfully.

5. BREASTFEEDING BEYOND SIX MONTHS 5.1 Why should complementary foods only be introduced after six months? Other foods do not provide all the important nutrients found in breast milk. This may result in inferior food or fluid replacing breast milk which could affect your babys growth and development. The food may be contaminated with germs that could cause diarrhoea or other illnesses. Foods like porridge, water, tea, juice, and milk formula during the first six months may damage the babys young intestines and make it easy for infections (including HIV) to enter the babys body. Breast milk has substances that protect the babys sensitive gut lining for the first six months. Other foods will fill up the babys small stomach and the baby will not breastfeed frequently resulting in less milk being produced. Milk is produced on demand - the more the mother breastfeeds, the more milk is produced. Should breastfeeding continue after six months? It is recommended that breastfeeding should continue until your baby is two years or older, when his/her immune system is fully developed. As your baby grows and becomes more active from around six months of age, breast milk alone is no longer sufficient to meet his/her nutritional needs. Start introducing solid food in addition to continuing to breastfeed. From six months on breast milk still plays an important role in the growth 6

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Breastfeeding Q & A Guide 2012 and development of your baby as it provides more than 50% of your babys nutritional needs. 5.3 When should breastfeeding stop? HIV-negative mothers should breastfeed their babies exclusively for six months. From six months the baby can be introduced to complementary foods while breastfeeding continues until two years of age or beyond. When the mother decides to stop breastfeeding, she should do so gradually. HIV-positive mothers should breastfeed exclusively for six months, and introduce complementary foods from six months. Breastfeeding should continue until 12 months while taking antiretroviral treatment (ART). After 12 months the mother should wean her baby over a period of a month while administering infant ARV prophylaxis. Her baby must continue to receive ARV prophylaxis for one week AFTER breastfeeding has stopped.

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MOST COMMON DIFFICULTIES RESULTING IN BREASTFEEDING FAILURE Not having enough milk Almost all mothers can produce enough breast milk for one or even two babies, providing that the baby latches on correctly and breastfeeds as often as he/she wants. The amount of milk the breast produces is determined by the amount that the baby takes - it increases when the baby takes more. Even if the mothers diet is not sufficient, she will be able to produce enough breast milk that is adequate for good infant growth. The only challenge is that the mothers own nutrient stores will be depleted. How does a mother know that her baby is getting enough milk? The following are reliable signs that the baby is receiving enough milk: The baby is passing urine, stools, and is alert and growing. Weight gain is a reliable sign use an accurate scale and have consecutive weight checks done on the same scale. Babies generally double their birth weight by 5-6 months and treble it by the age of one. Mothers should visit their clinics regularly every month for the first two years to monitor babys growth.

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What can mothers do to increase milk production and babys intake? Improve how they position and attach their babies to the breast. The clinic will be able to provide help and support Breastfeed more often and for longer Avoid complementary foods and comforters (dummies) Increase the frequency of feeding your body will start producing more milk for the growing baby 7

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Baby cries often Babies may cry if they are not getting enough milk due to poor latching or not suckling properly. At around two weeks, six weeks and three months the baby has growth spurts. During these periods they may need more breast milk. To increase supply, increase the frequency of feeding. The baby may not be well. Preparing to go to work Many mothers tend to introduce milk formula early in preparation for going back to work. This is unnecessary if breastfeeding is well established before she returns to work. Working mothers who want to breastfeed need to plan properly and need support from family and work colleagues. She will need to learn how to express and store breast milk. Sore or cracked nipples Sore and cracked nipples are caused by poor positioning of the baby and incorrect latching. Thrush infections can cause sore nipples. Should a breast need treatment, the baby can feed off the unaffected breast, or the mother can express breast milk and cup feed. After feeding, express a few drops of milk and gently rub on the nipples (human milk has natural healing properties) to soothe them. It may help the mother to air dry her nipples after feeding. Avoid using soap on cracked nipples as it causes the areola to become too dry. Health facilities need to ensure that no mother is discharged before her baby is latching correctly and feeding properly. Baby refuses to feed Infants may refuse to feed for various reasons. The baby may: be hungry be cold have a wet nappy have sores in the mouth be poorly positioned and incorrectly latched be experiencing a change in the taste of the breast milk - the milk could be salty due to subclinical mastitis or have a different taste as a result of a certain food that the mother may have eaten. It is critical for the mother to identify changes in her diet and seek advice from the health facility on how to keep her breasts healthy. Mother falls pregnant whilst breastfeeding A mother may continue breastfeeding if she falls pregnant, but she needs to take special care of her own health and nutritional needs because both activities are demanding on her body. She needs to rest and take micronutrient supplements. 8

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Breastfeeding Q & A Guide 2012 6.9 Engorged breasts (painful / swelling breasts) The breasts become full and the milk stops flowing. This may also result in nipples becoming painful as they become tight and flat which makes it more difficult for the baby to latch. This may result if baby is not suckling properly, delayed breastfeeding after the birth, infrequent feeding or stopping breastfeeding abruptly.

Breastfeeding should be an enjoyable experience. If it hurts, you are not doing it properly and you need to get help. A breastfeeding mom should avoid wearing tight bras

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Breasts are inflamed and swollen This often happens when the mothers breasts are engorged or when she has blocked ducts. This is called mastitis. Mastitis may be the result of poor positioning and attachment. The mother will need to breastfeed often to empty the breasts thoroughly. The child may refuse to feed from the breast during this period. Feed the baby expressed breast milk or feed from the uninfected breast. The mother may feel sick and feverish with mastitis and should go to a health facility for assistance. If the fever persists for more than 24 hours and the condition worsens, the mother should be treated at a healthcare centre. Untreated mastitis can lead to a breast abscess which needs medical treatment.

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BREASTFEEDING IN THE CONTEXT OF HIV Can an HIV positive mother breastfeed? Yes. Recent evidence shows that mothers who are HIV-positive should breastfeed exclusively because of the many health benefits to the baby and his/her survival. During the breastfeeding period the mother or baby should receive antiretroviral treatment or prophylaxis. Research shows that when antiretroviral treatment or prophylaxis is used by either the mother or baby, HIV transmission through breastfeeding is significantly reduced. Exclusively breastfed babies whose mothers are HIV-positive are at less risk of dying from diarrhoeal diseases and malnutrition than mixed-fed babies. The likelihood of HIV transmission increases when there is a higher viral load in the mothers blood or breast milk. Antiretroviral treatment or prophylaxis lowers the viral loads in the blood and in breast milk. This reduces the likelihood of mother-to-child transmission of HIV.

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If the baby tests HIV-positive, should the mother continue breastfeeding? Yes. If a baby is HIV-positive, the mother should definitely continue breastfeeding for as long as possible. Continued breastfeeding will provide protection against many infections and help the baby grow healthily. 9

Breastfeeding Q & A Guide 2012 The mother should have her own health checked and the HIVinfected baby should be referred for care and treatment. 7.3 Is Government offering Antiretroviral Treatment to HIV-positive mothers who are breastfeeding? Yes. Government policy states that: To significantly reduce the chances of HIV being transmitted to the baby, either the mother or the baby should be on antiretroviral treatment or prophylaxis. If a mother is already on lifelong antiretroviral treatment (ART), she must continue taking the treatment as normal throughout the breastfeeding period. In addition, the baby must receive antiretroviral prophylaxis daily for six weeks after birth. If the mothers CD4 count is above 350 she will probably not be on antiretroviral treatment (ART). In such instances the baby must get antiretroviral prophylaxis throughout the breastfeeding period and for one week after all breastfeeding stops.

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POLICY RELATED MATTERS Why has the Department of Health decided to stop issuing free infant formula? Infant and child mortality rates in South Africa remain unacceptably high and the Millennium Development Goals (MDGs) target of reducing the rate by two-thirds may not be achieved. The following are some of the reasons that influenced the Department of Health to stop issuing free milk formula: Breast milk is readily available and does not need to be prepared. Safe preparation of formula requires having clean, boiled water, sterilized equipment and correctly mixed formula. Breastfeeding rates in South Africa, especially exclusive breastfeeding rates, remain very low. Breastfeeding has been undermined by aggressive promotion and marketing of formula feeds, social and cultural perceptions and the distribution of milk formula in the past to prevent mother-to-child transmission (PMTCT) of HIV. Infant formula, popular with mothers in South Africa, increases the risk of death from diarrhoea, pneumonia and malnutrition. Will all mothers be forced to breastfeed? No mother will be forced to breastfeed against her will. However, all women will be informed about the benefits of breastfeeding so that they can make an educated choice Will any babies receive free formula? Yes. Some babies will continue receiving formula provided they have medical conditions that prevent them from breastfeeding. Strict criteria will be followed for issuing formula to infants or mothers who qualify. 10

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Can a mother choose not to breastfed? Yes. Ideally the mother should be counselled on the benefits of breastfeeding and a health worker should provide her with adequate information that will assist her to make an informed decision. Before deciding to use formula, a mother and her family must be able to meet ALL of the following criteria which will give an indication as to whether or not she will be able to feed her baby consistently and correctly. A mother who still chooses formula feeding should be assisted to choose an appropriate formula and be shown how to prepare it safely.

The following conditions should be met: Safe water and sanitation are assured at the household level and in the community. The mother, or caregiver, can reliably provide sufficient formula milk on her own for 12 months to support normal growth and development of the baby. The mother or caregiver can prepare the formula hygienically and frequently enough so that it is safe and caries a low risk of diarrhoea and malnutrition. The family is supportive of this practice. The mother or caregiver can access healthcare that offers comprehensive child health services. A mother must be advised that she should only use formula if she can ensure that her baby will get it consistently and that it will always be correctly prepared. NOTE: It is important for mothers who choose to formula feed to note that solid food should only be introduced when the baby is six months old. This excludes drops and syrups (vitamins, minerals and medicines) when needed. 8.5 Can home-modified animal milk be used as a replacement food? Home-modified animal milk is not recommended as a replacement food in the first six months if all other options have failed. Pasteurized full-cream milk may be introduced to the non-breastfed babys diet at about 12 months of age. However, in the absence of commercial infant formula and in families where allergies are not common, full-cream milk could be given at 9 months. Ideally, the introduction of full cream milk should be delayed until the baby is 12 months old. Meals, including milk-only feeds, other foods and a combination of milk feeds and other foods, should be provided four or five times per day. All children need complementary foods from six months of age.

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Breastfeeding Q & A Guide 2012 9. 9.1 BREASTFEEDING SUPPORT How can communities support breastfeeding mothers? Families and friends are important sources of support for breastfeeding mothers. They need to create an environment that is comfortable, nondiscriminatory and tolerant of breastfeeding. Some cultural beliefs discourage breastfeeding, and these need to be discussed in advance during antenatal visits. Shopping centres should provide a clean, comfortable, private breastfeeding room for mothers so they do not have to breastfeed in the toilet. Where can a mother get support in the community?

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Mother-to-mother support An experienced mother can provide individual support to a new mother. Ask your healthcare worker for the name of an experienced mother in the area. A few mothers or a health or community worker could start a group themselves. There may be special support groups for women who are HIV-positive. Some hospitals establish mother support groups that are led by a health worker and meet in the hospital. There may be a feeding clinic that the mother can attend if she has difficulty in feeding. La Leche League of South Africa La Leche League (LLL) South Africa is a voluntary organisation that provides information and support to women who want to breastfeed their babies. La Leche League Leaders are experienced breastfeeding mothers, trained and accredited by LLL, who are happy to help other mothers with questions and concerns about breastfeeding. The organisation provides a one-to-one approach that is most effective and a friendly way of giving the support mothers need. LLL also provides support and information for women in special circumstances (premature babies, multiple births, babies with cleft of the soft palate, babies with Down's syndrome and many others). Partner Partners Partners often lack basic breastfeeding knowledge and are unsure of their role in breastfeeding. A study showed that strong approval of breastfeeding from the father is associated with 98% of babies being breastfed, compared with 26% where the father is indifferent about the feeding choice. Family and community support influence the mothers decision to continue breastfeeding. Community health workers and peer supporters Some communities use community health workers that are trained in breastfeeding. Your clinic sister will be able to advise you. Developed by: Directorate, Nutrition National Department of Health

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