|Guidelines for Training Community Health Workers in Nutrition (WHO, 1986, 128 p.)|
After studying this chapter, taking part in discussions, and doing the exercises, a community health worker should be able to:
· Find out all about breast-feeding practices in the community.
· Find out from individual mothers how they feed their children and what they think about breast-feeding.
· Encourage women to breast-feed their infants and teach them convincingly and sympathetically the advantages of breast-feeding.
· Reassure and help mothers to overcome problems of breast-feeding-flat or sore nipples, swollen (engorged), tender or painful breasts, and fear of too little milk or poor quality of milk.
· Explain to a mother the risk and cost of bottle feeding.
· Teach a mother how to prepare an artificial feed if her own milk is not available under any circumstances and explain to her the risks of artificial feeding and how to avoid them.
Finding out how mothers feed their infants
It is important to know how mothers in the community feed their children. If an infant is properly fed during the first year, he or she will grow well and have a good start in life. Correct feeding and good growth in the first year mean that the risk of malnutrition in the second and third years is less. If a child is not fed well in the first year, it will be difficult to make up for this in later years. Breast milk is the most important food in the first year and continues to be very valuable in the second year. If we know how a child is fed, we can help him better.
One must be careful and gentle when finding out how mothers feed their children. Because feeding babies is a personal matter, one must first make friends with the mothers. Mothers should know that you want to learn about feeding practices so that you can help them.
One can find out about feeding practices by observing and questioning. Observing means watching carefully, trying to understand, and remembering. Questioning can be done in a simple way or in a systematic way with a list of questions. Both these methods are useful and for both, the questioner's approach should be friendly and sympathetic. Some observation and questioning was done when finding out about the community in Module 1. The community health worker should know answers to the following questions.
Some useful questions for finding: about infant feeding practices in the community.
· How soon after birth do mothers give the first breast-feed?
· What does the mother do with the colostrum-the watery milk-like fluid secreted from the breasts during the first 2 3 days after delivery?
· How are newborn babies fed for the first few days of life?
· Do all mothers in the community breast-feed their babies?
· For how many months does a mother breast-feed her baby in the community?
· How many times per day and night is breast milk given?
· What is the first other food or drink given to a baby? When and how is it given-by spoon, cup, bottle, or hand? At what age is it given?
· What feeding practices are forbidden (what are the food taboos)? (For example, in some areas breast-feeding during pregnancy is forbidden.) What foods should a mother not eat during lactation?
· Are there beliefs about certain foods or local herbs which are thought to increase the amount of milk produced by the mother?
· What food or drink is given to the baby when the mother goes out to work?
· Do any mothers have difficulties in breast-feeding their children? What are the problems? From whom do mothers seek advice about breast-feeding?
· If a mother is bottle-feeding her baby, why did she decide to feed the baby in that way? What mixture does she feed him?
Where breast-feeding is the normal practice in a community, little or no education is needed except for those with special problems. The traditional practice should be encouraged. In areas where traditional knowledge and practices are lost, especially in towns, education and personal support are needed. In many developing countries breast-feeding is usual in the first year of life. Recently, certain influences have been changing this important practice. These influences include the urban way of life, women working away from their homes to earn additional incomes, the advertising of infant foods, and the idea that bottle-feeding is modern and therefore somehow better. This is wrong. Community health workers should act to reduce the effect of these bad influences on breast-feeding.
Teaching about the advantages of breast-feeding
There are many advantages of breast-feeding. A community health worker must know and believe in these advantages. It is important that she and her relatives breast-feed their babies if they have any. If important and influential women in a community breast-feed their children, this will encourage others to do the same.
Breast milk is the best natural food for babies.
Breast milk contains the right mixture of fats, sugars, proteins, minerals, and most vitamins for a growing baby and is easy to digest. The nutrients in breast milk are essential for the growing body. It also contains substances which protect the child from infection. Cow's milk is the natural food for calves. Even if cow's milk is modified, it cannot have all the good qualities of human milk for a human baby.
Breast milk is suited to the growth needs of babies. Up to 4 months of age no other food is needed. Starting from 4-6 months other foods should also be given, but breast-feeding should continue. Even if a small quantity of mother's milk is available to the baby, it improves the quality of other foods the baby is taking from outside. Breast-feeding is still Important for growth in the second year of life.
Breast milk is always clean.
Mother's milk passes straight from the breast into the infant's mouth. In that way it cannot be infected by germs. Many germs grow well in milk. Other milks, such as cow's milk, are easily contaminated with germs from dirty hands, spoons, cups, bottles, or flies. These milks should be boiled before being given to babies. The utensils used in feeding infants with other milks should also be boiled before every feed.
Breast milk contains protective substances against the germs that cause diarrhoea and some coughs and colds. Breast-fed children have fewer infections.
Breast milk protects the baby from disease.
With breast milk there is a special mechanism of demand and supply. The more often a baby sucks, the more milk the mother will produce.
Other types of milk need to be boiled before being fed to babies. They also need to be diluted with water when a baby is small. Any water used for dilution should also be boiled and cooled. Sugar should be added. If sugar is added to milk, it is preferable to boil the milk afterwards, as the sugar in most cases is not clean. The boiling requires fuel, and the mixing and cooling take time.
Breast milk is available 24 hours I a day and requires no special preparation
Most foods cost money, but mothers' milk is free. An infant who is 3 months old needs 600-700 ml of milk per day. If breast milk is not given, other milk must be purchased. In an ordinary home this will mean a large part of the family's income. There will be extra cost for fuel. (A mother should have extra food when she is breast-feeding, but this costs only about a quarter or less of the price of buying milk). Illnesses are more common when you use other types of milk. Treatment of the illnesses will cost both time and money. Why waste money and invite illness by bottle-feeding?
Breast milk does not cost anything.
Breast-feeding permits a closeness between a baby and mother. Every human sense is involved in breast-feeding. This contact includes touching, warmth, smell, looking, etc. If this close contact is started in the first few hours of life, the relationship is especially strong. Breast-feeding gives a feeling of security and love to the baby.
Breast-feeding makes a special relationship between mother and baby.
When a mother breast-feeds, her womb contracts. There are also other changes in the mother that result from breast-feeding. Mothers who breast-feed do not menstruate as soon after delivery as mothers who give artificial feeding. Mothers who breast-feed do not generally become pregnant again so soon. Breast-feeding therefore helps in spacing children. In this way a mother can give full attention to a small child for a longer time before the next child is born. Of course, breast-feeding is not a certain way of avoiding pregnancy. If parents want to be sure of not having another baby too soon, they should use some other contraceptive method in addition to breast-feeding. (A contraceptive is a method which prevents a woman becoming pregnant. Most contraceptive pills should not be used by a mother who is breast-feeding; they decrease the amount of milk she produces.) Regarding other contraceptive methods, the community health worker should consult her supervisor.
Breast-feeding helps parents to space their children.
Questions and practical points about how to breast-feed
Mothers in the countryside are the world's experts in breast-feeding. They learn from watching their own mothers, relations, and neighbours breast-feed their babies. They learn naturally and do not need special education. But mothers in urban areas, especially those with a first child, quite often need advice on specific matters.
The most important things the community health worker needs to know about breast-feeding are given below. These are in the form of answers to questions mothers may ask. Some mothers may be too shy to ask; nevertheless they need to know the answers to get the best results from breast-feeding.
When should mothers start breast-feeding?
A mother should put her baby to her breasts on the day he is born. It is best to start very early, within 1 or 2 hours of birth. There is little milk at that time, but it helps to establish feeding and a close relationship.
Should the first watery milk that comes before the regular milk be given to the baby?
This first milk is called colostrum. Colostrum is very good for the baby. It protects the baby from infectious diseases such as diarrhoea. The regular milk comes on the third to fifth day after the birth.
Can all mothers breast-feed their babies?
Yes, practically all. There are very few conditions in which a mother cannot feed her baby. Difficulties of breast-feeding will be discussed later.
How do you put the baby to the breast?
A mother normally knows this. Only teach her if she is having difficulty.
The mother should be comfortable. After delivery, sitting up may be painful. The mother or baby can be supported by pillows, or she may feed the baby while Iying down on her side with the baby beside her.
If she touches the baby's cheek with her nipple, the baby will automatically turn his head and open his mouth. Not only the nipple, but also the areola (the dark skin around the nipple) should be in the baby's mouth. The baby's chin should be pressed up against the breast. If the breast is very full, it may press against the baby's nose and make it difficult for him to breathe. To avoid this the mother should lean towards the baby; she can also gently hold the breast away from the baby's nose with her fingers.
The baby should suck from both breasts at each feed. Feeding should start with the right breast on one occasion, and the left breast on another.
If the mother can relax, the milk will flow easily and she and the baby will enjoy the closeness and satisfaction of breast-feeding.
How often should the mother breast-feed?
The more often the baby sucks, the more breast milk will be produced by the mother. Allow the baby to breast-feed whenever he wants. During the first few days the baby will cry when he wants milk; mother and baby usually settle into a rhythm. It is not a good thing to feed at a precise time according to a clock.
How long should a baby be fed each time?
The baby should be allowed to suck for as long as he wants. At first the time may be quite short, 5-10 minutes from each side. When the baby gets older and stronger he will suck for a longer time because he needs more milk.
Should the baby be fed at night?
Small babies need to be fed at night. In the first few weeks of life most babies wake up with hunger in the night. They need extra feeding. In many countries babies sleep next to their mothers. There is no danger of a mother crushing her child. Babies enjoy the warmth and closeness of the mother's body. Many babies feed in the night, sometimes without waking the mother.
Up to what age should a child be breast-fed?
A baby should breast-feed for as long as possible. It is good to breast-feed for at least one year. Breast milk is still important for growth in the second year of life because even a small quantity of breast milk along with other foods can improve the diet of a two-year old child.
How do you know if the baby is getting enough breast milk?
Most mothers produce enough milk for a baby to grow well for the first 4 6 months of life. Growth should be measured by weighing the baby regularly (see Module 2).
How quickly should breast-feeding be stopped?
If a mother wants to stop breast-feeding, she should do it gradually. Stopping breast-feeding should not be sudden because the baby will need some time to get used to other foods. Other foods should first be introduced and increased over a period of 2-3 months. Then the baby will suck less, and less milk will be produced.
Should breast-feeding be stopped if the mother becomes pregnant?
It is not necessary to stop breast-feeding when a mother becomes pregnant. The quality of her milk will still be good, but the quantity may decrease.
Breast-feeding for the first few months of pregnancy will cause no harm to the child in her womb. A pregnant mother who is also breast-feeding will need extra food.
It is not good for a mother to become pregnant soon after she has had a baby. She will not be able to give the first child breast milk long enough.
What can a working mother do about feeding her baby when she is away at work?
If she is going to be away for a short time, she should feed the baby just before she leaves. If she has to be away for a long time, she should try and take the baby with her. The baby can be fed anywhere. Some countries have laws to ensure that working mothers have prolonged maternity leave and time during working hours to breast-feed babies. If she must leave the baby she should make good arrangements. Another mother may give the baby a breast-feed. If the baby can take other foods, something should be carefully prepared and preserved for him. A responsible person should be shown how to feed this food to the baby when the mother is away. (Suitable foods will be discussed in Module 4.)
Should the baby be given occasional feeds from a bottle?
NO. A small baby does not need extra feeds from a bottle. If the baby cries, he should be put to the breast more often. Mother's milk provides all that a young baby needs. Boiled water may be given if a baby has diarrhoea or fever, but breast-feeding should continue. The boiled water can be given with a spoon or a special feeding cup. Bottles are often dirty, difficult to clean, and can be dangerous. Older children can drink from a cup.
Can contraceptive pills be taken while breast-feeding?
Some contraceptive pills reduce the amount of breast milk. Breast-feeding mothers should use pills which do not affect milk production or preferably use other methods of avoiding pregnancy during the period of breast-feeding. This is important because a baby should receive breast milk for as long as possible.
Overcoming problems of breast-feeding
There are a few common problems with breast-feeding, especially in the first one or two weeks. The most frequent are a mother's anxieties about her performance, and the amount and quality of her milk. Others include flat nipples, sore nipples, and very swollen and tender breasts.
Preparation for breast-feeding during pregnancy can avoid a number of these problems. The community health worker should contact every mother during pregnancy and discuss breast-feeding. The mother should be taught to pull out the nipples, gently press out a few drops of fluid, and build up her confidence in the ability to feed successfully. This is particularly important because, for various reasons, the flow of milk during the first week after delivery may not be good. The community health worker should visit the mother soon after delivery and give encouragement, support, and comforting answers to the mother's questions.
Some women have short, flat nipples. Flat nipples are most common in women who are having their first child (Fig. 23). Most nipples are protractile (you can pull them out) and quite long. If a nipple is not protractile, the baby will have difficulty in feeding.
Examine the breasts of every pregnant woman. If the nipples are flat, see if they will protract. Teach her to squeeze her nipples and pull them gently (Fig. 24). She should do this for several minutes every day. Her nipples will grow longer.
After the baby is born, nipples can still be stretched further. The mother should squeeze the areola before putting the nipple in the baby's mouth. If the breast is very full, first express some milk before doing this.
Fig. 23. A flat nipple
Fig. 24. Preventing flat nipples
Swollen (engorged) breasts
Sometimes a mother's breasts make more milk than her baby needs. This is quite common in the first week after the baby is born. Sometimes the baby is too weak to suck all the milk. If a breast is not emptied normally, it becomes painful and swollen with milk (it becomes engorged). The skin is tight and the baby cannot put the whole areola in his mouth to suck. Sucking may be very painful to the mother. Prevent and treat engorged breasts by emptying them regularly.
Expressing breast milk. Teach a mother to express her milk when her breasts feel painfully full (Fig. 25). She should wash her hands and find a clean cup or bowl. Using both hands squeeze gently from the base of the breast towards the nipple. Then squeeze the breast and areola between fingers and thumb and let the milk squirt into the cup. Milk must be expressed from each part of the breast. You cannot express a breast quickly. An empty breast should be soft without any lumps. If an engorged breast is not emptied, the amount of milk produced by it will decrease quickly. The expressed milk can be fed to the baby in a number of ways (Fig. 26).
A tender lump in the first week of breast-feeding may be caused by a blocked milk duct in the breast. Empty the breast and then gently press and empty the lump. This will prevent serious problems later.
Nipples are very sensitive. If the skin is very soft and the baby sucks very hard, soreness develops. This happens more in women with engorged breasts and in women with small or flat nipples because the baby has to suck extra hard to hold the nipple in his mouth. Sometimes the soreness develops into a crack which is very painful. A crack is not usually due to a baby biting the nipple. Infection can get into the breast through a crack in the skin.
To prevent sore nipples keep the skin soft by rubbing the areola and nipple with some oil. Do not let the baby suck for too long at first. Change the position so that when the baby sucks the line of pressure will not always be at the same place. Make sure the breasts are emptied regularly, by expressing them if necessary. Let the nipples dry in the air after feeds.
Treat sore nipples by keeping the breasts empty. Sucking is usually too painful, and it will be necessary to express the milk. Put some antiseptic ointment or antibiotic (tetracycline ointment) on the crack. Let the child feed from the other breast. If necessary, give the mother aspirin or paracetamol tablets to relieve the pain.
Fig. 25. Expressing breast milk
Painful tender breasts with fever
Sometimes germs enter the breasts, perhaps through a crack in the nipple. This causes infections. A part of the breast becomes painful, swollen, red and warm. The woman may have fever.
Antibiotics are needed and the mother should be referred to the health centre or hospital. In this case also it is important to keep the breast empty of milk by feeding or expressing. The breast will be very painful, but the baby should go on sucking. Breast-feeding should be stopped only if there is pus coming out from the nipple. Give the mother aspirin or paracetamol tablets to relieve the pain and fever.
Fears that there is too little milk or that it is of poor quality
In the beginning, it is common for mothers to worry that they do not have enough milk for their babies. Breasts begin secreting milk from the third to the fifth day after delivery. However, during the first 2 or 3 days after delivery, breasts secrete enough colostrum to feed the baby. Encourage the mothers by telling them:
· Milk usually starts to flow on the third to fifth day, but breast-feeding should be started immediately so that the baby can get the colostrum. Immediate breast-feeding will promote early milk secretion.
· A baby is born with plenty of water in his body and does not need to drink much in the first few days.
· The baby should be put to the breast regularly. He will get some colostrum which is good, and sucking helps the milk to come.
Often mothers of 2 6 month-old babies worry that the baby is not getting enough milk, especially if the baby cries a lot. Help the mother in the following ways:
· Weigh the baby regularly. If there is steady weight gain, reassure the mother (see Module 2).
· The baby may cry for reasons other than hunger. Make sure he is not wet, cold, or uncomfortable. Crying after feeds is not usually due to hunger.
· If the baby is not gaining weight well, try first to increase the mother's milk. She should have more food, drink, and rest. Where culturally appropriate, give locally accepted herbs and drinks to increase breast milk. The baby should be put to the breast more often to feed. Help the mother to overcome any other anxieties, because anxiety can decrease her milk flow.
· Even if a mother has only a little breast milk, she must continue breast-feeding her child. Whatever breast milk she has is good, and she may have more later if she perseveres.
Fig. 26. Four ways of feeding a baby
Mothers sometimes worry that their milk is not suiting the baby, or that it is of poor quality. Ignorant women and grandmothers sometimes say such things. In fact a mother's milk is just right for her baby. It contains nourishment and substances that provide protection from infections. Strong reassurance should be given because if a woman loses confidence, her milk supply may decrease.
How to feed a baby if the mother has no milk: the dangers of bottle-feeding
If the mother of a small baby has no breast milk, or if the mother has died in childbirth, efforts should be made to find someone else who can breast-feed the child. A friend or relation may act as a wet-nurse. A wet-nurse is some woman other than the mother who breast-feeds a baby. Even if a woman is not lactating and does not have a small baby she may be able to breast-feed again. She must desire or feel it her duty to breast-feed the baby. The baby must be put to both her breasts frequently. She should also have extra food and drink. If there are local herbs believed to increase breast milk, she should use these. This process is called relactation. Relactation does not work with all women.
If the mother really cannot make her breast milk and a wet-nurse cannot be found, then it will be necessary to give the child artificial feeding, with milk from a cow or other animal or with powdered milk. The common practice of bottle-feeding is dangerous. Here are some of the reasons:
· Milk is easily contaminated with germs from dirty bottles, rubber teats, spoons, water, or hands. This danger is greatest in homes where there is no running water supply and where there is little fuel or time for sterilizing the feeding-bottles and teats.
· Except for breast milk, no other milk has any substances that can protect the child from infections.
· Milk goes bad if it is not used quickly. This happens much more quickly in hot climates.
· Cow's milk and powdered milks are often diluted too much. This is because they cost so much. If they are diluted the children do not get adequate nourishment and will not grow.
· The rubber teat of the bottle may have too small or too large a hole. If the hole is too small the child may struggle to get the milk and swallow a lot of air but not enough milk. Too large a hole may cause rapid feeding and sometimes vomiting.
Here are some things that can be done to make artificial feeding less dangerous:
What a mother can do.
· Wash hands with soap and water every time before preparing the feed.
· Use other methods of feeding rather than a bottle. Feed with a cup and spoon (Fig. 27) or a special feeding spoon.
· Wash and then boil these utensils before use. They are all much easier to clean than a bottle.
· If the milk has to be diluted or prepared (as in the case of powdered milk), use boiled water.
· Mix up only the amount needed for one feed. If too much is mixed and some of it is stored for a later feed, the danger of contamination is great.
Fig. 27. Cup and spoon feeding is safer than bottle feeding
What the community health worker can do.
· Find out if the family can afford to buy the milk. If the family is poor and cannot get free milk from the health service, the baby will need milk and porridge to give him enough nourishment.
· Only teach about artificial feeding to mothers who have no chance of breast-feeding. Do not teach about artificial feeding to a group of mothers.
· Teach the mother that artificial feeds must not be used to supplement breast milk. It will only reduce the production of breast milk. (Note that artificial feeding may be used to supplement breast-feeding if the growth chart of a child shows that he is not gaining weight.)
If cow's, or goat's, or camel's milk is used for artificial feeding:
· During the first 15 days of life: Give 1 part of boiled and cooled milk diluted with 1 equal part of boiled and cooled water.
· From 2 weeks to 4 months of age: Give 2 parts of boiled and cooled milk diluted with 1 part of boiled and cooled water.
· After 4 months of age: Give undiluted boiled and cooled milk.
(If buffalo's milk is used instead, the cream must be removed before the milk is boiled, since buffalo's milk contains too much fat for babies. After the cream has been taken off, follow the same instructions as for cow's milk.)
How much milk does a baby need?
An artificially fed baby needs about 150 millilitres of milk for each kilogram of his own weight each day. If pounds and ounces are used in weighing and measuring, the rule is to give 2½ ounces of milk per pound of body weight of the baby. One kilogram is 2.2 pounds and about 30 millilitres is one ounce. So a very young baby weighing 3 kg will need 450 ml of milk a day. He needs feeding about 6 8 times a day; therefore he will need about 55-75 ml of diluted milk at each feed. Feed older babies 5 times a day. A 5-month old baby weighing 7 kg will need a little more than 1 litre of undiluted milk a day; about 210 ml at each feed.
SOME IMPORTANT THINGS TO TEACH ABOUT ARTIFICIAL FEEDING
· Breast-feeding is the best feeding until a child is 18-24 months old, but additional foods should be given when the child reaches 4-6 months of age.
· Mixing and preparing powdered milk is very complicated. Anyone who needs to use powdered milk should have a demonstration from a trained person.
· It is very expensive to feed a baby with the correct amounts of powdered milk.
1. Lecture: Training content.
2. Demonstration: Preparation of an artificial feed.
3. Community survey: Finding out infant feeding practices in the community, and problems of breast-feeding.
4. Group discussion: Results of the community survey.
These can be done by the trainees in groups, pairs, or individually.
Exercise 1. Finding out about the infant feeding practices in the community
Using the questions on pages 59-60 of this module, ask each trainee to interview five mothers with infants and put together the collected information. This will give a picture of the infant and show what existing practices need to be corrected and how.
Exercise 2. Estimating the cost of bottle feeding
List and find out the prices of all the items needed to feed a 3-month old baby with powdered milk (tin of milk, bottle, teat, equipment for cleaning and boiling the bottle, fuel for boiling water, etc.). Calculate how much it costs to feed a 3-month old baby with the correct amount of milk for a day. Compare this cost with:
(a) the daily wage of an agricultural labourer in the area, and
(b) the cost of giving a mother 25% extra food per day (she needs this to help her make breast milk).
Exercise 3. Comparing the time taken to breast-feed and bottle-feed a child
Most village mothers have very little time to spare. They are busy with their household work and other jobs to earn money or grow food. Mothers often start work long before dawn and cannot rest until they go to bed at night. Find out how much time it takes to feed a child by bottle by doing the following exercise.
Calculate the time it takes to do all the activities necessary for artificial feeding (i.e., buying milk, fetching water, collecting fuel, boiling water, cleaning and sterilizing bottle, measuring and mixing milk, filling the bottle and feeding the baby). Bottle-feeding has to be done about 5 times a day. Calculate the time it takes to breast-feed a baby. Now compare the total time required each day to bottle-feed a baby with the time required to breast-feed him.
Exercise 4. Finding out reasons for stopping breast-feeding
Find 10-15 mothers in the area who are using milks other than breast milk for feeding their babies. Ask them the reasons why they stopped breast-feeding. Discuss the reasons they give. Are these the only reasons, or are there other factors which mothers did not want to tell you about? How can we decrease the influences which lead to artificial feeding?
Exercise 5. Comparing the growth and health of children fed on breast milk and other milks
Select two groups of children under 1 year of age from the local community. The first group should comprise breast-fed babies and the other babies fed on other milks. Look at their growth charts and clinical records. Compare and discuss the weight gains and number of illnesses in the two groups.
Exercise 6. Finding out how baby foods are advertised
Find out the different ways in which companies making baby food and milk advertise their products (e.g., radio, magazines, posters, free samples, etc.). Discuss the effect of this advertising and what should be done to decrease its influence.
Exercise 7. Finding out how mothers overcome difficulties of breast-feeding
Interview mothers who are experienced at breast-feeding. Ask them about any difficulties they might have had when they started breast-feeding and how they overcame these problems (e.g., sore nipples and engorged breasts).