Recommended breastfeeding and weaning practices

Backgrounder

Introduction

Breastfeeding

Why is this topic important to listeners?

• To help listeners understand that breastfeeding is not a sign of poverty.
• To help listeners understand that breastmilk is free and appropriate for a baby’s needs.
• To help listeners understand that bottle-feeding often exposes young children to health problems (oral and pharyngeal infections, gastroenteritis, etc.), especially in unsanitary conditions.
• To raise awareness among health professionals that any meeting with a pregnant woman should be seen as an opportunity to discuss the feeding of the newborn, and breast feeding in particular.
• To help listeners understand that children who are not exclusively breastfed for the first six months of their lives are at greater risk of developing diarrheal diseases, acute respiratory infections, and other health problems.
• To help listeners understand that a child born in a Sahelian country, according to UNICEF, is 14 times more likely to die in the first 28 days of life than a child born in a northern country. (16)

Inadequate breastfeeding practices compromise the health, development and survival of infants, children, and mothers. Improving these practices could save more than 820,000 lives per year globally. (15) Nearly half of all episodes of infant diarrhea and one-third of respiratory infections in infants are due to inadequate breastfeeding practices. (17)

Many people mistakenly believe that breast milk alone is not enough for a baby, hence introduce mixed feeding before infants reach six months of age.

Key data

• In 2020, the breastfeeding rate in Burkina Faso was 64.4% and the country expects to reach 80% by 2025. (11)
• According to the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO), investing in breastfeeding could save 520,000 children by 2025 globally. (3)
• Breast milk contains more than 200 components. Its composition adapts to the baby’s needs. These include sugars and fatty acids that provide energy for the cells, proteins and enzymes that enable digestion, essential fatty acids that influence both brain and vision development, hormones that stimulate the growth and development of the digestive and immune systems, and antibodies and antimicrobial molecules that protect the baby from bacteria and viruses (12).
• Several studies have established that of the rate of feeding formula to babies is higher among mothers with primary education or above than among mothers with no education. (2).

Basic information about breastfeeding

Definition

Breastfeeding is the method by which an infant is fed with milk from the mother’s breast. There may be different ways to feed this milk to an infant.

• Breastfeeding can be either exclusive or partial.
• According to UNICEF and WHO, exclusive breastfeeding means that the infant receives only the mother’s milk, not even water, until he or she is six months old. (18)
• Partial or mixed breastfeeding is feeding the infant with breast milk as well as other foods such as milk substitutes.
• Artificial feeding is feeding the infant with formula or any type of milk other than the mother’s milk.
• Breastfeeding also include passive reception, when the mother expresses the milk into a container to give it to the baby. (18).
• WHO recommends that all mothers bring their children to their breast within one hour of delivery to improves the mother’s section of milk and allows the child to benefit from colostrum, the first milk which is rich in proteins and antibodies (2).
• The ideal is to adopt exclusive breastfeeding until the baby is six months old (180 days) and then introduce other foods (fruits, vegetables, etc.). Breastfeeding should be continued till the child is two years old or older.

What does breast milk contain?

Breast milk is composed of:

• Proteins that are easy to absorb and digest.
• Sugars and fatty acids that provide energy for the baby’s body.
• Vitamins and minerals such as vitamin C and iron.
• Enzymes that facilitate the baby’s digestion.
• Essential fatty acids that influence the development of the brain and vision.
• Antibodies and antimicrobial molecules that build the baby’s defenses against bacteria and viruses.
• Hormones and growth factors that stimulate the growth and development of the child’s digestive and immune systems.
• Living cells that protect the baby from infection and stimulate the baby’s immune system. (12).

What are the differences between breast milk and milk substitutes?

There is a huge difference in the composition of breast milk and animal milk in terms of nutritional value. For example, animal milk may have too much or not enough of certain substances that the baby’s body needs. Breast milk contains multiple ingredients that are impossible to include in milk substitutes, in particular antibodies that contribute to the child’s protection against infections. (9).

Why is the first milk (colostrum) recommended for babies?

After delivery, the first breast milk produced is called colostrum. It is yellowish in colour and well-adapted to the newborn’s stomach, so easily assimilated. The first milk is like medicine for a baby because it is very rich in nutrients and protects infants from diseases. In the past and regrettably, mothers discarded this first milk because of certain mistaken beliefs. A few days after delivery, the colostrum changes into colostral, also called transitional milk, which is more fluid and has more volume than colostrum. Then, after two weeks to a month, the mother’s milk turns into “mature milk” which she produces for the rest of the breastfeeding period. (5)

How do you start breastfeeding?

During pregnancy, the breasts are prepared for breastfeeding, and, after delivery, they are ready to produce milk. Within the first few hours after birth, the baby will stimulate breastfeeding by suckling frequently. At the beginning, present the breast to the baby whenever he or she wakes up without waiting for them to express their need to suckle. Let the baby drink on demand, in other words, without a schedule and without limiting the number or length of feeds day and night. Skin-to-skin contact between mothers and babies is strongly encouraged immediately after birth or at least during the first hour (17).

Benefits of exclusive breastfeeding

Benefits for the baby

• Breastfed babies have fewer infections. Their risk of gastrointestinal infections (for example, gastroenteritis and diarrhea) is lower than formula-fed babies.
• Breastfed babies also have a lower risk of upper respiratory tract infections such as colds and flu).
• Breastfeeding also reduces the frequency of bronchiolitis*, pneumonia, and ear infections. (13).
• Breastfeeding is associated with a reduction in infant mortality and the risk of sudden infant death syndrome*.

Benefits for the mother

• Exclusive and prolonged breastfeeding can help the mother lose the weight gained during pregnancy while decreasing the risk of anemia. Breastfeeding also reduces the risk of breast cancer (7).
• Exclusive and prolonged breastfeeding delays the return of menstruation and helps the mother’s uterus to return to the pre-pregnancy state more quickly. (5)

Benefits for society

• According to UNICEF, investing in breastfeeding could save 520,000 children globally by 2025. (19)
• Adopting exclusive breastfeeding results in a substantial reduction in expenses. Families spend less on infant milk, mineral water and bottles, lower bottle maintenance costs (washing and sterilization), and there are reduced medical costs because infectious diseases can be avoided by breastfeeding.

Benefits for the baby and the mother

• Breastfeeding nurtures a close relationship and attachment between the mother and baby.
• The sight of the baby, his/her cry, his/her smell, and his/her contact with the mother are all stimuli that not only help establish a close mother-child bond but also trigger and increase the secretion of breast milk.
• This also occurs whenever a mother holds her baby to offer him/her a bottle (4).

What factors influence breastfeeding? (14)

Factors that influence the practice of breastfeeding include:

Socio-demographic factors

• These include the mother’s age, level of education, and employment status. These factors can have a positive or negative influence on whether a mother continues to breastfeed.

Preparation for childbirth

• Childbirth preparation sessions are a great opportunity to provide information on breastfeeding. They allow women who do not intend to breastfeed to interact with women who have decided to breastfeed. Before childbirth, health workers should strive to encourage future mothers to adopt exclusive breastfeeding.

Advertising of Breastmilk Substitutes

• Advertising campaigns for breastmilk substitutes encourage mothers who do not want to or cannot breastfeed with enticing milk formulas, encouraging early cessation of breastfeed, and encouraging parents to not feel guilty about using milk substitutes.

Providing childcare areas in the workplace

• Providing such areas in the workplace can encourage mothers to continue breastfeeding, delay early weaning, or even avoid needing to express milk to feed their babies.

Recommendations for breastfeeding facilitation in society

To authorities: Promote and enforce measures that allow breastfeeding mothers to breastfeed at work by ensuring that maternity leave is granted and that childcare facilities are established close to the workplace to allow mothers to breastfeed while continuing to work.
To mothers: Exclusive breastfeeding has economic advantages. It saves families the cost buying bottles and formula. It also reduces the loss in productivity caused by illness. By reducing financial costs, society saves money and improves mother and infant health.
To health care workers: Health care facilities that provide maternity and newborn care should have a clear, written breastfeeding policy that is regularly communicated to staff and parents.

Recommendations for infant feeding

Many mothers find it challenging to continue breastfeeding. Indeed, at the age of six months, when some mothers start to introduce other foods to their child’s diet, they tend to neglect breastfeeding. However, this can be negative consequences for the child. Here are some recommendations for infant feeding.

1. Know the right time: From six months onward, breast milk is no longer meets the nutritional needs of the child required to ensure his/her growth and development. The child must receive appropriate complementary foods. The mother must introduce other foods at the right time.
2. Continue breastfeeding: By six months of age, the infant’s digestive system is mature enough to digest foods other than breast milk. The mother should continue breastfeeding frequently and on demand until the child is two years old or older. Breast milk continues to protect the child from illnesses such as diarrhea, respiratory diseases, and ear infections.

Common breastfeeding problems and solutions

Some problems related to breastfeeding can lead to early weaning. Here are some possible solutions.

Breast congestion

• This is a swelling of the breasts that makes them sore and tender.

What to do:

• Encourage the baby to suckle and increase the frequency of feedings, letting the baby feed for as long as he/she wants. In particular, feed the baby from both breasts at each feeding. If the child cannot suckle, express the milk.
• Soothe the pain before each feeding by:
  • Applying warm compresses to the breasts or encouraging the mother to take a warm shower.
  • Massaging the mother’s neck and back and moistening the nipple area to allow the baby to easily take the breast.
  • Soothing the pain after each feeding by wrapping the breasts in cloth or wearing a bra. Consult a health care provider for advice.

Mastitis and breast abscesses

• These are inflammations of the breasts that can sometimes be associated with an infection.

What to do:

• Encourage the mother to breastfeed. Use a cloth wrapping or bra to support the breasts. Consult a health worker for advice.

Hypogalactia

• An insufficient amount of milk, and the main cause of early weaning. Hypogalactia is usually caused by milk remaining in the breasts for long periods of time, or breastfeeding not draining the breast. It is usually preventable, unless caused by medical conditions that have been estimated to affect a small percentage of women

What to do:

• Remove supplemental foods and increase the frequency of unrestricted feedings. Reassure the mother that she is able to produce enough milk. Wake the baby to breastfeed if he or she sleeps for more than three hours.

Sore or cracked nipples

• Pain and lesions of the nipples are sometimes due to abnormal friction between the nipple and the baby’s tongue, palate, gums, or lips. (8).

What to do:

• Do not stop breastfeeding abruptly. Keep feeding for as long as the baby wants. Shortening feeds to “rest” your nipples will not ease nipple pain and could affect the milk supply.
• Make sure the baby sucks in the correct position. And consult a health worker for advice.

Prenatal and postpartum depression

• Prenatal and postpartum depression is experienced by women before or during and after pregnancy. Symptoms include feelings of anger of irritability, lack of interest in the baby, disturbance in sleep and appetite, crying and sadness, and feelings of guilt, shame or hopelessness. Any of the following can increase the possibility of prenatal or postpartum depression: negative life events during pregnancy, lack of social support, low socioeconomic status, very young maternal age, maternal smoking, severely ill infants at one month of age, low birth weight, presence of obstetrical complications, postpartum anemia, maternal fatigue, and bottle-feeding.

What to do:

• Advise the mother to seek psychiatric care. Place her in a caring family environment.

Candidiasis (of the mother/child)

• This is a fungal infection that can develop on the mouth, throat, gut, and vagina

What to do:

• Treat the baby’s mouth, and if the mother has symptoms such as red and or sore nipples treat her too with antifungal medication. It is recommended to go to a health centre.

Premature child

• A child born before the normal nine-month pregnancy term.

What to do:

• If it is not possible to breastfeed the baby directly for some weeks, give the baby expressed milk. If the baby sleeps too long, wake him/her up and keep in an upright position.

Twins

The birth of twins can be distressing for a mother who doubts her ability to properly breastfeed both babies.

What to do:

• Try to maintain exclusive breastfeeding for both babies. Opt for the position or having one baby on each breast. Ensure that the mother receives good emotional and physical support.

Conflicts with mother’s work

• Continuing to breastfeed exclusively while working is a challenge. Many women lack the time (6), so the mother should breastfeed her baby as often as possible when she is at home, or express the milk to be given at feeding times. According to the law in Burkina Faso, after three months of maternity leave, a woman is entitled to an hour and a half per day for 15 months to breastfeed her child during the work day. The use of these hours is by mutual agreement between a woman and her supervisor. In some cases, women may breastfeed their baby before going to work, or while at the workplace. Some workplaces even provide facilities to allow women to breastfeed, which allows mothers to exclusively breastfeed their baby, and may even encourage mothers to delay weaning.

Rejection of the breast by the infant

• Sometimes the infant rejects only one breast. This can be due to an uncomfortable position while feeding from that breast, or because of inflammation that increases the concentration of sodium and chlorine in the milk, thus changing its taste.

What to do:

• Express milk occasionally. Put the baby in a comfortable position and rub his or her lower lip on the nipple until he or she takes it.
• Don’t limit the length of feedings.
• Avoid the use of bottles and soothers, which replace the sensation of breastfeeding and confuse the child.

Illness in the mother

• Some mothers choose to wean their child when they are ill. These mothers can continue breastfeeding when they are taking most medications.

What to do:

• Rest and drink plenty of water. Continue breastfeeding. However, if the mother has untreated active tuberculosis, a positive HIV test, or is a chronic smoker, she should stop breastfeeding and seek the advice of a health worker without delay. With regard to medications, it is recommended that the mother consult a pharmacist or visit a health centre.

Mother’s refusal to breastfeed

• This can cause of non-exclusive breastfeeding or early weaning.

What to do:

• Promote the benefits of exclusive breastfeeding, and the best interests of the child.

A new pregnancy while breastfeeding

• In many cultures, there is a widespread belief that the pregnant woman’s milk is harmful to the first child. This can stop women from breastfeeding. However, recent studies show that a breastfeeding woman can continue to breastfeed if she wishes throughout her pregnancy. She can even breastfeed the previous child and the newborn baby. This is called tandem breastfeeding or co-breastfeeding. (8)

Complementary food

Pay attention to quantity, consistency, frequency, and quality

• Quantity: As of the age of six months, the mother should begin to introduce a small amount of food into the baby’s diet. The amount should be increased over time.
• Consistency: Start with liquid food, then pureed food, and then small pieces.
  • At six months: the child can eat purees, mashed foods, and semi-solid foods.
  • At nine months: the child can start to eat small pieces of fruit and vegetables with fingers.
  • At 12 months: the child can eat the same meals as the rest of the family.
• Frequency: Increase the number of meals per day. Between six and eight months of age, offer two to three meals a day, and between nine and 23 months of age, offer three to four meals a day.
• Quality: To maintain the young child’s growth, the mother should take fortified complementary foods or vitamin and mineral supplements. At all stages, breast milk should be given to the baby frequently. For example, the mother can give staple foods such as cereals or tubers, including rice, maize, cassava, potatoes, and sweet potatoes, and fortify this staple food with:
  • Protein-rich foods of animal or vegetable origin.
  • Oil or fat at eight months of age.

Safe and contamination-free food

There may be a lack of basic hygiene in sanitation, food preparation, and preservation. There are several basic rules to follow, including:

• Avoid baby bottles as they are difficult to clean. It is better to use a cup or a bowl.
• Before meals, the mother should wash her hands and the child’s hands with soap and water.
• Store food properly and serve the meal immediately after preparation.
• Use properly washed utensils.

Listen to a child who is learning to eat 

• Assist and encourage the child to eat. The child should eat with the family in an atmosphere that fosters psycho-emotional development.
• Prepare an individual plate for the child, sit with them, and feed him/her slowly and patiently.
• Encourage but don’t force the child to eat and limit distractions if the child has a poor ability to concentrate.
• It is important to make eating an activity that the child enjoys.
• Mealtime is a good time to stimulate the child’s verbal and intellectual development:
  • Play with the baby while he/she eats; by singing or telling stories.
  • Be patient and let the child eat at his/her own pace.
  • Offer the baby his/her favourite foods and encourage the baby to eat if he/she loses interest.
  • If the baby refuses some foods, try other tastes and food combinations, and vary the consistencies and methods of preparation.
• If locally available foods do not provide micronutrients in sufficient quantities (which is most often the case for iron), micronutrient supplementation may be recommended. Provide fortified food and, if resources are available, give micronutrient supplements, following national daily recommended allowances.

Weaning

 

• Weaning from the breast means separating the baby from the mother or nurse who is breastfeeding. It means a transition from exclusively breastfeeding to a varied diet. This weaning can be “abrupt” or definitive. In other words, it can happen from one day to the next or gradually as the mother introduces complementary foods into the infant’s diet. This is called progressive weaning.
• Do not confuse a “feeding strike” with weaning. A baby may suddenly refuse to drink from the breast. This is not weaning, but rather a “feeding strike”. A baby can go on a feeding strike for different reasons, including illness, a cold and blocked nose, teething, ear infection, thrush, etc. (1)
• According to WHO, early weaning is the cessation of breastfeeding before six months old.

Recommended weaning practices

WHO and UNICEF (United Nations Children’s Fund) recommend gradual weaning.

• Weaning should be neither too early nor too late.
• It must be introduced gently, never imposing food, but proposing it, never insisting, nor forcing it. Without being overly flexible, do not set rigid schedules.
• It is best to try one food at a time, and make only one change. Food presentation should be as varied as possible, but the child should be able to recognize foods that he or she likes or dislikes.

A spoon can be used after six months, but gently, when the food becomes more consistent. In practice, weaning requires tact, flexibility, and adaptation to the psychology of each child (8).

Practical tips for successful weaning

• When you decide to start weaning your child, it is best to do it gradually. Your breasts will be swollen and tense at first. It may take a few days or weeks for your breasts to adjust (10).
• If you are unable to continue breastfeeding your baby until he or she is six months old and wish to start the weaning process, begin by eliminating one breastfeeding session per day and replacing it with a bottle of formula.
• When your body has adjusted to the new volume of feeding, usually after a few days, cut out one more feeding a day. Continue until you have stopped all breastfeeding sessions and your baby is completely weaned.
• Invite the father to give the bottle: it’s easier for him to participate in bottle feeding than in breast feeding. And baby will be less likely to want breastfeeding after being bottle fed.

 

Definitions

 

Breast congestion: A swelling of the breasts that makes them painful and sensitive.

Bronchiolitis: Common lung infection in young children and infants that causes inflammation and congestion in the small airways (bronchioles) of the lung and is almost always caused by a virus.

Formula: A manufactured food designed and marketed for feeding to babies and infants under 12 months of age, usually prepared for bottle-feeding or cup-feeding from powder (mixed with water) or liquid (with or without additional water).

Gastroenteritis: An inflammation of the mucous membrane of the stomach and small intestine. Symptoms include nausea, vomiting, abdominal cramps, and diarrhea.

Hypogalactia: Hypogalactia or an insufficient amount of milk is the main cause of early weaning.

Mastitis: An inflammation of the breasts that is sometimes associated with an infection.

Oral-pharyngeal infection: A bacterial or viral inflammation of the mouth and larynx.

Sudden infant death syndrome: The unexplained death, usually during sleep, of a seemingly healthy baby less than a year old.