The word ‘Birth’ starts with alphabet B which also
is the first alphabet of the word ‘Breastfeeding!’ Breastfeeding is a
cornerstone of children’s survival, nutrition and early development.
Breastfeeding not only provides children with the best start in life but
also benefits maternal health, protects against non-communicable
diseases, and contributes to environmental sustainability. Early
initiation and exclusive breastfeeding till six months are the two
important aspects of infant feeding. Sadly, however, the general
delivery room picture after a baby is born is dismal. The obstetrician
hands over the baby, the pediatrician stabilizes the baby and the
nursing staff gets engaged in routine work – hardly anyone is bothered
about early initiation of breastfeeding. According to the NFHS-4 data of
17 states of India, while rate of institutional deliveries is 84.3%,
early initiation of breastfeeding is done in only 50.5%, exclusive
breastfeeding in 57% and timely complementary feeding in 49.6% of
infants [1]. The apathy amongst practitioners and the ‘just average’
national figures are quite disturbing.
Improvements in breastfeeding rates are critical to
the attainment of the Sustainable Development Goals (SDG). The recent
analysis from World Breastfeeding Trends Initiative (WBTi) on policy and
programs reveals that India lags behind in most indicators [2]. Let us
introspect and find out areas where we need to improve on our knowledge,
attitudes and skills.
• The concept ‘Protect, Promote, and
Support Breastfeeding’ is not known to many. We need to be aware of
its enormous importance – not only as a public health measure, but
also in the day-to-day practice.
• Some ‘obsessed’tricians (obsessed with
infant milk formula), and also some pediatricians, soon after the
newborn examination, prescribe infant milk formula to all the
newborns delivered in the nursing homes. Whenever the mother says
that she does not have enough milk, the formula is prescribed at the
drop of a hat.
• Most pediatricians do not check the percentage
of weight loss after birth and thus miss out on timely intervention
if lactation is not getting established. Finding excessive weight
loss in first few days can alert the pediatrician to failure of
establishment of lactation and prompt proper action can be taken.
• The first time mother, mother with
breastfeeding problems in previous pregnancy, mother with caesarean
delivery, baby with birth weight <2.5 kg, any mother reporting pain
in breast, and any baby who was sick and separated from mother need
to be assessed in detail. These are the situations where so called
‘lactation failure’ can occur. Many of us make no efforts to help
mother establish successful and exclusive breastfeeding; the only
option resorted to is formula. One should counsel the mother that
frequent suckling is the only way of getting early and enough milk,
and help her in positioning the baby at the breast.
• Most of us do not know handling of
breastfeeding problems. Every pediatrician and obstetrician should
know the management of breast engorgement, breast abscess and
cracked nipples.
• Many pediatricians have a misconception about
the risk of hypoglycemia with exclusive breastfeeding, and prescribe
sugar water initially.
• The risk of dehydration and hyperbilirubinemia
in summer is mainly due to the environmental heat and not due to the
inadequacy of breastmilk. The solution is not giving water or
formula to the baby either to prevent or treat these conditions; the
solution is to maintain the appropriate temperature in the baby’s
surroundings along with more frequent breastfeeds.
• Baby Friendly Hospitals Initiative (BFHI) and
Ten Steps to Successful Breastfeeding (dasha-sutri) are not
known to many pediatricians. It is necessary that a pediatrician
develops a good rapport with the obstetric colleagues and helps them
make their maternity homes BFHI-certified and see that all babies
start their life with BREAST sutras which include Breast
crawl, Refraining from prelacteal feeds, Exclusive
breastfeeding, proper Attachment, Support to the
mother and Training of paramedics.
The initial Golden One Hour is not to be lost. The
importance of skin-to-skin contact must be understood and encouraged at
every visit to the maternity homes. A new concept of Amrit Kaksha
has been developed by Govt. of Rajasthan, which means that a room should
be available next to the delivery room devoted exclusively to give the
baby the first one hour with the mother in skin-to-skin contact. The
first Golden Hour is thus guaranteed to the baby.
Women face many barriers to breastfeeding. They may
receive inaccurate information from health providers, lack lactation
support within the household, have no access to skilled breastfeeding
counseling, face aggressive marketing of breastmilk substitutes, or are
forced to return to work shortly after giving birth. Women need support
to be able to breastfeed optimally. Mother must be cocooned by positive
thoughts, positive words, positive actions and proactive behavior. The
cocooning needs to be implemented by husband, parents, obstetrician,
pediatrician and people at workplace. Elderly persons and the neighbors
should refrain from making negative comments.
A confident mother alone can breastfeed the baby
confidently, and get DNB (Diploma in Nurturing and
Breastfeeding!). This confidence has to be instilled into the
mother by a confident pediatrician and an obstetrician. Confidence comes
through knowledge and to make our members knowledgeable, Indian
Academy of Pediatrics (IAP) is shortly launching an online course on
human lactation management. As the pediatricians and obstetricians are
usually too busy to spend a lot of time with the mother, trained
lactation counselors or lactation consultants are very useful in
tackling breastfeeding problems. More and more persons should take up
this course. Counseling has great role to play in successful
breastfeeding. Remember that in Mahabharata, Pandavas were only
five in number while Kauravas were hundred. But finally
Pandavas won. The victory was possible because of Krishna – a
great counselor!
Complementary feeding is another area where a lot
needs to be done. Very commonly, solids are advised from 4 months (even
3 months at times!). The age old fluids – dal water, rice water,
fruit juices – are still advocated and even prescribed on files. There
are definite recommendations by WHO, UNICEF and IAP on these issues. No
place for individual whims now! One should not give a positive
nod to the mother keen to put the baby on complementary feeds at the end
of 4 months because of no growth advantage of early introduction,
increased risk of diarrhea and weight loss, and displacement of
breastmilk that can affect total duration of breastfeeding. Breast milk
should be continued along with complementary foods at least till second
birthday.
Many pediatricians’ files still show how to use a
feeding bottle with pictures and description with hardly any message on
breastfeeding! I suggest that every pediatrician should print
recommendations of the Infant and Young Child Feeding (IYCF) chapter of
IAP [3] on the file.
In the society, there are many misconceptions related
to breastfeeding. In 1987, we, a group of 15-20 pediatricians from Pune
started an activity called ‘Parivartan’ for eradication of
such blind faiths. Kangaroo Mother Care (KMC) is a simple method where
the infant is placed in an upright position on the upper part of
mother’s bare chest, in between the breasts. Mother’s own body
temperature keeps her infant warm. KMC includes Kangaroo Father Care
(KFC) too! KMC is particularly useful for nursing low birth weight
infants. In addition to providing ATM (Any Time
Milk) for the baby, it satisfies all the five senses of the baby and
helps in overall better development. Immediate benefits of KMC include
prevention of hypothermia, early physiological stability in terms of
stable heart rate and respiration, better breastfeeding and growth,
secure feeling, better mother infant bonding, and prevention of
infections. Long term benefits include successful exclusive
breastfeeding rate, good weight gain, and better IQ and brain growth.
The strategy used by us to educate parents is very
simple. On every Monday, before pediatric outpatient services start, the
nurse in-charge writes a few sentences about a faith on a blackboard.
Parents read it and discuss it among themselves. This informal
discussion and sharing of thoughts followed by small speech by the
nurse/lady pediatrician has a great influence. They address the
scientific view regarding a particular faith in simple and local
language. Pediatricians’ words and opinions are often respected by
parents, and one can implement Parivartan to help parents change
their mindset. The Hirkani Kaksha is conceptualized by
Maharashtra branch of Brestfeeding Promotion Network of India, and
adopted by the government of Maharashtra. It provides a separate place
for the mother to breastfeed (or express breastmilk) at public places
like bus stations, railway stations and offices. It should have a
comfortable seating environment for the mother with full privacy and
security.
Over the years, the month of August has become
synonymous with breastfeeding promotion for pediatricians. This year’s
Breastfeeding week focuses on 17 SDGs that governments around the world
have agreed to achieve by 2030 [4]. No one else but we
pediatricians are going to be an important part of the
team to sustain the development. The Lancet series [5] shows how
essential the protection, promotion, and support of breastfeeding is for
the achievement of many of the sustainable goals like ‘no poverty’ ,
‘zero hunger’, ‘good health and well-being’, ‘quality education’,
‘decent work and economic growth’, ‘reduced inequalities’ and ‘Climate
Action’.
My ‘position’ as President of IAP and ‘attachment’
with promotion of breastfeeding will be of some worth only if IAPians
remember PRAMOD and become Proactive, are Ready to
give time, get Academically perfect in the science of
breastfeeding, Motivate the mothers and paramedics, convince the
Obstetricians, and Discard bottles and tins. Breastfeeding
is an eternally natural phenomenon. Let each one of us pledge that ‘as
an IAP member, I will ‘exclusively’ try to Initiate, Advocate and
Protect breastfeeding, and act fast before babies go on stanyagraha!’
References
1. IIPS. National Family Health Survey. Key Findings
from NFHS-4. Available from: http://rchiips.org/nfhs/factsheet
_nfhs-4.shtml. Accessed July 24, 2016.
2. WBTi 2015- Arrested Development . 4th Assessment
of India’s Policy and Programs on Infant and Young Child Feeding.
Available from:
http://www.bpni.org./report/WBTi-India-Report-2015.pdf. Accessed
July 24, 2016.
3. Tiwari S, Bharadva K, Yadav B, Malik S, Gangal P,
Banapurmath Cr, et al.; the IYCF chapter of IAP. Infant and young
child feedng guidelines, 2016. Indian Pediatr. 2016;53:703-13
4. United Nations. Transforming our World: The 2030
Agenda for Sustainable Development. Available from:
https://sustainabledevelopment.un.org/post2015/transforming ourworld.
Accessed July 24, 2016.
5. Victora CG, Bahl R, Barros AJ, França GV, Horton
S, Krasevec J, et al.; Lancet Breastfeeding Series Group.
Breastfeeding in the 21st century: epidemiology, mechanisms, and
lifelong effect. Lancet. 2016;387:475-90.
