(a) Breastfeeding should be promoted as the gold standard feeding options.

(b) Antenatal counseling individually or in groups organized by maternity facility or mother support group (MSG) should prepare expectant mothers for successful breastfeeding.

(c) For all normal newborns (including those by caesarean section) skin-to-skin contact should be initiated in about 5 minutes of birth in order that baby initiates breastfeeding in an hour of birth. The method of ‘Breast crawl’ can be adopted for early initiation [5]. In case of operative birth, the mother may need extra motivation and support. Skin-to-skin contact between the mother and new born should be encouraged by ‘bedding in the mother and baby pair’. Mother should communicate, look into the eyes, touch and caress the baby while feeding. The new born should be kept warm by promoting Kangaroo Mother Care and promoting local practices to keep the room warm [6].

(d) Baby should be fed "on cues". The early feeding cues include sucking movements and sucking sounds, hand to mouth movements, rapid eye movements, soft cooing or sighing sounds, lip smacking, restlessness etc. Crying is a late cue and may interfere with successful feeding. Babies should be breastfed at least 8 to 10 times in 24 hours till lactation is established (1 to 2 weeks) indicated by frequent urination, stooling and adequate weight gain. A sleepy baby can be easily woken up by removing blankets, removing clothes, changing loin cloth if wet, skin-to-skin contact in kangaroo position and gently massaging the back and the limbs. Periodic feeding is practiced in certain situations like in the case of a very small infant who is likely to become hypoglycemic unless fed regularly, or an infant who ‘does not demand’ milk in initial few days. Adequacy of breastfeeding in this critical period should be monitored by clinical parameters complemented by weighing on digital weighing scale (minimum sensitivity of 5 g) on Day 1, 4, 7, 14 and 28. Maternity service should have a protocol to manage post-discharge follow ups along with protocols for management of excessive weight loss (>10%) and weight-faltering.

(e) Every mother, especially the primipara, should receive support from doctors, nursing staff or community health workers (in case of non-institutional birth) with regards to correct positioning, latching and treatment of problems, such as engorgement, nipple fissures and delayed ‘coming-in’ of milk. If available, dedicated skilled supports like Lactation Consultants/ Mother Support Counselors/ Peer Counselors should be facilitated to support the mother in the antenatal, immediate postnatal period, post discharge follow-ups and in neonatal care units.

(f) Mothers need skilled help and confidence-building during all health contacts and at home through home visits by trained community worker, especially after the baby is 3 to 4 months when a mother may begin to doubt her ability to fulfill the growing needs and demands of baby.

(g) The main reason given by majority of working mothers for stopping breastfeeding is their return to work following the maternity leave. Mothers who work outside should be assisted with obtaining adequate Maternity/ Baby Care/Breastfeeding leave, should be encouraged to continue EBF for 6 months by expressing milk while they are out at work. They may be encouraged to carry the baby to a work place/ crèche wherever such facility exists. The concept of "Hirkani’s rooms" may be considered at work places (Hirkani’s rooms are specially allocated room at the workplace where working mothers can express milk and store in a refrigerator during their work schedule). Every such mother leaving the maternity facility should be taught manual expression of her breast milk; however, for a working mother this skill would prove invaluable.

(h) If the breastfeeding was temporarily discontinued due to an inadvertent situation, re-lactation should be tried as soon as possible [7]. Supplemental Suckling Technique (SST) is a technique which can be used as a strategy to initiate re-lactation in mothers who have developed lactation failure or Mother’s Milk Insufficiency (MMI). WHO recommends re-lactation through Supplemental Suckling technique. The drip and drop method helps to sustain the infant’s interest of suckling at the breast [8].

(i) The possibility of índuced lactation shall be explored according to the situation e.g. adoption, surrogacy. It helps to create mother-infant bonding apart from security and comfort for the baby. The technique involves motivating the surrogate mother, having a willing and　vigorously　sucking infant, and an adequate support group. Prolactin and oxytocin, the hormones which govern lactation, are　pituitary　and not　ovarian. Hence, stimulation of nipple and areola and repeated suckling by the baby are important.　Lact-aid as nursing trainer is also useful [9].　A course of prolactin enhancing drugs such as Metoclopromide or Domperidone is initiated [10].　Non-puerperal lactation in surrogate mothers has been successfully demonstrated among Indian mothers [11].

(j) Nursing in Public (NIP): Mothers should feel comfortable to nurse in public. All efforts should be taken to remove hurdles impeding breastfeeding in public places, special areas / rooms shall be identified/ constructed or established in places like Bus stands, Railway stations, Air ports etc.

(k) Adoption of latest WHO Growth Charts is recommended for monitoring growth [12].

(a) Appropriately thick homogenous complementary foods home-made from locally available foods should be introduced at six completed months while continuing breastfeeding ad libitum [14,15]. During this period, breastfeeding should be actively supported and the term ‘weaning’ should be avoided [16]. Complementary feeding should be projected as the bridge that the mother has to make between liquid to solid transition and to empower the baby to ‘family pot feeding’.

(b) To address the issue of a small stomach size, each meal must be made energy dense by adding sugar / jaggery and ghee/butter/oil. To provide more calories from smaller volumes, food must be thick in consistency–thick enough to stay on the spoon without running off, when the spoon is tilted [17]

(c) Foods can be enriched by making a fermented porridge, use of germinated or sprouted flour and toasting of grains before grinding [16, 18].

(d) Adequate total energy intake can also be ensured by addition of one to two nutritious snacks between the three main meals. Snacks are in addition and should not replace meals. They should not to be confused with foods such as sweets, chips or other processed foods [18].

(e) Parents must identify the staple homemade food (as these are fresh, clean and cheap), comprising of cereal-pulse mixture in the ratio 2:1, and make them caloric and nutrient rich with locally available products.

(f) Research has time and again proved the disadvantages of bottle feeding. Hence bottle feeding shall be discouraged at all levels.

(g) The food should be a balanced diet consisting of various (as diverse as possible) food groups / components in different combinations. Easily available, cost-effective seasonal uncooked fruits, green and other dark colored vegetables, milk and milk products, pulses/ legumes, animal foods, oil/ butter, sugar/ jaggery may be added in the staples gradually [16,17].

(h) Hygienic practices are essential for food safety during all the involved steps viz. preparation, storage and feeding. Hand washing with soap and water at critical times- including before eating or preparing food and after using the toilet [17,18].

(i) Practice responsive feeding. Self-feeding should be encouraged despite spillage. Each child should be fed under supervision in a separate plate to develop an individual identity. Forced feeding, threatening and punishment interfere with development of good/ proper feeding habits [17]. Along with feeding, mother and care givers should provide psycho-social stimulation to the child through ordinary age-appropriate play and communication activities to ensure early childhood development.

(j) Consistency of foods should be appropriate to the developmental readiness of the child in munching, chewing and swallowing. ‘Neophobia’ is the rule in them and any item may have to be offered several times for acceptance. Avoid foods which can pose choking hazard. Introduce lumpy or granular foods and most tastes by about 9 to 10 months. The details of food including; texture, frequency and average amount are summarized in Table II.

(a) Human Milk Banks should be promoted considering the large number of babies needing pasteurized donor human milk when mother’s own milk is not available. In 1980 the WHO and UNICEF jointly declared: "Where it is not possible for the biological mother to breastfeed, the first alternative, if available, should be the use of human milk from other sources" [26].

(b) Cost effectiveness of using banked human milk in neonatal intensive care units has been documented in Western countries, largely due to reduction in rates of necrotizing enterocolitis [27,28], reduction in severe infections [29-31] and decreased length of hospital stay [32]. Given the high incidence of sepsis and a large burden of premature births, this intervention has a potential to result in substantial saving for the nation in terms of finances and human capital.

(c) Presence of human milk bank is also a factor promoting breastfeeding.

• Use of pasturized donor human milk in NICU is associated with increased breastfeeding rate at discharge from the hospital for very low birth weight (VLBW) infants [33].

• The novel approach of promoting human milk banks through mode of collecting breast milk donations in form of camps can be a strong means of promoting breastfeeding in the society.

(d) It is recommended that there should be a human milk bank in each sick newborn care units (SNCU) and neonatal ICU initially preferably in government set-up, and subsequently in private and corporate sectors.

(a) Feeding during sickness is important for recovery and for prevention of under nutrition. Even sick babies mostly continue to breastfeed and the infant can be encouraged to eat small quantities of nutrient rich food more frequently and by offering foods that the child likes to eat.

(b) Infant feeding in maternal illnesses

(c) Infant feeding in various conditions related to the infant

(i) Breastfeeding on demand should be promoted in normal active babies. However, in difficult situations like VLBW, sick, or depressed babies, alternative methods of feeding can be used based on neuro-developmental status. These include feeding expressed breastmilk through intra-gastric tube or with the use of cup and spoon. For very sick babies, expert guidance should be sought. If the baby is transferred to SNCU/NICU, mothers should be supported to start breastmilk expression within initial hours, continue at least 3 hourly during the day time and at least once at night.

(ii) Ensure early transfer of mothers with the baby in SNCU/NICU and that has arrangement to accommodate the mothers in the immediate vicinity and that mothers are permitted to visit, hold and touch the baby at will if the baby’s condition permits.

(iii) Ensure that majority of babies are on exclusive breastfeeding or on breastfeeding plus expressed breastmilk at discharge from the SNCU/NICU.

(iv) Gastro-Esophageal Reflux Disease (GERD) is often treated conservatively when it is mild, through thickening of the complementary foods, frequent small feeds and upright positioning for 30 minutes after feeds.

(v) Primary Lactose Intolerance is congenital and may require long term lactose restriction. Secondary Lactose Intolerance is usually transient and resolves after the underlying condition has remitted. Most of the cases of diarrhea do not require stoppage of breastfeeding.

(vi) Various Inborn Errors of Metabolism warrant restriction of specific offending agent and certain dietary modifications e.g. in galactosemia, dietary lactose and galactose should be avoided. This is probably the only absolute contraindication to breastfeeding.

(vii) During emergencies, priority health and nutrition support should be arranged for pregnant and lactating mothers. Donated or subsidized supplies of breastmilk substitutes (e.g. infant formula) should be avoided, must never be included in a general ration distribution, and must be distributed, if at all, only according to well-defined strict criteria. Donations of bottles and teats should be refused, and their use actively avoided.

(a) Breastmilk has usually adequate amount of iron, calcium, phosphorus and vitamin A for a normal newborn. Preterm infants who are breastfed should receive 2 mg of supplemental iron per kg of body weight each day after one month of age [35]. Preterm and low birth weight infants may also need calcium and multivitamin supplements.

(b) Breastfed infants can maintain normal vitamin D status in the early post-natal period only when their mother’s vitamin D status is normal and /or the infants are exposed to adequate amount of sunlight. Corroborative evidences of high prevalence of vitamin D deficiency in Indian infants suggest that they should be given routine vitamin D supplementation of 400 IU daily, especially in those with higher risk of getting less of vitamin D. Even those on formula feed needs supplementation unless they consume more than 1000 mL of formula daily [36,37]. VLBW infants should be given vitamin D supplements at a dose ranging from 400 to 1000 IU per day until six months of age [38].

(c) Food items that supply micronutrients should be encouraged like GYOR (green, yellow, orange and red) vegetables and fruits, Use of food fortification like iron-fortified foods, iodized salt, vitamin A enriched food etc. are to be encouraged.

(a) Consumers are often bewildered by nutritive and health claims, while children are highly influenced by advertisements enticing them to buy a product which may be unhealthy or in fact detrimental [39].

(b) The parents should understand that though the companies are promoting many foods as "Magic food" in reality such products do not exist.

(c) Avoid Junk and Commercial food which are high in SSFAP (sugar, salt, fat, additives/preservatives and pesticides). Avoid giving ready-made, processed commercial food from the market.

(d) Junk foods are one of the important reasons for the increasing incidence of childhood obesity. There is need to restrict consumption of junk food especially in and around educational institutions and remote areas of the country.

(e) The provisions of The Food Safety and Standards Act 2006 should be implemented and monitored regularly [40].

(i) In India, 22% babies born each year have low birth weight (LBW), which has been linked to maternal under-nutrition and anemia among other causes. Half of adolescents (boys and girls) have below normal body mass index (BMI) and almost 56% of adolescent girls aged 15-19 years have anemia.

(ii) Optimal nutrition of adolescent girls, pre-pregnant women and pregnant mothers is critical to intrauterine growth, fetal well-being and to prevent malnutrition in the postnatal period [41].

(iii) There is growing evidence that maternal nutritional status can alter the epigenetic state (stable alterations of gene expressions through DNA methylation and histone modifications) of the fetal genome. This may provide a molecular mechanism for the impact of maternal nutrition on both fetal programming and genomic imprinting. Just as the damaging effects of malnutrition, pass from one generation to the next, so can benefits of good nutrition [42].

(iv) The maternal nutrition should also be balanced, fresh and preferably home-made and there should not be any unscientific restrictions.

(a) Global legislation, binding to all states and private organizations including labor benefits, 6 months maternity and appropriate paternity leave is strongly recommended. Maternity leave, day care facilities and paid breastfeeding breaks should be available to all employed women in all sectors including those engaged in atypical forms of dependent work.

(b) Breastfeeding is a human right both for the mother as well as baby. With due weightage and respect to National Family Planning Policies and Program, the benefits should be given to mother and the child (even after 2 issues) born out of unplanned pregnancy (Family planning method failure) or as a result of accidental death of previous child.

(c) Scientific and unbiased IYCF practices must be promoted through regular advertisements in state, public or private owned audiovisual and print media. Public should be made aware that artificial, junk or packaged food can be injurious to the health of the children.

(d) Necessary and adequate arrangements should be made for propaganda and implementation of the provisions of Infant Milk Substitute (IMS) Act which prevents advertising or promoting infant milk substitutes, feeding bottles and teats. In addition, further strengthening of the existing Act must be tried.

(e) Adopt a National policy to avoid conflict of interests in the areas of child health and nutrition. Popularization of "unscientific health claims" by commercial ads through media needs to be restricted. UN agencies shall help in promoting the home made/ available food (especially through various media) with the help of their brand ambassadors/ endorsers.

(f) There should be a board, commission or committee to monitor, evaluate and censor food product before it is released in the market. Such board or committees shall have a sensitized pediatrician and/ or other equivalent health care expert/ nutrition expert. A pediatrician shall also be involved in the commission/ committee/ board entrusted with drafting of any code, bill, laws, rules/ regulations related to food, nutrition, drinks, food products, etc.

(g) Human milk banks shall be promoted, established and maintained at least in District/ Civil hospitals and Medical colleges.

(a) Various programs or community projects should be initiated to provide home care and counseling on IYCF through formation of mother support groups especially by women’s organizations.

(b) The voluntary organizations should understand and advocate important recommendations at all levels. Various like-minded organizations should work preferably on the same platform and co-ordinate with each-other in promoting the IYCF practices.

(a) Media has to take concrete steps to avoid directly or indirectly glamorizing/promoting bottle feeding, artificial, commercial and ready to use food. Instead, the risks involved in artificial feeding and other suboptimal feeding practices should be advertised prominently in bold prints.

(b) Media support is even more important on certain occasions, celebrations, and social mobilization activities such as World Breastfeeding Week and Nutrition Weeks.

(c) The companies and media should have self-regulatory pledge for responsible advertising/ marketing. They should help in promoting healthier dietary choices and a more active life style for Indian children.

(d) Sportsman, celebrities should not promote various nutritional products; only evidence-based scientifically sound and authentic information shall be provided.

(a) It is recommended that all the community health workers, PPTCT counselors, and other personnel caring for children including doctors should undergo three days skill training on IYCF (including IMS Act). In situations where three day training is not feasible, some impact can be made with short duration sensitization programs of half day or one day.

(b) IYCF should also be included in the curriculum of undergraduate and postgraduate medical education, nursing education, home science, child nutrition courses etc.

(c) State, National and International level workshops on IYCN should be organized at regular intervals for capacity building of IYCN Resource Personnel.

(d) In addition to above measures dedicated skilled breastfeeding (IYCN) support is critical to achieve IYCF goals. Hence there is a need to launch an ambitious program to create a spectrum of such resources [Lactation consultants, IYCF counselors and Peer counselors).