STEP 1. Have a written breastfeeding policy that is routinely communicated to all health care staff

A hospital policy and related guidelines should cover all aspects of management outlined by the Ten Steps, and all staff should be fully informed about the policy. To be accredited as baby-friendly a hospital is required to avoid all promotion of breast-milk substitutes (BMS) and related products, bottles and teats, and not to accept free or low-cost supplies or to give out samples of those products (see Session 9.1.2 on the Code).

STEP 2. Train all health care staff in skills necessary to implement this policy

All health care staff with responsibility for mothers and babies should be trained to implement the policy, which includes being able to help mothers to initiate and establish breastfeeding, and to overcome difficulties. Training courses have been developed by WHO and UNICEF for this purpose (7,8).

STEP 3. Inform all pregnant women about the benefits and management of breastfeeding

Women need information about:

• the benefits of breastfeeding and the risks of artificial or mixed feeding;
• optimal practices, such as early skin-to-skin contact, exclusive breastfeeding, rooming-in, starting to breastfeed soon after delivery, and why colostrum is important;
• what to expect, including how the milk “comes in”, and how a baby suckles;
• what they will need to do: skin-to-skin contact, putting the baby to the breast, and appropriate patterns of feeding.

Some questions are usefully discussed in groups, while for others individual counselling is more appropriate. Opportunities for both are needed antenatally and postnatally when mothers visit a health facility, or during contacts with a community health worker. At group sessions, women can raise doubts and ask questions, and discuss them together. Women who have concerns that they do not want to share with a group, or who have had difficult experiences before, need to discuss them privately.

Antenatal preparation of the breasts for breastfeeding is not helpful. Exercises to stretch fat or inverted nipples, and devices worn over the nipples during pregnancy, are not effective in increasing breastfeeding success (9). Providing skilled support to help the baby to attach soon after delivery is more effective.

STEP 4. Help mothers initiate breastfeeding within one half hour of birth

A baby should be delivered straight onto the mother's abdomen and chest, before delivery of the placenta or any other procedures, unless there are medical or obstetric complications that make it impossible (12,13). The baby must be dried immediately to prevent heat loss and then placed in skin-to-skin contact with the mother, usually in an upright position. Skin-to-skin contact means that both the mother's upper body and her baby should be naked, with the baby's upper body between the mother's breasts. They should be covered together to keep them warm. Skin-to-skin contact should start immediately after delivery or within at least half an hour; and should continue for as long as possible, but for at least one hour uninterrupted (12). Mothers usually find the experience a pleasure and emotionally meaningful.

Skin-to-skin contact is the best way to initiate breastfeeding. A few babies want to suckle immediately. Most babies remain quiet for some time, and only start to show signs of readiness to feed after 20–30 minutes or more; some take over an hour (14). Caregivers should ensure that the baby is comfortably positioned between the mother's breasts, but they should not try to attach the baby to the mother's breast; the baby can do this in his or her own time. Eventually a baby becomes more alert, and may start raising his or her head, looking around, making mouthing movements, sucking his or her hands, or massaging the breast with them. Some babies move towards and may find the areola and nipple by themselves, guided by their sense of smell (15). The mother can help move her baby closer to the areola and nipple to start suckling. Many babies attach well at this time, which helps them to learn to suckle effectively (14,16). This early contact stimulates the flow of oxytocin, helps with release of the placenta, reduces the risk of haemorrhage (17,18) and facilitates emotional bonding of the mother and baby (19).

If a mother has been given an anaesthetic or analgesic (especially pethidine), the baby may be sedated and may take longer to become alert and seek the nipple (20). If there is a delay in the first breastfeed for any reason, the mother can express her colostrum and feed it to the baby by cup or spoon. She should be encouraged and given help to hold her baby in skin-to-skin contact whenever he or she needs comforting and at feeds.

STEP 5. Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants

Showing a mother how to breastfeed

• A mother needs help in the first few days to make sure that she is able to position and attach her baby correctly to the breast. The person giving support should watch her putting her baby to the breast, and assess the breastfeed, using the breastfeed observation job aid, described in Session 5.4. If a mother needs practical help, the helper can use either her own body or a model breast and doll or a picture to show the mother what to do. Minimal touching of the mother and baby should be needed.
• If the baby is well attached and suckling effectively, the mother should be praised to reinforce her good practices, and she should be reminded of the importance of demand feeding and exclusive breastfeeding.
• If the baby is not well attached, the mother should be helped to improve the baby's position and attachment (see Box 6, How to help a mother to position and attach her baby).

BOX 6

How to help a mother to position and attach her baby. Help the mother to get into a comfortable and relaxed position, sitting or lying down. The helper should sit in a comfortable, convenient position.

Showing a mother how to maintain lactation

• Mothers need to know how to express their milk, so that they can continue to feed their babies and keep up their milk supply if they are separated (see Box 7). Babies who are ill, or who suffered trauma during delivery, and some babies who are low birth weight or premature may be separated from the mother in a special care baby unit (see Session 6.1 on low-birth-weight babies).
• If a baby is able to take oral or enteral feeds, breast milk is usually the best feed to give.
• If a baby cannot take oral feeds, then it is helpful for the mother to express her milk to build up and maintain the supply, for when the baby is able to start breastfeeding. Expressed breast milk (EBM) can be frozen and stored until the baby needs it (21). In some facilities that are able to operate adequate standards for milk banking, it may be possible to donate milk for other infants (22).

BOX 7

How to express breast milk by hand. The mother should: Have a clean, dry, wide-necked container for the expressed breast milk;

A health worker or counsellor should explain to the mother the basic principles:

• Express both breasts each time.
• Express the milk into a cup, glass, jug or jar that has been thoroughly washed with water and soap.
• Store EBM in a glass with a cover indicating time and date.
• Keep EBM at room temperature for 8 hours or in a refrigerator for 24 to 48 hours. If she has a deep freeze she can store it for 3 months (21).

Stimulating the oxytocin reflex

Before the mother expresses her milk, she should stimulate her oxytocin reflex, to help the milk flow. She may do this herself by lightly massaging her breasts, or stimulating her nipples, and at the same time thinking about the baby, watching him or her if nearby, or looking at a photograph of him or her. She can also ask a helper to massage up and down her back on either side of her spine between her shoulder blades (see Figure 12).

FIGURE 12

Back massage to stimulate the oxytocin reflex before expressing breast milk.

STEP 6. Give newborn infants no food or drink other than breast milk unless medically indicated

Foods and drinks given to a newborn baby before breastfeeding has started are called prelacteal feeds. Giving these feeds increases the risk of illnesses such as diarrhoea and other infections and allergies, particularly if they are given before the baby has had colostrum. Prelacteal feeds satisfy a baby's hunger and thirst, making him or her less interested in feeding at the breast, so there is less stimulation of breast milk production. If a bottle is used, it may interfere with the baby learning to suckle at the breast. Since prelacteal feeds can interfere with establishing breastfeeding, they should not be given without an acceptable medical reason (23). (See Annex 1 for acceptable medical reasons for use of breast-milk substitutes).

STEP 7. Practice rooming-in – allow mothers and infants to remain together – 24 hours a day

Babies should be allowed to stay in the same room as their mother, either in a cot beside her bed or in the bed with her, 24 hours a day (24). They should be separated only when strictly necessary, for example for a medical or surgical procedure. A cot should be beside the mother's bed, where she can easily see and reach her baby, not at the end of the bed, where it is more difficult. Studies have shown that babies cry less and mothers sleep as much when they are together as when the infant is in a separate room (8). Separating infants from their mothers may be associated with long-term psychological trauma (25).

Rooming-in is essential to enable a mother to breastfeed her baby on demand and for her to learn the cues such as wakefulness, rooting and mouthing, which show that her baby is ready for a feed. It is better to feed the baby in response to these cues than to wait until the baby is crying.

STEP 8. Encourage breastfeeding on demand

Encourage mothers to breastfeed their babies as often as they want, day and night, whenever the baby shows signs of readiness to feed. This is called demand feeding, or baby-led or unrestricted breastfeeding (see Session 2.12).

A mother should let her baby stay on the breast until he or she comes off by him- or herself. The baby usually suckles more slowly, with fewer suckles and longer pauses, and then spits the nipple out, and lies back looking contented. After a few minutes, the mother should offer the other breast, but the baby may or may not want to take more. She can start on the other breast at the next feed. In the first few days, babies may want to feed very often, and this is beneficial because it stimulates milk production. The health worker should make sure that the baby is well attached and suckling effectively, and help the mother to understand that the baby will feed less often when breastfeeding is established.

STEP 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants

Feeding a baby from a bottle with an artificial teat may make it more difficult for the baby to learn to attach well at the breast and may make it more difficult to establish breastfeeding satisfactorily (26). If an infant cannot feed from the breast, then the safest alternative is to feed from a cup (see Figure 13 and Box 8). Even low-birth-weight and premature babies can cup feed. The reasons to feed with a cup include:

FIGURE 13

Feeding a baby by cup.

BOX 8

How to cup feed a baby. Hold the baby sitting upright or semi-upright on your lap – wrap the baby with a cloth to provide some support and to stop his or her hands from knocking the cup. Hold the cup of milk resting on the lower lip so that the (more...)

• Cups are easier to clean, and can be cleaned with soap and water, if boiling is not possible.
• Feeding from a cup does not interfere with the baby learning to suckle at the breast.
• A cup cannot be left for the baby to feed him- or herself. Someone has to hold the baby and give him some of the contact that he needs.
• Cup feeding is generally easier and better than spoon feeding: spoon feeding takes longer and requires an extra hand, and sometimes a baby does not get enough milk by spoon.

STEP 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic

This step addresses the need that mothers have for follow-up support for breastfeeding after they leave a maternity facility (see Session 7). Breastfeeding may not be established for a few weeks, and many problems can arise during this time. To be accredited as baby-friendly, a hospital must be able to refer a mother to an accessible source of ongoing skilled support. This may be outpatient care provided by the hospital, a health centre or clinic, a primary care worker or a community health worker trained in breastfeeding counselling, a peer counsellor, or a mother-to-mother support group.

Baby-friendly hospitals often find it very difficult to set up community groups, which may be more easily organised by health workers already based in the community. However, hospitals should encourage the establishment of these groups, help to train them, know who and where they are, and be in contact with them. They should refer women to them on discharge, and accept referrals from them of mothers who need more specialised help than the community resource itself can provide.

When a mother leaves a maternity facility, she should be given information about where support for breastfeeding is available in her locality, and how to access it. Community breastfeeding counselling is discussed further in Sessions 5 and 9.