Infant and Young Child Feeding

Infant and young child feeding
Model Chapter for textbooks

for medical students and allied health professionals
Infant and
young child
feeding
Model Chapter for textbooks
for medical students and allied health professionals
WHO Library Cataloguing-in-Publication Data
Infant and young child feeding : model chapter for textbooks for medical students
and allied health professionals.
1.Infant nutrition. 2.Breastfeeding. 3.Infant, Low birth weight. 4.Malnutrition – therapy.
5.Maternal health services – standards. 6.Teaching materials. 7.Textbooks. 8.Students, Medical.
9.Allied health personnel. I.World Health Organization.
ISBN 978 92 4 159749 4 (NLM classification: WS 125)
© World Health Organization 2009

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Designed by minimum graphics
Printed in France
iii
Contents
Acknowledgments vi
Abbreviations vii
Introduction 1
Session 1 The importance of infant and young child feeding and recommended practices 3
Session 2 The physiological basis of breastfeeding 9
Session 3 Complementary feeding 19
Session 4 Management and support of infant feeding in maternity facilities 29
Session 5 Continuing support for infant and young child feeding 37
Session 6 Appropriate feeding in exceptionally difficult circumstances 51
Session 7 Management of breast conditions and other breastfeeding difficulties 65
Session 8 Mother’s health 77
Session 9 Policy, health system and community actions 81
Annexes
Annex 1 Acceptable medical reasons for use of breast-milk substitutes 89
Annex 2 Growth standards 92
Annex 3 Growth velocity (weight-for-age) tables 95
Annex 4 Indicators for assessing infant and young child feeding practices 97
List of boxes, figures and tables

Boxes
Box 1 Guiding principles for complementary feeding of the breastfed child 19
Box 2 Responsive feeding 20
Box 3 Five keys to safer food 21
Box 4 Good complementary foods 23
Box 5 The ten steps to successful breastfeeding 29
Box 6 How to help a mother position and attach her baby 31
iv Infant and Young Child Feeding – Model Chapter for textbooks
Box 7 How to express breast milk by hand 32

Box 8 How to cup feed a baby 34
Box 9 Key points of contact to support optimal feeding practices 37
Box 10 Communication and support skills 38
Box 11 Feeding History Job Aid, infants 0–6 months 42
Box 12 Feeding History Job Aid, children 6–23 months 43
Box 13 Breastfeed Observation Job Aid 44
Box 14 Supporting good feeding practices 48
Box 15 How to express breast milk directly into a baby’s mouth 52
Box 16 Definitions of Acceptable, Feasible, Affordable, Sustainable and Safe 60
Box 17 Replacement feeding 61
Box 18 Lactational amenorrhoea method 79
Figures
Figure 1 Major causes of death in neonates and children under five in the world, 2004 3
Figure 2 Trends in exclusive breastfeeding rates (1996–2006) 4
Figure 3 Anatomy of the breast 11
Figure 4 Prolactin 11
Figure 5 Oxytocin 11
Figure 6 Good attachment – inside the infant’s mouth 13
Figure 7 Poor attachment – inside the infant’s mouth 13
Figure 8 Good and poor attachment – external signs 14
Figure 9 Baby well positioned at the breast 15
Figure 10 Energy required by age and the amount from breast milk 21
Figure 11 Gaps to be filled by complementary foods for a breastfed child 12–23 months 23
Figure 12 Back massage to stimulate the oxytocin reflex before expressing breast milk 32
Figure 13 Feeding a baby by cup 33
Figure 14 Measuring mid-upper arm circumference 40
Figure 15 Assessing and classifying infant and young child feeding 46
Figure 16 Useful positions to hold a LBW baby for breastfeeding 52
Figure 17 Cup feeding a low-birth-weight baby 53
Figure 18 Baby in Kangaroo mother care position 54
Figure 19 Using supplementary suckling to help a mother relactate 58
Contents v
Figure 20 Preparing and using a syringe for treatment of inverted nipples 68

Figure 21 Dancer hand position 75
Figure 22 Elements of a comprehensive infant and young child feeding programme 82
Tables
Table 1 Practical guidance on the quality, frequency and amount of food to offer children
6–23 months of age who are breastfed on demand 22
Table 2 High-dose universal distribution schedule for prevention of Vitamin A deficiency 25
Table 3 Appropriate foods for complementary feeding 26
Table 4 Identifying growth problems from plotted points 41
Table 5 Food Intake Reference Tool, children 6–23 months 47
Table 6 Feeding low-birth-weight babies 51
Table 7 Recommended fluid intake for LBW infants 53
Table 8 Recommended feed volumes for LBW infants 53
Table 9 Reasons why a baby may not get enough breast milk 70
Table 10 Breastfeeding and mother’s medication 78
vi
Acknowledgments
T he development of this Model Chapter was initiated by the Department of Child and Adolescent Health and
Development of the World Health Organization, as part of its efforts to promote the integration of evidence-
based public health interventions in basic training of health professionals. The Model Chapter is designed for use
in textbooks used by health sciences faculties, as a result of the positive experience with the Model Chapter on
Integrated Management of Childhood Illness.
The process of development of the Model Chapter on infant and young child feeding started in 2003. Drafts were
presented in meetings with professors of health sciences schools in various regions and modifications made
accordingly. There was an external review of the document in 2006, with the group of reviewers including Anto-
nio da Cunha, Dai Yaohua, Nonhlanhla Dlamini, Hoang Trong Kim, Sandra Lang, Chessa Lutter, Nalini Singhal,
Maryanne Stone-Jimenez and Elizabeth Rodgers. All of the reviewers have declared no conflict of interest. Even
though the document was developed with inputs from many experts, some of them deserve special mention.
Ann Brownlee edited an earlier version of the document, while Felicity Savage King wrote the final draft. Peggy
Henderson conducted the editorial review. The three have declared no conflict of interest.
Staff from the Departments of Child and Adolescent Health and Development and Nutrition for Health and
Development were technically responsible and provided oversight to all aspects of the developmental work.
While developing the Model Chapter, several updates of existing recommendations were conducted by WHO,
and these were integrated into the Chapter. The updates include information on HIV and infant feeding (2007),
management of uncomplicated severe acute malnutrition (2007), infant and young child feeding indicators
(2008) and medical reasons for use of breast-milk substitutes (2008)
The chapter is expected to be updated by the year 2013.
vii
Abbreviations
ARA Arachidonic acid

ARVs Anti-retroviral drugs
BFHI Baby-friendly Hospital Initiative
BMS Breast-milk substitute
cm centimetre
Code International Code of Marketing of Breast-milk Substitutes (including subsequent relevant World
Health Assembly resolutions)
CRC Convention on the Rights of the Child
DHA Docosahexaenoic acid
EBM Expressed breast milk
ENA Essential Nutrition Actions
FIL Feedback inhibitor of lactation
g gram
GnRH Gonadotrophic releasing hormone
ILO International Labour Organization
IMCI Integrated management of childhood illness
IUGR Intrauterine growth retardation
Kcal kilocalorie
KMC Kangaroo mother care
LBW Low birth weight
ml millilitre
MTCT Mother-to-child transmission of HIV
MUAC Middle upper-arm circumference
NGO Non-governmental organization
RUTF Ready-to-use therapeutic food
SGA Small for gestational age
slgA secretory immunoglobulin A
VBLW Very low birth weight
WHA World Health Assembly
1
Introduction
O ptimal infant and young child feeding practices

rank among the most effective interventions to
improve child health. In 2006 an estimated 9.5 mil-
there are feeding problems, and they may overtly or
covertly promote breast-milk substitutes.
This Model Chapter brings together essential knowl-
lion children died before their fifth birthday, and two
edge about infant and young child feeding that health
thirds of these deaths occurred in the first year of life.
professionals should acquire as part of their basic
Under-nutrition is associated with at least 35% of child
education. It focuses on nutritional needs and feed-
deaths. It is also a major disabler preventing children
ing practices in children less than 2 years of age – the
who survive from reaching their full developmental
most critical period for child nutrition after which
potential. Around 32% of children less than 5 years
sub-optimal growth is hard to reverse. The Chapter
of age in developing countries are stunted and 10%
does not impart skills, although it includes descrip-
are wasted. It is estimated that sub-optimal breast-
tions of essential skills that every health professional
feeding, especially non-exclusive breastfeeding in the
should master, such as positioning and attachment
first 6 months of life, results in 1.4 million deaths and
for breastfeeding.
10% of the disease burden in children younger than
5 years. The Model Chapter is organized in nine sessions
according to topic areas, with scientific references at
To improve this situation, mothers and families need
the end of each section. These references include arti-
support to initiate and sustain appropriate infant and
cles or WHO documents that provide evidence and
young child feeding practices. Health care profession-
further information about specific points.
als can play a critical role in providing that support,
through influencing decisions about feeding practices Useful resource materials are listed on the inside of
among mothers and families. Therefore, it is critical the back cover. Training institutions may find it use-
for health professionals to have basic knowledge and ful to have these resources available for students.
skills to give appropriate advice, counsel and help The Chapter is accompanied by a CD-ROM with ref-
solve feeding difficulties, and know when and where erence materials. It includes an annotated listing of
to refer a mother who experiences more complex references presented in the Model Chapter, Power-
feeding problems. Point slides to support technical seminars on infant
Child health in general, and infant and young child and young child feeding, and the document Effective
feeding more specifically, is often not well addressed teaching: a guide for educating healthcare profession-
in the basic training of doctors, nurses and other als that can be used to identify effective methods
allied health professionals. Because of lack of adequate and approaches to introduce the content. Proposed
knowledge and skills, health professionals are often learning objectives and core competencies for medi-
barriers to improved feeding practices. For example, cal students and allied health professionals in the area
they may not know how to assist a mother to initiate of infant and young child feeding are also part of the
and sustain exclusive breastfeeding, they may recom- CD-ROM.
mend too-early introduction of supplements when
The importance of infant and young child
Session 1
feeding and recommended practices
1.1 Growth, health and Figure 1

development Major causes of death in neonates and children under five in the world, 2004
Adequate nutrition during infan- Deaths among children under five Neonatal deaths
cy and early childhood is essen-
Noncommunicable diseases
tial to ensure the growth, health, (postneonatal) 4%
Other infectious and
and development of children to parasitic diseases 9% Injuries (postneonatal) 4% Other 1.3%
their full potential. Poor nutrition HIV/AIDS 2% Congenital anomalies 6.8%
Neonatal tetanus 3.4%
increases the risk of illness, and is Measles 4%
Diarrhoeal diseases 2.6%
responsible, directly or indirectly, Malaria 7%
Neonatal
Other non-infectious
deaths
for one third of the estimated 36% perinatal causes 5.7%
Neonatal infections 26%
9.5 million deaths that occurred Diarrhoeal diseases
Birth asphyxia and
(postneonatal) 16%
in 2006 in children less than 5 birth trauma 23%
Prematurity and
years of age (1,2) (Figure 1). Inap- Acute respiratory low birth weight 31%
infections (postneonatal)
propriate nutrition can also lead 17% 35% of under-five deaths are due to the presence of undernutrition
to childhood obesity which is an
increasing public health problem Sources: World Health Organization. The global burden of disease: 2004 update. Geneva, World Health Organization,
in many countries. 2008; Black R et al. Maternal and child undernutrition: global and regional exposures and health consequences.
Lancet, 2008, 371:243–260.
Early nutritional deficits are also
linked to long-term impairment in growth and health. 1.2 The Global Strategy for infant and
Malnutrition during the first 2 years of life causes young child feeding
stunting, leading to the adult being several centime-
In 2002, the World Health Assembly and UNICEF
tres shorter than his or her potential height (3). There
adopted the Global Strategy for infant and young child
is evidence that adults who were malnourished in ear-
feeding (10). The strategy was developed to revitalise
ly childhood have impaired intellectual performance
world attention to the impact that feeding practices
(4). They may also have reduced capacity for physical
have on the nutritional status, growth and devel-
work (5,6). If women were malnourished as children,
opment, health, and survival of infants and young
their reproductive capacity is affected, their infants
children (see also Session 9). This Model Chapter sum-
may have lower birth weight, and they have more
marizes essential knowledge that every health profes-
complicated deliveries (7). When many children in a
sional should have in order to carry out the crucial
population are malnourished, it has implications for
role of protecting, promoting and supporting appro-
national development. The overall functional conse-
priate infant and young child feeding in accordance
quences of malnutrition are thus immense.
with the principles of the Global Strategy.
The first two years of life provide a critical window
of opportunity for ensuring children’s appropri- 1.3 Recommended infant and young child feeding
ate growth and development through optimal feed- practices
ing (8). Based on evidence of the effectiveness of WHO and UNICEF’s global recommendations for
interventions, achievement of universal coverage of optimal infant feeding as set out in the Global Strat-
optimal breastfeeding could prevent 13% of deaths egy are:
occurring in children less than 5 years of age globally,
while appropriate complementary feeding practices K exclusive breastfeeding for 6 months (180 days)
would result in an additional 6% reduction in under- (11);
five mortality (9).
4 Infant and Young Child Feeding – Model Chapter for textbooks
Figure 2
Trends in exclusive breastfeeding rates (1996–2006)
50
44 45 around 1996
Percentage of infants exclusively breastfed
40 37 around 2006
for the first six months of life
32 33
30 30
30 27
26
22
20 19
10
10
0
CEE/CIS Middle East/ Sub-Saharan East Asia/Pacific South Asia Developing countries
North Africa Africa (excluding China) (excluding China)
Source: UNICEF. Progress for children: a world fit for children. Statistical Review, Number 6. New York, UNICEF, 2007.
K nutritionally adequate and safe complementary foods are often introduced too early or too late and are
feeding starting from the age of 6 months with con- often nutritionally inadequate and unsafe.
tinued breastfeeding up to 2 years of age or beyond.
Data from 64 countries covering 69% of births in
Exclusive breastfeeding means that an infant receives the developing world suggest that there have been
only breast milk from his or her mother or a wet improvements in this situation. Between 1996 and
nurse, or expressed breast milk, and no other liquids 2006 the rate of exclusive breastfeeding for the first
or solids, not even water, with the exception of oral 6 months of life increased from 33% to 37%. Sig-
rehydration solution, drops or syrups consisting of nificant increases were made in sub-Saharan Africa,
vitamins, minerals supplements or medicines (12). where rates increased from 22% to 30%; and Europe,
with rates increasing from 10% to 19% (Figure 2). In
Complementary feeding is defined as the process start-
Latin America and the Caribbean, excluding Bra-
ing when breast milk is no longer sufficient to meet the
zil and Mexico, the percentage of infants exclusively
nutritional requirements of infants, and therefore oth-
breastfed increased from 30% in around 1996 to 45%
er foods and liquids are needed, along with breast milk.
in around 2006 (15).
The target range for complementary feeding is gener-
ally taken to be 6 to 23 months of age,1 even though
breastfeeding may continue beyond two years (13). 1.5 Evidence for recommended feeding practices
These recommendations may be adapted according Breastfeeding
to the needs of infants and young children in excep- Breastfeeding confers short-term and long-term
tionally difficult circumstances, such as pre-term benefits on both child and mother (16), including
or low-birth-weight infants, severely malnourished helping to protect children against a variety of acute
children, and in emergency situations (see Session 6). and chronic disorders. The long-term disadvantages
Specific recommendations apply to infants born to of not breastfeeding are increasingly recognized as
HIV-infected mothers. important (17,18).
Reviews of studies from developing countries show
1.4 Current status of infant and young child that infants who are not breastfed are 6 (19) to 10
feeding globally times (20) more likely to die in the first months of life
Poor breastfeeding and complementary feeding prac- than infants who are breastfed. Diarrhoea (21) and
tices are widespread. Worldwide, it is estimated that pneumonia (22) are more common and more severe
only 34.8% of infants are exclusively breastfed for the in children who are artificially fed, and are responsi-
first 6 months of life, the majority receiving some other ble for many of these deaths. Diarrhoeal illness is also
food or fluid in the early months (14). Complementary more common in artificially-fed infants even in situ-
ations with adequate hygiene, as in Belarus (23) and
When describing age ranges, a child 6–23 months has complet-
1 Scotland (24). Other acute infections, including otitis
ed 6 months but has an age less than 2 years. media (25), Haemophilus influenzae meningitis (26),
1. The importance of infant and young child feeding and recommended practices 5
and urinary tract infection (27), are less common and were exclusively instead of partially breastfed for the
less severe in breastfed infants. first 4 months of life (48). Exclusive breastfeeding for 6
months has been found to reduce the risk of diarrhoea
Artificially-fed children have an increased risk of long-
(49) and respiratory illness (50) compared with exclu-
term diseases with an immunological basis, including
sive breastfeeding for 3 and 4 months respectively.
asthma and other atopic conditions (28,29), type 1
diabetes (30), celiac disease (31), ulcerative colitis and If the breastfeeding technique is satisfactory, exclu-
Crohn disease (32). Artificial feeding is also associ- sive breastfeeding for the first 6 months of life meets
ated with a greater risk of childhood leukaemia (33). the energy and nutrient needs of the vast majority of
infants (51). No other foods or fluids are necessary.
Several studies suggest that obesity in later childhood
Several studies have shown that healthy infants do
and adolescence is less common among breastfed chil-
not need additional water during the first 6 months
dren, and that there is a dose response effect, with a
if they are exclusively breastfed, even in a hot climate.
longer duration of breastfeeding associated with a low-
Breast milk itself is 88% water, and is enough to sat-
er risk (34,35). The effect may be less clear in popula-
isfy a baby’s thirst (52). Extra fluids displace breast
tions where some children are undernourished (36). A
milk, and do not increase overall intake (53). How-
growing body of evidence links artificial feeding with
ever, water and teas are commonly given to infants,
risks to cardiovascular health, including increased
often starting in the first week of life. This practice
blood pressure (37), altered blood cholesterol levels
has been associated with a two-fold increased risk of
(38) and atherosclerosis in later adulthood (39).
diarrhoea (54).
Regarding intelligence, a meta-analysis of 20 studies
For the mother, exclusive breastfeeding can delay
(40) showed scores of cognitive function on average
the return of fertility (55), and accelerate recovery of
3.2 points higher among children who were breastfed
pre-pregnancy weight (56). Mothers who breastfeed
compared with those who were formula fed. The dif-
exclusively and frequently have less than a 2% risk of
ference was greater (by 5.18 points) among those chil-
becoming pregnant in the first 6 months postpartum,
dren who were born with low birth weight. Increased
provided that they still have amenorrhoea (see Session
duration of breastfeeding has been associated with
8.4.1).
greater intelligence in late childhood (41) and adult-
hood (42), which may affect the individual’s ability to
contribute to society. Complementary feeding from 6 months
From the age of 6 months, an infant’s need for energy
For the mother, breastfeeding also has both short- and
and nutrients starts to exceed what is provided by
long-term benefits. The risk of postpartum haemor-
breast milk, and complementary feeding becomes
rhage may be reduced by breastfeeding immediately
necessary to fill the energy and nutrient gap (57). If
after delivery (43), and there is increasing evidence
complementary foods are not introduced at this age
that the risk of breast (44) and ovarian (45) cancer is
or if they are given inappropriately, an infant’s growth
less among women who breastfed.
may falter. In many countries, the period of comple-
mentary feeding from 6–23 months is the time of
Exclusive breastfeeding for 6 months peak incidence of growth faltering, micronutrient
The advantages of exclusive breastfeeding compared deficiencies and infectious illnesses (58).
to partial breastfeeding were recognised in 1984,
Even after complementary foods have been intro-
when a review of available studies found that the risk
duced, breastfeeding remains a critical source of
of death from diarrhoea of partially breastfed infants
nutrients for the young infant and child. It provides
0–6 months of age was 8.6 times the risk for exclu-
about one half of an infant’s energy needs up to the
sively breastfed children. For those who received no
age of one year, and up to one third during the second
breast milk the risk was 25 times that of those who
year of life. Breast milk continues to supply higher
were exclusively breastfed (46). A study in Brazil in
quality nutrients than complementary foods, and also
1987 found that compared with exclusive breastfeed-
protective factors. It is therefore recommended that
ing, partial breastfeeding was associated with 4.2
breastfeeding on demand continues with adequate
times the risk of death, while no breastfeeding had
complementary feeding up to 2 years or beyond (13).
14.2 times the risk (47). More recently, a study in Dha-
ka, Bangladesh found that deaths from diarrhoea and Complementary foods need to be nutritionally-
pneumonia could be reduced by one third if infants adequate, safe, and appropriately fed in order to meet
the young child’s energy and nutrient needs. How- 12. W HO/UNICEF/USAID. Indicators for assessing
ever, complementary feeding is often fraught with infant and young child feeding practices. Geneva,
problems, with foods being too dilute, not fed often World Health Organization, 2008.
enough or in too small amounts, or replacing breast
13. PAHO/WHO. Guiding principles for complemen-
milk while being of an inferior quality. Both food and
tary feeding of the breastfed child. Washington
feeding practices influence the quality of complemen-
DC, Pan American Health Organization/World
tary feeding, and mothers and families need support
Health Organization, 2002.
to practise good complementary feeding (13).
14. W HO Global Data Bank on Infant and Young
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of overweight: a meta-analysis. American Journal control of diarrhoeal disease among young chil-
of Epidemiology, 2005, 162:397–403. dren: promotion of breastfeeding. Bulletin of the
World Health Organization, 1984, 62:271–291.
35. Burke V et al. Breastfeeding and overweight: lon-
gitudinal analysis in an Australian birth cohort. 47. Victora C et al. Evidence for protection by breast-
Journal of Pediatrics, 2005, 147:56–61. feeding against infant deaths from infectious dis-
eases in Brazil. Lancet, 1987, 330:319–322.
36. Grummer-Strawn LM, Mei Z. Does breastfeed-
ing protect against pediatric overweight? Analysis 48. A rifeen S et al. Exclusive breastfeeding reduces
of longitudinal data from the Centers for Disease acute respiratory infection and diarrhoea deaths
Control and Prevention Pediatric Nutrition Sur- among infants in Dhaka slums. Pediatrics, 2001,
veillance System. Pediatrics, 2004, 113:e81–86. 108:1–8.
49. Kramer M et al. Infant growth and health out- 55. The World Health Organization Multinational
comes associated with 3 compared with 6 months Study of Breast-feeding and Lactational Amenor-
of exclusive breastfeeding. American Journal of rhea. III. Pregnancy during breast-feeding. World
Clinical Nutrition, 2003, 78:291–295. Health Organization Task Force on Methods for
the Natural Regulation of Fertility. Fertility and
50. Chantry C, Howard C, Auinger P. Full breastfeed-
sterility, 1999, 72:431–440.
ing duration and associated decrease in respirato-
ry tract infection in US children. Pediatrics, 2006, 56. Dewey KG et al. Effects of exclusive breastfeeding
117:425–432. for 4 versus 6 months on maternal nutritional sta-
tus and infant motor development: results of two
51. Butte N, Lopez-Alarcon MG, Garza C. Nutrient
randomized trials in Honduras. The Journal of
adequacy of exclusive breastfeeding for the term
Nutrition, 2001, 131:262–267.
infant during the first six months of life. Geneva,
World Health Organization, 2002. 57. Dewey K and Brown K. Update on technical issues
concerning complementary feeding of young chil-
52. LINKAGES. Exclusive breastfeeding: The only water
dren in developing countries and implications for
source young infants need. FAQ Sheet 5 Frequently
intervention programs. Food and Nutrition Bulle-
Asked Questions. Washington DC, Academy for
tin, 2003, 24:5–28.
Educational Development, 2002.
58. Dewey KG, Adu-Afarwuah S. Systematic review
53. Sachdev H et al. Water supplementation in exclu-
of the efficacy and effectiveness of complemen-
sively breastfed infants during summer in the
tary feeding interventions in developing countries.
tropics. Lancet, 1991, 337:929–933.
Maternal and Child Nutrition, 2008, 4(s1):24–85.
54. Brown K et al. Infant feeding practices and their
relationship with diarrhoeal and other diseases in
Huascar (Lima) Peru. Pediatrics, 1989, 83:31–40.
The physiological basis of breastfeeding
Session 2
2.1 Breast-milk composition a baby. The concentration of protein in breast milk
Breast milk contains all the nutrients that an infant (0.9 g per 100 ml) is lower than in animal milks. The
needs in the first 6 months of life, including fat, car- much higher protein in animal milks can overload
bohydrates, proteins, vitamins, minerals and water the infant’s immature kidneys with waste nitrogen
(1,2,3,4). It is easily digested and efficiently used. products. Breast milk contains less of the protein
Breast milk also contains bioactive factors that aug- casein, and this casein in breast milk has a different
ment the infant’s immature immune system, provid- molecular structure. It forms much softer, more eas-
ing protection against infection, and other factors ily-digested curds than that in other milks. Among
that help digestion and absorption of nutrients. the whey, or soluble proteins, human milk contains
more alpha-lactalbumin; cow milk contains beta-
lactoglobulin, which is absent from human milk and
Fats
to which infants can become intolerant (4).
Breast milk contains about 3.5 g of fat per 100 ml of
milk, which provides about one half of the energy
Vitamins and minerals
content of the milk. The fat is secreted in small drop-
lets, and the amount increases as the feed progresses. Breast milk normally contains sufficient vitamins for
As a result, the hindmilk secreted towards the end of an infant, unless the mother herself is deficient (5).
a feed is rich in fat and looks creamy white, while the The exception is vitamin D. The infant needs expo-
foremilk at the beginning of a feed contains less fat and sure to sunlight to generate endogenous vitamin D –
looks somewhat bluish-grey in colour. Breast-milk or, if this is not possible, a supplement. The minerals
fat contains long chain polyunsaturated fatty acids iron and zinc are present in relatively low concentra-
(docosahexaenoic acid or DHA, and arachidonic acid tion, but their bioavailability and absorption is high.
or ARA) that are not available in other milks. These Provided that maternal iron status is adequate, term
fatty acids are important for the neurological devel- infants are born with a store of iron to supply their
opment of a child. DHA and ARA are added to some needs; only infants born with low birth weight may
varieties of infant formula, but this does not confer need supplements before 6 months. Delaying clamp-
any advantage over breast milk, and may not be as ing of the cord until pulsations have stopped (approxi-
effective as those in breast milk. mately 3 minutes) has been shown to improve infants’
iron status during the first 6 months of life (6,7).
Carbohydrates
Anti-infective factors
The main carbohydrate is the special milk sugar lac-
tose, a disaccharide. Breast milk contains about 7 g Breast milk contains many factors that help to protect
lactose per 100 ml, which is more than in most other an infant against infection (8) including:
milks, and is another important source of energy. K immunoglobulin, principally secretory immuno
Another kind of carbohydrate present in breast milk globulin A (sIgA), which coats the intestinal mucosa
is oligosaccharides, or sugar chains, which provide and prevents bacteria from entering the cells;
important protection against infection (4).
K white blood cells which can kill micro-organisms;
Protein K whey proteins (lysozyme and lactoferrin) which

Breast milk protein differs in both quantity and qual- can kill bacteria, viruses and fungi;
ity from animal milks, and it contains a balance of K oligosacccharides which prevent bacteria from
amino acids which makes it much more suitable for attaching to mucosal surfaces.
The protection provided by these factors is unique- 2.3 Animal milks and infant formula
ly valuable for an infant. First, they protect without Animal milks are very different from breast milk
causing the effects of inflammation, such as fever, in both the quantities of the various nutrients, and
which can be dangerous for a young infant. Second, in their quality. For infants under 6 months of age,
sIgA contains antibodies formed in the mother’s body animal milks can be home-modified by the addition
against the bacteria in her gut, and against infections of water, sugar and micronutrients to make them
that she has encountered, so they protect against bac- usable as short-term replacements for breast milk in
teria that are particularly likely to be in the baby’s exceptionally difficult situations, but they can never
environment. be equivalent or have the same anti-infective proper-
ties as breast milk (13). After 6 months, infants can
Other bioactive factors receive boiled full cream milk (14).
Bile-salt stimulated lipase facilitates the complete
Infant formula is usually made from industrially-
digestion of fat once the milk has reached the small
modified cow milk or soy products. During the
intestine (9). Fat in artificial milks is less completely
manufacturing process the quantities of nutrients are
digested (4).
adjusted to make them more comparable to breast
Epidermal growth factor (10) stimulates maturation of milk. However, the qualitative differences in the fat
the lining of the infant’s intestine, so that it is better and protein cannot be altered, and the absence of
able to digest and absorb nutrients, and is less easily anti-infective and bio-active factors remain. Pow-
infected or sensitised to foreign proteins. It has been dered infant formula is not a sterile product, and may
suggested that other growth factors present in human be unsafe in other ways. Life threatening infections
milk target the development and maturation of nerves in newborns have been traced to contamination with
and retina (11). pathogenic bacteria, such as Enterobacter sakazakii,
found in powdered formula (15). Soy formula con-
2.2 Colostrum and mature milk tains phyto-oestrogens, with activity similar to the
Colostrum is the special milk that is secreted in the human hormone oestrogen, which could potentially
first 2–3 days after delivery. It is produced in small reduce fertility in boys and bring early puberty in
amounts, about 40–50 ml on the first day (12), but is girls (16).
all that an infant normally needs at this time. Colos-
trum is rich in white cells and antibodies, especially 2.4 Anatomy of the breast
sIgA, and it contains a larger percentage of protein, The breast structure (Figure 3) includes the nipple and
minerals and fat-soluble vitamins (A, E and K) than areola, mammary tissue, supporting connective tis-
later milk (2). Vitamin A is important for protection sue and fat, blood and lymphatic vessels, and nerves
of the eye and for the integrity of epithelial surfaces, (17,18).
and often makes the colostrum yellowish in colour.
The mammary tissue – This tissue includes the alveoli,
Colostrum provides important immune protection
which are small sacs made of milk-secreting cells, and
to an infant when he or she is first exposed to the
the ducts that carry the milk to the outside. Between
micro-organisms in the environment, and epidermal
feeds, milk collects in the lumen of the alveoli and
growth factor helps to prepare the lining of the gut
ducts. The alveoli are surrounded by a basket of
to receive the nutrients in milk. It is important that
myoepithelial, or muscle cells, which contract and
infants receive colostrum, and not other feeds, at this
make the milk flow along the ducts.
time. Other feeds given before breastfeeding is estab-
lished are called prelacteal feeds. Nipple and areola – The nipple has an average of nine
milk ducts passing to the outside, and also muscle
Milk starts to be produced in larger amounts between
fibres and nerves. The nipple is surrounded by the
2 and 4 days after delivery, making the breasts feel
circular pigmented areola, in which are located Mont-
full; the milk is then said to have “come in”. On the
gomery’s glands. These glands secrete an oily fluid that
third day, an infant is normally taking about 300–400
protects the skin of the nipple and areola during lac-
ml per 24 hours, and on the fifth day 500–800 ml (12).
tation, and produce the mother’s individual scent that
From day 7 to 14, the milk is called transitional, and
attracts her baby to the breast. The ducts beneath the
after 2 weeks it is called mature milk.
areola fill with milk and become wider during a feed,
when the oxytocin reflex is active.
2. The physiological basis of breastfeeding 11
Figure 3 Figure 4
Anatomy of the breast Prolactin
Sensory impulses
from nipples
Prolactin
in blood
Baby suckling • More prolactin

secreted at night
• Suppresses
ovulation
Secreted after feed to produce next feed
2.5 Hormonal control of milk production More prolactin is produced at night, so breastfeeding
There are two hormones that directly affect breast- at night is especially helpful for keeping up the milk
feeding: prolactin and oxytocin. A number of other supply. Prolactin seems to make a mother feel relaxed
hormones, such as oestrogen, are involved indirectly in and sleepy, so she usually rests well even if she breast-
lactation (2). When a baby suckles at the breast, sensory feeds at night.
impulses pass from the nipple to the brain. In response, Suckling affects the release of other pituitary hor-
the anterior lobe of the pituitary gland secretes prolac- mones, including gonadotrophin releasing hormone
tin and the posterior lobe secretes oxytocin. (GnRH), follicle stimulating hormone, and luteinising
hormone, which results in suppression of ovulation
Prolactin and menstruation. Therefore, frequent breastfeeding
Prolactin is necessary for the secretion of milk by the can help to delay a new pregnancy (see Session 8 on
cells of the alveoli. The level of prolactin in the blood Mother’s Health). Breastfeeding at night is important
increases markedly during pregnancy, and stimulates to ensure this effect.
the growth and development of the mammary tissue,
in preparation for the production of milk (19). How- Oxytocin
ever, milk is not secreted then, because progesterone Oxytocin makes the myoepithelial cells around the
and oestrogen, the hormones of pregnancy, block this alveoli contract. This makes the milk, which has col-
action of prolactin. After delivery, levels of progester- lected in the alveoli, flow along and fill the ducts (21)
one and oestrogen fall rapidly, prolactin is no longer (see Figure 5). Sometimes the milk is ejected in fine
blocked, and milk secretion begins. streams.
When a baby suckles, the level of prolactin in the
Figure 5
blood increases, and stimulates production of milk Oxytocin
by the alveoli (Figure 4). The prolactin level is highest
about 30 minutes after the beginning of the feed, so
its most important effect is to make milk for the next Sensory impulses
feed (20). During the first few weeks, the more a baby from nipples
suckles and stimulates the nipple, the more prolac- Oxytocin
tin is produced, and the more milk is produced. This in blood
effect is particularly important at the time when lac-
tation is becoming established. Although prolactin is
still necessary for milk production, after a few weeks Baby suckling
• Makes uterus
there is not a close relationship between the amount
contract
of prolactin and the amount of milk produced. How-
ever, if the mother stops breastfeeding, milk secretion
may stop too – then the milk will dry up. Works before or during a feed to make the milk flow
The oxytocin reflex is also sometimes called the “let- Psychological effects of oxytocin
down reflex” or the “milk ejection reflex”. Oxytocin Oxytocin also has important psychological effects,
is produced more quickly than prolactin. It makes the and is known to affect mothering behaviour in ani-
milk that is already in the breast flow for the current mals. In humans, oxytocin induces a state of calm,
feed, and helps the baby to get the milk easily. and reduces stress (22). It may enhance feelings of
Oxytocin starts working when a mother expects a affection between mother and child, and promote
feed as well as when the baby is suckling. The reflex bonding. Pleasant forms of touch stimulate the secre-
becomes conditioned to the mother’s sensations and tion of oxytocin, and also prolactin, and skin-to-skin
feelings, such as touching, smelling or seeing her baby, contact between mother and baby after delivery helps
or hearing her baby cry, or thinking lovingly about both breastfeeding and emotional bonding (23,24).
him or her. If a mother is in severe pain or emotion-
ally upset, the oxytocin reflex may become inhibited, 2.6 Feedback inhibitor of lactation
and her milk may suddenly stop flowing well. If she Milk production is also controlled in the breast by a
receives support, is helped to feel comfortable and lets substance called the feedback inhibitor of lactation, or
the baby continue to breastfeed, the milk will flow FIL (a polypeptide), which is present in breast milk
again. (25). Sometimes one breast stops making milk while
Understanding the oxytocin reflex is important in the other breast continues, for example if a baby suck-
practice, because it explains why it is important to les only on one side. This is because of the local con-
keep a mother and baby together and for them to have trol of milk production independently within each
skin-to-skin contact, to help the flow of milk. breast. If milk is not removed, the inhibitor collects
and stops the cells from secreting any more, helping
Oxytocin makes a mother’s uterus contract after to protect the breast from the harmful effects of being
delivery and helps to reduce bleeding. The contrac- too full. If breast milk is removed the inhibitor is also
tions can cause severe uterine pain when a baby suck- removed, and secretion resumes. If the baby cannot
les during the first few days. suckle, then milk must be removed by expression.
Signs of an active oxytocin reflex FIL enables the amount of milk produced to be deter-
mined by how much the baby takes, and therefore
Mothers may notice signs that show that the oxytocin
by how much the baby needs. This mechanism is
reflex is active:
particularly important for ongoing close regulation
K a tingling sensation in the breast before or during a after lactation is established. At this stage, prolactin
feed; is needed to enable milk secretion to take place, but it
does not control the amount of milk produced.
K milk flowing from her breasts when she thinks of
the baby or hears him crying;
2.7 Reflexes in the baby
K milk flowing from the other breast when the baby
The baby’s reflexes are important for appropriate
is suckling;
breastfeeding. The main reflexes are rooting, suckling
K milk flowing from the breast in streams if suckling and swallowing. When something touches a baby’s
is interrupted; lips or cheek, the baby turns to find the stimulus, and
opens his or her mouth, putting his or her tongue
K slow deep sucks and swallowing by the baby, which
down and forward. This is the rooting reflex and is
show that milk is flowing into his mouth;
present from about the 32nd week of pregnancy.
K uterine pain or a flow of blood from the uterus; When something touches a baby’s palate, he or she
K thirst during a feed. starts to suck it. This is the sucking reflex. When the
baby’s mouth fills with milk, he or she swallows. This
If one or more of these signs are present, the reflex is the swallowing reflex. Preterm infants can grasp
is working. However, if they are not present, it does the nipple from about 28 weeks gestational age, and
not mean that the reflex is not active. The signs may they can suckle and remove some milk from about
not be obvious, and the mother may not be aware of 31 weeks. Coordination of suckling, swallowing and
them. breathing appears between 32 and 35 weeks of preg-
nancy. Infants can only suckle for a short time at that
age, but they can take supplementary feeds by cup. K the baby is suckling from the breast, not from the
A majority of infants can breastfeed fully at a gesta- nipple.
tional age of 36 weeks (26).
As the baby suckles, a wave passes along the tongue
When supporting a mother and baby to initiate and from front to back, pressing the teat against the hard
establish exclusive breastfeeding, it is important to palate, and pressing milk out of the sinuses into the
know about these reflexes, as their level of maturation baby’s mouth from where he or she swallows it. The
will guide whether an infant can breastfeed directly baby uses suction mainly to stretch out the breast tis-
or temporarily requires another feeding method. sue and to hold it in his or her mouth. The oxytocin
reflex makes the breast milk flow along the ducts,
2.8 How a baby attaches and suckles at the breast and the action of the baby’s tongue presses the milk
To stimulate the nipple and remove milk from the from the ducts into the baby’s mouth. When a baby
breast, and to ensure an adequate supply and a good is well attached his mouth and tongue do not rub or
flow of milk, a baby needs to be well attached so traumatise the skin of the nipple and areola. Suckling
that he or she can suckle effectively (27). Difficulties is comfortable and often pleasurable for the mother.
often occur because a baby does not take the breast She does not feel pain.
into his or her mouth properly, and so cannot suckle
effectively. Poor attachment
Figure 7 shows what happens in the mouth when a
Figure 6 baby is not well attached at the breast.
Good attachment – inside the infant’s mouth
The points to notice are:
K only the nipple is in the baby’s mouth, not the
underlying breast tissue or ducts;
K the baby’s tongue is back inside his or her mouth,
and cannot reach the ducts to press on them.
Suckling with poor attachment may be uncomfort-
able or painful for the mother, and may damage the
skin of the nipple and areola, causing sore nipples and
fissures (or “cracks”). Poor attachment is the com-
monest and most important cause of sore nipples (see
Session 7.6), and may result in inefficient removal of
milk and apparent low supply.
Figure 7
Good attachment Poor attachment – inside the infant’s mouth
Figure 6 shows how a baby takes the breast into his
or her mouth to suckle effectively. This baby is well
attached to the breast.
The points to notice are:
K much of the areola and the tissues underneath
it, including the larger ducts, are in the baby’s
mouth;
K the breast is stretched out to form a long ‘teat’, but
the nipple only forms about one third of the ‘teat’;
K the baby’s tongue is forward over the lower gums,
beneath the milk ducts (the baby’s tongue is in fact
cupped around the sides of the ‘teat’, but a drawing
cannot show this);
Figure 8 Sometimes much of the areola is outside the baby’s

Good and poor attachment – external signs mouth, but by itself this is not a reliable sign of poor
attachment. Some women have very big areolas,
which cannot all be taken into the baby’s mouth.
If the amount of areola above and below the baby’s
mouth is equal, or if there is more below the lower lip,
these are more reliable signs of poor attachment than
the total amount outside.
2.9 Effective suckling

If a baby is well attached at the breast, then he or she
can suckle effectively. Signs of effective suckling indi-
Signs of good and poor attachment cate that milk is flowing into the baby’s mouth. The
Figure 8 shows the four most important signs of good baby takes slow, deep suckles followed by a visible or
and poor attachment from the outside. These signs audible swallow about once per second. Sometimes
can be used to decide if a mother and baby need help. the baby pauses for a few seconds, allowing the ducts
to fill up with milk again. When the baby starts suck-
The four signs of good attachment are:
ling again, he or she may suckle quickly a few times,
K more of the areola is visible above the baby’s top lip stimulating milk flow, and then the slow deep suckles
than below the lower lip; begin. The baby’s cheeks remain rounded during the
K the baby’s mouth is wide open; feed.
K the baby’s lower lip is curled outwards; Towards the end of a feed, suckling usually slows down,
with fewer deep suckles and longer pauses between
K the baby’s chin is touching or almost touching the them. This is the time when the volume of milk is
breast. less, but as it is fat-rich hindmilk, it is important for
These signs show that the baby is close to the breast, the feed to continue. When the baby is satisfied, he
and opening his or her mouth to take in plenty of or she usually releases the breast spontaneously. The
breast. The areola sign shows that the baby is taking nipple may look stretched out for a second or two, but
the breast and nipple from below, enabling the nipple it quickly returns to its resting form.
to touch the baby’s palate, and his or her tongue to
reach well underneath the breast tissue, and to press Signs of ineffective suckling
on the ducts. All four signs need to be present to show A baby who is poorly attached is likely to suckle inef-
that a baby is well attached. In addition, suckling fectively. He or she may suckle quickly all the time,
should be comfortable for the mother. without swallowing, and the cheeks may be drawn in
The signs of poor attachment are: as he or she suckles showing that milk is not flow-
ing well into the baby’s mouth. When the baby stops
K more of the areola is visible below the baby’s bot- feeding, the nipple may stay stretched out, and look
tom lip than above the top lip – or the amounts squashed from side to side, with a pressure line across
above and below are equal; the tip, showing that the nipple is being damaged by
K the baby’s mouth is not wide open; incorrect suction.
K the baby’s lower lip points forward or is turned

Consequences of ineffective suckling
inwards;
When a baby suckles ineffectively, transfer of milk
K the baby’s chin is away from the breast. from mother to baby is inefficient. As a result:
If any one of these signs is present, or if suckling is K the breast may become engorged, or may develop a
painful or uncomfortable, attachment needs to be blocked duct or mastitis because not enough milk
improved. However, when a baby is very close to the is removed;
breast, it can be difficult to see what is happening to
the lower lip. K the baby’s intake of breast milk may be insufficient,
resulting in poor weight gain;
K the baby may pull away from the breast out of frus- Figure 9
tration and refuse to feed; Baby well positioned at the breast
K the baby may be very hungry and continue suck-

ling for a long time, or feed very often;
K the breasts may be over-stimulated by too much
suckling, resulting in oversupply of milk.
These difficulties are discussed further in Session 7.
2.10 Causes of poor attachment

Use of a feeding bottle before breastfeeding is well estab-
lished can cause poor attachment, because the mecha-
nism of suckling with a bottle is different. Functional
difficulties such as flat and inverted nipples, or a very
small or weak infant, are also causes of poor attach-
ment. However, the most important causes are inex-
a) Sitting
perience of the mother and lack of skilled help from
the health workers who attend her. Many mothers need
skilled help in the early days to ensure that the baby
attaches well and can suckle effectively. Health workers
need to have the necessary skills to give this help.
2.11 Positioning the mother and baby for good

attachment
To be well attached at the breast, a baby and his or her
mother need to be appropriately positioned. There are
several different positions for them both, but some
b) Lying down
key points need to be followed in any position.
Position of the mother K He or she should be facing the breast. The nip-
The mother can be sitting or lying down (see Figure 9), ples usually point slightly downwards, so the baby
or standing, if she wishes. However, she needs to be should not be flat against the mother’s chest or
relaxed and comfortable, and without strain, particu- abdomen, but turned slightly on his or her back
larly of her back. If she is sitting, her back needs to be able to see the mother’s face.
supported, and she should be able to hold the baby at K The baby’s body should be close to the mother
her breast without leaning forward. which enables the baby to be close to the breast,
and to take a large mouthful.
Position of the baby
K His or her whole body should be supported. The
The baby can breastfeed in several different positions
baby may be supported on the bed or a pillow, or
in relation to the mother: across her chest and abdo-
the mother’s lap or arm. She should not support
men, under her arm, or alongside her body.
only the baby’s head and neck. She should not
Whatever the position of the mother, and the baby’s grasp the baby’s bottom, as this can pull him or
general position in relation to her, there are four key her too far out to the side, and make it difficult for
points about the position of the baby’s body that are the baby to get his or her chin and tongue under
important to observe. the areola.
K The baby’s body should be straight, not bent or These points about positioning are especially impor-
twisted. The baby’s head can be slightly extended tant for young infants during the first two months of
at the neck, which helps his or her chin to be close life. (See also Feeding History Job Aid, 0–6 months,
in to the breast. in Session 5.)
2.12 Breastfeeding pattern References

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12. Casey Cet al. Nutrient intake by breastfed infants
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Complementary feeding
Session 3
3.1 Guiding Principles for Box 1
Complementary Feeding
Guiding principles for complementary feeding
After 6 months of age, it becomes increasingly diffi-
of the breastfed child
cult for breastfed infants to meet their nutrient needs
from human milk alone. Furthermore most infants 1. Practise exclusive breastfeeding from birth to 6 months of
are developmentally ready for other foods at about 6 age, and introduce complementary foods at 6 months of
months. In settings where environmental sanitation age (180 days) while continuing to breastfeed.
is very poor, waiting until even later than 6 months to 2. Continue frequent, on-demand breastfeeding until 2 years
introduce complementary foods might reduce expo- of age or beyond.
sure to food-borne diseases. However, because infants
are beginning to actively explore their environment at 3. Practise responsive feeding, applying the principles of
this age, they will be exposed to microbial contami- psychosocial care.
nants through soil and objects even if they are not 4. Practise good hygiene and proper food handling.
given complementary foods. Thus, 6 months is the
5. Start at 6 months of age with small amounts of food
recommended appropriate age at which to introduce
and increase the quantity as the child gets older, while
complementary foods (1).
maintaining frequent breastfeeding.
During the period of complementary feeding, chil-
6. Gradually increase food consistency and variety as the
dren are at high risk of undernutrition (2). Comple-
infant grows older, adapting to the infant’s requirements
mentary foods are often of inadequate nutritional
and abilities.
quality, or they are given too early or too late, in too
small amounts, or not frequently enough. Premature 7. Increase the number of times that the child is fed
cessation or low frequency of breastfeeding also con- complementary foods as the child gets older.
tributes to insufficient nutrient and energy intake in
8. Feed a variety of nutrient-rich foods to ensure that all
infants beyond 6 months of age.
nutrient needs are met.
The Guiding principles for complementary feeding of
9. Use fortified complementary foods or vitamin-mineral
the breastfed child, summarized in Box 1, set standards
supplements for the infant, as needed
for developing locally appropriate feeding recom-
mendations (3). They provide guidance on desired 10. Increase fluid intake during illness, including more
feeding behaviours as well as on the amount, consist- frequent breastfeeding, and encourage the child to eat
ency, frequency, energy density and nutrient content soft, favourite foods. After illness, give food more often
of foods. The Guiding principles are explained in more than usual and encourage the child to eat more.
detail in the paragraphs below.
A Guiding Principle 1. Practise exclusive breastfeeding but also in industrialized countries. According to the
from birth to 6 months of age and introduce WHO growth standards, children who are exclusively
complementary foods at 6 months of age (180 days) breastfed grow better in the first 6 months than other
while continuing to breastfeed infants (4).
Exclusive breastfeeding for 6 months confers several By the age of 6 months, a baby has usually at least
benefits to the infant and the mother. Chief among doubled his or her birth weight, and is becoming
these is the protective effect against gastrointestinal more active. Exclusive breastfeeding is no longer suf-
infections, which is observed not only in developing ficient to meet all energy and nutrient needs by itself,
and complementary foods should be introduced to have revealed that a casual style of feeding predomi-
make up the difference. At about 6 months of age, an nates in some populations. Young children are left to
infant is also developmentally ready for other foods feed themselves, and encouragement to eat is rarely
(5). The digestive system is mature enough to digest observed. In such settings, a more active style of feed-
the starch, protein and fat in a non-milk diet. Very ing can improve dietary intake. The term “responsive
young infants push foods out with their tongue, but feeding” (see Box 2) is used to describe caregiving that
by between 6 and 9 months infants can receive and applies the principles of psychosocial care.
hold semi-solid food in their mouths more easily.
A child should have his or her own plate or bowl so
that the caregiver knows if the child is getting enough
A Guiding Principle 2. Continue frequent on-demand
food. A utensil such as a spoon, or just a clean hand,
breastfeeding until 2 years of age or beyond
may be used to feed a child, depending on the culture.
Breastfeeding should continue with complementary The utensil needs to be appropriate for the child’s age.
feeding up to 2 years of age or beyond, and it should Many communities use a small spoon when a child
be on demand, as often as the child wants. starts taking solids. Later a larger spoon or a fork may
Breast milk can provide one half or more of a child’s be used.
energy needs between 6 and 12 months of age, and Whether breastfeeds or complementary foods are giv-
one third of energy needs and other high quality en first at any meal has not been shown to matter. A
nutrients between 12 and 24 months (6). Breast milk mother can decide according to her convenience, and
continues to provide higher quality nutrients than the child’s demands.
complementary foods, and also protective factors.
Breast milk is a critical source of energy and nutrients A Guiding Principle 4. Practise good hygiene and
during illness (7), and reduces mortality among chil- proper food handling
dren who are malnourished (8, 9). In addition, as dis-
Microbial contamination of complementary foods is
cussed in Session 1, breastfeeding reduces the risk of a
a major cause of diarrhoeal disease, which is partic-
number of acute and chronic diseases. Children tend
ularly common in children 6 to 12 months old (12).
to breastfeed less often when complementary foods
Safe preparation and storage of complementary foods
are introduced, so breastfeeding needs to be actively
can prevent contamination and reduce the risk of
encouraged to sustain breast-milk intake.
diarrhoea. The use of bottles with teats to feed liquids
is more likely to result in transmission of infection
A Guiding Principle 3. Practise responsive feeding
than the use of cups, and should be avoided (13).
applying the principles of psychosocial care
All utensils, such as cups, bowls and spoons, used
Optimal complementary feeding depends not only
for an infant or young child’s food should be washed
on what is fed but also on how, when, where and
thoroughly. Eating by hand is common in many cul-
by whom a child is fed (10,11). Behavioural studies
tures, and children may be given solid pieces of food
to hold and chew on, sometimes called “finger foods”.
Box 2
It is important for both the caregiver’s and the child’s
Responsive feeding hands to be washed thoroughly before eating.
K Feed infants directly and assist older children when they Bacteria multiply rapidly in hot weather, and more
feed themselves. Feed slowly and patiently, and encourage slowly if food is refrigerated. Larger numbers of bacte-
children to eat, but do not force them. ria produced in hot weather increase the risk of illness
K If children refuse many foods, experiment with different (14). When food cannot be refrigerated it should be
food combinations, tastes, textures and methods of eaten soon after it has been prepared (no more than 2
encouragement. hours), before bacteria have time to multiply.
K Minimize distractions during meals if the child loses Basic recommendations for the preparation of safe
interest easily. foods (15) are summarized in Box 3.
K Remember that feeding times are periods of learning

and love – talk to children during feeding, with eye-to-eye
contact.
3. Complementary feeding 21
Box 3 Table 1 summarizes the amount of food required at

different ages,1 the average number of kilocalories that
Five keys to safer food a breastfed infant or young child needs from com-
K Keep clean plementary foods at different ages, and the approxi-
mate quantity of food that will provide this amount
K Separate raw and cooked
of energy per day. The quantity increases gradually
K Cook thoroughly month by month, as the child grows and develops,
and the table shows the average for each age range.
K Keep food at safe temperatures
The actual amount (weight or volume) of food
K Use safe water and raw materials
required depends on the energy density of the food
offered. This means the number of kilocalories per
ml, or per gram. Breast milk contains about 0.7 kcal
A Guiding Principle 5. Start at 6 months of age with per ml. Complementary foods are more variable, and
small amounts of food and increase the quantity usually contain between 0.6 and 1.0 kcal per gram.
as the child gets older, while maintaining frequent Foods that are watery and dilute may contain only
breastfeeding about 0.3 kcal per gram. For complementary foods
The overall quantity of food is usually measured for to have 1.0 kcal per gram, it is necessary for them to
convenience according to the amount of energy – that be quite thick and to contain fat or oil, which are the
is, the number of kilocalories (kcal) – that a child most energy-rich foods.
needs. Other nutrients are equally important, and are Complementary foods should have a greater energy
either part of, or must be added to, the staple food. density than breast milk, that is, at least 0.8 kcal per
Figure 10 shows the energy needs of infants and young gram. The quantities of food recommended in Table
children up to 2 years of age, and how much can be 1 assume that the complementary food will contain
provided by breast milk. It shows that breast milk 0.8–1.0 kcal per gram. If a complementary food is
covers all needs up to 6 months, but after 6 months more energy dense, then a smaller amount is needed
there is an energy gap that needs to be covered by to cover the energy gap. A complementary food that
complementary foods. The energy needed in addition is more energy-dilute needs a larger volume to cover
to breast milk is about 200 kcal per day in infants 6–8 the energy gap.
months, 300 kcal per day in infants 9–11 months, and When complementary food is introduced, a child
550 kcal per day in children 12–23 months of age. The tends to breastfeed less often, and his or her intake
amount of food required to cover the gap increases as of breast milk decreases (17), so the food effectively
the child gets older, and as the intake of breast milk displaces breast milk. If complementary food is more
decreases (16). energy diluted than breast milk, the child’s total
energy intake may be less than it was with exclusive
Figure 10 breastfeeding, an important cause of malnutrition.
Energy required by age and the amount from breast milk
A young child’s appetite usually serves as a guide to
the amount of food that should be offered. However,
1200
Energy from breastmilk Energy gap illness and malnutrition reduce appetite, so that a
1000 sick child may take less than he or she needs. A child
recovering from illness or malnutrition may require
800
Energy (Kcal/day)
extra assistance with feeding to ensure adequate

600 intake. If the child’s appetite increases with recovery,
400
then extra food should be offered.
200
0
0–2 m 3–5 m 6–8 m 9–11 m 12–23 m
Age (months)
The age ranges should be interpreted as follows: a child 6–8
1
months is 6 months or older (≥ 180 days) but is not yet 9 months

old (< 270 days).
Table 1
Practical guidance on the quality, frequency and amount of food to offer children 6–23 months of age
who are breastfed on demand
Age Energy needed per day in Texture Frequency Amount of food an average
addition to breast milk child will usually eat at
each meala
6–8 months 200 kcal per day Start with thick porridge, 2–3 meals per day Start with 2–3 tablespoonfuls
well mashed foods per feed, increasing gradually
Depending on the child’s appetite, to ½ of a 250 ml cup
Continue with mashed 1–2 snacks may be offered
family foods
9–11 months 300 kcal per day Finely chopped or mashed 3–4 meals per day ½ of a 250 ml cup/bowl
foods, and foods that baby
can pick up Depending on the child’s appetite,
1–2 snacks may be offered
12–23 months 550 kcal per day Family foods, chopped or 3–4 meals per day ¾ to full 250 ml cup/bowl
mashed if necessary
Depending on the child’s appetite,
1–2 snacks may be offered
Further information
The amounts of food included in the table are recommended when the energy density of the meals is about 0.8 to 1.0 kcal/g.
If the energy density of the meals is about 0.6 kcal/g, the mother should increase the energy density of the meal (adding special foods) or increase the amount of food per meal. For
example:
— for 6 to 8 months, increase gradually to two thirds cup
— for 9 to 11 months, give three quarters cup
— for 12 to 23 months, give a full cup.
The table should be adapted based on the energy content of local complementary foods.
The mother or caregiver should feed the child using the principles of responsive feeding, recognizing the signs of hunger and satiety. These signs should guide the amount of food
given at each meal and the need for snacks.
a
If baby is not breastfed, give in addition: 1–2 cups of milk per day, and 1–2 extra meals per day (18).
A Guiding Principle 6. Gradually increase food to give more kcal and to include a variety of nutri-
consistency and variety as the infant grows older, ent-rich ingredients including animal-source foods.
adapting to the infant’s requirements and abilities There is evidence of a critical window for introducing
‘lumpy’ foods: if these are delayed beyond 10 months
The most suitable consistency for an infant’s or
of age, it may increase the risk of feeding difficulties
young child’s food depends on age and neuromus-
later on. Although it may save time to continue feed-
cular development (19). Beginning at 6 months, an
ing semi-solid foods, for optimal child development it
infant can eat pureed, mashed or semi-solid foods. By
is important to gradually increase the solidity of food
8 months most infants can also eat finger foods. By
with age.
12 months, most children can eat the same types of
foods as consumed by the rest of the family. However, A Guiding Principle 7. Increase the number of times
they need nutrient-rich food, as explained in Guiding that the child is fed complementary foods as the child
principle 8, and foods that can cause choking, such as gets older
whole peanuts, should be avoided.
As a child gets older and needs a larger total quantity
A complementary food should be thick enough so of food each day, the food needs to be divided into a
that it stays on a spoon and does not drip off. Gen- larger number of meals.
erally, foods that are thicker or more solid are more
energy- and nutrient-dense than thin, watery or soft The number of meals that an infant or young child
foods. When a child eats thick, solid foods, it is easier needs in a day depends on:
K how much energy the child needs to cover the ener- Figure 11
gy gap. The more food a child needs each day, the Gaps to be filled by complementary foods for a breastfed
more meals are needed to ensure that he or she gets child 12–23 months
enough. 100 Gap
K the amount that a child can eat at one meal. This
Percentage of daily needs (%)

Provided
75 by 550 ml
depends on the capacity or size of the child’s stom- breast milk
ach, which is usually 30 ml per kg of the child’s 50
body weight. A child who weighs 8 kg will have a
stomach capacity of 240 ml, about one large cup- 25
ful, and cannot be expected to eat more than that 0

at one meal. Energy Protein Iron Vitamin A
Nutrient
K the energy density of the food offered. The energy
density of complementary foods should be more
than breast milk, that is, at least 0.8 kcal per gram.
If the energy density of food is lower, a larger vol- The largest gap is for iron, so it is especially impor-
ume of food is needed to fill the gap, which may tant that complementary foods contain iron, if pos-
need to be divided into more meals. sible from animal-source foods such as meat, organs,
As shown in Table 1, a breastfed infant 6-8 months old poultry or fish. Pulses (peas, beans, lentils, nuts) fed
needs 2–3 meals a day, and a breastfed infant 9–23 with vitamin C-rich foods to aid absorption provide
months needs 3–4 meals a day. Depending on the an alternative, but they cannot replace animal-source
child’s appetite, 1–2 nutritious snacks may be offered. foods completely.
Snacks are defined as foods eaten between meals, Box 4 summarizes characteristics of good complemen-
often self-fed finger foods, which are convenient and tary foods.
easy to prepare. If they are fried, they may have a
high energy density. The transition from 2 to 3 meals,
and from smaller to larger meals, happens gradually Box 4
between those ages, depending on the child’s appetite
Good complementary foods are:
and how he or she is developing.
K Rich in energy, protein and micronutrients (particularly
If a child eats too few meals, then he or she will not
iron, zinc, calcium, vitamin A, vitamin C and folate);
receive enough food to cover energy needs. If a child
eats too many meals, he or she may breastfeed less, K Not spicy or salty;
or may even stop breastfeeding altogether. In the first
K Easy for the child to eat;
year of life, displacement of breast milk may reduce
the quality and amount of the child’s total nutrient K Liked by the child;
intake. K Locally available and affordable.
A Guiding Principle 8. Feed a variety of nutrient-rich

foods to ensure that all nutrient needs are met
The basic ingredient of complementary foods is usu-
Complementary foods should provide sufficient ally the local staple. Staples are cereals, roots and
energy, protein and micronutrients to cover a child’s starchy fruits that consist mainly of carbohydrate
energy and nutrient gaps, so that together with breast and provide energy. Cereals also contain some pro-
milk, they meet all his or her needs. tein; but roots such as cassava and sweet potato, and
starchy fruits such as banana and breadfruit, contain
Figure 11 shows the energy, protein, iron and vitamin A
very little protein.
gaps that need to be filled by complementary foods for
a breastfed child 12–23 months of age. The light part A variety of other foods should be added to the staple
of each bar shows the percentage of the child’s daily every day to provide other nutrients. These include:
needs that can be provided by an average intake of 550
K Foods from animals or fish are good sources of pro-
ml of breast milk. The dark part of the bar shows the
tein, iron and zinc. Liver also provides vitamin A
gap that needs to be filled by complementary foods.
and folate. Egg yolk is a good source of protein and
vitamin A, but not of iron. A child needs the solid young children can consume a variety of foods from
part of these foods, not just the watery sauce. the age of six months, including cow milk, eggs, pea-
nuts, fish and shellfish (18).
K Dairy products, such as milk, cheese and yoghurt,
are useful sources of calcium, protein, energy and
A Guiding Principle 9. Use fortified complementary
B vitamins.
foods or vitamin-mineral supplements for the infant as
K Pulses – peas, beans, lentils, peanuts, and soybeans needed
are good sources of protein, and some iron. Eat-
Unfortified complementary foods that are predomi-
ing sources of vitamin C (for example, tomatoes,
nantly plant-based generally provide insufficient
citrus and other fruits, and green leafy vegetables)
amounts of certain key nutrients (particularly iron,
at the same time helps iron absorption.
zinc and vitamin B6) to meet recommended nutrient
K Orange-coloured fruits and vegetables such as car- intakes during complementary feeding. Inclusion of
rot, pumpkin, mango and papaya, and dark-green animal-source foods can meet the gap in some cases,
leaves such as spinach, are rich in carotene, from but this increases cost and may not be practical for
which vitamin A is made, and also vitamin C. the lowest-income groups. Furthermore, the amounts
of animal-source foods that can feasibly be consumed
K Fats and oils are concentrated sources of energy,
by infants (e.g. at 6–12 months) are generally insuf-
and of certain essential fats that children need to
ficient to meet the gap in iron. The difficulty in meet-
grow.
ing the needs for these nutrients is not unique to
Vegetarian (plant-based) complementary foods do not developing countries. Average iron intakes in infants
by themselves provide enough iron and zinc to meet in industrialized countries would fall well short of
all the needs of an infant or young child aged 6–23 recommended intake if iron-fortified products were
months. Animal-source foods that contain enough not widely available. Therefore, in settings where lit-
iron and zinc are needed in addition. Alternatively, tle or no animal-source foods are available to many
fortified foods or micronutrient supplements can fill families, iron-fortified complementary foods or foods
some of the critical nutrient gaps. fortified at the point of consumption with a multinu-
Fats, including oils, are important because they trient powder or lipid-based nutrient supplement may
increase the energy density of foods, and make them be necessary.
taste better. Fat also helps the absorption of vitamin
A Guiding Principle 10. Increase fluid intake during
A and other fat-soluble vitamins. Some fats, espe-
illness, including more frequent breastfeeding, and
cially soy and rapeseed oil, also provide essential fatty
encourage the child to eat soft, favourite foods. After
acids. Fat should comprise 30–45% of the total ener-
illness, give food more often than usual and encourage
gy provided by breast milk and complementary foods
the child to eat more
together. Fat should not provide more than this pro-
portion, or the child will not eat enough of the foods During an illness, the need for fluid often increases,
that contain protein and other important nutrients, so a child should be offered and encouraged to take
such as iron and zinc. more, and breastfeeding on demand should continue.
A child’s appetite for food often decreases, while the
Sugar is a concentrated source of energy, but it has
desire to breastfeed increases, and breast milk may
no other nutrients. It can damage children’s teeth,
become the main source of both fluid and nutrients.
and lead to overweight and obesity. Sugar and sug-
ary drinks, such as soda, should be avoided because A child should also be encouraged to eat some com-
they decrease the child’s appetite for more nutritious plementary food to maintain nutrient intake and
foods. Tea and coffee contain compounds that can enhance recovery (20). Intake is usually better if the
interfere with iron absorption and are not recom- child is offered his or her favourite foods, and if the
mended for young children. foods are soft and appetizing. The amount eaten at
any one time is likely to be less than usual, so the
Concerns about potential allergic effects are a com-
caregiver may need to give more frequent, smaller
mon reason for families to restrict certain foods in
meals.
the diets of infants and young children. However,
there are no controlled studies that show that restric- When the infant or young child is recovering, and his
tive diets have an allergy-preventing effect. Therefore, or her appetite improves, the caregiver should offer
an extra portion at each meal or add an extra meal or Iodine

snack each day. In 1994, WHO and UNICEF recommended universal
salt iodization (USI) as a safe, cost-effective and sus-
3.2 Recommendations for micronutrient tainable strategy to ensure sufficient intake of iodine
supplementation by all individuals. However, in areas with severe
Micronutrients are essential for growth, develop- iodine deficiency, vulnerable groups – pregnant and
ment and prevention of illness in young children. As lactating women and children less than 2 years –
discussed earlier in Guiding principle 9, micronutrient may not be adequately covered when USI is not fully
supplementation can be an effective intervention in implemented, and iodine supplementation may be
some situations. Recommendations are summarized necessary. The WHO/UNICEF Joint Statement on
below. reaching optimal iodine nutrition in pregnant and
lactating women and young children provides guid-
Vitamin A ance for the categorization of countries and subse-
WHO and UNICEF recommend universal supple- quent planning of an adequate response (24).
mentation with vitamin A as a priority in children
aged 6–59 months in countries with a high risk of Zinc
deficiency (Table 2). In these countries, a high dose Zinc supplementation is recommended as adjunct
of vitamin A should also be given to children with therapy in the management of diarrhoea. Zinc (20 mg/
measles, diarrhoea, respiratory disease, chickenpox, day) should be given to all children with diarrhoea for
other severe infections or severe protein-energy mal- 10–14 days. In infants below 6 months of age, the dose
nutrition, or who live in the vicinity of children with of zinc should be 10 mg/day (25).
vitamin A deficiency (21).
3.3 Local adaptation of complementary feeding
recommendations
Table 2
High-dose universal distribution schedule for prevention Table 3 lists types of foods, the principle nutrients they
of vitamin A deficiency contain, and how they can be fed to children for good
complementary feeding. To develop specific feeding
Infants 6–12 months of age 100 000 IU orally, every 4–6 months
recommendations that respond to the Guiding prin-
Children > 12 months of age 200 000 IU orally, every 4–6 months ciples and that are locally acceptable and affordable, a
process of adaptation is needed. It is useful to involve
caregivers and families in the process of adaptation,
Iron and of deciding what is culturally appropriate (26).
As a rule, fortified foods should be preferred to iron The following steps are usually required:
supplements for children during the complementary K Review existing national or local feeding guide
feeding period. Caution should be exercised with iron lines.
supplementation in settings where the prevalence
of malaria and other infectious diseases is high. In K Develop a list of locally available foods.
malaria-endemic areas, universal iron supplemen- K Find out the nutrient content of the local foods
tation is not recommended. If iron supplements are from food tables (27).
used, they should not be given to children who have
K Calculate the amount of various foods that would
sufficient iron stores as the risks of severe adverse
provide a child with his or her daily needs of the
events appear to be greater in those children. Pre-
various nutrients – linear programming tech-
vention and management of anaemia in such areas
niques can be used for this (28).
requires a screening system to identify iron-deficient
children, and the availability of and accessibility to K Assess which foods and quantities of foods caregiv-
appropriate anti-malarial and other anti-infective ers and families accept as suitable for children, and
treatments (22,23). identify their feeding practices and preferences.
K Arrange trials of improved practices, asking moth-
ers or other caregivers to choose new, improved
feeding practices and try them out themselves.
Table 3
Appropriate foods for complementary feeding
What foods to give and why How to give the foods
Breast milk: continues to provide energy and high quality nutrients Infants 6–11 months
up to 23 months
K Continue breastfeeding
Staple foods: provide energy, some protein (cereals only) and
K Give adequate servings of:
vitamins
K Examples: cereals (rice, wheat, maize, millet, quinoa), roots — Thick porridge made out of maize, cassava, millet; add milk, soy, ground
(cassava, yam and potatoes) and starchy fruits (plantain and nuts or sugar
breadfruit)
— Mixtures of pureed foods made out of matoke, potatoes, cassava, posho
Animal-source foods: provide high quality protein, haem iron, zinc (maize or millet) or rice: mix with fish, beans or pounded groundnuts;
and vitamins add green vegetables
K Examples: liver, red meat, chicken, fish, eggs (not good source of
K Give nutritious snacks: egg, banana, bread, papaya, avocado, mango, other
iron)
fruits, yogurt, milk and puddings made with milk, biscuits or crackers, bread or
Milk products: provide protein, energy, most vitamins (especially chapati with butter, margarine, groundnut paste or honey, bean cakes, cooked
vitamin A and folate), calcium potatoes
K Examples: milk, cheese, yogurt and curds
Children 12–23 months
Green leafy and orange-coloured vegetables: provide vitamins
A, C, folate K Continue breastfeeding
K Examples: spinach, broccoli, chard, carrots, pumpkins, sweet
K Give adequate servings of:
potatoes
— Mixtures of mashed or finely cut family foods made out of matoke,
Pulses: provide protein (of medium quality), energy, iron (not well
potatoes, cassava, posho (maize or millet) or rice; mix with fish or beans
absorbed)
or pounded groundnuts; add green vegetables
K Examples: chickpeas, lentils, cowpeas, black-eyed peas, kidney
beans, lima beans — Thick porridge made out of maize, cassava, millet; add milk, soy, ground
nuts or sugar
Oils and fats: provide energy and essential fatty acids
K Examples: oils (preferably soy or rapeseed oil), margarine, butter K Give nutritious snacks: egg, banana, bread, papaya, avocado, mango, other
or lard fruits, yogurt, milk and puddings made with milk, biscuits or crackers, bread or
chapati with butter, margarine, groundnut paste or honey, bean cakes, cooked
Seeds: provide energy
potatoes
K Examples: groundnut paste or other nut pastes, soaked or
germinated seeds such as pumpkin, sunflower, melon, sesame
Reminder:
Foods rich in iron
K Liver (any type), organ meat, flesh of animals (especially red meat), flesh of birds (especially dark meat), foods fortified with iron
Foods rich in Vitamin A
K Liver (any type), red palm oil, egg yolk, orange coloured fruits and vegetables, dark green vegetables
Foods rich in zinc
K Liver (any type), organ meat, food prepared with blood, flesh of animals, birds and fish, shell fish, egg yolk
Foods rich in calcium
K Milk or milk products, small fish with bones
Foods rich in Vitamin C
K Fresh fruits, tomatoes, peppers (green, red, yellow), green leaves and vegetables
Obtain feedback on what works best in their

circumstances.
Whether or not vitamin-mineral supplements should
be included in the recommendations depends on the
micronutrient content of locally-available foods, and
whether children can eat enough suitable foods.
References 12. Bern C et al. The magnitude of the global problem

1. WHO. The optimal duration of exclusive breastfeed- of diarrhoeal disease; a ten-year update. Bulletin of
ing: report of an expert consultation. Geneva, World the World Health Organization, 1992, 70:705–714.
Health Organization, 2001 (WHO/NHD/01.09, 13. Black RE et al. Incidence and etiology of infan-
WHO/FCH/CAH 01.24). tile diarrhoea and major routes of transmission in
2. Shrimpton R et al. Worldwide timing of growth Huascar, Peru. American Journal of Epidemiology,
faltering: implications for nutritional interven- 1989, 129:785–799.
tions. Pediatrics, 2001;107(5):e75. 14. Black RE et al. Contamination of weaning foods
3. PAHO/WHO. Guiding principles for complemen- and transmission of enterotoxigenic Escherichia
tary feeding of the breastfed child. Washington coli diarrhoea in children in rural Bangladesh.
DC, Pan American Health Organization/World Transcripts of the Royal Society of Tropical Medicine
Health Organization, 2002. and Hygiene, 1982, 76(2):259–264.
4. WHO. Training course on child growth assessment. 15. WHO. The five keys to safer food. Geneva, World
Geneva, World Health Organization, 2008 (in Health Organization, 2001.
press). 16. WHO. Complementary feeding. Family foods for
5. Naylor AJ, Morrow AL. Developmental readiness of breastfed children. Geneva, World Health Organi-
normal full term infants to progress from exclusive zation, 2000.
breastfeeding to the introduction of complementary 17. Drewett R et al. Relationships between nursing
foods. Washington DC, LINKAGES/Wellstart patterns, supplementary food intake, and breast-
International, 2001. milk intake in a rural Thai population. Early
6. Dewey KG, Brown KH. Update on technical issues Human Development, 1989, 20:13–23.
concerning complementary feeding of young chil- 18. WHO. Guiding principles for feeding non-breastfed
dren in developing countries and implications for children 6–24 months of age. Geneva, World Health
intervention programs. Food and Nutrition Bulle- Organization, 2005.
tin, 2003, 24:5–28.
19. WHO/UNICEF. Complementary feeding of young
7. Brown KH et al. Effects of common illnesses on children in developing countries: a review of cur-
infants’ energy intakes from breast milk and oth- rent scientific knowledge. Geneva, World Health
er foods during longitudinal community-based Organization, 1998 (WHO/NUT/98.1).
studies in Huascar (Lima), Peru. American Jour-
20. Brown K. A rational approach to feeding infants
nal of Clinical Nutrition, 1990, 52:1005–1013.
and young children with acute diarrhea. In: Lif-
8. Briend A, Bari A. Breastfeeding improves surviv- schiz CH, ed. Pediatric gastroenterology and nutri-
al, but not nutritional status, of 12–35 months old tion in clinical practice. New York, Marcel Dekker
children in rural Bangladesh. European Journal of Inc., 2001.
Clinical Nutrition, 1989, 43(9):603–8.
21. WHO/UNICEF/IVACG Task Force. Vitamin A
9. Mobak K et al. Prolonged breastfeeding, diarrhoeal supplements: a guide to their use in the treatment of
disease, and survival of children in Guinea-Bissau. vitamin A deficiency and xerophthalmia. Geneva,
British Medical Journal, 1994, 308:1403–1406. World Health Organization, 1997.
10. Engle P, Bentley M, Pelto G. The role of care in 22. WHO/UNICEF. Joint statement: iron supplemen-
nutrition programmes: current research and a tation of young children in regions where malaria
research agenda. Proceedings of the Royal Society, transmission is intense and infectious disease highly
2000, 59:25–35. prevalent. Geneva, World Health Organization,
11. Pelto G, Levitt E, Thairu L. Improving feeding 2006.
practices: current patterns, common constraints, 23. WHO. Conclusions and recommendations of the
and the design of interventions. Food and Nutri- WHO consultation on prevention and control of
tion Bulletin, 2003, 24(1):45–82. iron-deficiency anaemia in infants and young chil-
dren in malaria-endemic areas. Geneva World
24. WHO/UNICEF Joint Statement. Reaching optimal 27. FAO. World Food Dietary Assessment System. Rome,
iodine nutrition in pregnant and lactating women Food and Agriculture Organization, 1996 (http://
and young children. Geneva, World Health Organ- www.fao.org/infoods/software_worldfood_ en.stm,
ization, 2007. accessed 27 August, 2008).
25. WHO/UNICEF. Joint statement on clinical man- 28. Linear programming module. NutriSurvey (http://
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Organization, 2004. 2008).
26. WHO. IMCI adaptation guide. Part 3: the study
protocols. Geneva, World Health Organization,
2002.
Management and support of infant
Session 4
feeding in maternity facilities
4.1 The Baby-friendly Hospital Initiative Box 5

Many deliveries take place in hospitals or maternity
The ten steps to successful breastfeeding
facilities, and health care practices in these facilities
have a major effect on infant feeding. To encourage 1. Have a written breastfeeding policy that is routinely
breastfeeding from the time of childbirth, to prevent communicated to all health care staff.
difficulties from arising and to overcome difficulties 2. Train all health care staff in skills necessary to implement
should they occur, mothers need appropriate man- this policy.
agement and skilled help. Support and counselling
should be available routinely during antenatal care, 3. Inform all pregnant women about the benefits and
to prepare mothers; at the time of birth to help them management of breastfeeding.
initiate breastfeeding; and in the postnatal period to 4. Help mothers initiate breastfeeding within one half hour
ensure that breastfeeding is fully established. Moth- of birth.
ers and other caregivers who are not able to breastfeed
5. Show mothers how to breastfeed and how to maintain
need counselling and support for alternative methods
lactation even if they should be separated from their
of infant feeding.
infants.
The Baby-friendly Hospital Initiative (BFHI) was
6. Give newborn infants no food or drink other than breast
launched in 1992 with the aim of transforming
milk, unless medically indicated.
maternity facilities to provide this standard of care
(1). Without the BFHI, practices often undermine 7. Practice rooming-in – allow mothers and infants to
breastfeeding, with damaging consequences for remain together – 24 hours a day.
infant health. Hospitals become baby-friendly by
8. Encourage breastfeeding on demand.
implementing the Ten Steps to Successful Breastfeed-
ing, summarized in Box 5 (2), and complying with rel- 9. Give no artificial teats or pacifiers (also called dummies or
evant sections of the International Code of Marketing soothers) to breastfeeding infants.
of Breast-milk Substitutes and subsequent relevant 10. Foster the establishment of breastfeeding support groups
Health Assembly resolutions (collectively referred to and refer mothers to them on discharge from the hospital
as the Code)1 (3). Facilities that are working to achieve or clinic.
baby-friendly accreditation are formally assessed on
their policies, training, and full implementation of all
of the Ten Steps including compliance with the Code.
Standards are defined in more detail in the global
criteria, and tools for assessing practices according
to these criteria have been developed by WHO and 4.2 Policy and training
UNICEF and are used worldwide (1).
Fundamental to the implementation of the BFHI and
The baby-friendly approach has been shown to be other components of the Global Strategy for Infant and
effective in increasing exclusive breastfeeding rates Young Child Feeding, is to have clear, well-supported
(4,5). Evidence exists for the effectiveness of individ- policies, coupled with appropriate training of health
ual steps, but even more so for full implementation of workers. This is set out clearly in the first two of the
all steps together (6). Ten Steps.
References to the Code generally imply also subsequent relevant

1
Health Assembly resolutions.

A Step 1: Have a written breastfeeding policy that is Antenatal preparation of the breasts for breastfeed-
routinely communicated to all health care staff ing is not helpful. Exercises to stretch flat or inverted
nipples, and devices worn over the nipples during
A hospital policy and related guidelines should cover
pregnancy, are not effective in increasing breastfeed-
all aspects of management outlined by the Ten Steps,
ing success (9). Providing skilled support to help the
and all staff should be fully informed about the policy.
baby to attach soon after delivery is more effective.
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
4.4 Early contact
to accept free or low-cost supplies or to give out sam- The first hour of a baby’s life is of great importance for
ples of those products (see Session 9.1.2 on the Code). the initiation and continuation of breastfeeding, and
to establish the emotional bond between mother and
A Step 2: Train all health care staff in skills necessary to baby. Delays in initiation of breastfeeding after the
implement this policy first hour increase the risk of neonatal mortality, in
particular neonatal deaths due to infections (10,11).
All health care staff with responsibility for mothers
and babies should be trained to implement the policy, A Step 4: Help mothers initiate breastfeeding within
which includes being able to help mothers to initiate one half hour of birth
and establish breastfeeding, and to overcome difficul-
ties. Training courses have been developed by WHO A baby should be delivered straight onto the mother’s
and UNICEF for this purpose (7,8). abdomen and chest, before delivery of the placenta
or any other procedures, unless there are medical
4.3 Antenatal preparation or obstetric complications that make it impossible
(12,13). The baby must be dried immediately to pre-
Preparation of mothers before they give birth is fun-
vent heat loss and then placed in skin-to-skin contact
damental to the success of the BFHI.
with the mother, usually in an upright position. Skin-
to-skin contact means that both the mother’s upper
A Step 3: Inform all pregnant women about the
body and her baby should be naked, with the baby’s
benefits and management of breastfeeding
upper body between the mother’s breasts. They should
Women need information about: be covered together to keep them warm. Skin-to-skin
K the benefits of breastfeeding and the risks of artifi- contact should start immediately after delivery or
cial or mixed feeding; within at least half an hour; and should continue for
as long as possible, but for at least one hour uninter-
K optimal practices, such as early skin-to-skin con- rupted (12). Mothers usually find the experience a
tact, exclusive breastfeeding, rooming-in, starting pleasure and emotionally meaningful.
to breastfeed soon after delivery, and why colos-
trum is important; Skin-to-skin contact is the best way to initiate breast-
feeding. A few babies want to suckle immediately.
K what to expect, including how the milk “comes in”, Most babies remain quiet for some time, and only
and how a baby suckles; start to show signs of readiness to feed after 20–30
K what they will need to do: skin-to-skin contact, minutes or more; some take over an hour (14). Car-
putting the baby to the breast, and appropriate pat- egivers should ensure that the baby is comfortably
terns of feeding. positioned between the mother’s breasts, but they
should not try to attach the baby to the mother’s
Some questions are usefully discussed in groups,
breast; the baby can do this in his or her own time.
while for others individual counselling is more appro-
Eventually a baby becomes more alert, and may start
priate. Opportunities for both are needed antenatally
raising his or her head, looking around, making
and postnatally, when mothers visit a health facility,
mouthing movements, sucking his or her hands, or
or during contacts with a community health worker.
massaging the breast with them. Some babies move
At group sessions, women can raise doubts and ask
towards and may find the areola and nipple by them-
questions, and discuss them together. Women who
selves, guided by their sense of smell (15). The mother
have concerns that they do not want to share with a
can help move her baby closer to the areola and nip-
group, or who have had difficult experiences before,
ple to start suckling. Many babies attach well at this
need to discuss them privately.
time, which helps them to learn to suckle effectively
4. Management and support of infant feeding in maternity facilities 31
(14,16). This early contact stimulates the flow of oxy- Box 6

tocin, helps with release of the placenta, reduces the
risk of haemorrhage (17,18) and facilitates emotional How to help a mother to position and attach
bonding of the mother and baby (19). her baby
If a mother has been given an anaesthetic or analgesic K Help the mother to get into a comfortable and relaxed
(especially pethidine), the baby may be sedated and position, sitting or lying down.
may take longer to become alert and seek the nipple K The helper should sit in a comfortable, convenient
(20). If there is a delay in the first breastfeed for any position.
reason, the mother can express her colostrum and
K Explain to the mother how to hold her baby, according to
feed it to the baby by cup or spoon. She should be
the four key points:
encouraged and given help to hold her baby in skin-
to-skin contact whenever he or she needs comforting — with the head and body straight
and at feeds. — facing the breast, and starting with his/her nose opposite
the nipple
4.5 Showing mothers how to breastfeed — with his/her body close to her body
All mothers need help to ensure that their babies are — supporting the whole body.
suckling effectively, and to express breast milk for the K Show her how to support her breast:
situations when this may be necessary.
— with her fingers flat against her chest wall under her
A Step 5: Show mothers how to breastfeed and how breast
to maintain lactation even if they should be separated — with her thumb above the breast
from their infants — her fingers should not be on the areola or near the nipple,
because this can interfere with attachment.
Showing a mother how to breastfeed
K Explain or show the mother how to help her baby to attach
K A mother needs help in the first few days to make by:
sure that she is able to position and attach her baby
correctly to the breast. The person giving support — touching the baby’s lips with her nipple
should watch her putting her baby to the breast, and — waiting until the baby’s mouth is open wide
assess the breastfeed, using the breastfeed observa- — moving the baby quickly onto her breast
tion job aid, described in Session 5.4. If a mother — aiming her nipple up towards the roof of the baby’s
needs practical help, the helper can use either her mouth
own body or a model breast and doll or a picture to — aiming his/her lower lip behind her nipple, so his/her
show the mother what to do. Minimal touching of chin touches the breast.
the mother and baby should be needed. K Notice how the baby responds and ask her how the
K If the baby is well attached and suckling effec- suckling feels.
tively, the mother should be praised to reinforce K Look for signs of correct attachment. The four signs of
her good practices, and she should be reminded of good attachment are:
the importance of demand feeding and exclusive
— more of the areola is visible above the baby’s top lip than
breastfeeding.
below the lower lip
K If the baby is not well attached, the mother should — the baby’s mouth is wide open
be helped to improve the baby’s position and — the baby’s lower lip is curled outwards
attachment (see Box 6, How to help a mother to — the baby’s chin is touching or almost touching the breast.
position and attach her baby).
K If attachment is not good, or if the mother is
uncomfortable, ask her to try again.
Showing a mother how to maintain lactation
K Mothers need to know how to express their milk, K Show her how to take the baby off the breast by slipping
so that they can continue to feed their babies and her little finger into the baby’s mouth to release the suction.
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
Figure 12
Box 7
Back massage to stimulate the oxytocin reflex before
How to express breast milk by hand expressing breast milk
The mother should:
K Have a clean, dry, wide-necked container for the expressed
breast milk;
K Wash her hands thoroughly;
K Sit or stand comfortably and hold the container under her
nipple and areola;
K Put her thumb on top of her breast and her first finger
on the underside of her breast so that they are opposite each
other about 4 cms from the tip of the nipple;
K Compress and release her breast between her finger and
thumb a few times. If milk does not appear, re-position her
thumb and finger a little closer or further away from the
nipple and compress and release a number of times as before.
This should not hurt – if it hurts, the technique is wrong. At
first no milk may come, but after compressing a few times,
milk starts to drip out. It may flow in streams if the oxytocin A health worker or counsellor should explain to the
reflex is active; mother the basic principles:
K Compress and release all the way around her breast, with K Express both breasts each time.
her finger and thumb the same distance from the nipple; K Express the milk into a cup, glass, jug or jar that
K Express each breast until the milk drips slowly; has been thoroughly washed with water and soap.
K Repeat expressing from each breast 5 to 6 times; K Store EBM in a glass with a cover indicating time
and date.
K Stop expressing when milk drips slowly from the start of
compression, and does not flow; K Keep EBM at room temperature for 8 hours or in
a refrigerator for 24 to 48 hours. If she has a deep
K Avoid rubbing or sliding her fingers along the skin; freeze she can store it for 3 months (21).
K Avoid squeezing or pinching the nipple itself.
Stimulating the oxytocin reflex
Before the mother expresses her milk, she should
weight or premature may be separated from the stimulate her oxytocin reflex, to help the milk flow.
mother in a special care baby unit (see Session 6.1 She may do this herself by lightly massaging her
on low-birth-weight babies). breasts, or stimulating her nipples, and at the same
time thinking about the baby, watching him or her
K If a baby is able to take oral or enteral feeds, breast
if nearby, or looking at a photograph of him or her.
milk is usually the best feed to give.
She can also ask a helper to massage up and down her
K If a baby cannot take oral feeds, then it is helpful back on either side of her spine between her shoulder
for the mother to express her milk to build up and blades (see Figure 12).
maintain the supply, for when the baby is able to
start breastfeeding. Expressed breast milk (EBM) 4.6 Creating a supportive environment for
can be frozen and stored until the baby needs it breastfeeding
(21). In some facilities that are able to operate ade- Maternity facilities should ensure that their practices
quate standards for milk banking, it may be pos- are supportive, so that babies stay close to their moth-
sible to donate milk for other infants (22). ers for demand feeding, and that babies are not giv-
en unnecessary supplements, fed by bottle, or given
dummies (pacifiers).
A Step 6: Give newborn infants no food or drink other mother should offer the other breast, but the baby
than breast milk unless medically indicated may or may not want to take more. She can start on
the other breast at the next feed. In the first few days,
Foods and drinks given to a newborn baby before
babies may want to feed very often, and this is ben-
breastfeeding has started are called prelacteal feeds.
eficial because it stimulates milk production. The
Giving these feeds increases the risk of illnesses such
health worker should make sure that the baby is well
as diarrhoea and other infections and allergies, par-
attached and suckling effectively, and help the mother
ticularly if they are given before the baby has had
to understand that the baby will feed less often when
colostrum. Prelacteal feeds satisfy a baby’s hunger
breastfeeding is established.
and thirst, making him or her less interested in feed-
ing at the breast, so there is less stimulation of breast A Step 9: Give no artificial teats or pacifiers (also called
milk production. If a bottle is used, it may inter- dummies or soothers) to breastfeeding infants
fere with the baby learning to suckle at the breast.
Since prelacteal feeds can interfere with establish- Feeding a baby from a bottle with an artificial teat
ing breastfeeding, they should not be given without may make it more difficult for the baby to learn to
an acceptable medical reason (23). (See Annex 1 for attach well at the breast and may make it more dif-
acceptable medical reasons for use of breast-milk ficult to establish breastfeeding satisfactorily (26). If
substitutes). an infant cannot feed from the breast, then the safest
alternative is to feed from a cup (see Figure 13 and Box
A Step 7: Practice rooming-in – allow mothers and 8). Even low-birth-weight and premature babies can
infants to remain together – 24 hours a day cup feed. The reasons to feed with a cup include:
Babies should be allowed to stay in the same room K Cups are easier to clean, and can be cleaned with
as their mother, either in a cot beside her bed or in soap and water, if boiling is not possible.
the bed with her, 24 hours a day (24). They should be K Feeding from a cup does not interfere with the
separated only when strictly necessary, for example baby learning to suckle at the breast.
for a medical or surgical procedure. A cot should be
beside the mother’s bed, where she can easily see and K A cup cannot be left for the baby to feed him- or
reach her baby, not at the end of the bed, where it is herself. Someone has to hold the baby and give him
more difficult. Studies have shown that babies cry less some of the contact that he needs.
and mothers sleep as much when they are together as K Cup feeding is generally easier and better than
when the infant is in a separate room (8). Separating spoon feeding: spoon feeding takes longer and
infants from their mothers may be associated with requires an extra hand, and sometimes a baby does
long-term psychological trauma (25). not get enough milk by spoon.
Rooming-in is essential to enable a mother to breast-
feed her baby on demand and for her to learn the cues
such as wakefulness, rooting and mouthing, which Figure 13
Feeding a baby by cup
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.
A 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 feed-
ing, or baby-led or unrestricted breastfeeding (see Ses-
sion 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
Box 8 easily organised by health workers already based in

the community. However, hospitals should encour-
How to cup feed a baby age the establishment of these groups, help to train
K Hold the baby sitting upright or semi-upright on your lap them, know who and where they are, and be in con-
– wrap the baby with a cloth to provide some support and to tact with them. They should refer women to them on
stop his or her hands from knocking the cup. discharge, and accept referrals from them of mothers
who need more specialised help than the community
K Hold the cup of milk resting on the lower lip so that the
resource itself can provide.
rim touches the baby’s upper lip.
When a mother leaves a maternity facility, she should
K Tip the cup so that the milk just reaches the baby’s lips.
be given information about where support for breast-
K A younger baby will start to take milk into his mouth with feeding is available in her locality, and how to access
his tongue. A term or older baby will suck the milk, spilling it. Community breastfeeding counselling is discussed
some of it. further in Sessions 5 and 9.
K DO NOT POUR the milk into the baby’s mouth. Just hold the
cup to the baby’s lips and let him or her take it him- or herself. References
1. UNICEF/WHO. Baby-friendly Hospital Initiative,
K When he or she has had enough, the baby closes his or her
revised, updated and expanded for integrated care,
mouth and will not take any more. If the baby has not taken
Sections 1–5. Geneva, World Health Organiza-
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This step addresses the need that mothers have for
breastfeeding. Geneva, World Health Organiza-
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24. Christenson K et al. Temperature, metabolic adap-
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ulus elicits crawling towards the odour source. cared for skin-to-skin or in a cot. Acta Paediatrica,
Acta Paediatrica, 2001, 90(4):372–375. 1992, 81:488–493.
16. Mikeil-Kostyra K, Mazure J, Boltrusko I. Effect of 25. Christenson K et al. Separation distress call in the
early skin-to-skin contact after delivery on dura- human neonate in the absence of maternal body
tion of breastfeeding: a prospective cohort study. contact. Acta Paediatrica, 1992, 84:468–473.
Acta Paediatrica, 2002, 91:1301–1306.
26. Collins C et al. Effects of bottles, cups, and
17. Irons DW, Sriskandabalan P, Bullough CHW. A dummies on breastfeeding in preterm infants: a
simple alternative to parenteral oxytocics for the randomized controlled trial. British Medical Jour-
third stage of labour. International Federation of nal, 2004, 329:193–198.
Gynaecology and Obstetrics, 1994, 46:15–18.
27. Coutinho S et al. Comparison of the effect of two
18. Chua S et al. Influence of breastfeeding and nipple systems of promotion of exclusive breastfeeding.
stimulation on postpartum uterine activity. Brit- Lancet, 2005, 366:1094–1100.
ish Journal of Obstetrics and Gynaecology, 1994,
28. Merten S, Dratva J, Ackerman-Liebrich U. Do
101:804–805.
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19. Klaus M. Mother and infant: early emotional ties. duration on a national level? Pediatrics, 2005,
Paediatrics, 1998,102:1244–1246. 116:702–708.
Continuing support for infant
Session 5
and young child feeding
5.1 Support for mothers in the community Box 9

Health workers do not always have the opportunity
Key points of contact to support optimal
to ensure that mothers successfully establish breast-
feeding practices
feeding. Mothers may give birth at home, or they may
be discharged from a maternity facility within a day K During antenatal care
or so after delivery. Difficulties may arise in the first K At the time of childbirth and in the immediate postpartum
few weeks with breastfeeding, and later on when com- period
plementary foods are needed. Illness of infants and
young children is often associated with poor feed- K In the postnatal period:
ing. Families and friends are usually a mother’s main — for healthy term babies on day 2–3, day 5–7, and around
source of advice about feeding her children, but this 3–4 weeks
advice is sometimes fraught by misconceptions. — for low-birth-weight babies more frequently: on day 2,
Mothers need continuing support to maintain exclu- day 3, day 5–7, day 14, and day 28
sive and continued breastfeeding, to implement other K At 6 weeks post partum for all mothers and babies
methods of infant feeding when breastfeeding is not
K During immunization contacts
possible, and to establish adequate complementary
feeding when the child is 6 months of age and older K During well-baby clinics and/or growth assessment visits
(1). If a child becomes ill, the mother may require
K During sick child visits and their follow-up
skilled support from a health worker to continue
feeding her child. This support can be provided by
trained personnel in the community, and in various
other settings, such as a primary care facility or a pae-
diatric department in a hospital. approach to promoting and supporting infant and
young child feeding has been shown to be effective in
There should be no missed opportunities for sup- many settings (3).
porting feeding in any contact that a mother and
child have with the health system, whether it involves Box 9 summarizes key points of contact that mothers
doctors, midwives, nurses or community health might have with a health worker who is knowledge-
workers. Lay or peer counsellors who have the skills able and skilled to support her in practising appro-
and knowledge to support optimal infant and young priate infant and young child feeding. Mothers who
child feeding can also contribute to improved feeding are not breastfeeding also need help with infant feed-
practices (2). Collectively, all these providers should ing at these times, and many of the skills needed by
ensure a continuum of care from pregnancy through health workers to support them are similar.
the postnatal period into early childhood. When they
help a mother, they should also talk to other family 5.2 Infant and young child feeding counselling
members, showing respect for their ideas, and help- Infant and young child feeding counselling is the
ing them to understand advice on optimal feeding. process by which a health worker can support moth-
In addition, they can share information and create ers and babies to implement good feeding practices
awareness about the importance of appropriate infant and help them overcome difficulties. Details of infant
and young child feeding through other channels, and young child feeding counselling depend on the
for example, by involving school children or exten- child’s age and the mother’s circumstances. Gener-
sion workers from other sectors. This multi-pronged ally, a health worker should:
Use good communication and support skills: Box 10

K Listen and learn Communication and support skills
K Build confidence and give support.
Listening and learning
Assess the situation:
K Use helpful non-verbal communication.
K Assess the child’s growth K Ask open questions.
K Take a feeding history K Use responses and gestures which show interest.
K Observe a breastfeed K Reflect back what the mother says.
K Assess the health of the child and the mother. K Empathize – show that you understand how she feels.
Manage problems and reinforce good practices: K Avoid words which sound judging.
K Refer the mother and child if needed Building confidence and giving support
K Help the mother with feeding difficulties or poor K Accept what a mother thinks and feels.
practices K Recognize and praise what a mother and infant are doing
K Support good feeding practices right.
K Counsel the mother on her own health, nutrition K Give practical help.
and family planning. K Give a little, relevant information.
Follow-up K Use simple language.
K Make one or two suggestions (e.g. small “do-able”
5.3 Using good communication and support skills actions), not commands
If a health care worker is to effectively counsel a moth-
er or other caregiver, he or she should have good com-
munication skills. The same skills are useful in many be able to follow, and which may even make her
situations, for example for family planning, and also unwilling to talk to you again.
in ordinary life. They may be described in slightly
different ways and with different details in different Listening and learning skills
publications, but the principles are the same. The Using helpful non-verbal communication. Non-
tools described here include the basic skills useful in verbal communication means how you communicate
relation to infant and young child feeding. There are a other than by speaking. Helpful non-verbal com-
number of similar tools that can be used for the same munication shows that the health worker respects
purpose. the mother and is interested in her. It includes: keep-
ing your head about level with the mother’s, and not
towering over her; making eye contact, nodding and
smiling; making sure that there are no barriers, such
The sections that follow provide concrete guidance on infant as a table or conspicuous papers, between you and the
and complementary feeding counselling. They are written in a mother; making sure that you do not seem to be in a
direct style and often address the reader with ‘you’ to make it hurry; touching her or the baby in a culturally appro-
more interesting and easier to absorb the content. priate way.
Asking open questions. “Open questions” often
start with “how”, “when”, “who”, “what”, “why”. To
There are two groups of skills (see Box 10):
answer them it is necessary to give some information,
K listening and learning skills help you to encour- so they encourage a person to talk, and conversation
age a mother to talk about her situation and how becomes easier. The opposite are “closed questions”,
she feels in her own way, and they help you to pay which usually start with “Do you?”, “Are you”, “Is
attention to what she is saying; he?”, “Has she?”. A person can answer them with a
“yes” or “no”, thus giving little information. Open
K building confidence and giving support skills help
questions can also be more general, for example “Tell
you to give a mother information and suggest what
me more about…”.
she might do in her situation, so that she can decide
for herself what to do. Supporting a mother is more Using responses and gestures that show interest.
useful than giving direct advice which she may not Such responses include “Oh dear”, “Really?”, “Go
5. Continuing support for infant and young child feeding 39
on…” or “Eeeeh”. Gestures such as nodding and smil- of advice or has been struggling with her baby, this
ing are also responses that show interest. Showing kind of practical help may be the best way to show
interest encourages a mother to say more. that you understand, and she may be more receptive
to new information and suggestions. Helping with
Reflecting back what the mother says. Reflecting is
her breastfeeding technique is also practical help, but
a very helpful way to show that you are listening and
of a different kind as it involves giving her informa-
to encourage a mother to say more. It is best to reflect
tion too. She may not be ready for that at first.
back using slightly different words from the mother,
not to repeat exactly what she has said. You may only Giving a little relevant information. After you have
need to use one or two of the important words that listened to a mother or caregiver, think about her sit-
she used to show that you have heard her. uation and decide what information is most relevant
and useful at the time. You should avoid telling her
Empathizing. Showing that you understand how she
too much, because she may become confused and for-
feels lets the woman know that you understand her
get what is most important. Sometimes the most use-
feelings from her point of view, using phrases such as
ful information is a clear explanation of what she has
“you are worried”, “you were very upset” or “that is
noticed, for example the baby’s behaviour, or changes
hard for you”. You can also empathize with good feel-
in her breasts; or what to expect, for example how
ings, for example, “you must feel pleased”.
breast milk “comes in”, or when and why the infant
Avoiding words that sound judging. These are words needs foods in addition to breast milk. Helping her
such as “right”, “wrong”, “good”, “well”, “badly”, to understand the process is better than immediately
“properly”, “enough”. For example, the care provider telling her what to do.
should not say “Are you feeding your baby properly?
Using simple language. It is important to give infor-
Do you have enough milk?” This can make a mother
mation in a way that is easy for a person to under-
feel doubtful, and that she may be doing something
stand, using simple, everyday words.
wrong. It is better to ask “How are you feeding your
baby? How about your breast milk?” Sometimes ask- Making suggestions, not commands. If you tell a
ing “why” may sound judging, for example “Why did mother what to do, she may not be able to do it, but it
you give a bottle last night?” It is better to ask “What can be difficult for her to disagree with you. She may
made you give a bottle?” just say “yes” and not come back. Giving a suggestion
allows her to discuss whether or not she can follow
Confidence and support skills it. You can make other suggestions, encourage her to
Accepting what a mother thinks and feels. Accept- think of more practical alternatives and help her to
ing means not disagreeing with a mother or caregiver, decide what to do. This is particularly important in
but at the same time not agreeing with an incorrect the case of infant and young child feeding, when there
idea. Disagreeing with someone can make her feel often are different options.
criticised, and reduce her confidence and willing-
ness to communicate with you. Accepting involves 5.4 Assessing the situation
responding in a neutral way. Later, you can give the 5.4.1 Assessing the child’s growth
correct information.
Assessing a child’s growth provides important infor-
Recognizing and praising what a mother and baby mation on the adequacy of the child’s nutritional sta-
are doing right. Health workers are trained to look tus and health. There are several measures to assess
for problems and may only see what is wrong and growth, including weight-for-age, weight-for-height,
then try to correct it. Recognizing and praising a and height-for-age. In the past, many countries used
mother’s good practices helps to reinforce them and weight-for-age to assess both children’s growth and
build her confidence. You can also praise what a baby their present nutritional status. National growth curves
does, such as growing and developing well. were based on weight-for-age. With the availability of
the WHO growth standards (4), countries may revisit
Giving practical help. Helping a mother or caregiver
their growth charts and introduce weight-for-height as
in other ways than talking, often quite simply, such
the standard for measuring nutritional status, and pro-
as giving her a drink of water, making her comfort-
vide training for health workers. It is recommended to
able in bed or helping her to wash are examples of
use separate standards for boys and girls.
practical help. When a mother has had a great deal
When counselling on infant and young child feed- indicator can help identify children who are stunted
ing, it is important to understand growth charts. If (or short) due to prolonged undernutrition or repeat-
growth is not recorded correctly, and charts are not ed illness. Children who are tall for their age can also
interpreted accurately, incorrect information can be be identified, but tallness is rarely a problem unless
given to a mother, leading to worry or loss of confi- it is excessive and may reflect uncommon endocrine
dence. The following sections explain briefly the dif- disorders. Acute malnutrition does not affect height.
ferent measures.
Mid-upper arm circumference
Weight-for-age Another useful way to assess a child’s present nutri-
Weight-for-age reflects body weight relative to the tional status is to measure the mid-upper arm cir-
child’s age on a given day. A series of weights can tell cumference (MUAC) (5). MUAC below 115 mm is an
you whether or not a child’s weight is increasing over accurate indicator of severe malnutrition in children
time, so it is a useful indicator of growth. This indica- 6–59 months of age (6). MUAC should be measured
tor is used to assess whether a child is underweight in all children who have a very low weight-for-age (see
or severely underweight, but it is not used to clas- Figure 14). MUAC can also be used for rapidly screen-
sify a child as overweight or obese. Because weight is ing all children in a community for severe malnutri-
relatively easily measured, this indicator is commonly tion. Management of severe malnutrition is discussed
used, but it cannot be relied upon in situations where in Session 6.
the child’s age cannot be accurately determined. Also,
it cannot distinguish between acute malnutrition and Figure 14
chronic low energy and nutrient intake. Examples of Measuring mid-upper arm circumference
weight-for-age charts for boys and girls are included
in Annex 2.
Note: If a child has oedema of both feet, fluid retention

increases the child’s weight, masking what may actually
be very low weight. The growth chart should be marked
to show that the child has oedema. A child with oedema is
automatically considered severely undernourished and should
be referred for specialized care.
Weight-for-length/height1
Weight-for-length/height reflects body weight in pro- Deciding whether a child is growing adequately or not
portion to attained growth in length or height. This The curved lines printed on the growth charts will
indicator is especially useful in situations where chil- help you interpret the plotted points that represent a
dren’s ages are unknown (e.g. refugee settlements). child’s growth status. The line labelled “0” on each
Weight-for-length/height charts help identify chil- chart represents the median, which is, generally speak-
dren with low weight-for-height who may be wasted ing, the average. The other curved lines are z-score
or severely wasted. These charts also help identify lines,2 which indicate distance from the average.
children with high weight-for-length/height who may
be at risk of becoming overweight or obese. However, Z-score lines on the growth charts are numbered pos-
assessing weight-for-height requires two measure- itively (1, 2, 3) or negatively (−1, −2, −3). In general,
ments – of weight and height – and this may not be a plotted point that is far from the median in either
feasible in all settings.
Length of children less than 2 years of age is measured lying
1
Length/height-for-age down, while standing height is measured for children 2 years of

Length/height-for-age reflects attained growth in age or older.
length or height at the child’s age at a given visit. This Z-scores are also known as standard deviations (SD).
2
direction (for example, close to the 3 or −3 z-score Low weight-for-age

line) may represent a growth problem, although other If a child has been weighed only once, the informa-
factors must be considered, such as the growth trend, tion does not say much about the child’s growth, but
the health condition of the child and the height of the only about the child’s body weight relative to the stan-
parents. dard for his or her age. Some infants are constitution-
ally small, and others are born with low birth weight
Identifying growth problems from plotted points due to prematurity or intrauterine growth restriction.
Growth problems can be identified by interpreting These children may have low weight-for-age, but they
the plotted points in the child’s Growth Record. Read may grow satisfactorily following the lowest standard
plotted points as follows: curve. There is a need for full assessment and appro-
priate counselling. When the child is followed up and
A point between the z-score lines −2 and −3 is
weighed again, the situation may become clearer.
“below −2.”
However, low weight-for-age can also be a sign of poor
A point between the z-score lines 2 and 3 is “above
feeding or illness. If weight-for-age is below the -2 z
2.”
score line the child is underweight; if the weight-for-
Table 4 below provides a summary of definitions of age is below the -3 z-score line (the lowest standard
growth problems according to z-scores. Notice that curve) the child is severely underweight. A child who is
the child falls into a category if his or her growth indi- severely underweight is at risk of severe malnutrition,
cator is plotted above or below a particular z-score and needs special attention urgently.
line. If the growth indicator is plotted exactly on the
z-score line, it is considered in the less severe category. Growth faltering
For example, weight-for-age on the −3 line is consid-
If a child’s weight is not increasing, or if it is increas-
ered “underweight” as opposed to “severely under-
ing more slowly than the standard curve for more
weight.” Measurements in the shaded boxes are in the
than 1 month in babies less than 4 months of age, or
normal range.
2 months in older children, then the child has growth
Table 4
Identifying growth problems from plotted points
Z-score Growth indicators
Length/height-for-age Weight-for-age Weight-for-length/height
Above 3 See note 1 See note 2 Obese

Above 2 Overweight
Above 1 Possible risk of overweight
(See note 3)
0 (median)
Below −1
Below −2 Stunted Underweight Wasted
(See note 4)
Below −3 Severely stunted Severely underweight Severely wasted
(See note 4) (See note 5)
Explanation of Notes:
Note 1: A child in this range is very tall. Tallness is rarely a problem, unless it is so excessive that it may indicate an endocrine disorder such as a growth-hormone-producing tumour.
Refer a child in this range for assessment if there is suspicion of an endocrine disorder (e.g. if parents of normal height have a child who is excessively tall for his or her age).
Note 2: A child whose weight-for-age falls in this range may have a growth problem, but this is better assessed with weight-for-length/height.
Note 3: A plotted point above 1 shows possible risk of overweight. A trend towards the 2 z-score line shows definite risk of overweight.
Note 4: It is possible for a stunted or severely stunted child to become overweight.
Note 5: This is referred to as very low weight in Integrated Management of Childhood Illness training modules.
faltering. Growth faltering is common in the first 2 Box 11

years of life, and may be the first sign of inadequate
feeding in an otherwise healthy child. The child may Feeding History Job Aid, infants 0–6 months
be less active than others of the same age. Sometimes Age of child
growth faltering is due to illness or abnormality. Particular concerns about feeding of child
When a child is ill, the weight may decrease. Follow-
Feeding
ing a period of growth faltering, a recovering child
K Milk (breast milk, formula, cow milk, other)
should gain weight more rapidly than the standard
K Frequency of milk feeds
curves until he or she returns to his or her original
K Length of breastfeeds/quantity of other milks
growth trend.
K Night feeds
K Other foods in addition to milk (when started, what,
Loss of weight
frequency)
If a child’s growth curve is falling, the child may be ill K Other fluids in addition to milk (when started, what,
with an infection, for example, tuberculosis or AIDS. frequency)
Children who are losing weight need a full assessment K Use of bottles and how cleaned
according to the Integrated Management of Child- K Feeding difficulties (breastfeeding/other feeding)
hood Illness (IMCI) guidelines and should be referred
if they have any serious illness or danger sign. If acute Health
malnutrition due to a shortage of food in the house- K Growth chart (birth weight, weight now, length)
hold is the likely reason for the weight loss, and there K Urine frequency per day (6 times or more, if less than
are no other complications, the child can be managed 6 months)
in the community (see Session 6.2). Close follow-up is K Stools (frequency, consistency)
needed to ensure that weight gain is achieved within K Illnesses
two weeks. Pregnancy, birth, early feeds (where applicable)
K Antenatal care
Rapid rise in the growth curve K Feeding discussed at antenatal care
Any sharp increase in a child’s growth requires atten- K Delivery experience
tion. If a child has been ill or undernourished, a rapid K Rooming-in
rise is expected during the re-feeding period as the K Pre-lacteal feeds
child experiences “catch-up” growth. Otherwise, a K Postnatal help with feeding
sharp increase may indicate inappropriate feeding Mother’s condition and family planning
practices that can lead to overweight. K Age
If a child has gained weight rapidly, it is important to K Health – including nutrition and medications
look also at height. If only the weight increased, this is K Breast health
a problem. If weight and height increased proportion- K Family planning
ately, this is probably catch-up growth from previous Previous infant feeding experience
undernutrition. In this situation, the weight-for-age K Number of previous babies
and height-for-age curves should both rise, but the K How many breastfed and for how long
weight-for-height growth curve follows along the K If breastfed – exclusive or mixed-fed
standard curves. K Other feeding experiences
Even if a child is overweight and trying to lose weight, Family and social situation
he or she should not have a sharp decrease in the K Work situation
growth curve, as losing too much weight rapidly is K Economic situation
undesirable. The overweight child should instead K Family’s attitude to infant feeding practices
maintain his weight while increasing in height, i.e.
the child should “grow into his weight.”
5.4.2 Taking a feeding history

During any contact with a mother and child, it
is important to ask how feeding is progressing.
Simple open questions can generate a great deal of Box 12

information.
Feeding History Job Aid, children 6–23 months
Taking a feeding history in infants 0–6 months of age K Is the child still breastfed?
When a child is not growing well or the mother has — How many times per day? Day and night?
a feeding difficulty, it is useful to conduct a detailed — If using expressed breast milk, how is the milk stored and
feeding history. The Feeding History Job Aid for given?
infants 0–6 months in Box 11 summarizes key top-
ics to cover in a counselling session with a mother K What other foods is the child receiving?
with an infant less than 6 months of age. The form — How many meals and snacks each day?
is not a questionnaire, and it may not be necessary — How much food at each meal?
to cover all topics in a conversation with the mother. — What is the consistency of the main meals?
Concentrate on those that are relevant according to — Do meals include: animal-source foods, dairy products,
the child’s age and situation. Ask the mother about dark green vegetables or red or orange fruits or
the child and how he or she is fed, about herself, the vegetables, pulses (beans, lentils, peas, nuts), oil?
family and their social situation using listening and — Who helps the child to eat?
learning skills. — What bowl does the child get food from (his or her own
bowl, or the family pot)?
Taking a feeding history in children 6–23 months of age — Is the child given any vitamin or mineral supplements?
To learn more details about how a child over the age — How does the child eat during sickness?
of 6 months is fed, you need to follow the history for
younger infants (Box 11), and in addition ask relevant
questions listed in Box 12. Again, this is not a ques- to improve positioning and attachment while the
tionnaire, but a reminder about the important things baby is still hungry (see Session 4.5).
to learn which will help you to counsel and guide the
The signs of good positioning and attachment are
mother to feed her child adequately.
explained in more detail in Session 2.8.
These questions are combined into the Food Intake
While observing a feed, make a tick in the small box
Reference Tool (see Session 5.6), which you can use to
beside any sign observed. If a sign is not seen, simply
help you decide on the information and messages that
leave the box empty.
a mother needs when you counsel her.
Signs down the left side of the form show that breast-
5.4.3 Observing a breastfeed feeding is going well. Signs down the right side of the
At all contacts with lactating mothers of infants under form show that there may be a difficulty. If there are
2 months of age, observe a breastfeed. After the age of some ticks down the right side, then the mother needs
2 months, include an observation if a mother has any help, even if there are also ticks down the left side.
feeding difficulty or if the infant has growth faltering
or low weight-for-age. 5.4.4 Assessing the health of the child and the mother
The Breastfeed Observation Job Aid in Box 13 is a tool Assessing the health of the child
to assist in observing a breastfeed. If the baby has During feeding counselling it is important to assess
just breastfed or is fast asleep, it may take some time the health status of the child using the systematic
before he or she is ready to breastfeed again. To initi- approach described in the IMCI guidelines (7,8), and
ate an observation: manage the child accordingly.
K Ask the mother whether she could offer her baby Decide if the child has:
the breast and to breastfeed in her usual way.
K cough or difficult breathing
K Try to observe a complete feed, to see how long the K diarrhoea
baby suckles for, and if he or she releases the breast K fever
by him- or herself. K ear problems
K malnutrition or anaemia.
If the mother has obvious difficulties, it may be
appropriate to interrupt the feed in order to help her
Box 13
Breastfeed Observation Job Aid
Mother’s name......................................................................................................................... Date..............................................................
Baby’s name............................................................................................................................. Baby’s age....................................................
Signs that breastfeeding is going well: Signs of possible difficulty:

GENERAL
Mother: Mother:
l Mother looks healthy l Mother looks ill or depressed
l Mother relaxed and comfortable l Mother looks tense and uncomfortable
l Signs of bonding between mother and baby l No mother/baby eye contact
Baby: Baby:
l Baby looks healthy l Baby looks sleepy or ill
l Baby calm and relaxed l Baby is restless or crying
l Baby reaches or roots for breast if hungry l Baby does not reach or root
BREASTS
l Breasts look healthy l Breasts look red, swollen, or sore
l No pain or discomfort l Breast or nipple painful
l Breast well supported with fingers away from nipple l Breasts held with fingers on areola
l Nipple stands out, protractile l Nipple flat, not protractile
BABY’S POSITION
l Baby’s head and body in line l Baby’s neck and head twisted to feed
l Baby held close to mother’s body l Baby not held close
l Baby’s whole body supported l Baby supported by head and neck
l Baby approaches breast, nose opposite nipple l Baby approaches breast, lower lip to nipple
BABY’S ATTACHMENT
l More areola seen above baby’s top lip l More areola seen below bottom lip
l Baby’s mouth open wide l Baby’s mouth not open wide
l Lower lip turned outwards l Lips pointing forward or turned in
l Baby’s chin touches breast l Baby’s chin not touching breast
SUCKLING
l Slow, deep sucks with pauses l Rapid shallow sucks
l Cheeks round when suckling l Cheeks pulled in when suckling
l Baby releases breast when finished l Mother takes baby off the breast
l Mother notices signs of oxytocin reflex l No signs of oxytocin reflex noticed
Recognize if the child has any signs of severe illness decide on management. Figure 15 summarizes three
that require immediate referral: categories of actions that may be required, namely:
Refer urgently; Help with difficulties and poor prac-
K unconscious or lethargic
tices and refer, if necessary; Support for good feeding
K severely malnourished
practices.
K not able to eat or drink
K not able to breastfeed even after help with attach
ment 5.5.1 Refer urgently
K copious vomiting after all feeds. Refer the infant or young child urgently to hospital if
he or she:
Also check for conditions that can interfere with
breastfeeding: K is unconscious or lethargic, and thus may be very
ill;
K blocked nose (makes suckling and breathing
difficult) K is severely malnourished;
K jaundice (baby may be sleepy and suckle less) K is not able to drink or eat anything;
K thrush (Candida) (baby may take short feeds only,
or may refuse to feed) K is not able to breastfeed even after help with
K cleft lip or palate (makes attachment difficult and attachment;
baby may have low milk intake) K vomits copiously, which may be both a sign of
K tongue tie (makes attachment difficult, may cause serious illness and of danger because he or she
sore nipples and low milk intake). will not be able to take medications or fluids for
rehydration.
Assessing the health of the mother
There may be a need to give one or more treatments
During feeding counselling it is also important to in the clinic before the infant or child leaves for
enquire about the mother’s own health status, her hospital:
mental health, her social situation and her employ-
ment. These are all factors that will affect her abil- K Oral or intramuscular antibiotic for possible severe
ity to care for her young child. Important topics to infection;
address are listed in the Feeding History Job Aid (Box K Rectal or intramuscular antimalarial for severe
11), and include: malaria;
K Observe the state of her nutrition, general health K If a child is still able to breastfeed, particularly if
and breast health as part of the observation of a malnourished, ask the mother to continue offer-
breastfeed. ing the breast while being referred. Otherwise give
K Try to learn her ideas about another pregnancy, and sugar water to prevent low blood sugar (hypogly-
if she is adequately informed about family plan- caemia) by mixing 2 teaspoons (10 g) of sugar with
ning and has access to appropriate counselling. half a glass (100 ml) of water;
K If a mother seems to have serious clinical or mental K Ensure warmth, especially for newborn babies and
health problems or if she is taking regular medica- malnourished children.
tion, make an additional physical examination and
refer as necessary for specialized treatment (see 5.5.2 Help with difficulties and poor practices
Session 8). Breastfeeding
K If not recorded on medical records, ask the moth- Most feeding difficulties and poor practices can be
er if she has been tested for HIV. If not, encour- managed with outpatient care or care in the commu-
age her to do so (depending on current national nity.
guidance).
You may be concerned about poor practices, even
though the mother is not aware of particular difficul-
5.5 Managing problems and supporting good ties. You may need to help a mother to position and
feeding practices attach her baby at the breast to establish optimal and
The results of the assessment are used to classify the effective breastfeeding (see Session 4.5) and discuss
mother and baby according to their situation and to with her how to improve her breastfeeding pattern.
Figure 15
Assessing and classifying infant and young child feeding
Assess the situation

1. Assess the child’s growth
2. Take a feeding history
3. Observe a breastfeed
4. Assess the child’s health and assess the mother’s condition
Refer urgently Help with difficulties and poor Support good

practices feeding practices
Refer if necessary
If the child: If you find: If you find:

K Is unconscious or lethargic K Growth faltering K Adequate growth
K Is severely malnourished K Low weight-for-age K Exclusive breastfeeding with
K Is not able to eat or drink K Poor attachment or feeding good practices
anything pattern (infants 0–6 months)
K Is not able to breastfeed despite K Non-exclusive breastfeeding K Continued breastfeeding
help with attachment (infants < 6 months) (children 6–23 months)
K Vomits copiously after all feeds K Breast condition K Adequate complementary
K Breastfeeding difficulty feeding practices
K Inappropriate complementary (children 6-23 months)
feeding K Child healthy
K Mother has a health problem K Mother healthy
such as HIV/AIDS K Appropriate family planning
K No family planning
A mother may ask for help with a difficulty that she Complementary feeding
herself has become aware of. Session 7 describes the Sometimes a child over 6 months of age may be mal-
most common feeding difficulties and summarizes nourished or growing poorly, or may not be eating
key steps in their management. well. Mothers and other caregivers may not complain
Non-urgent referral may be necessary if more spe- of difficulties with complementary feeding, but their
cialized help is needed than is available at your level. practices are not optimal. In either situation, you
Refer children with: should recognise the need to counsel them about
improving the way in which they feed the child.
K poor growth that continues despite health centre
or community care; Use the Food Intake Reference Tool (Table 5) to find
out if the child is fed according to recommendations.
K breastfeeding difficulties that do not respond to
Decide what information the mother needs, and what
the usual management;
she is able to do to improve the child’s feeding.
K abnormalities including cleft lip and palate, tongue
The first column contains questions about what the
tie, Down syndrome, cerebral palsy.
child has eaten in the previous 24 hours, to help you
learn how the child is fed. The second column shows
the ideal practice and the third column suggests a key
message to help you decide what information to give Mother’s health

the mother about what she should do. Mothers may need help to adopt better practices, or
Sometimes a child may be gaining weight too fast to overcome difficulties with their own health, nutri-
compared to height and the child is at risk of becom- tion, or family planning. Session 8 discusses important
ing overweight. Using the Food Intake Reference issues that a health worker should address with moth-
Tool is still helpful to assess the child’s diet, although ers in an infant and young child feeding counselling
it may be necessary to add some specific questions contact.
related to the consumption of energy-rich, centrally Non-urgent referral may be necessary to obtain more
processed foods. specialized help than is available at health centre lev-
el. Refer mothers if they:
Table 5
Food Intake Reference Tool, children 6–23 months
Feeding practice Ideal practice Key message to use in counselling the mother
Growth curve rising? Growth follows the reference curve Explain child’s growth curve and praise good
growth
Child received breast milk? Frequently on demand, day and night Breastfeeding for 2 years or longer helps a child
to develop and grow strong and healthy
Child ate sufficient number of meals and snacks K Child 6–8 months: 2–3 meals plus 1–2 snacks A growing child needs to eat often, several times
yesterday, for his or her age? if hungry a day according to age
K Child 9–23 months: 3–4 meals plus 1–2 snacks
if hungry
Quantity of food eaten at main meal yesterday K Child 6–8 months: start with a few spoons and A growing child needs increasing amounts of food
appropriate for child’s age? gradually increase to approx. ½ cup at each meal
K Child 9–11 months: approx. ½ cup at each meal
K Child 12–23 months: approx. ¾ to 1 cup at
each meal
How many meals of a thick consistency did the K Child 6–8 months: 2–3 meals Foods that are thick enough to stay on the spoon
child eat yesterday? (Use consistency photos K Child 9–23 months: 3–4 meals give more energy to the child
as needed)
Child ate an animal-source food yesterday Animal-source foods should be eaten daily Animal-source foods are especially good for
(meat/fish/offal/bird/eggs)? children to help them grow strong and lively
Child ate a dairy product yesterday? Give diary products daily Milk, cheese and yogurt are especially good
for children
Child ate pulses, nuts or seeds yesterday? If meat is not eaten, pulses or nuts should be eaten Peas, beans, lentils and nuts help children to grow
daily – with vitamin-rich fruits to help absorb iron strong and lively, especially if eaten with fruit
Child ate red or orange vegetable or fruit, or a dark A dark green vegetable or red or orange vegetable Dark green leaves and red or orange coloured
green vegetable yesterday? or fruit should be eaten daily fruits and vegetables help the child to have
healthy eyes and fewer infections
Small amount of oil added to child’s food A little oil or fat should be added to a meal each Oil gives a child more energy, but is only needed
yesterday? day in small amounts
Mother assisted the child at meal times? Mother assists and encourages the child to eat, A child needs to learn to eat: encourage and give
but does not force help responsively and with lots of patience
Child had his or her own bowl, or ate from Child should have his or her own bowl of food If a child has his/her own bowl, it makes it easier
family pot? to see how much the child has eaten
Child took any vitamin or mineral supplements? Vitamin and mineral supplements may be needed Explain how to use vitamin and mineral
if child’s needs are not met by food intake supplements if they are needed
Child ill or recovering from an illness? Continue to feed during illness and recovery Encourage the child to drink and eat during illness,
and provide extra food after illness to help the
child recover quickly
K have a breast condition that does not respond to Box 14

the usual management, or that requires medica-
tion or other treatment that is not available at the Supporting good feeding practices
health facility; If the infant is less than 6 months old:
K are on medication that may affect breastfeeding K If the baby is growing well, point this out to the mother
(see Session 8); and praise her and the baby.
K have tested positive for HIV, and infant feeding K Check breastfeeding position and attachment, and that
counselling for this situation is not available at the the infant is suckling effectively.
health facility (see Session 6.5).
K Check that the pattern of breastfeeding is optimal:
feeding on demand day and night; letting the baby come off
Child’s health
the breast by him- or herself; finishing the first breast and
Assessing the child according to the IMCI guidelines then offering the other one.
will help you decide whether the child needs urgent
referral or treatment for a common childhood condi- K Praise the mother’s good practices, and encourage her to
tion, such as diarrhoea, pneumonia or malaria. It will continue them.
also help you decide whether a child needs vaccination K Explain about exclusive breastfeeding, remind the mother
or a micronutrient supplement, such as vitamin A. that she does not need to give anything else before the baby is
6 months old, and that feeding bottles are dangerous.
5.5.3 Support good feeding practices
K Explain that this way of feeding the baby helps her to
An important part of counselling for every mother make plenty of milk.
and child is active support and reinforcement of good
feeding practices. Mothers may not be aware how K Explain about family planning methods and breastfeeding
important and valuable it is to continue them. Sup- (see Session 8.4).
port and reinforcement are equally important if all K At about 5 months of age, start to discuss complementary
her practices are already good, or if you are encour- foods.
aging her to improve some which are not optimal.
K Introduce complementary foods from 6 months (180 days)
Praise helps to build her confidence.
of age.
Box 14 summarises the main points for supporting
If the infant is more than 6 months old:
good practices.
Praise the mother if the infant:
5.5.4 Counsel the mother on her own health, nutrition K is growing well, and is healthy
and fertility
K is still breastfeeding.
Feeding counselling also provides a unique oppor-
tunity to counsel mothers about their own nutrition Praise the mother or caretaker for the following good
and to ensure that they are fully informed and able practices:
to access family planning. If the mother is taking
K if the infant has meals and snacks with sufficient
medication, there is only rarely a reason to advise her
frequency and quantity.
to stop breastfeeding. Session 8 provides some more
details on these issues and can be used for reference. K if the quality of feeds is adequate, with appropriate variety
of foods and adequate consistency.
5.6 Follow-up K if she is assisting the baby to feed appropriately.
Follow-up and continuing care of all children is
K if she is giving the child his or her own bowl.
important, whether they have feeding difficulties or
not, in order to support good practices, prevent dif- K if she gives extra food to a child recovering from illness.
ficulties and manage difficulties if they arise. Follow- Remind the mother when to bring the child for immunization.
up may take place at a health facility or on a home
visit. Remind the mother when to bring the child to a qualified
health provider for signs of illness.
Follow-up of the infant or young child with feeding Continuing management:

difficulties K If the child is not gaining weight or has persistent
Infants 0–6 months old feeding difficulties, offer additional help with new
K For a newborn with feeding difficulties, reassess suggestions and follow-up again after 1–2 weeks.
after 1–2 days. K Make a home follow-up visit if possible and if not
K For an infant older than one month with feeding already made.
difficulty: reassess after 2–5 days, depending on K If the child is still not gaining weight after 2
the severity of the infant’s condition and conven- months, consider referral.
ience of the mother.
K If the infant or young child has gained weight and
Reassessment includes: feeding difficulties are resolved, he or she should
K a general enquiry on progress; continue follow-up at the same frequency as chil-
dren with no difficulties.
K an enquiry about the mother’s experience trying
suggestions discussed at a previous contact; K A child with overweight should not have a sharp
decline in weight as losing too much weight is
K weighing the child and assessing growth; undesirable. An overweight child should instead
K observation of a breastfeed; maintain weight while increasing height, i.e. the
child should ‘grow into his or her weight’.
K examination of the mother’s breasts;
K assessment of the infant’s health; Follow-up of infant or young child with no feeding difficulty
K if the mother has been expressing breast milk, Infants and young children without any feeding dif-
checking whether she is managing to do this effec- ficulties also need follow-up at regular intervals for
tively and that her technique is satisfactory. growth assessment and infant and young child feed-
ing counselling, as described in the introduction to
Continuing management:
this Session.
K If the infant is not gaining weight or has persistent
Suggested intervals for feeding counselling and
feeding difficulties, offer additional help and fol-
growth assessment for healthy full-term babies are:
low up again after 2–5 days, or consider referral. A
child who has not gained weight on two consecu- K within 6 hours of delivery, and again within 2–3
tive visits or within 1 month needs to be referred. days: birth weight, feeding counselling (position
and attachment, colostrum and how milk “comes
K If the infant has gained weight and feeding dif-
in”, exclusive breastfeeding and optimal feeding
ficulties are resolved, he or she should return for
pattern, expressing milk);1
further follow-up after 2–4 weeks, and thereafter
at the same time as children with no difficulties. K around day 7: feeding counselling and weighing
(positioning and attachment, exclusive breastfeed-
Infant or young child 6 months or older ing and optimal feeding pattern, avoidance of sup-
plements);
Follow up after 5–7 days an infant or young child over
6 months of age with feeding difficulties. This reas- K around 4 weeks: feeding counselling and assess-
sessment should include: ing growth (positioning and attachment, exclu-
sive breastfeeding and feeding pattern, sustaining
K a general enquiry on progress, including breast-
confidence in breast-milk supply, avoiding supple-
feeding and complementary feeding;
ments despite growth spurt);
K an enquiry about the mother’s experience trying
K at 6 weeks: feeding counselling and assessing
suggestions discussed at previous contact;
growth, postpartum care for the mother (family
K weighing the child and monitoring growth; planning including the lactational amenorrhoea
K general assessment of the infant’s condition. method (LAM, see Session 8.4)), immunization;
Low-birth-weight babies may require additional support, in

1
particular in the first weeks of their life (see Session 6 for further
guidance).
K At 3 and 4 months of age: continue assessing References

growth, continue to support exclusive breastfeed- 1. Aidam B, Perez-Escamilla R, Lartey A. Lacta-
ing and help with any difficulties, advise on immu- tion counselling increases exclusive breastfeed-
nization; ing rates in Ghana. Journal of Nutrition, 2005,
K At 5–6 months of age: continue assessing growth, 135:1691–1695.
provide guidance on starting complementary feed- 2. Haider R et al. Effect of community-based peer
ing; counsellors on exclusive breastfeeding practices
K At 8–9 months, and 11–12 months: continue in Dhaka, Bangladesh: a randomized controlled
assessing growth, counselling on progress of com- trial. Lancet, 2000, 356:1643–1647.
plementary feeding and continued breastfeeding, 3. WHO. Community-based strategies for breastfeed-
advise on immunization. ing promotion and support in developing countries.
K Every 2–3 months after these other contacts have Geneva, World Health Organization, 2003.
stopped, up to at least 2 years of age. 4. WHO. Child growth standards: child catalogue.
K At other contacts with health care workers, for Geneva, World Health Organization, 2005 (http://
example, immunisation or because the child is www.who.int/childgrowth/standards/chart_cat-
sick. alogue/en/index.html, accessed 27 August 2008).
5. WHO/UNICEF/WFP/UNSCN. Community-based
management of severe acute malnutrition. WHO,
Geneva, 2007.
6. WHO/UNICEF Joint Statement. The use of the
WHO child growth standards for the identifica-
tion of severe acute malnutrition in 6–60 month
old infants and children. Geneva, World Health
Organization (in press).
7. WHO. Integrated management of childhood illness:
chartbook and training modules. Geneva, World
Health Organization, 1997 (WHO/CHD/97.3
A–K).
8. WHO. Integrated management of childhood illness:
model chapter for textbooks. Geneva, World Health
Organization, 2001.
Appropriate feeding in exceptionally
Session 6
difficult circumstances
One of the operational targets of the Global Strategy maintenance, hygienic cord and skin care, and early
for Infant and Young Child Feeding addresses specifi- detection and treatment of infections can substan-
cally the needs of mothers and children in exception- tially reduce excess mortality (2,3).
ally difficult circumstances. These circumstances
This section deals with feeding low-birth-weight
include babies who are low birth weight, and infants
babies. It summarizes what, how, when and how
and young children who are malnourished, who are
much to feed to low-birth-weight babies. Table 6 sum-
living in emergency situations, or who are born to
marizes the information that is discussed in more
mothers living with HIV.
detail in other parts of this Session.
6.1 Low-birth-weight babies 6.1.1 What to feed?

A baby weighing less than 2500 g at birth is low birth A baby’s own mother’s milk is best for LBW infants of
weight (LBW). A baby less than 1500 g is very low all gestational ages. Breast milk is especially adapted
birth weight (VLBW). LBW can be a consequence to the nutritional needs of LBW infants, and strong
of pre-term birth (before 37 weeks of completed ges- and consistent evidence (1) shows that feeding moth-
tation), small for gestational age (SGA, defined as er’s own milk is associated with lower incidence of
weight for gestation less than 10%), or a combina- infections and better long-term outcomes.
tion of both. Intrauterine growth restriction (IUGR),
defined as slower than normal velocity of growth, is Not all LBW infants are able to feed from the breast
usually responsible for SGA. in the first days of life. For infants who are not able
to breastfeed effectively, feeds have to be given by an
Being born with low birth weight is a disadvantage for alternative, oral feeding method (cup/paladai/spoon/
the infant. LBW directly or indirectly may contribute direct expression into mouth) or by intra-gastric tube
to 60% to 80% of all neonatal deaths. LBW infants are feeding (see Session 4.6).
also at higher risk of early growth retardation, infec-
tion, developmental delay, and death during infancy In these situations, the options available for feeding
and childhood (1). the LBW infant are, in order of preference (1):
Nevertheless, experience from developed and devel- K expressed breast milk (EBM) (from his or her own
oping countries has shown that appropriate care of mother);
LBW infants, including their feeding, temperature K donor breast milk (4);
Table 6
Feeding low-birth-weight babies
Feeding low-birth-weight babies
Borderline pre-term and term LBW 32–36 weeks gestational age < 32 weeks gestational age
WHAT breast milk breast milk, expressed or suckled from expressed breast milk
the breast
HOW breastfeeding cup, spoon, paladai naso-gastric tube
WHEN K start within one hour of birth K start within one hour of birth or as K start 12–24 hours after birth
K breastfeed at least every 3 hours soon as the baby is clinically stable K feed every 1–2 hours
K feed every 2–3 hours
HOW MUCH feed on demand see Tables 7 and 8 see Tables 7 and 8
K infant formula: Figure 16

Useful positions to hold a LBW baby for breastfeeding
— standard infant formula for infants with birth
weight >1500 g
— pre-term formula for infants with birth weight
<1500 g;
A LBW baby who is not able to breastfeed usual-
ly needs care in a special newborn care unit. Every
effort should be made to enable a mother to stay in or
near this unit. Otherwise, she should spend as much
time there as possible every day. When breastfeeding
is established, care can continue at home with close
follow-up.
A baby should have as much skin-to-skin contact a) The underarm position b) Holding with the arm
with his or her mother as possible, to help both bond- opposite the breast
ing and breastfeeding. If a baby is too sick to move,
the mother should at least be able to talk to him or
expressed milk by cup after the breastfeed, or give
her, and to have hand contact.
alternate breast and cup feeds.
A mother should be given skilled help to express her
Babies of 32 to 36 weeks gestational age need to be fed
milk and to establish lactation starting, if possible,
partly or fully on EBM by cup or spoon until full
within 6 hours of birth. She should express at least 8
breastfeeding can be established. Feeds can start as
times in 24 hours, expressing at home if she is not stay-
soon as the baby is clinically stable, if possible within
ing in the health facility. The EBM can be given every
one hour of birth, and should be given 2–3 hourly.
1–3 hours according to the age and weight of the baby.
To stimulate breastfeeding, these babies should be
Supplements of vitamin D and phosphate may be rec- allowed to suckle or lick the breast as much as they
ommended as soon as enteral feeding commences for
VLBW infants, and supplements of iron are recom- Box 15
mended for all LBW infants from the age of 6 to 8
weeks. How to express breast milk directly into a
baby’s mouth
6.1.2 How to feed? Ask the mother to:
Babies of 36 weeks gestational age or more can often K Wash her hands
suckle well enough at the breast to feed themselves
fully. Help the mother to have skin-to-skin contact K Hold her baby skin-to skin, positioned as for a breastfeed,
with the baby, and to let the baby try to suckle as soon with the baby’s mouth close to her nipple
as possible after delivery. Show the mother how to K Express some drops of milk onto her nipple
hold the baby in the underarm position, or hold with
K Wait until her baby is alert and opens the mouth widely
the arm from the side opposite the breast (see Figure
16). These positions are especially useful for very K Stimulate the baby if he or she appears sleepy
small babies. Make sure that the baby is well attached
K Let the baby smell and lick the nipple and attempt to suck
at the breast. When a LBW baby first suckles, he or
she may pause quite often and for long periods during K Let some breast milk fall into the baby’s mouth
a feed, and may need to continue feeding for an hour. K Wait until the baby swallows before expressing more
It is important not to take the baby off the breast dur- drops of breast milk
ing these pauses.
K When the baby has had enough, he or she will close the
The baby should be allowed to suckle every three mouth and will take no more milk
hours, or more frequently on demand. If a baby
has difficulty suckling effectively, tires quickly at K Ask the mother to repeat this every 1 to 2 hours if her baby
the breast or does not gain adequate weight, offer is very small, or every 2 to 3 hours if her baby is bigger.
6. Appropriate feeding in exceptionally difficult circumstances 53
wish. Offer the full amount of feed by cup initially. If at each feed. The quantity needs to be exact. However,
the baby has already had some milk from the breast, babies less than < 1500g may need to receive some of
he or she may refuse to finish the cup feed. If the baby these requirements as intravenous fluids, as they may
is suckling well and gaining weight, cup feeds can be not tolerate full enteral feeds.
reduced. If the baby is still having difficulties attach-
The quantities in the table are calculated according to
ing correctly at the breast, encourage the mother
the baby’s need for:
to express her milk directly into her baby’s mouth
(see instructions in Box 15). Bottle feeding should be K 60 ml/kg on day 1, increasing by 10 or 20 ml per
avoided, as it may interfere with the baby learning to day over 7 days up to 160 ml/kg/day.
breastfeed. K 8 feeds in 24 hours.
Babies less than 32 weeks gestational age usually need If a baby has more than 8 feeds in 24 hours, the amount
to be fed by gastric tube. They should not receive any per feed must be reduced accordingly, to achieve the
enteral feeds in the first 12–24 hours. Table 7 shows the same total volume in 24 hours.
quantity of milk that a LBW baby fed by gastric tube
needs each day and Table 8 shows how much is needed
Cup feeds
Table 7
A baby who is cup fed (see Figure 17) needs to be offered
Recommended fluid intake for LBW infants 5 ml extra at each feed. This slightly larger amount
allows for spillage with cup feeding. Also, a baby hav-
Day of life Fluid requirements (ml/kg/day)
ing cup feeds may take more or less than is recom-
2000–2500 g 1500–2000 g 1000–1500 g mended. Adding 5 ml allows for different amounts to
Day 1 60 60 60 be taken at each feed. It is important to keep a record
of the 24-hour total and ensure that it meets the
Day 2 80 75 70
required total ml/kg per day for the baby’s weight.
Day 3 100 90 80
Day 4 120 115 90 Figure 17
Day 5 140 130 110 Cup feeding a low-birth-weight baby
Day 6 150 145 130
Day 7 160+ 160 150*
* if the infant is on intravenous fluids, do not increase above 140 ml/kg/day
Table 8
Recommended feed volumes for LBW infants
Day of life Feed volumes (ml)
2000–2500 g 1500–2000 g 1000–1500 g

(3-hourly) (3-hourly) (every 2 hours)*
Day 1 17 12 6
Day 2 22 16 7
Day 3 27 20 8
Day 4 32 24 9
Day 5 37 28 11
Quantities after 7 days
If a baby is still having EBM by cup or gastric tube
Day 6 40 32 13
after 7 days, increase the quantity given by 20 ml/
Day 7 42 35 16 kg each day until the baby is receiving 180 ml/kg per
If the baby is cup feeding, add 5 ml per feed to allow for spillage and variability of day.
infant’s appetite.
The baby’s weight needs to be monitored. Satisfactory
* For infants with birth weight <1250 g who do not show signs of feeding
readiness, start with small 1–2 ml feeds every 1–2 hours and give the rest of the weight gain should be more than 15 g/kg each day.
fluid requirement as intravenous fluids. If the weight gain is less than 15 g/kg each day over
3  days, the quantity of milk should be increased by Figure 18

20 ml/kg each day until 200 ml/kg is reached. Baby in Kangaroo mother care position
As the baby begins to breastfeed more frequently, the

amount of EBM given by gastric tube or cup may be
gradually reduced.
Discharge
A LBW baby can be discharged from hospital when
he or she is:
K Breastfeeding effectively or the mother is confident
using an alternative feeding method;
K Maintaining his or her own temperature between
36.5 °C and 37.5 °C for at least 3 consecutive days;
K Gaining weight, at least 15 g/kg for three consecu-
tive days; and
K The mother is confident in her ability to care for
her baby.
Before discharging a mother and her LBW baby from
hospital, a discussion should take place with her on
how she can be supported at home and in the com-
Management
munity. If a mother lives a long distance from the hos-
pital and it is difficult for her to return for a follow-up The mother keeps her baby in prolonged skin-to-skin
visit, her baby should not be discharged until he or contact day and night, in an upright position between
she fully meets the criteria. If possible, the mother her breasts (Figure 18). The baby is supported in this
should stay with her baby to establish breastfeeding position by the mother’s clothes, or by cloths tied
before discharge. She should be given the name and around her chest. The baby’s head is left free so that
contact details of any local breastfeeding support he or she can breathe, and the face can be seen. The
groups, whether health facility or community based. baby wears a nappy for cleanliness and a cap to keep
the head warm.
6.1.3 Follow up of LBW babies KMC has been shown to keep the baby warm, to
The baby should have follow-up visits at least once stabilize his or her breathing and heart rate, and to
2–5 days after discharge, and at least weekly until reduce the risk of infection. It helps the mother to ini-
fully breastfeeding and weighing more than 2.5 kg. tiate breastfeeding earlier, and the baby to gain weight
Ideally these should be home visits by a community faster. Most routine care can be carried out while
breastfeeding counsellor, or visits by the mother to the baby remains in skin-to-skin contact. When the
a nearby health facility. Further follow-up can then mother has to attend to her own needs, skin-to-skin
continue monthly as for a term baby. contact can be continued by someone else, for exam-
ple by the father or a grandparent, or the baby can be
6.1.4 Kangaroo mother care wrapped and put into a cot or on a bed until KMC can
be continued.
Kangaroo mother care (KMC) is a way in which a
mother can give her LBW or small baby benefits simi- It is not essential for a baby to be able to coordinate
lar to those provided by an incubator (5). The mother sucking and swallowing to be eligible for KMC. Other
has more involvement in the baby’s care; and she has methods of feeding can be used until the baby is able
extended skin-to-skin contact, which helps both breast- to breastfeed. Close contact with the mother means
feeding and bonding, probably because it stimulates that the baby is kept very near to her breasts, and can
the release of prolactin and oxytocin from her pituitary easily smell and lick milk expressed onto her nipple.
gland. KMC helps a mother to develop a close relation- He or she can be given breast milk by direct expres-
ship with her baby, and increases her confidence. sion into his mouth until able to attach well.
KMC should be continued for as long as necessary, The first form of RUTF was invented in the late 1990s.
which is usually until the baby is able to maintain his Products qualifying to be called RUTF are energy-
or her temperature, is breathing without difficulty dense mineral- and vitamin-enriched foods equiva-
and can breastfeed without the need for alternative lent in formulation to Formula 100 (F100), which is
methods of feeding. It is usually the baby who indi- recommended by WHO for the treatment of malnu-
cates that he or she is ready and ‘wants to get out’. trition in in-patient settings. However, recent studies
If the mother lives near the hospital or health facil- have shown that RUTF promotes faster recovery from
ity the baby may be discharged breastfeeding and/ severe acute malnutrition than standard F100. It has
or using an alternative feeding method, such as cup little available water (low water activity), which means
feeding with the mother’s EBM. that it is microbiologically safe, will keep for several
The mother and her baby should be monitored regu- months in simple packaging and can be made easily
larly. In the first week after discharge, the baby should using low-tech production methods. RUTF is eaten
be weighed daily, if possible, and a health care worker uncooked, and is an ideal vehicle to deliver many
should discuss any difficulties with the mother, pro- micronutrients that might otherwise be broken down
viding her with support and encouragement. Moni- by cooking. RUTF is useful to treat severe malnutri-
toring should continue until the baby weighs more tion without complications in communities with lim-
than 2.5 kg. When the baby becomes less tolerant of ited access to appropriate local diets for nutritional
the position, the mother may reduce the time in KMC rehabilitation. As full replacement of the normal diet,
and then stop altogether over about a week. Once the 150–220 kcal/kg per day should be provided until the
baby has stopped KMC, monthly follow-up should be child has gained 15% to 20% of his or her weight.
continued to monitor feeding, growth and develop- However, if a child has severe malnutrition with an
ment until the baby is several months old. associated complication, most commonly an infec-
tion, the child should be admitted to hospital (7,8).
6.2 Severe malnutrition Infections are the most common complications, and
Severe malnutrition in children 6–59 months of age is can manifest themselves by lack of appetite only.
defined as weight-for-height less than 70% of the medi- The initial management should include preven-
an, or less than –3 Z scores, or the presence of oede- tion or treatment of hypoglycaemia, hypothermia,
ma of both feet, or a mid-upper arm circumference dehydration and infection, and regular feeding and
(MUAC) of less than 115 mm (see Session 5.4). Children monitoring. A special therapeutic formula diet, F75,
with a MUAC <115 mm should be treated for severe is required. In the initial phase, a child’s metabolic
malnutrition regardless of their weight-for-height. state is fragile, and feeding must be cautious, with
frequent small feeds of low osmolarity and low in lac-
There are no defined cut-off points for MUAC for
tose. If a child is breastfed, this should be continued,
infants less than 6 months. In this age group, visible
but scheduled amounts of therapeutic formula given
severe wasting and oedema, in conjunction with dif-
first. When a child improves and his or her appetite
ficulties in breastfeeding, are criteria for identifying
is returning, he or she should be given a special diet
infants who are severely malnourished.
adapted for catch-up growth. A child aged more than
Severely malnourished children are in need of special 6 months can be offered RUTF. If intake is satisfac-
care both during the early rehabilitation phase and tory, treatment can continue at home, with weekly or
over the longer term. They are at risk of life-threat- bi-weekly follow-up.
ening complications such as hypoglycaemia, hypo-
thermia, serious infections, dehydration, and severe For infants aged less than 6 months, continued fre-
electrolyte disturbances. quent breastfeeding is important, in addition to any
necessary therapeutic feeds. If breastfeeding has
Malnourished infants and young children should been discontinued or if breast-milk production has
be assessed clinically to look for associated compli- decreased, it can often be re-established by use of the
cations. Above the age of 6 months, if the general supplementary suckling technique with therapeutic
condition of the child is good, and in particular if feeding (see Session 6.4). Relactation by supplementary
the appetite is maintained, the child can be treated suckling, or by allowing the baby to suckle as often as
at home with provision of a ready-to-use therapeutic he or she is willing while cup feeding, is an important
food (RUTF), in addition to breastfeeding and com- part of management (9). Malnutrition often has its
plementary feeding, with weekly or bi-weekly follow- origin in inadequate or disrupted breastfeeding.
up by a trained health care provider (6).
6.3 Infants and young children living in Supportive general conditions

emergency situations A number of general conditions can greatly benefit
Why infant and young child feeding is exceptionally infant and young child feeding, and staff who are
vulnerable in emergencies managing an emergency response should endeavour
to establish them:
In emergencies infants and young children are more
likely than older children or adults to become ill and Recognition of vulnerable groups: Pregnant women,
die from malnutrition and disease (10). Optimal feed- infants under 6 months, and young children between
ing is often disrupted because of lack of basic resourc- 6 and 24 months should be counted and registered
es such as shelter and water, and physical and mental separately. Newborn infants should be registered
stress on families. Breastfeeding may stop because immediately, and the household made eligible for an
mothers are ill, traumatised, or separated from their additional ration for the breastfeeding mother and
babies, and yet it is particularly valuable in emergency food suitable for complementary feeding of young
situations (11). Artificial feeding is more dangerous children, when appropriate.
because of poor hygiene, lack of clean water and fuel, Adequate food, water and nutrients: Mothers should
and unreliability of supplies. There may be no food receive an adequate general ration, and sufficient drink-
suitable for complementary feeding, or facilities for ing water. If the full general ration is not available, food
preparing feeds and storing food safely. and micronutrient supplements should be provided as
Breast-milk substitutes including infant formula and a priority for pregnant and lactating women.
feeding bottles may be sent to emergency situations Shelter and privacy: Shelters for families should be
in inappropriate amounts by donors who believe provided in preference to communal shelters. Breast-
that they are urgently required, but who are poorly feeding women need private areas (as culturally
informed about the real needs. Without proper con- appropriate) at distribution or registration points,
trols, these supplies are often given freely to families and rest areas in transit sites.
who do not need them, and stocks run out before
more arrive for those who might have a genuine need Community support: Women need support from their
(12). The result is inappropriate and unsafe use of family and communities, so the population should be
breast-milk substitutes, and a dangerous and unnec- helped to settle in familiar groups.
essary increase in early cessation of breastfeeding. Reduction of demands on time: People spend hours
Babies may be given unsuitable foods, such as dried queuing for relief commodities such as food, water,
skimmed milk, because nothing else is available. and fuel, which is difficult for mothers caring for
young children. Priority access for mothers and other
Management in emergencies caregivers enables them to give children more time.
The principles and recommendations for feeding Sanitary washing facilities should be set up near the
infants and young children in emergency situations area assigned to women with infants.
are exactly the same as for infants in ordinary cir-
cumstances. For the majority, the emphasis should be Specific help with feeding in emergencies
on protecting, promoting and supporting breastfeed- In addition to supportive general conditions, mothers
ing, and ensuring timely, safe and appropriate com- need help with infant and young child feeding specifi-
plementary feeding. Most malnourished mothers can cally. An emergency response should aim to include
continue to breastfeed while they are being fed and the following forms of support:
treated themselves. A minority of infants will need to
be fed on breast-milk substitutes, short term or long Baby-friendly maternity care: The Ten Steps for Suc-
term. This may be necessary if their mothers are dead cessful Breastfeeding (see Session 4.1, Box 5) should be
or absent, or too ill or traumatised to breastfeed, and implemented at both health facilities and for home
no wet-nurses are available; or for infants who have deliveries. Skilled support from trained breastfeeding
been artificially fed prior to the emergency or whose counsellors and community groups is needed antena-
HIV-positive mothers choose not to breastfeed. tally and in the first weeks after delivery.
Availability of suitable complementary foods: In addi-
tion to breast milk, infants and young children from
6 months onwards need complementary foods that
are hygienically prepared and easy to eat and digest. K If a mother is very ill (temporary use may be all
Blended foods, especially if they are fortified with that is necessary).
essential nutrients, can be useful for feeding older
K If a mother is relactating (temporary use).
infants and young children. However, their provi-
sion should not interfere with promoting the use of K If a mother tests HIV-positive and chooses to use a
local ingredients and other donated commodities breast-milk substitute (see Session 6.5).
for preparing suitable complementary foods (see Ses- K If a mother rejects the infant, for example after
sion 3). The use of feeding bottles should continue to rape (temporary use may be all that is necessary).
be discouraged.
K If an infant (born before the emergency) is already
Skilled help in the community to: dependent on artificial feeding (use BMS to at least
K teach mothers how to breastfeed and continue to six months or use temporarily until relactation is
support them until their infant reaches 24 months; achieved).
K teach mothers about adequate complementary For an infant identified according to agreed criteria
feeding from 6 months of age using available as in need of BMS, supplies should be provided for
ingredients; as long as the infant needs them. Caregivers should
receive guidance about hygienic and appropriate
K support mothers to practise responsive feeding;
feeding with BMS (10). Every effort should be made
K identify and help mothers with difficulties, and to prevent “spill over” of artificial feeding to mothers
follow them up at home if possible; and babies who do not need it, by teaching the care
giver privately to prepare feeds, and by taking care not
K monitor the growth of infants and young children,
to display containers of BMS publicly.
and counsel the mother accordingly.
Adequate health services to: 6.4 Relactation
K support breastfeeding and complementary feed The re-establishment of breastfeeding is an important
ing; management option in emergency situations, and for
infants who are malnourished or ill (9).
K help mothers to express their milk and cup feed
any infant who is too small or sick to breastfeed;
Motivation and support
K search actively for malnourished infants and young
Most women can relactate any number of years after
children so that their condition can be assessed
their last child, but it is easier for women who stopped
and treated;
breastfeeding recently, or if the infant still suckles
K admit mothers of sick or malnourished infants to sometimes. A woman needs to be highly motivated,
the health or nutrition rehabilitation clinic with and well supported by health care workers. Continu-
their children; ing support can be provided by community health
workers, mother support groups, women friends,
K help mothers of malnourished infants to relactate
older women and traditional birth attendants.
and achieve adequate breastfeeding before dis-
charge from care, in addition to necessary thera-
peutic feeding. Stimulation of the breasts
Stimulation of the breasts is essential, preferably by
Controlled use of breast-milk substitutes (BMS): Breast-
the infant suckling as often and for as long as possible.
milk substitutes should be procured and distributed
Many infants who have breastfed before are willing to
as part of the regular inventory of foods and medi-
suckle, even if there is not much milk being produced
cines, in quantities only as needed (see also UNHCR
currently. Suckling causes release of prolactin, which
policy (13)). There should be clear criteria for their
stimulates growth of alveoli in the breast and the pro-
use, agreed by the different agencies that are involved
duction of breast milk. The mother and infant must
for each particular situation (14), but usually includ-
stay together all the time. Skin-to-skin contact, or
ing the following:
kangaroo mother care (see Session 6.1.4) are helpful. If
K If a child’s mother has died or is unavoidably the infant is willing to suckle, the mother should put
absent. him or her to the breast frequently, at least 8–12 times
every 24 hours, ensuring that attachment is good. If
the infant is not willing to suckle, she can start the Figure 19
relactation process by stimulating her breasts with Using supplementary suckling to help a mother to relactate
gentle breast massage and then with 20–30 minutes
of hand expression 8–12 times a day.
Supplementary feeds for the infant

The infant needs a temporary supplement, which can
be expressed milk, artificial milk or therapeutic for-
mula. The full amount of supplement should be given
initially, in a way that encourages the infant to resume
breastfeeding, by cup or supplementer (see below).
Avoid using feeding bottles or pacifiers. Whenever
the baby wants to suckle, he or she should do so from
the breast. For infants who are not willing to suckle
at the breast, the supplementary suckling technique
is useful.
The supplementary suckling technique

This technique usually needs to be practised under Signs that breast milk is being produced
supervision at a health facility. A breastfeeding sup- Breast-milk production may start in a few days or a
plementer consists of a tube which leads from a cup few weeks. Signs include:
of supplement to the breast, and which goes along the K Breast changes: The breasts feel fuller or firmer, or
nipple and into the infant’s mouth. The infant suckles milk leaks or can be expressed.
and stimulates the breast at the same time drawing the
supplement through the tube, and is thereby nourished K Less supplement consumed: The infant takes less
and satisfied (see Figure 19). A fine nasogastric tube supplement while continuing to gain weight.
(gauge 8) or other fine plastic tubing should be used. K Stool changes: The infant’s stools become softer,
The mother can control the flow by raising or lowering more like those of a breastfed infant.
the cup so that the infant suckles for about 30 minutes
at each feed. If the tube is wide, a knot can be tied in Lactogogues
it, or it can be pinched. The cup and tube should be
Drugs (called lactogogues) are sometimes used to
cleaned and sterilized each time she uses them.
stimulate increased lactation, if the above measures
Encourage the mother to let the infant suckle on the are not effective by themselves. Drugs used are meto-
breast at any time that he or she is willing – not just clopramide (given 10 mg 3 times a day for 7–14 days)
when she is giving the supplement. When the infant is or domperidone (given 20–40 mg 3 times a day for
willing to suckle at the breast without the supplement, 7–10 days). However, drugs help only if the woman
then she can start giving breast milk by cup instead. also receives adequate help and her breasts are fully
This should be more feasible in home conditions. stimulated by the infant suckling.
Quantity of supplement to give Follow-up

The full amount of milk normally required by a term When relactation is well under way, the mother-baby
baby is 150 ml/kg body weight per day. To start relac- pair can be discharged for daily community-level
tation, give the full amount of supplement each day. follow-up, with checks as often as possible from health
Divide this into six to twelve feeds depending on the and nutrition workers.
infant’s age and condition. Young, weak or sick infants
will need more frequent, smaller, feeds. 6.5 Infants of HIV-positive mothers
Monitor the infant’s weight and urine production (see Feeding infants of HIV-positive mothers is a major
Session 7.10). When the infant is gaining weight, and concern of governments and agencies concerned with
there are signs of breast-milk production, the supple- infant feeding. The aim of preventing mother-to-child
ment can be reduced, by 50 ml per day every few days. transmission of HIV (MTCT) through breastfeeding
needs to be balanced with the need to support opti- K Exclusive breastfeeding is recommended for HIV-
mal nutrition of all infants through exclusive and infected mothers for the first 6 months of life unless
continued breastfeeding and adequate complemen- replacement feeding is acceptable, feasible, afford-
tary feeding. able, sustainable and safe for them and their infants
before that time (see Box 16 for definitions).
Mother-to-child transmission of HIV K When replacement feeding is acceptable, feasi-
In 2007, about 2.5 million children under 15 years ble, affordable, sustainable and safe, avoidance
of age were living with HIV, and an estimated 420 of all breastfeeding by HIV-infected mothers is
000 children were newly infected. The predomi- recommended.
nant source of HIV infection in young children is
K All HIV-exposed infants should receive regu-
MTCT. The virus may be transmitted during preg-
lar follow-up care and periodic re-assessment of
nancy, labour and delivery, or during breastfeeding
infant feeding choices, particularly at the time of
(15). Without intervention, an estimated 5%–20%
infant diagnosis and at 6 months.
of infants born to HIV-infected women acquire the
infection through breastfeeding. Transmission can K At 6 months, if adequate feeding from other sourc-
occur at any time while a child is breastfeeding, es cannot be ensured, HIV-infected women should
and continuing to breastfeed until the child is older continue to breastfeed their infants and give com-
increases the overall risk. Exclusive breastfeeding in plementary foods in addition, and return for regu-
the first few months of life carries a lower risk of HIV lar follow-up assessments. All breastfeeding should
transmission than mixed feeding (16). stop once an adequate diet without breast milk can
be provided.
The main factors which increase the risk of HIV
transmission through breastfeeding include (15): K Breastfed infants and young children who are HIV-
infected should continue to breastfeed according
K acquiring HIV infection during breastfeeding,
to recommendations for the general population.
because of high initial viral load;
Women who need anti-retroviral drugs (ARVs) for
K the severity of the disease (as indicated by a low
their own health should receive them, as they are the
CD4+ count or high RNA viral load in the mother’s
women most likely to transmit HIV through breast-
blood, or severe clinical symptoms);
feeding. Comparative studies in women who do not yet
K poor breast health (e.g. mastitis, sub-clinical mas- require treatment on the safety and efficacy of ARVs
titis, fissured nipples); taken during breastfeeding solely to reduce transmis-
K possibly, oral infection in the infant (thrush and sion are ongoing. There is increasing evidence from
herpes); observational studies that women taking ARVs are
likely to have a low risk of transmission (18).
K non-exclusive breastfeeding (mixed feeding);
Five priority areas for national governments in the
K longer duration of breastfeeding; context of the Global Strategy are proposed in HIV
K possibly, nutritional status of the mother. and Infant Feeding: Framework for Priority Action
(19) that has been endorsed by nine United Nations
Current feeding recommendations (17,18) agencies:
The United Nations recommendations for feeding of 1. Develop or revise (as appropriate) a comprehen-
infants by mothers who are HIV- infected include:1 sive national infant and young child feeding policy,
which includes HIV and infant feeding.
K The most appropriate infant feeding option for an
HIV-infected mother depends on her individual 2. Implement and enforce the International Code
circumstances, including her health status and of Marketing of Breast-milk Substitutes and sub-
the local situation, but should take consideration sequent relevant World Health Assembly resolu-
of the health services available and the counselling tions.
and support she is likely to receive.
3. Intensify efforts to protect, promote and support
appropriate infant and young child feeding prac-
A full listing can be found in Annex 1 of the HIV and Infant
1 tices in general, while recognising HIV as one of a
Feeding Update (18). number of exceptionally difficult circumstances.
4. Provide adequate support to HIV-positive women Box 16

to enable them to select the best feeding option for
themselves and their babies and to successfully Definitions of Acceptable, Feasible,
carry out their infant feeding decisions. Affordable, Sustainable and Safe
5. Support research on HIV and infant feeding, Acceptable:
including operations research, learning, monitor- The mother perceives no significant barrier to choosing a
ing and evaluation at all levels, and disseminate feeding option for cultural or social reasons or for fear of
findings. stigma and discrimination.
Feasible:
Counselling about feeding options (20,21) The mother (or other family member) has adequate time,
All women should be made aware of the risk of MTCT knowledge, skills and other resources to prepare feeds and
in general, and that there is an increased risk of trans- to feed the infant, as well as the support to cope with family,
mission if they become infected during breastfeeding. community and social pressures.
Women and their partners should be encouraged to Affordable:
accept HIV testing and counselling during pregnan- The mother and family, with available community and/or
cy, so that they know their status, and so that they health system support, can pay for the costs of replacement
can take advantage of help that is available and make feeds – including all ingredients, fuel and clean water –
appropriate decisions before the baby is born. without compromising the family’s health and nutrition
Counselling about feeding options for HIV-posi- budget.
tive women needs to start during pregnancy. HIV- Sustainable:
positive women and their partners should be informed The mother has access to a continuous and uninterrupted
about: supply of all ingredients and commodities needed to
K the risks of mother-to-child transmission of the implement the feeding option safely for as long as the infant
virus; needs it.
K feeding options that are appropriate and feasible in Safe:

the local context, considering national policies; Replacement foods are correctly and hygienically prepared
and stored, and fed in nutritionally adequate quantities, with
K the advantages and disadvantages of each feeding clean hands and using clean utensils, preferably by cup.
option.
They should also be made aware that:
K replacement feeding carries an increased risk for only the two main feeding options (replacement feed-
the child of morbidity and mortality associated ing and exclusive breastfeeding) need to be discussed
with malnutrition and infectious diseases other during counselling, but others may be explained if
than HIV, when compared with breastfeeding; the woman appears interested.
K mixed feeding carries both the risk of transmission
of HIV and the risk of other infections and is the Support for the chosen feeding method
worst option; If an HIV-positive mother chooses to give replace-
ment feeding, she will need to be taught how to
K it is important for the mother to take care of her
measure ingredients and how to prepare breast-milk
own health and nutrition, but that breastfeeding
substitutes hygienically (see Box 17) (20,21,22). Pro-
will not affect her health adversely;
grammes should try to improve conditions that make
K it is particularly important to practise safer sex replacement feeding safer for HIV-infected mothers
when the baby is breastfeeding, because of the and families (23).
greater risk of transmission of HIV to the infant
If an HIV-positive mother chooses to breastfeed her
should the mother be infected at this time.
baby herself, she should be given support to help her
HIV-positive women should be given guidance to help to breastfeed exclusively (17), with a good technique to
them decide what is the best infant feeding method ensure a plentiful supply of milk and to prevent masti-
for their own situation, and they should be taught tis and sore nipples; and guidance about treating these
how to carry out their chosen method safely. Usually, conditions early should they occur (see Session 7.7).
If an HIV-positive mother chooses to stop breastfeed- Box 17

ing early, she will need help to change to replacement
feeding and to stop breastfeeding completely over a Replacement feeding
time period of a few days to 2–3 weeks. She will need Replacement feeding is the process of feeding a child who is
support to: not breastfeeding with a diet that provides all the nutrients
K express her breast milk and accustom the baby to the child needs, until the child is fully fed on family food.
cup feeding of EBM; Replacement feeding includes replacement of breast milk
K gradually reduce breastfeeds, and replace them with a suitable breast-milk substitute in the first 6 months
with EBM; of life, and ensuring adequate complementary food and
replacement of breast milk from 6 months to 2 years. This
K change from EBM to replacement feeds given by is the period during which a child is at greatest risk from
cup; if the baby is receiving replacement feeds and malnutrition.
EBM at the same time, then the EBM should be
heat treated; To replace breast milk, a child needs a breast-milk substitute
of suitable composition, and of which the supply is reliable
K comfort the baby by cuddling, rubbing and rock- and uninterrupted. Heat-treated expressed breast milk can
ing, and by giving him or her a finger or forearm to also be used (though not strictly a replacement feed, it needs
suck on: hygienic preparation and measuring so is included here).
K keep her breasts healthy, by expressing enough To prepare feeds, a mother or caretaker needs water, soap,
milk to prevent engorgement until milk produc- fuel and utensils, time to make the feeds, and knowledge of
tion stops. The milk should be discarded, or if used how to prepare them accurately and hygienically. She needs
to feed the infant, it should be heat treated. detailed guidance on how to measure milk, water and other
HIV-positive women who choose to express and heat ingredients and how to clean utensils.
treat their milk, need guidance on expression, heat Commercial infant formula must be prepared carefully
treatment, cup feeding and quantities of EBM to give. according to the instructions on the label, and given in
If a family decides on a wet-nurse, she will need all quantities appropriate for the child’s weight and age.
the support that a breastfeeding mother needs, and Information about the volume of feeds is also included on the
counselling about avoiding any risk of HIV infection label.
while she is feeding the baby (24).
Heat-treated breast milk. The mother expresses enough milk
All mothers and caregivers should receive follow- for one or two feeds, and then heats it to boiling in a small
up care for at least 2 years to ensure that the child is pan, or in a small metal container standing in a pan of water.
adequately fed and growing and that other foods are She leaves the milk to cool in a clean, covered container, and
introduced when the child is 6 months old (see Session feeds it by cup.
3 and below)
Volume of milk required :
Home-modified animal milk is no longer recom-
mended as a replacement feeding option to be used for K Give 150 ml of prepared milk per kg of the child’s body
all of the first 6 months of life. It does not provide all weight per day, divided into 8 feeds in 24 hours.
the nutrients that an infant needs, and the micronu- K For the first few days of life, start with 60 ml/kg per day
trient mix originally recommended to be added to it on the first day, and increase the total by 20 ml/kg per day,
is not available (25). For women who choose replace- dividing into 8 feeds in 24 hours.
ment feeding, home-modified animal milk should
After complementary foods are introduced, milk feeds
only be used for short times when commercial infant
continue at approximately the same amount as is given to the
formula is not available. For infants 6 months of age
child at 6 months of age, but may vary according to availability
and older, undiluted animal milks can be added to
of milk and other foods and the child’s demands.
the diet, and serve as a suitable substitute for breast
milk. The recommended volumes are 200–400 ml
per day if adequate amounts of other animal source
foods are consumed regularly, otherwise 300–500 ml
per day (26).
Baby-friendly hospitals and HIV To feed children aged 6–23 months satisfactorily, all
Baby-friendly hospitals have a responsibility to care the principles of safe, adequate complementary feed-
for and support both HIV-positive and HIV-negative ing apply, as described in Session 3. However, to cover
women. the requirements that would otherwise be covered by
breast milk, a child needs to be fed a larger quantity of
K If a mother is HIV-positive, and after counselling the foods containing high-quality nutrients.
has chosen replacement feeding, this is an accepta-
ble medical reason for giving artificial feeds, and is This can be achieved by giving the child:
thus compatible with a hospital being baby-friend- K extra meals, to help ensure that sufficient amounts
ly. The staff should support her in her choice, and of energy and nutrients are eaten;
teach her how to prepare feeds safely. However, they K meals of greater energy density, to help ensure that
should give this help privately, and not in front of sufficient energy is consumed;
other women who may not be HIV-positive. This
is necessary both to comply with the Code, and K larger quantities of foods of animal origin to help
also to prevent the spillover of artificial feeding to ensure that enough nutrients are eaten;
women who do not need it. These women may lose K nutrient supplements, if foods of animal origin are
confidence and interest in their own milk if they not available.
see replacement feeds being prepared.
K If an HIV-positive mother chooses breastfeeding, Extra meals
the staff have an equal responsibility to support Non-breastfed children need to eat meals 4–5 times
her to breastfeed exclusively, and to ensure that she per day with additional nutritional snacks 1–2 times
learns a good technique. per day as desired.
K For women who are HIV-negative or of unknown
Energy density of meals
status, staff should make sure that they are fully
informed and supported to breastfeed optimally. Foods of thick consistency, or with some added fat,
help to ensure an adequate intake of energy for a
Although baby-friendly hospitals should not accept child.
free or low-cost supplies of breast-milk substitutes
from manufacturers or distributors, the government
Foods of animal origin
may supply them or the hospital or mothers may pur-
chase them for use during the hospital stay. Only the Some meat, poultry, fish, or offal should be eaten eve-
quantity that is actually needed should be available ry day to ensure that the child gets enough iron and
in the hospital, and distribution should be carefully other nutrients (see Table 3 in Session 3.3).
controlled. Dairy products are important to provide calcium. A
A course for hospital administrators provides guid- child needs 200–400 ml of milk or yoghurt every day
ance for how to implement the baby-friendly Ten if other animal source foods are eaten, or 300–500 ml
Steps in settings with high HIV prevalence (27). per day if no other animal source foods are eaten.
6.6 Feeding non-breastfed children 6–23 months Vegetable foods

of age The child should be given pulses daily to help provide
iron and vitamins, with vitamin C-rich foods to help
Guiding principles
iron absorption.
Sometimes young children between the ages of 6
months and 2 years are not breastfed. Reasons include The child should also be given orange and yellow
when their mother is unavailable, or has died, or is fruits and dark-green leafy vegetables to provide vita-
HIV-positive. These children need extra food to com- min A and other vitamins.
pensate for not receiving breast milk, which can pro-
vide one half of their energy and nutrient needs from Micronutrient supplements
6 to 12 months, and one third of their needs from If the child receives no foods of animal origin, then it
12–23 months (26). is necessary to give vitamin and mineral supplements
to ensure sufficient intake, particularly of iron, zinc,
calcium and vitamin B12.
Follow-up of Infants and young children 10. Emergency Nutrition Network. Infant feeding in
who are not breastfed emergencies. Module 1: For emergency relief staff,
The same principles of follow-up and referral apply orientation and reference; Module 2: For health and
to non-breastfed children as to breastfed children nutrition workers in emergency situations. Geneva,
(see Session 5.6). They should be followed up regu- ENN, 2007 (http://www.ennonline.net/ife/results.
larly for at least 2 years to ensure that their feeding is aspx?tag=74, accessed 3 November 2008).
adequate, and that they are growing and remaining 11. Jacobsen M et al. Breastfeeding status as a pre-
well-nourished. dictor of mortality among refugee children in an
All infants of HIV-positive mothers, at whatever age emergency situation in Guinea-Bissau. Tropical
they stop breastfeeding, should be followed up for at Medicine and International Health, 2003, 8(11):
least 2 years to ensure that their feeding is adequate, 992–996.
and to establish if they are HIV-positive themselves. 12. Save the Children Alliance. Meeting the nutritional
needs of infants in emergencies: recent experiences
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agement of severe malnutrition. Food and Nutri- infant feeding technical consultation held on behalf
tion Bulletin, 2006, 27(3):S99–S108. of the Inter-agency Task Team (IATT) on preven-
tion of HIV infections in pregnant women, moth-
7. WHO. Management of severe malnutrition: a man-
ers and their infants: consensus statement. Geneva,
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World Health Organization, 2006.
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8. WHO. Management of the child with a serious infec-
feeding update. Geneva, World Health Organiza-
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2009.
Management of breast conditions and
Session 7
other breastfeeding difficulties
This section discusses the symptoms, causes and Management:

management of breastfeeding difficulties referred
K The mother must remove the breast milk. If the
to in Session 5, classified under “Help with difficul-
baby can attach well and suckle, then she should
ties and poor practices. Refer if necessary”. Those
breastfeed as frequently as the baby is willing. If
discussed here include breast conditions and other
the baby is not able to attach and suckle effective-
breastfeeding difficulties, twins, a mother separated
ly, she should express her milk by hand or with a
from her baby, a child with sickness, abnormality or
pump a few times until the breasts are softer, so
a condition that interferes with suckling, and con-
that the baby can attach better, and then get him
ditions of the mother. Growth faltering and non-
or her to breastfeed frequently.
exclusive breastfeeding are discussed in Session 5.4;
complementary feeding difficulties in Session 5.5; and K She can apply warm compresses to the breast or
low–birth-weight infants in Session 6.1. take a warm shower before expressing, which helps
the milk to flow. She can use cold compresses after
7.1 Full breasts feeding or expressing, which helps to reduce the
oedema.
Symptoms: Full breasts occur from 3–5 days after
delivery when the breast milk “comes in”. The moth- K Engorgement occurs less often in baby-friendly
er feels uncomfortable and her breasts feel heavy, hot hospitals which practise the Ten Steps and which
and hard. Sometimes they are lumpy. The milk flows help mothers to start breastfeeding soon after
well, and sometimes drips from the breast. delivery.
Cause: This is normal fullness.
7.3 Blocked duct
Management: The baby needs to be well attached, and
Symptoms: A tender, localised lump in one breast, with
to breastfeed frequently to remove the milk. The full-
redness in the skin over the lump.
ness decreases after a feed, and after a few days the
breasts become more comfortable as milk production Cause: Failure to remove milk from part of the breast,
adjusts to the baby’s needs. which may be due to infrequent breastfeeds, poor
attachment, tight clothing or trauma to the breast.
7.2 Breast engorgement (1) Sometimes the duct to one part of the breast is blocked
by thickened milk.
Symptoms: The breasts are swollen and oedematous,
and the skin looks shiny and diffusely red. Usually the Management: Improve removal of milk and correct the
whole of both breasts are affected, and they are pain- underlying cause.
ful. The woman may have a fever that usually subsides
K The mother should feed from the affected breast
in 24 hours. The nipples may become stretched tight
frequently and gently massage the breast over the
and flat which makes it difficult for the baby to attach
lump while her baby is suckling.
and remove the milk. The milk does not flow well.
K Some mothers find it helpful to apply warm com-
Cause: Failure to remove breast milk, especially in the
presses, and to vary the position of the baby (across
first few days after delivery when the milk comes in
her body or under her arm).
and fills the breast, and at the same time blood flow to
the breasts increases, causing congestion. The com- K Sometimes after gentle massage over the lump, a
mon reasons why milk is not removed adequately are string of the thickened milk comes out through
delayed initiation of breastfeeding, infrequent feeds, the nipple, followed by a stream of milk, and rapid
poor attachment and ineffective suckling. relief of the blocked duct.
7.4 Mastitis (2) Management: An abscess needs to be drained and treat-

Symptoms: There is a hard swelling in the breast, with ed with penicillinase-resistant antibiotics. When pos-
redness of the overlying skin and severe pain. Usually sible drainage should be either by catheter through
only a part of one breast is affected, which is different a small incision, or by needle aspiration (which may
from engorgement, when the whole of both breasts need to be repeated). Placement of a catheter or nee-
are affected. The woman has fever and feels ill. Masti- dle should be guided by ultrasound. A large surgical
tis is commonest in the first 2–3 weeks after delivery incision may damage the areola and milk ducts and
but can occur at any time. interfere with subsequent breastfeeding, and should
be avoided. The mother may continue to feed from
Causes: An important cause is long gaps between feeds, the affected breast. However, if suckling is too painful
for example when the mother is busy or resumes or if the mother is unwilling, she can be shown how to
employment outside the home, or when the baby starts express her milk, and advised to let her baby start to
sleeping through the night. Other causes include poor feed from the breast again as soon as the pain is less,
attachment, with incomplete removal of milk; unre- usually in 2–3 days. She can continue to feed from the
lieved engorgement; frequent pressure on one part of other breast. Feeding from an infected breast does not
the breast from fingers or tight clothing; and trauma. affect the infant (unless the mother is HIV-positive,
Mastitis is usually caused in the first place by milk see Session 7.7).
staying in the breast, or milk stasis, which results in
non-infective inflammation. Infection may supervene Sometimes milk drains from the incision if lactation
if the stasis persists, or if the woman also has a nip- continues. This dries up after a time and is not a rea-
ple fissure that becomes infected. The condition may son to stop breastfeeding.
then become infective mastitis.
7.6 Sore or fissured nipple
Management: Improve the removal of milk and try to
Symptoms: The mother has severe nipple pain when the
correct any specific cause that is identified.
baby is suckling. There may be a visible fissure across
K Advise the mother to rest, to breastfeed the baby the tip of the nipple or around the base. The nipple
frequently and to avoid leaving long gaps between may look squashed from side-to-side at the end of a
feeds. If she is employed, she should take sick leave feed, with a white pressure line across the tip.
to rest in bed and feed the baby. She should not
Cause: The main cause of sore and fissured nipples is
stop breastfeeding.
poor attachment. This may be due to the baby pulling
K She may find it helpful to apply warm compresses, the nipple in and out as he or she suckles, and rubbing
to start breastfeeding the baby with the unaffected the skin against his or her mouth; or it may be due
breast, to stimulate the oxytocin reflex and milk to the strong pressure on the nipple resulting from
flow, and to vary the position of the baby. incorrect suckling.
K She may take analgesics (if available, ibuprofen, Management: The mother should be helped to improve
which also reduces the inflammation of the breast; her baby’s position and attachment. Often, as soon as
or paracetamol). the baby is well attached, the pain is less. The baby can
K If symptoms are severe, if there is an infected nip- continue breastfeeding normally. There is no need to
ple fissure or if no improvement is seen after 24 rest the breast – the nipple will heal quickly when it is
hours of improved milk removal, the treatment no longer being damaged.
should then include penicillinase-resistant anti-
biotics. However antibiotics will not be effective 7.7 Mastitis, abscess and nipple fissure in an HIV-
without improved removal of milk. infected woman (2)
If a woman is HIV-infected, mastitis, breast abscess
7.5 Breast abscess (2) and nipple fissure (especially if the nipple is bleeding
Symptoms: A painful swelling in the breast, which feels or oozing pus) may increase the risk of HIV transmis-
full of fluid. There may be discoloration of the skin at sion to the infant. The recommendation to increase
the point of the swelling. the frequency and duration of feeds is not appropriate
for a mother who is HIV-positive.
Cause: Usually secondary to mastitis that has not been
effectively managed.
7. Management of breast conditions and other breastfeeding difficulties 67
Management for a woman who is HIV-positive: K There may be a red rash over the nappy area (“dia-
per dermatitis”).
K She should avoid breastfeeding on the affected side
while the condition persists. Cause: This is an infection with the fungus Candida
albicans, which often follows the use of antibiotics in
K She should remove the milk from the affected
the baby or in the mother to treat mastitis or other
breast by expression, to help the breast to recover
infections.
and to maintain the flow of milk. She should be
helped to make sure that she can express her milk Management: Treatment is with gentian violet or nys-
effectively. tatin. If the mother has symptoms, both mother and
baby should be treated. If only the baby has symp-
K If only one breast is affected, the baby can continue
toms, it is not necessary to treat the mother.
to feed on the unaffected breast, and can feed more
often from that side to increase production and Gentian Violet paint:
ensure an adequate intake. Apply 0.25% solution to baby’s mouth daily for 5
days, or until 3 days after lesions heal.
K Give antibiotics for 10–14 days, rest and analgesics
as required, and incision if there is an abscess, as Apply 0.5% solution to mother’s nipples daily for 5
for an HIV-negative woman. days.
K She can resume breastfeeding from the affected Nystatin:
breast when the condition subsides. Nystatin suspension 100,000 IU/ml; apply 1 ml by
dropper to child’s mouth 4 times daily after breast-
K Some mothers decide to stop breastfeeding at this
feeds for 7 days, or as long as the mother is being
time if they are able to give replacement feeds safe-
treated.
ly. They should continue to express enough milk to
allow the breasts to recover, until milk production Nystatin cream 100,000 IU/ml; apply to nipples 4
ceases. times daily after breastfeeds. Continue to apply for 7
days after lesions have healed.
K If both breasts are affected, she will not be able
to feed the baby from either side, and will need
to consider other feeding options as a permanent 7.9 Inverted, flat, large and long nipples (3)
solution. She may decide to heat-treat her own Signs to look for: Nipples naturally occur in a wide vari-
milk and give that, or to give formula. She should ety of shapes that usually do not affect a mother’s
feed the baby by cup. ability to breastfeed successfully. However, some nip-
ples look flat, large or long, and the baby has difficulty
7.8 Candida infection (thrush) in mother and baby attaching to them. Most flat nipples are protractile –
(3) if the mother pulls them out with her fingers, they
stretch, in the same way that they have to stretch in
Symptoms:
the baby’s mouth. A baby should have no difficulty
In the mother: suckling from a protractile nipple. Sometimes an
K Sore nipples with pain continuing between feeds, inverted nipple is non-protractile and does not stretch
pain like sharp needles going deep into the breast, out when pulled; instead, the tip goes in. This makes
which is not relieved by improved attachment. it more difficult for the baby to attach. Protractil-
ity often improves during pregnancy and in the first
K There may be a red or flaky rash on the areola, with week or so after a baby is born. A large or long nipple
itching and depigmentation. may make it difficult for a baby to take enough breast
In the baby: tissue into his or her mouth. Sometimes the base of
the nipple is visible even though the baby has a widely-
K White spots inside the cheeks or over the tongue,
open mouth.
which look like milk curds, but they cannot be
removed easily. Cause: Different nipple shapes are a natural physical
feature of the breast. An inverted nipple is held by
K Some babies feed normally, some feed for a short
tight connective tissue that may slacken after a baby
time and then pull away, some refuse to feed alto-
suckles from it for a time.
gether, and some are distressed when they try to
attach and feed, suggesting that their mouth is sore.
Management: The same principles apply for the man- Figure 20

agement of flat, inverted, large or long nipples. Preparing and using a syringe for treatment
of inverted nipples
K Antenatal treatment is not helpful. If a pregnant
Step one Cut along this line with blade
woman is worried about the shape of her nipples,
explain that babies can often suckle without dif-
ficulty from nipples of unusual shapes, and that
skilled help after delivery is the most important
thing.
K As soon as possible after delivery, the mother
should be helped to position and try to attach her Step Two
baby. Sometimes it helps if the mother takes a dif-
ferent position, such as leaning over the baby, so
that the breast and nipple drop towards the baby’s Insert plunger from cut end
mouth.
Step Three
K The mother should give the baby plenty of skin-to-
skin contact near the breast, and let the baby try to
find his or her own way of taking the breast, which
many do.
Mother gently pulls the plunger
K If a baby cannot attach in the first week or two, the
mother can express her breast milk and feed it by
cup.
K The mother should keep putting the baby to the
breast in different positions, and allowing him however, the reason for a low intake is a faulty tech-
or her to try. She can express milk into the baby’s nique or pattern of feeding. If the breastfeeding tech-
mouth, and touch the lips to stimulate the rooting nique or pattern improves, the baby’s intake increases.
reflex and encourage the baby to open his or her When a baby takes only part of the milk from the
mouth wider. breast, production decreases, but it increases again
K As a baby grows, the mouth soon becomes larger, when the baby takes more.
and he or she can attach more easily. Symptoms which make a mother think that her breast
K Feeding bottles or dummies, which do not encour- milk is insufficient include:
age a baby to open the mouth wide, should be K the baby crying a lot, and seeming not to be satis-
avoided. fied with feeds;
K For flat or inverted nipples, a mother can use a 20 K the baby wanting to feed very often or for a long
ml syringe, with the adaptor end cut off and the time at each feed;
plunger put in backwards to stretch out the nipple
just before a feed (see Figure 20). K the breasts feeling soft;
K not being able to express her milk.
7.10 Perceived insufficiency and low breast-milk
These symptoms can occur for other reasons, and
production
they do not necessarily show that a baby’s intake is
Symptoms: The commonest difficulty that mothers low.
describe is a feeling that they do not have enough milk.
In many cases, the baby is in fact getting all the milk If a mother is worried about her milk supply, it is nec-
that he or she needs, and the problem is the mother’s essary to decide if the baby is taking enough milk or
perception that the milk supply is insufficient. not.
In some cases, a baby does have a low intake of breast If the baby has a low milk intake, then it is necessary
milk, insufficient for his or her needs. Occasional- to find out if it is due to breastfeeding technique, or
ly, this is because the mother has a physiological or low breast-milk production.
pathological low breast-milk production (4). Usually,
If the baby’s intake is adequate, then it is necessary to physical condition; and baby’s condition (illness or
decide the reasons for the signs that are worrying the abnormality).
mother.
Breastfeeding factors
Low breast-milk intake A low breast-milk intake may be due to:
Signs: There are two reliable signs that a baby is not
K delayed initiation of breastfeeding, so that milk
getting enough milk:
production does not adjust in the early days to
K poor weight gain. match the infant’s needs;
K low urine output. K poor attachment, so that the baby does not take the
milk from the breast efficiently;
Passing meconium (sticky black stools) 4 days after
delivery is also a sign of the baby not getting enough K infrequent feeds, feeds at fixed times or no night
milk. feeds, so that the baby simply does not suckle
enough; breastfeeding less than 8 times in 24 hours
Poor weight gain in the first 8 weeks, or less than 5–6 times in 24
Babies’ weight gain is variable, and each child follows hours after 8 weeks;
his or her own pattern. You cannot tell from a single K short feeds, if a mother is very hurried, or if she
weighing if a baby is growing satisfactorily – it is nec- takes the baby off the breast during a pause before
essary to weigh several times over a few days at least he or she has finished, or if the baby stops quickly
(see Annex 3 for tables showing the range of weights for because he is wrapped up and too hot, then he or
babies of different birth weights). she may not take as much milk as needed, espe-
Soon after birth a baby may lose weight for a few days. cially the fat-rich hind milk;
Most recover their birth weight by the end of the first K using bottles or pacifiers which replace suckling at
week, if they are healthy and feeding well. All babies the breast, so the baby suckles less. Babies who use
should recover their birth weight by 2 weeks of age. A pacifiers tend to breastfeed for a shorter period.
baby who is below his or her birth weight at the end of Pacifiers may be a marker or a cause of breastfeed-
the second week needs to be assessed. ing failure (5). They may interfere with attach-
From 2 weeks, babies who are breastfed may gain from ment, so the baby suckles less effectively;
about 500 g to 1 kg or more each month. All these K giving other foods or drinks causes the baby to
weight gains are normal. The baby should be checked suckle less at the breast and take less milk, and also
for illness or congenital abnormality and urine out- stimulates the breast less, so less milk is produced.
put. The technique and pattern of breastfeeding, and
the mother-baby interaction should also be assessed, Psychological factors of the mother
to decide the cause of poor weight gain, as explained
A mother may be depressed, lacking in confidence,
below.
worried, or stressed; or she may reject the baby or
dislike the idea of breastfeeding. These factors do
Low urine output not directly affect her milk production, but can
An exclusively breastfed baby who is taking enough interfere with the way in which she responds to her
milk usually passes dilute urine 6-8 times or more in baby, so that she breastfeeds less. This can result in
24 hours. If a baby is passing urine less than 6 times the baby taking less milk, and failing to stimulate
a day, especially if the urine is dark yellow and strong milk production.
smelling, then he or she is not getting enough fluid.
This is a useful way to find out quickly if a baby is Mother’s physical condition
probably taking enough milk or not. However, it is
A few mothers have low milk production for a patho-
not useful if the baby is having other drinks in addi-
logical reason including endocrine problems (pitui-
tion to breast milk.
tary failure after severe haemorrhage, retained piece
Causes: The reasons for a low breast-milk intake are of placenta) or poor breast development. A few moth-
summarised in Table 9, and classified as breastfeeding ers have a physiological low breast-milk production,
factors; psychological factors with mother; mother’s for no apparent reason, and production does not
Table 9
Reasons why a baby may not get enough breast milk
Breastfeeding factors Mother: Psychological factors Mother: Physical condition Baby’s condition
K Delayed start K Lack of confidence K Contraceptive pill, diuretics K Illness

K Feeding at fixed times K Depression K Pregnancy K Abnormality
K Infrequent feeds K Worry, stress K Severe malnutrition
K No night feeds K Dislike of breastfeeding K Alcohol
K Short feeds K Rejection of baby K Smoking
K Poor attachment K Retained piece of placenta
K Bottles, pacifiers K Pituitary failure (rare)
K Other foods or fluids (water, teas) K Poor breast development (very rare)
These are COMMON These are NOT COMMON
increase when the breastfeeding technique and pat- K suckles for a long time at each feed (more than one
tern improve. half hour, unless newborn or low birth weight);
Other factors that can reduce milk production tem- K is generally unsettled.
porarily include hormone-containing contraceptive
Management of perceived insufficiency and low breast milk
pills, pregnancy, severe malnutrition, smoking and
production: A health worker may use counselling skills
alcohol consumption.
to listen and learn, to take a feeding history and to
understand the difficulty, particularly if there may
Baby’s condition
be psychological factors affecting breastfeeding. A
A baby may fail to gain weight, or may fail to breast- breastfeed should be observed, checking the baby’s
feed well and stimulate milk production because of attachment. The mother’s physical condition and the
illness, prematurity or congenital abnormality, such baby’s condition and weight should also be noted. A
as a palate defect, heart condition or kidney abnor- health worker should decide if the difficulty is due to
mality. It is always important to consider these factors low milk intake, or perceived insufficiency.
and to examine a baby carefully before concluding
that a mother has low breast-milk production. If the difficulty is low milk intake, a health worker
should:
Conclusion K decide the reason for the low milk intake;
The common reasons for a baby not getting enough K treat or refer the baby, if there is any illness or
breast milk are due to poor technique or mismanage- abnormality;
ment of breastfeeding, which can be overcome. Only
a few mothers have long-term difficulty with milk K help the mother with any of the less common caus-
production. es, for example if she is using oestrogen-containing
contraceptive pills. Referral may be necessary;
Perceived insufficiency K discuss how the mother can improve her breast-
Signs: If a baby is gaining weight according to the feeding technique and pattern and improve the
expected growth velocity, and is passing dilute urine 6 baby’s attachment;
or more times in 24 hours, then his or her milk intake K use counselling skills to help her with any psycho-
is adequate. If the mother thinks that she does not logical factors, and to build her confidence in her
have enough milk, then it is perceived insufficiency. milk supply.
Causes: Poor attachment is likely to be the cause if a If the difficulty is perceived insufficiency, the health
baby: worker should:
K wants to feed very often (more often than 2 hour-
K decide the reason;
ly all the time, with no long intervals between
feeds); K explain the difficulty, and what might help;
K discuss how the mother can improve her breast- Management:

feeding technique and pattern, and help her to
K If a specific cause, such as pain or illness, can be
improve the baby’s attachment;
identified, it should be treated.
K if the baby has reflux, suggest that she holds him or
K The mother can try a change in her diet, such as
her in a more upright position;
stopping drinking milk or coffee for a week, to see
K use counselling skills to help the mother with any if there is an improvement.
psychological factors, and to build her confidence
K Holding the baby upright may help reflux, or med-
in her milk supply.
ication may be suggested.
7.11 Crying baby K For colic or a high-needs baby, the mother can
carry and rock the baby with gentle pressure on the
Signs or symptoms: The baby cries excessively, and is
abdomen. She may need reassurance that the cry-
difficult to comfort. The pattern of crying may sug-
ing will lessen as the baby grows.
gest the cause.
Cause: 7.12 Oversupply of breast milk
K Pain or illness. This may be the case when a baby Symptoms:
suddenly cries more than before.
K The baby cries as if he or she has colic and wants to
K Hunger due to sudden faster growth, common at ages feed often.
2 weeks, 6 weeks and 3 months (sometimes called a
K The baby may have frequent loose stools, which
“growth spurt”). If the baby feeds more often for a
may be green.
few days, the breast milk supply increases and the
problem resolves. K He or she may grow well, or may have poor weight
gain, suggesting low milk production.
K Sensitivity to substances from the mother’s food. This
may be any food, but is commonly milk, soy, egg K The mother may have a forceful oxytocin reflex, so
or peanuts. Caffeine in coffee, tea and colas, and that her milk flows fast. This can make the baby
substances from cigarette smoke can also upset a choke and pull away from the breast during feeds.
baby. If the mother avoids the food or drink that Cause:
may be causing the problem, the baby cries less.
K The baby may be poorly attached, and suckling a
K Gastro-oesophageal reflux. The baby cries after lot but not removing the milk efficiently. Constant
feeds, often on lying down, and may vomit a large suckling may stimulate the breast to produce a lot
amount of the feed, more than the slight regurgi- of milk.
tation that is very common. The opening between
the oesophagus and the stomach (cardiac orifice) is K The mother may take her baby off the first breast
weak, allowing milk to flow back into the oesopha- before he or she has finished to put him on the sec-
gus, which can cause pain. ond breast. The baby may get mostly low-fat fore
milk, and suckle more to get more energy, and so
K Colic. Often crying occurs at certain times of day, stimulate the breasts to make more milk.
typically the evening. The baby may pull up his legs
as if in pain. He or she wants to feed but is difficult K Large amounts of foremilk overload the baby
to comfort. The cause is not clear. Babies with colic with lactose, causing loose stools and colicky
usually grow well, and the crying decreases after behaviour.
3–4 months. Carrying the baby more, using a gen- Management:
tle rocking movement, and pressure on the abdo-
men with the hands, or against the shoulder, may K The mother should be helped to improve her baby’s
help. attachment.
K High-needs babies. Some babies cry more than oth- K The mother should offer only one breast at each
ers, and they need to be carried and held more. feed, until the baby finishes by him- or herself. The
This problem is less common in communities baby will get more fat-rich hindmilk. She should
where mothers carry their babies with them, and offer the other breast at the next feed.
keep them in the same bed.
K If a forceful oxytocin reflex continues, she can lie K avoid shaking her breast or pressing the baby’s
on her back to breastfeed, or hold the breast with head to force him or her to the breast;
her fingers closer to the areola during feeds.
K feed the baby by cup, if possible with her own
breast milk, until he or she is willing to take the
7.13 Refusal to breastfeed breast again.
Symptoms: The baby refuses to breastfeed, and may cry,
arch his or her back, and turn away when put to the 7.14 Twins
breast. The mother may feel rejected and frustrated,
Management
and be in great distress.
Twins who are low birth weight need to be managed
Causes: There may be a physical problem such as:
accordingly (see Session 6.1).
K illness, an infection, or a sore mouth, for example
For larger twins, management should be as for single-
thrush (see Session 7.8);
tons, with early contact, help to achieve good attach-
K pain, for example bruising after a traumatic deliv- ment at the breast, and exclusive on-demand feeding
ery or gastro-oesophageal reflux; from birth, or from as soon as the mother is able to
respond. Early effective suckling can ensure an ade-
K sedation, if the mother received analgesics during
quate milk supply for both infants.
labour.
Mothers may need help to find the best way to hold
The baby may have difficulty or frustration with
two babies to suckle, either at the same time, or one at
breastfeeding because of:
a time. They may like to give each baby its own breast,
K sucking on a bottle or pacifier; or to vary the side. Holding one or both babies in the
K difficulty attaching to the breast; underarm position for feeding, and support for the
babies with pillows or folded clothes is often helpful.
K pressure applied to his or her head by someone Building the mother’s confidence that she can make
helping with positioning; enough milk for two, and encouraging relatives to
K the mother shaking her breast when trying to help with other household duties, may help her to
attach him or her. avoid trying to feed the babies artificially.
The baby may be upset by a change in the environ-

7.15 Caesarean section
ment including:
Management
K a changed routine, the mother resuming employ-
ment or moving house; Initiating breastfeeding
Mothers and babies delivered by caesarean section
K a different carer, or too many carers;
can breastfeed normally, unless there is some other
K a change in the mother’s smell – for example, if she complication, such as illness or abnormality.
uses a different soap or perfume.
If the mother has had spinal or epidural anaesthesia,
Management: If a cause is identified, it should be treat- the baby should be delivered onto her chest, and she
ed or removed, if possible. can start skin-to-skin contact and initiate breastfeed-
ing during the first hour in a similar way to that after
The mother could consider how she can reduce the
vaginal delivery.
time she spends away from the baby, or avoid other
changes that may be upsetting. She can be helped If she has had a general anaesthetic, she should start
to improve her breastfeeding technique, and how to skin-to-skin contact and initiate breastfeeding as
avoid the use of bottles and pacifiers. She can also be soon as she is able to respond, usually about 4 hours
helped to: after delivery. A baby who is full term and in good
condition can wait for the first feed until the mother
K keep her baby close, with plenty of skin-to-skin
responds. Babies who are at risk of hypoglycaemia
contact, and no other carers for a time;
may need an alternative feed until they can start
K offer her breast whenever the baby shows signs of breastfeeding (see Session 6.1). Any other feeds should
interest in suckling; be given by cup so that they do not interfere with later
K express milk into the baby’s mouth; establishment of breastfeeding.
Later feeds How to maintain her milk supply

After caesarian section, a mother should continue to She should:
feed her baby on demand, but she will need help for a
K breastfeed her baby whenever she is at home, such
few days to hold the baby, to learn how to breastfeed
as at night and weekends;
lying down, and to turn over and to position herself
comfortably for feeds (see Session 2.11). Hospital staff K sleep with her baby, so that she can breastfeed at
and family members can all help her in this way. night and early in the morning;
Most mothers can breastfeed normally after a caesar- K express milk in the morning before she leaves for
ean delivery if they are given appropriate help. Dif- work;
ficulties in the past have often been because mothers K express her milk while she is at work to keep up
did not receive enough help to establish breastfeeding the supply. She can refrigerate the milk if this is
in the post-operative period, and because babies were possible, or keep it for up to 8 hours at room tem-
given other feeds meanwhile. perature and bring it home. If this is not possible,
If a baby is too ill or too small to fed from the breast she may have to discard it. She needs to understand
soon after delivery, the mother should be helped that the milk is not lost – her breasts will make
to express her milk to establish the supply, starting more. If a mother does not express when at work,
within 6 hours of delivery or as soon as possible, in her milk production will decrease.
the same way as after a vaginal delivery (see Session
4.5). The EBM can be frozen for use when the baby is TEMPORARY SEPARATION FOR OTHER REASONS
able to take oral feeds. A mother and her baby may be separated and unable
If the mother is too ill to breastfeed, the baby should to breastfeed if either of them is ill and admitted to
be given artificial milk or banked breast milk by cup hospital, or if the baby is LBW or has problems at birth
until the mother is able to start breastfeeding. and is in the Special Care Baby Unit (see Session 6.1).
Management
7.16 Mother separated from her baby
While separated, encourage the mother to express
SHORT-TERM SEPARATION SUCH AS EMPLOYMENT OUTSIDE her milk as often as the baby would feed, in order to
THE HOME establish or keep up the supply. If facilities are avail-
The commonest reason for a mother being separated able, she can store her milk by freezing it (see Session
from her baby for part of the day is because she is 4.5). Help the baby to start breastfeeding as soon as he
employed outside the home, for example when mater- or she is able and can be with the mother again.
nity leave is not adequate to enable her to continue
breastfeeding exclusively for 6 months. 7.17 Illness, jaundice and abnormality of the child
Management ILLNESS
Options should be discussed with the mother. She Symptoms related to feeding
should be encouraged to breastfeed the baby as much K The infant may want to breastfeed more often than
as possible when she is at home, and to consider before.
expressing her milk to leave for someone else to give
to her baby. K Local symptoms such as a blocked nose, or oral
thrush can interfere with suckling. The infant may
suckle for only a short time and not take enough
Expressing her milk for the baby
milk.
A trained health worker should teach her how to
express and store her breast milk (see Session 4.5), how K The infant may be too weak to suckle adequately,
to feed her baby by cup (Session 4.6), and why it is best or may be unable to suckle at all.
to avoid using a feeding bottle. K During surgery an infant may not be able to receive
any oral or enteral feeds.
Management: Infants and young children who are ill
should continue to breastfeed as much as possible,
while they receive other treatment. Breast milk is the and to feed her infant using supplementary suckling
ideal food during illness, especially for infants less to stimulate breast-milk production (see Session 6.4).
than 6 months old, and helps them to recover. With appropriate skilled support, many mothers can
resume exclusive breastfeeding within 1–2 weeks.
Babies under 6 months of age
If a baby is in hospital, the mother should be allowed Infants and young children over 6 months of age
to stay with him or her, and to have unrestricted A young child may prefer breastfeeding to comple-
access so that she can respond to and feed the baby mentary foods while he or she is ill, and breastfeed
as needed. more than before. Milk production may increase,
so that the mother notices increased fullness of her
If a baby has a blocked nose breasts. She should be encouraged to stay with her
The mother can be taught how to use drops of salt- child in hospital and to breastfeed on demand.
ed water or breast milk, and clear the baby’s nose by The mother or caregiver should continue to offer
making a wick with a twist of tissue. She can give complementary foods, which may need to be given
shorter more frequent breastfeeds, allowing the baby more often, in smaller quantities and of a softer con-
time to pause and breathe through the mouth until sistency than when the child is well. Offer extra food
the nose clears. during recovery as the child’s appetite increases.
If a baby has a sore mouth because of thrush (Candida) JAUNDICE

The mother’s nipple and the baby’s mouth should Symptoms
both be treated with gentian violet or nystatin (see
Session 7.8). Early jaundice appears between 2 and 7 days of life.
It is usually physiological, and clears after a few days.
If a baby is not able to breastfeed adequately, but can take oral Jaundice can make a baby sleepy so that he or she suck-
or enteral feeds les less. Early initiation of breastfeeding and frequent
breastfeeding reduce the severity of early jaundice.
The mother can express her milk (see Session 4.5). She
should express as often as the baby would feed, that Prolonged jaundice starts after the seventh day of life
is 8 times in 24 hours, to keep up her milk supply. and continues for some weeks. It is usually due to hor-
The mother can feed her EBM to the baby by cup or mones or other substances in the mother’s milk, so it
nasogastric tube or syringe. She should be encouraged is sometimes called “breast-milk jaundice” which is
to let the baby suckle whenever he or she wants to. harmless and clears by itself. If the jaundice is due to
a more serious condition there are usually other signs,
If a baby is not able to take any oral or enteral feeds such as pale stools, dark urine, or enlarged liver and
spleen.
The mother should be encouraged to continue
expressing to keep up her milk supply. Her expressed Management
milk can be stored safely and given to the baby as
soon as he or she starts enteral feeds. She can resume Early jaundice
breastfeeding as the baby recovers. She may be able Water and glucose water do not help, and may make
to freeze unused milk for later use. If the hospital a baby suckle less at the breast. Taking more breast
has milk-banking facilities, the milk may be used for milk helps jaundice to clear more quickly, so the
another child. mother should be encouraged to breastfeed as often
as her baby is willing. She can also express her milk
If breast-milk production decreases during an illness after feeds and give some extra by cup or tube. If she is
feeding her baby on expressed breast milk, she should
A decrease in production is especially likely if a moth-
give 20% extra. If jaundice is severe, phototherapy
er has breastfeeding difficulties or if she has given
(light treatment) may be needed.
inappropriate supplements. Feeding difficulties and
supplements may have contributed to the infant’s
illness, and are an important cause of malnutrition. Prolonged jaundice
The mother needs help to increase her milk supply The baby should be referred for clinical assessment,
again. The mother should be encouraged to relactate, to exclude a serious condition. The mother should
continue breastfeeding until the infant has been fully This is effective and can now be done simply and
assessed. safely (6).
ABNORMALITIES Muscular weakness

Symptoms The mother should be shown how to help the baby to
attach to the breast by using the dancer hand position
Cleft lip and/or palate: attachment and suckling may
(Figure 21). She supports the baby’s chin and head to
be difficult because of the anatomical gap. If only
keep the mouth close on to the breast. These babies
the lip is affected, the breast covers the cleft, and the
may feed slowly, and it may be necessary for the
baby may be able to suckle effectively. Sometimes a
mother to express her milk and give some feeds by
baby with a cleft palate can suckle quite well, if there
cup or tube. The mother will need extra support and
is enough palate for the tongue to press the nipple
counselling to bond with her baby, to feel that she is
against.
doing the best for him or her, and to persist.
Tongue-tie: the strip of tissue underneath the tongue,
called the frenulum, is too short and holds the tongue
Figure 21
down. This can make attachment difficult, which may Dancer hand position
cause sore nipples. The baby may not suckle effective-
ly and may have a low intake of breast milk.
Muscular weakness: babies with Down syndrome or
cerebral palsy have difficulty attaching to the breast
and suckling because of the weakness.
Congenital heart or kidney problems: a baby fails to
grow, but there is no apparent difficulty with breast-
feeding or breast-milk supply. These abnormalities
are not obvious, and require careful examination of
the baby.
Heart, kidney or other abnormalities
Management
Consider these possibilities in a baby who fails to
Cleft lip and/or palate grow despite good breastfeeding practices. Examine
The baby should be referred for surgery, which usually the baby carefully, and refer for further assessment.
takes place in one or more stages after some months.
It is important for the baby to grow and to be well References
nourished before undergoing surgery.
1. WHO. Evidence for the Ten Steps to successful
The mother can be helped to hold the baby in an breastfeeding. Geneva, World Health Organiza-
upright sitting position at the breast with the baby’s tion, 1998.
legs on either side of the mother’s thigh. This makes
2. WHO. Mastitis: causes and management. Geneva,
swallowing easier and may help the baby to breast-
World Health Organization, 2000 (WHO/FCH/
feed, fully or partially. She can express her milk and
CAH/00.13).
feed it to the baby by cup or spoon until surgical help
is available, or an orthopaedic device is provided to 3. Mohrbacher N, Stock J. The breastfeeding answer
facilitate breastfeeding. book, 3rd revised ed. Schaumburg, Illinois, USA,
La Leche League International, 2003 (http://www.
The family may need a great deal of support and help
lalecheleague.org, accessed 4 November 2008).
to accept the baby, to persist with feeding, and to
believe that the baby will look almost normal and will 4. Woolridge, MW. Breastfeeding: physiology into
be able to lead a normal life if he or she has surgery. practice. In: Davies DP, ed. Nutrition in child
health. London, Royal College of Physicians of
Tongue-tie London, 2003.
If tongue-tie is causing problems with feeding, the 5. Kramer MS et al. Pacifier use, early weaning, and
baby will need referring for cutting of the frenulum. cry/fuss behavior: a randomized controlled trial.
Journal of the American Medical Association, 2001,

286:322–326.
6. Hogan M, Westcott C, Griffiths M. Randomized
control trial of division of tongue-tie in infants
with feeding problems. Journal of Paediatrics and
Child Health, 2005, 41: 246–250.
Mother’s health
Session 8
When counselling a mother on infant and young take enough food to cover any extra needs. However,
child feeding, it is important to remember her own a woman with a poor diet may not have laid down
health, and care for her as well as the baby. Issues to body stores in pregnancy. She needs to eat an extra
address include any illness she may have, her nutri- meal with a variety of foods each day to cover her
tional status and food intake, maternal medication, needs and protect those stores that she has.
and birth spacing and family planning.
It is generally helpful to advise the woman to eat a
greater amount and variety of foods, such as meat,
8.1 Mother’s Illness fish, oils, nuts, seeds, cereals, beans, vegetables, cheese
If a mother has an illness or other condition, it is and milk, to help her feel well and strong. It is impor-
important to consider what effect it might have on tant to determine if there are taboos about foods, and
breastfeeding. She may need extra support to enable to advise against any harmful taboos. Pregnant and
her to breastfeed, for example if she has a disability, lactating women can eat any foods normally included
or is mentally ill. If a mother is very ill and unable in the local diet – these will not harm the breastfeed-
to breastfeed, options for feeding her infant or child ing baby. Very thin women and adolescents require
until she can resume will need to be considered. special attention, and they may need more intensive
nutrition counselling. Family members, such as the
If a mother has tuberculosis, she and her infant should
partner and mother-in-law, also influence a mother’s
be treated together according to national guidelines,
feeding practices. They can help to ensure that the
and breastfeeding should continue (1).
woman eats enough and avoids hard physical work.
If a mother has hepatitis (A, B, or C) breastfeeding
If extra food is not available, this should not prevent
can continue normally as the risk of transmission by
a mother from breastfeeding. Even when a woman
breastfeeding is very low (2).
is moderately malnourished, she continues to pro-
If a mother is HIV-positive, she needs counselling duce good quality breast milk. Only when a woman
about different feeding options and support for her is seriously malnourished does the quantity of breast
choice (see Session 6.5). milk decrease. Where household resources are scarce,
breast milk is likely to be the most complete and safest
8.2 Maternal nutrition (3) food for the baby, and breastfeeding the most efficient
During lactation, a mother’s intake should be way for the mother to use her own and her family’s
increased to cover the energy cost of breastfeeding: resources to feed the child.
by about 10% if the woman is not physically active, Mothers with specific micronutrient deficiencies may
but 20% or more if she is moderately or very active. A need supplements of fortified products both for their
diet that is poor in quantity or quality may affect her own health and that of their breastfeeding infants.
energy and ability to breastfeed or to feed and care
for her infant or child. In practice, a lactating mother 8.3 Medication and drugs (4)
uses about 500 kilocalories (roughly equivalent to one
Some medications taken by a mother may pass into her
extra meal) each day to make 750 ml of breast milk
milk. There are very few medicines for which breast-
for an infant. Some nutrients come from her body
feeding is absolutely contra-indicated. However there
stores, laid down during pregnancy. Others need to
are some medicines that can cause side-effects in the
come from an increased intake.
baby – they may warrant use of a safer alternative or
A woman who is well nourished with a varied diet avoidance of breastfeeding temporarily. Table 10 pro-
and who eats according to her appetite will usually vides a guidance for medicines listed in the Eleventh
Table 10
Breastfeeding and mother’s medication
Breastfeeding contraindicated Anticancer drugs (antimetabolites);

Radioactive substances (stop breastfeeding temporarily)
Continue breastfeeding
Side-effects possible Selected psychiatric drugs and anticonvulsants (see individual drug)
Monitor baby for drowsiness
Use alternative drug if possible Chloramphenicol, tetracyclines, metronidazole, quinolone antibiotics (e.g. ciprofloxacin)
Monitor baby for jaundice Sulfonamides, dapsone,
sulfamethoxazole+trimethoprim (cotrimoxazole),
sulfadoxine+pyrimethamine (fansidar)
Use alternative drug Estrogens, including estrogen-containing contraceptives, thiazide diuretics, ergometrine
(may inhibit lactation)
Safe in usual dosage Most commonly used drugs:
Monitor baby
Analgesics and antipyretics: short courses of paracetamol, acetylsalicylic acid, ibuprofen;
occasional doses of morphine and pethidine.
Antibiotics: ampicillin, amoxicillin, cloxacillin and other penicillins, erythromycin,
Antituberculosis drugs, anti-leprosy drugs (see dapsone above)
Antimalarials (except mefloquine, fansidar)
Anthelminthics, antifungals
Bronchodilators (e.g. salbutamol), corticosteroids, antihistamines, antacids, drugs for diabetes,
most antihypertensives, digoxin
Nutritional supplements of iodine, iron, vitamins
WHO Model List of Essential Drugs (4), while Annex 1 ovulation, and so delay the return of menstruation
includes an additional summary of medicines with and fertility after childbirth (see Session 2.5). This is
side-effects. called the Lactation Amenorrhoea Method (LAM),
and all mothers of infants and young children should
8.4 Family planning and breastfeeding know about it. They also need to know the limita-
The harmful effects of pregnancies too close together tions of LAM, including when they are not protected
are well recognized. Birth-to-pregnancy intervals of against pregnancy, even if they are breastfeeding.
6 months or shorter are associated with a higher risk LAM is effective under the following three conditions
of maternal mortality. Birth-to-pregnancy intervals of (see Box 18):
around 18 months or less are associated with a signifi-
The mother must be amenorrhoeic – that is, she must
cantly higher risk of neonatal and infant mortality, low
not be menstruating. If she menstruates, it is a sign
birth weight, small size for gestational age and preterm
that her fertility has returned, and she can become
birth. Couples should be advised to wait at least 24
pregnant again.
months after a live birth and 6 months after a miscar-
riage before attempting the next pregnancy (5). The baby must breastfeed exclusively,1 and feed fre-
quently during both day and night. If the baby has
8.4.1 Lactational Amenorrhoea Method (6,7) any artificial feeds, or complementary food, then he
Breastfeeding is an important method of family
planning, because it is available to women who are 1
Evidence shows that LAM remains effective even if a baby is
unable for social or other reasons to obtain or use fully or nearly fully breastfed (meaning that the child may have
received vitamins, minerals, water, juice or ritualistic feeds
modern contraceptives, and it is under their control. infrequently in addition to breastfeeds), as long as the vast
Hormones produced when a baby suckles prevent majority of feeds are breastfeeds
8. Mother’s health 79
or she suckles less, and the mother may ovulate. If Box 18

there is a gap of 6 hours or more between breastfeeds,
ovulation may occur. Lactational amenorrhoea method
The baby must be less than 6 months old. After 6 No other method Use another method if:
months, a woman is more likely to be fertile, even needed if:
if she has not started to menstruate. After this age, K No menstruation K Menstruation has returned
babies should have complementary food, and they AND OR
suckle less often.
K Baby LESS than K Baby MORE than
If these three conditions are met, then a woman’s risk 6 months old 6 months old
of becoming pregnant is less than 2%, which is as reli-
AND OR
able as other family planning methods. It is not nec-
essary to use another method for contraception. Even K Baby exclusively K Other foods and fluids
after 6 months, if she has not menstruated and the breastfed have been introduced
baby is still breastfeeding frequently, she is partially
protected. This can be useful if she cannot use anoth-
er method. However, if she menstruates at any time,
then she is not protected at all. If she wishes to avoid Hormonal methods can have an effect on lactation, and
pregnancy she should start another method imme- reduce breast-milk production. None should be used
diately. A few women do start to menstruate 2 or 3 within 6 weeks of delivery.
months after delivery, even though they are breast-
Progestogen-only methods such as depo-provera, nor-
feeding exclusively.
plant and progestogen-only pills can be used from 6
Women should use another family planning method weeks after delivery.
from 6 months if they want to be sure that they do not
Combined oestrogen-progesterone methods such as
conceive. It is also recommended that a woman use
the “combined pill” or the monthly injection are
another method if she does not want to rely on exclu-
the least suitable, as they may sometimes reduce a
sive breastfeeding – for example, if she has to go back
mother’s milk supply even after 6 weeks. It is better
to work and cannot breastfeed her baby while she is
to avoid them altogether if possible. However, if no
away from home. If she is not exclusively breastfeed-
other method is available, then it is better for both
ing, she should start another method of family plan-
mother and child if she uses the combined pill than
ning no later than 6 weeks after delivery, at her final
if she risks an early pregnancy. Encourage her to con-
postnatal check.
tinue breastfeeding frequently, to make sure that her
While LAM will protect a woman against pregnancy, breast-milk production does not decrease.
it will not protect her against HIV infection. Depend-
ing on the woman’s circumstances, it may be advis- References
able for her to ask her partner to use condoms, or for 1. WHO. Implementing the WHO Stop TB strategy:
her to use female condoms for additional protection. a handbook for national tuberculosis control pro
grammes. Geneva, WHO, 2008 (WHO/HTM/
8.4.2 Other methods of family planning when breastfeeding TB/2008.401).
It is important to discuss other methods of family
2. Lawrence R. Given the benefits of breastfeeding,
planning with breastfeeding mothers, as well as LAM,
what contraindications exist? Pediatric Clinics of
and to help them to choose a suitable method.
North America, 2001, 48(1):235–251.
Non-hormonal methods are all suitable. They have no
3. WHO, UNFPA, UNICEF, World Bank. Integrated
effect on lactation.
Management of Pregnancy and Childbirth: preg-
K Intra Uterine Devices are very suitable. nancy, childbirth, postpartum and newborn care: a
guide for essential practice, 2nd ed. Geneva, World
K Condoms, diaphragms and spermicides are suitable,
provided a couple can use them correctly. They
may help to supplement the partial protection by 4. WHO, UNICEF. Breastfeeding and maternal med-
breastfeeding after the baby is 6 months old. ication: recommendations for drugs in the eleventh
WHO model list of essential drugs. Geneva, World Health Organization Task Force on Methods for
Health Organization, 2003. the Natural Regulation of Fertility. Fertility and
Sterility, 1999, 72(3):431–440.
5. WHO. Report of the WHO consultation on birth
spacing: 13–15 June 2005. Geneva, World Health 7. Labbok M et al. Guidelines: breastfeeding, family
Organization, 2006. planning and the lactational amenorrhoea meth-
od. Washington DC, Institute for Reproductive
6. The World Health Organization Multinational
Health, 1994.
Study of Breast-feeding and Lactational Amenor-
rhea. III. Pregnancy during breast-feeding. World
Policy, health system and
Session 9
community actions
The Global Strategy for Infant and Young Child Feeding K Ensure that the health and other relevant sectors
(1) is the overarching framework for action by gov- protect, promote and support exclusive breastfeed-
ernments and all concerned parties to ensure that the ing for 6 months and continued breastfeeding up
health and other sectors are able to protect, promote to 2 years of age or beyond, while providing women
and support appropriate infant and young child feed- access to the support they require – in the family,
ing practices. The Global Strategy was endorsed unan- community and workplace – to achieve this goal;
imously by WHO Member States in the 55th World
K Promote timely, adequate, safe and appropriate
Health Assembly in 2002 and adopted by UNICEF’s
complementary feeding with continued breast
Executive Board in the same year.
feeding;
The Global Strategy reaffirms and builds on the Inno-
K Provide guidance on feeding infants and young
centi Declaration on the Protection, Promotion and
children in exceptionally difficult circumstances,
Support of Breastfeeding that was adopted in 1990 and
and on the related support required by mothers,
revitalized in 2005. It identifies four operational tar-
families and other caregivers;
gets (2):
K Consider what new legislation or other suitable
K Appoint a national breastfeeding co-ordinator
measures may be required, as part of a comprehen-
with appropriate authority, and establish a multi-
sive policy on infant and young child feeding, to
sectoral national breastfeeding committee com-
give effect to the principles and aim of the Code.
posed of representatives from relevant government
departments, non-governmental organisations To implement the Global Strategy, actions at interna-
(NGOs) and health professional associations; tional, national and local level are needed to:
K Ensure that every facility providing maternity serv- K Strengthen policies and legislation to protect infant
ices fully practises all of the “Ten steps to success- and young child feeding;
ful breastfeeding” set out in the WHO/UNICEF K Strengthen health system and health services to
statement on breastfeeding and maternity services support optimal infant and young child feeding;
(3);
K Strengthen actions to promote and support optimal
K Give effect to the principles and aim of the Inter- infant and young child feeding practices within
national Code of Marketing of Breast-milk Sub- families and communities.
stitutes and subsequent relevant Health Assembly
resolutions in their entirety (4);
9.1 Strengthening national policies and
K Enact imaginative legislation protecting the breast- legislation
feeding rights of working women and establishing A primary obligation of governments is to formulate,
means for its enforcement (5). implement, monitor and evaluate a comprehensive
The Global Strategy includes five additional targets, national policy on infant and young child feeding
namely: (see Figure 22), to ensure a better use of resources and
coordination of efforts.
K Develop, implement, monitor and evaluate a
comprehensive policy on infant and young child Internationally recognized policy instruments to pro-
feeding, in the context of national policies and mote, protect and support optimal infant and young
programmes for nutrition, child and reproductive child feeding practices include the:
health, and poverty reduction; K United Nations Convention on the Rights of the
Child (CRC)
Figure 22
Elements of a comprehensive infant and young feeding programme
POLICY
K National coordinator and coordinating body
for infant and young child feeding
K Health system norms
K Code of marketing of breast-milk substitutes
K Worksite laws and regulations
K Information, education and communication
Health Services Community

K Pre-service curriculum reform K Community participation
K Baby-friendly Hospital Initiative K Training and supervision of counselling network
K In-service training K Community education
K Supportive supervision
K Information, education and communication

K Referral and counter referral
K Health information systems
K Monitoring, research and evaluation
(Source: Wellstart International, 1996)
K International Code of Marketing of Breast-milk Sub- the advantages of breastfeeding”. The CRC is an
stitutes, and subsequent relevant WHA resolutions important tool to hold governments to account on
progress in the area of infant and young child feeding.
K International Labour Organization (ILO) Maternity
The periodic review and reporting process also pro-
Protection Convention 2000 (183).
vides an entry point for making recommendations to
strengthen national plans and actions in the area of
9.1.1 Convention on the Rights of the Child
infant and young child feeding.
The CRC is an instrument for protecting and ful-
filling the rights of children (6). It was adopted by
United Nations member states almost universally in 9.1.2 International Code of Marketing of Breast-milk
November 1989, and countries which have agreed to Substitutes and subsequent relevant Health Assembly
it (also referred to as States Parties) are required to resolutions – the Code
report regularly to the United Nations about progress The Code was adopted by WHO Member States in
in implementation. 1981 in response to the realization that wide-spread
marketing of breast-milk substitutes was leading to
Article 24 of the CRC addresses child health and
adverse health outcomes in infant and young children
nutrition, and some quotations are particularly rel-
all over the world (4). Progress in the implementa-
evant. States Parties agree to “take appropriate meas-
tion of the Code is reported every alternate year in the
ures to diminish infant and child mortality”, and “to
World Health Assembly (WHA), and through this
combat disease and malnutrition … through the pro-
process, a series of resolutions to further clarify the
vision of adequate nutritious foods and clean drink-
Code have been adopted by WHO Member States.
ing water”; and to “ensure that all segments of society,
particularly parents and children, are informed, have Manufacturers of infant formula often promote and
access to education and are supported in the use of market their products in ways which encourage moth-
basic knowledge of child health and nutrition, and ers and health workers to believe that breastfeeding
9. Policy, health system and community actions 83
and artificial feeding are equivalent. This under- and their children. This consensus is reflected in the
mines mothers’ confidence in breast milk and in their international labour standards of the ILO, which set
ability to breastfeed according to global recommen- out basic requirements of maternity protection at
dations. The Code seeks to regulate the marketing of work. ILO Maternity Protection Convention No. 183,
breast-milk substitutes, including infant formula and adopted by ILO Member States in 2000 (5), covers:
other milk products, foods and drinks, and bottle-
K 14 weeks of maternity leave, including 6 weeks of
fed complementary foods, when they are presented as
compulsory postnatal leave;
replacements for breast milk. The Code also seeks to
regulate the marketing of feeding bottles and teats. K cash benefits during leave of at least two thirds of
previous or insured earnings;
The Code addresses the quality and availability of the
products, and information concerning their use. It K access to medical care, including prenatal, child-
provides recommendations concerning the market- birth and postnatal care, as well as hospitalization
ing of industrially-prepared complementary foods, when necessary;
encouraging the use of locally-available foods. Thus K health protection: the right of pregnant and nurs-
the Code does not seek to ban products, but to control ing women not to perform work prejudicial to their
promotion that may influence families to use them health or that of their child;
when they are not needed.
K breastfeeding: minimum one daily break, with pay;
Health workers have important responsibilities to
K employment protection and non-discrimination.
comply with the provisions of the Code (7). For exam-
ple, health care facilities should not be used for the Few countries have ratified this Convention, although
purpose of promoting or displaying infant formula or many countries have adopted some provisions
other products within the scope of the Code. If prepa- through ratification of previous ILO maternity pro-
ration of formula feeds has to be demonstrated, this tection conventions. Health professionals have an
should be done only by trained health workers and important role to advocate for good legislation on
only to mothers or family members who need to use maternity protection, and hospitals and other health
formula, or who have made an informed decision to facilities should offer maternity leave and breastfeed-
do so. Health workers should explain clearly the dan- ing support for their own personnel.
gers of using the products.
9.2 Strengthening the health system and
Health facility administrators and staff need to
health services
understand and fulfil their responsibilities under the
Code. These include: Health workers have a critical role in protecting,
promoting and supporting infant and young child
K to encourage and protect breastfeeding; feeding. The advice given by health workers has been
K not to accept financial or material inducements to identified as one of the key determinants influencing
promote these products; mothers’ feeding practices. Health workers therefore
should have the necessary knowledge and skills to
K not to give samples of infant formula to pregnant
counsel caregivers and help them overcome feeding
women, mothers of infants and young children, or
difficulties when they occur. They should comply
members of their families.
with the Code and ensure that breast-milk substitutes
The fact that HIV can be transmitted through breast are not displayed in the health facility but only intro-
milk should not undermine efforts to implement the duced to those mothers and babies who need them.
Code. HIV-positive mothers, as all women, need to be To protect, promote and support optimal infant and
protected from commercial promotion of infant for- young child feeding, health services should:
mula and other products, and to remain free to make
an informed decision regarding infant feeding. The K Adhere to the Code and maternity protection legis-
Code fully covers their needs. lation for their own workers;
K Implement and maintain the BFHI (see Session 4);
9.1.3 ILO Maternity Protection Convention, 2000 (No. 183) K Ensure that health workers are trained and sup-
Maternity protection at work is essential for safe- ported to provide breastfeeding counselling and
guarding the health and economic security of women complementary feeding counselling (see Session 5);
K Implement the IMCI strategy; K control of iodine deficiency disorders.

K Integrate infant and young child feeding sup- These actions should be implemented at all critical
port with other health care activities, for exam- times when mothers and children have contact with
ple, as promoted in the Essential Nutrition Actions health services, including during:
approach;
K antenatal care;
K Provide support for caregivers and children in
K labour, delivery and immediate post-partum care;
exceptionally difficult circumstances, including
cases of low birth weight and malnutrition, in K postnatal care and family planning;
emergency situations, and for those living with K immunization;
HIV (see Session 6).
K growth monitoring and promotion;
9.2.1 Integrated Management of Childhood Illnesses K well-baby and sick child visits.
WHO and UNICEF developed the IMCI strategy The ENA approach is a useful complement to IMCI
to reduce child mortality and promote the healthy and may guide programme planning and manage-
growth and development of children (8). The IMCI ment for infant and young child feeding at various
strategy combines preventive and curative interven- levels.
tions to combat the major causes of child mortality. It
promotes a continuum of care by focusing on actions
9.3 Strengthening family and community
in the health system and at the family and commu-
practices
nity levels.
The support that mothers receive in their families
IMCI includes the promotion of appropriate feed- and communities also greatly influences their ability
ing practices among both healthy and sick children. to adequately feed their infants and young children.
In countries where IMCI has been evaluated, feeding When mothers live in an environment in which exclu-
practices improved, and children showed less growth sive breastfeeding is the norm, they will be less likely to
faltering (9,10). IMCI is an important delivery strat- introduce other foods or fluids too early. Activities to
egy for infant and young child feeding interventions create a breastfeeding culture and ensure that moth-
through which many children can be reached and ers, other caregivers and the wider community have
coverage improved. knowledge and skills about appropriate infant and
young child feeding practices is therefore essential as a
9.2.2 Essential Nutrition Actions complement to a supportive health system (12).
While IMCI focuses on child health services, the Appropriate actions in the community that can be
Essential Nutrition Actions (ENA) approach promotes carried out in partnership with the health sector
integration of concise nutrition messages and inter- include:
ventions into multiple entry points in the health care
system (11). K behaviour change communication;
The ENA approach promotes seven essential nutri- K training and support of community health workers;
tion actions: K training and support of lay or peer counsellors;
K exclusive breastfeeding from birth to 6 months; K fostering breastfeeding support groups.
K appropriate complementary feeding from 6 months
with continued breastfeeding up to 24 months or 9.3.1 Behaviour change communication
beyond; Mothers do not make infant or young child feeding
K appropriate feeding of infants and young children decisions alone. Other people in the family and com-
during and after illness; munity influence them. To improve practices, a com-
munication strategy must address the beliefs of these
K adequate nutrition of women; other people, so that there is a change in family and
K control of vitamin A deficiency; community norms.
K control of anaemia through iron supplementation When developing a communication strategy, it is use-
and de-worming of women and children; ful to understand the stages of an individual person’s
change. A person often moves from pre-awareness of birth to at least one child and breastfed successfully.
a recommended practice to awareness, contemplation Lay counsellors may not have so much in common
of trying the new practice, trial of the practice, adop- with those whom they help, and may not have breast-
tion of the practice, maintenance, and finally advo- feeding experience. However, both can be effective if
cacy of the new practice (13). committed and well trained. They may provide indi-
vidual counselling, visit the homes of pregnant or
When communicators understand this process, they
breastfeeding women, lead support groups, give talks
can identify the stage of their target group, and then
to community groups, or work alongside a commu-
can design a strategy to move them to the next stage.
nity health worker in a health facility.
For someone in the “pre-awareness” stage, the most
important need is information. If a person is con- Peer and lay counsellors can be trained in necessary
templating trying out what he or she has learned, skills using local adaptations of the courses developed
it is useful to encourage him or her, and to provide for health workers (18). They need an on-going con-
opportunities to try it. If a person is already trying nection to someone who can support them to sustain
a new practice, the health workers should emphasise their efforts, and to whom they can refer difficult cas-
the benefits and help him or her to overcome resist- es. This support may be a health worker or a health
ance from family or community, through home visits facility, or a NGO.
and support groups.
9.3.4 Fostering breastfeeding support groups
Moving from one stage of change to another requires
a mixture of communication approaches, including Breastfeeding support groups, or mother-to-mother
mass, electronic and print media; community advo- support groups, enable mothers to encourage and assist
cacy and events; and interpersonal communication each other to establish and sustain breastfeeding (19).
(community groups, individual counselling, mother- They can also support appropriate complementary
to-mother support groups and home visits). These feeding. A hospital that is designated Baby-friendly is
approaches need to be directed towards mothers and required, when discharging a mother, to refer her to
family members, community leaders, and others who a breastfeeding support group, if there is one nearby,
are influential in the community. and to foster and promote the establishment of such
groups (see Step 10 in Session 4.7).
9.3.2 Training and support of community health workers Group meetings are led by members with experi-
Community health workers can be important agents ence and some training, but depend on a sense of
of change in a community and provide services to equality and acceptance, which encourages moth-
support infant and young child feeding (14). How- ers to share experiences, ask questions and help each
ever, to do so effectively they need to be trained in other in a familiar, non-threatening community set-
the requisite knowledge and skills, and be supported ting. Breastfeeding support groups can be initiated
by supervisors and more highly-skilled health work- by health workers from primary and referral level
ers to practise accordingly. WHO and UNICEF have facilities, community health workers, or lay or peer
developed several courses that can be used for such counsellors.
training (15,16). Research shows that infant and
young child feeding counselling provided by commu- 9.3.5 Health workers’ roles in supporting community-based
nity health workers can improve caregiver knowledge approaches
and practices and lead to improved health outcomes Involvement of the health sector is necessary for
including child growth. community-based approaches to succeed (12). Health
workers’ supporting roles include:
9.3.3 Training and support of lay and peer counsellors
K Helping with the training of lay or peer counsel
Health workers often do not have enough time to lors;
provide all the help that mothers and families need.
Peer and lay counsellors can extend the reach of K Providing feedback to lay or peer counsellors when
health services, and provide more easily-accessible they refer infants with feeding difficulties;
infant and young child feeding counselling (17). Peer K Initiating and participating in breastfeeding sup-
counsellors have a similar background to those whom port group meetings to provide information and
they help; they typically are women who have given discuss appropriate feeding practices;
K Encouraging women’s groups formed for other rea- References

sons, such as micro-enterprise, community serv- 1. WHO. The Global strategy for infant and young
ice, or for economic, social, political or religious child feeding. Geneva, World Health Organization,
reasons, to include support for optimal infant and 2002.
young child feeding in their activities;
2. UNICEF, WHO, WABA et al. Innocenti declara-
K Participating in other community activities where tion on infant and young child feeding. New York,
appropriate infant feeding can be promoted (such UNICEF, 2005.
as health fairs, community meetings and radio
programmes); 3. WHO, UNICEF. Protecting, promoting and sup-
porting breastfeeding: the special role of maternity
K Protecting, promoting and supporting appropri- services. A joint WHO/UNICEF statement. Gene-
ate feeding practices whenever they are in contact va, World Health Organization, 1989.
with mothers, caregivers or families.
4. WHO. The international code of marketing of
9.4 Assessing progress in coverage of effective breast-milk substitutes. Geneva, World Health
interventions Organization, 1981.
In 2008, WHO and partners issued a set of indicators 5. ILO. Maternity protection convention No. 183. Gene-
for assessing infant and young child feeding practices va, International Labour Organization, 2000.
(20). The indicators are intended for use in large-scale 6. United Nations. Convention on the rights of the
population-based surveys such as Demographic and child. New York, United Nations, 1989.
Health Surveys, and Multiple Indicator Cluster Sur-
veys. They provide information on key dimensions 7. WHO. International code of marketing of breast-
of appropriate infant and young child feeding, in milk substitutes: frequently asked questions. Gene-
accordance with the Guiding principles for comple- va, World Health Organization, 2006.
mentary feeding of the breastfed child (21) and the 8. WHO, UNICEF. Integrated management of child-
Guiding principles for feeding non-breastfed chil- hood illness: chartbook and training course. Geneva,
dren 6–23 months of age (22). A summary list of the World Health Organization, 1995.
core indicators and their definitions is in Annex 4. In
addition to population-based coverage data, periodic 9. Santos I et al. Nutrition counseling increases
assessment of quality care in health facilities (23) and weight gain among Brazilian children. Journal of
of progress towards the attainment of the operational Nutrition, 2001, 131(11):2866–2873.
targets defined by the Global Strategy is also impor- 10. Zaman S, Ashraf RN, Martines J. Training in
tant to increase the proportion of infants and young complementary feeding counselling of health care
children who are reached by effective feeding inter- workers and its influence on maternal behaviours
ventions (24). and child growth: a cluster-randomized trial in
Lahore, Pakistan. Journal of Health, Population
and Nutrition, 2008, 26(2):210–222.
11. WHO, UNICEF, BASICS. Nutrition essentials: a
guide for health managers. Geneva, World Health
Organization, 1999.
12. WHO. Community-based strategies for breastfeed-
ing promotion and support in developing countries.
13. Prochaska JO, DiClemente CC. Transtheoreti-
cal therapy toward a more integrative model of
change. Psychotherapy: Theory, Research and Prac-
tice, 1982, 19(3): 276–287.
14. Bhandari N et al. An educational intervention
to promote appropriate complementary feed-
ing practices and physical growth in infants and
young children in rural Haryana, India. Journal of 20. WHO, IFPRI, UC Davis, FANTA, USAID,
Nutrition, 2004, 134:2342–2348. UNICEF. Indicators for assessing infant and young
child feeding practices. Part I. Definitions. Geneva,
15. WHO, UNICEF. Breastfeeding counselling: a train-
World Health Organization, 2008.
ing course. Geneva, World Health Organization,
1993. 21. PAHO/WHO. Guiding Principles for complemen-
tary feeding of the breastfed child. Washington DC,
16. WHO, UNICEF. Infant and young child feeding
Pan American Health Organization, 2003.
counselling: an integrated course. Geneva, World
Health Organization, 2007. 22. WHO. Guiding Principles for feeding non-breastfed
children 6–23 months of age. Geneva, World Health
17. Haider R et al. Effect of community-based peer
Organization, 2005.
counsellors on exclusive breastfeeding practices
in Dhaka, Bangladesh: a randomized controlled 23. WHO/UNICEF. Indicators for assessing health
trial. Lancet, 2000, 356:1643–1647 facility practices that affect breastfeeding. Gene-
va, World Health Organization, 1993 (WHO/
18. Haider R et al. Training peer counsellors to pro-
CDR/93.1, UNICEF/SM/93.1)
mote and support exclusive breastfeeding in
Bangladesh. Journal of Human Lactation, 2002, 24. WHO/LINKAGES. Infant and young child feeding:
18:7–12. a tool for assessing national practices, policies and
programmes. Geneva, World Health Organization,
19. de Maza IC et al. Sustainability of a community-
2003
based mother-to-mother support project in peri-
urban areas of Guatemala City: La Leche League
study. Arlington, Virginia, BASICS, 1997.
89
Annex 1
Acceptable medical reasons for use of

breast-milk substitutes1
Introduction INFANT CONDITIONS
Almost all mothers can breastfeed successfully, which Infants who should not receive breast milk or any other milk
includes initiating breastfeeding within the first hour except specialized formula
of life, breastfeeding exclusively for the first 6 mon- K Infants with classic galactosemia: a special galac-
ths and continuing breastfeeding (along with giving tose-free formula is needed.
appropriate complementary foods) up to 2 years of
age or beyond. K Infants with maple syrup urine disease: a special
formula free of leucine, isoleucine and valine is
Exclusive breastfeeding in the first six months of life needed.
is particularly beneficial for mothers and infants.
K Infants with phenylketonuria: a special phenyla-
Positive effects of breastfeeding on the health of lanine-free formula is needed (some breastfeeding
infants and mothers are observed in all settings. is possible, under careful monitoring).
Breastfeeding reduces the risk of acute infections
such as diarrhoea, pneumonia, ear infection, Haemo-
Infants for whom breast milk remains the best feeding option
philus influenza, meningitis and urinary tract infec-
but who may need other food in addition to breast milk for a
tion (1). It also protects against chronic conditions in
limited period
the future such as type I diabetes, ulcerative colitis,
and Crohn’s disease. Breastfeeding during infancy is K Infants born weighing less than 1500 g (very low
associated with lower mean blood pressure and total birth weight).
serum cholesterol, and with lower prevalence of type- K Infants born at less than 32 weeks of gestation (pre-
2 diabetes, overweight and obesity during adolescen- term).
ce and adult life (2). Breastfeeding delays the return
K Newborn infants who are at risk of hypoglycae-
of a woman’s fertility and reduces the risks of post-
mia by virtue of impaired metabolic adaptation
partum haemorrhage, pre-menopausal breast cancer
or increased glucose demand (such as those who
and ovarian cancer (3).
are preterm, small for gestational age or who have
Nevertheless, a small number of health conditions of experienced significant intrapartum hypoxic/
the infant or the mother may justify recommending ischaemic stress, those who are ill and those whose
that she does not breastfeed temporarily or perma- mothers are diabetic (5)) if their blood sugar fails
nently (4). These conditions, which concern very to respond to optimal breastfeeding or breast milk
few mothers and their infants, are listed below toge- feeding.
ther with some health conditions of the mother that,
although serious, are not medical reasons for using MATERNAL CONDITIONS
breast-milk substitutes..
Mothers who are affected by any of the conditions
Whenever stopping breastfeeding is considered, the mentioned below should receive treatment according
benefits of breastfeeding should be weighed against to standard guidelines.
the risks posed by the presence of the specific condi-
tions listed.
Reference: WHO/UNICEF. Acceptable medical reasons for use

1
of breast-milk substitutes. World Health Organization, Geneva,

2008.
Maternal conditions that may justify permanent avoidance K Substance use2 (11):
of breastfeeding — maternal use of nicotine, alcohol, ecstasy,
K HIV infection:1 if replacement feeding is accept- amphetamines, cocaine and related stimulants
able, feasible, affordable, sustainable and safe has been demonstrated to have harmful effects
(AFASS) (6). on breastfed babies;
— alcohol, opioids, benzodiazepines and canna-
Maternal conditions that may justify temporary avoidance
bis can cause sedation in both the mother and
of breastfeeding
the baby.
K Severe illness that prevents a mother from caring
for her infant, for example sepsis. Mothers should be encouraged not to use these
substances and given opportunities and support to
K Herpes simplex virus type 1 (HSV-1): direct con- abstain.
tact between lesions on the mother’s breasts and
the infant’s mouth should be avoided until all
References
active lesions have resolved.
1. Technical updates of the guidelines on Integrated
K Maternal medication: Management of Childhood Illness (IMCI). Evidence
— sedating psychotherapeutic drugs, anti-epilep- and recommendations for further adaptations.
tic drugs and opioids and their combinations Geneva, World Health Organization, 2005.
may cause side effects such as drowsiness and 2. Evidence on the long-term effects of breastfeeding:
respiratory depression and are better avoided if systematic reviews and meta-analyses. Geneva,
a safer alternative is available (7); World Health Organization, 2007.
— radioactive iodine-131 is better avoided given 3. León-Cava N et al. Quantifying the benefits of
that safer alternatives are available – a mother breastfeeding: a summary of the evidence. Wash-
can resume breastfeeding about two months ington, DC, Pan American Health Organization,
after receiving this substance; 2002 (http://www.paho.org/English/AD/FCH/BOB-
— excessive use of topical iodine or iodophors (e.g., Main.htm, accessed 26 June 2008).
povidone-iodine), especially on open wounds 4. Resolution WHA39.28. Infant and Young Child
or mucous membranes, can result in thyroid Feeding. In: Thirty-ninth World Health Assembly,
suppression or electrolyte abnormalities in the Geneva, 5–16 May 1986. Volume 1. Resolutions
breastfed infant and should be avoided; and records. Final. Geneva, World Health Organi-
— cytotoxic chemotherapy requires that a mother zation, 1986 (WHA39/1986/REC/1), Annex 6:
stops breastfeeding during therapy. 122–135.
Maternal conditions during which breastfeeding can still

continue, although health problems may be of concern
K Breast abscess: breastfeeding should continue on
the unaffected breast; feeding from the affected The most appropriate infant feeding option for an HIV-infected
1
breast can resume once treatment has started (8). mother depends on her and her infant’s individual circumstan-
ces, including her health status, but should take consideration
K Hepatitis B: infants should be given hepatitis B of the health services available and the counselling and support
vaccine, within the first 48 hours or as soon as pos- she is likely to receive. When replacement feeding is acceptable,
sible thereafter (9). feasible, affordable, sustainable and safe (AFASS), avoidance
of all breastfeeding by HIV-infected women is recommended.
K Hepatitis C. Mixed feeding in the first 6 months of life (that is, breastfeeding
while also giving other fluids, formula or foods) should always
K Mastitis: if breastfeeding is very painful, milk must be avoided by HIV-infected mothers.
be removed by expression to prevent progression of Mothers who choose not to cease their use of these substances
2
the condition(8). or who are unable to do so should seek individual advice on

the risks and benefits of breastfeeding depending on their indi-
K Tuberculosis: mother and baby should be managed vidual circumstances. For mothers who use these substances in
according to national tuberculosis guidelines (10). short episodes, consideration may be given to avoiding breast-
feeding temporarily during this time.
Annex 1. Acceptable medical reasons for use of breast-milk substitutes 91
5. Hypoglycaemia of the newborn: review of the litera- 9. Hepatitis B and breastfeeding. Geneva, World
ture. Geneva, World Health Organization, 1997 Health Organization, 1996. (Update No. 22)
(WHO/CHD/97.1; http://whqlibdoc.who.int/hq/
10. Breastfeeding and Maternal tuberculosis. Geneva,
1997/WHO_CHD_97.1.pdf, accessed 24 June
World Health Organization, 1998 (Update No.
2008).
23).
6. HIV and infant feeding: update based on the techni-
11. Background papers to the national clinical guidelines
cal consultation held on behalf of the Inter-agency
for the management of drug use during pregnancy,
Task Team (IATT) on Prevention of HIV Infection
birth and the early development years of the new-
in Pregnant Women, Mothers and their Infants,
born. Commissioned by the Ministerial Council
Geneva, 25–27 October 2006. Geneva, World
on Drug Strategy under the Cost Shared Funding
Health Organization, 2007 (http://whqlibdoc.
Model. NSW Department of Health, North Syd-
who.int/publications/2007/9789241595964_eng.
ney, Australia, 2006.
pdf, accessed 23 June 2008).
Further information on maternal medication and
7. Breastfeeding and maternal medication: recom-
breastfeeding is available at the following United States
mendations for drugs in the Eleventh WHO Model
National Library of Medicine (NLM) website: http://
List of Essential Drugs. Geneva, World Health
toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
Organization, 2003.
8. Mastitis: causes and management. Geneva, World
Health Organization, 2000 (WHO/FCH/CAH/00.13;
http://whqlibdoc.who.int/hq/2000/WHO_FCH_
CAH_00.13.pdf, accessed 24 June 2008).
92
Annex 2
Growth standards
In 1993 the World Health Organization (WHO) and related information from 8440 healthy breastfed
undertook a comprehensive review of the uses and infants and young children from diverse ethnic back-
interpretation of anthropometric references. The grounds and cultural settings (Brazil, Ghana, India,
review concluded that the NCHS/WHO growth refer- Norway, Oman and USA). The weight-for-age charts
ence, which had been recommended for international presented in this Annex are part of these standards.
use since the late 1970s, did not adequately represent The selection of standard deviations (SD) curves and
early childhood growth and that new growth curves the presentation of the charts are adapted for use in
were necessary. The World Health Assembly endorsed the IMCI context, with weekly divisions in the first
this recommendation in 1994. The WHO Multicentre two months and monthly divisions from 2 to 60
Growth Reference Study (MGRS) was undertaken months of age. Expanded reference tables necessary
in response to that endorsement and implemented for construction of national child health records are
between 1997 and 2003 to generate new curves for available at http://www.who.int/childgrowth/stand-
assessing the growth and development of children the ards/weight_for_age/en/index.html, where there are
world over. The MGRS collected primary growth data detailed instructions on how to use them.
IMCI – Weight-for-age (girls)
Weight (kg)
Age (completed weeks and months)
Annex 2. Growth standards
93
Age (completed weeks and months)

IMCI – Weight-for-age (boys)
Weight (kg)
95
Annex 3
Growth velocity (weight-for-age) tables1
Table 1
Boys weight increments (g) by birth-weight groups
Birth weight (g)
Age (days) Centile 2000–2500 2500–3000 3000–3500 3500–4000 4000+ All
0–7 Median 150 150 150 150 50 150

25th —* 0 0 0 -50 0
10th —* -150 -150 -250 -250 -150
5th —* -200 -250 -300 -250 -250
(n) (7) (88) (142) (100) (46) (383)

7–14 Median 275 250 250 250 275 250
25th —* 150 150 100 150 150
10th —* 0 50 0 50 0
5th —* -100 -50 -50 -100 -50
(n) (6) (88) (141) (100) (46) (381)

14–28 Median 600 700 650 700 725 650
25th —* 550 550 500 550 550
10th —* 450 450 400 400 450
5th —* 450 350 350 400 350
(n) (7) (95) (154) (113) (48) (417)

28–42 Median 600 550 550 550 548 550
25th —* 500 450 450 450 450
10th —* 350 350 350 300 350
5th —* 300 300 300 300 300
(n) (7) (95) (156) (113) (46) (417)

42–60 Median 450 650 650 650 611 650
25th —* 550 500 500 400 500
10th —* 450 400 400 300 400
5th —* 450 350 350 217 350
(n) (7) (96) (153) (113) (47) (416)
Note: Results are based on empirical centiles.
(n) number of subjects assessed.
* n is too small to estimate lower centiles.
1
Reference: WHO Multicentre Growth Reference Study Group.
WHO Child Growth Standards. Growth velocities based on
weight, length and head circumference: Methods and develop-
ment. Geneva, World Health Organization, 2009.
Table 2
Girls weight increments (g) by birth-weight groups
Birth weight (g)
Age (days) Centile 2000–2500 2500–3000 3000–3500 3500–4000 4000+ All
0–7 Median 0 150 100 100 150 100

25th —* 0 0 0 0 0
10th —* -100 -100 -150 -100 -100
5th —* -150 -200 -250 -200 -200
(n) (18) (109) (147) (85) (25) (384)

7–14 Median 200 200 200 200 200 200
25th —* 100 100 100 100 100
10th —* 0 0 0 50 0
5th —* -100 -50 -100 0 -50
(n) (18) (108) (147) (84) (25) (382)

14–28 Median 500 600 550 550 600 550
25th —* 450 436 450 450 450
10th —* 400 350 300 300 350
5th —* 300 300 250 200 300
(n) (20) (124) (176) (93) (28) (441)

28–42 Median 500 500 465 457 525 500
25th —* 382 400 325 375 382
10th —* 300 300 295 300 300
5th —* 300 250 200 300 250
(n) (20) (127) (174) (92) (28) (441)

42–60 Median 550 550 500 585 550 550
25th —* 400 400 408 334 400
10th —* 300 300 350 155 300
5th —* 300 289 250 150 288
(n) (18) (127) (175) (92) (28) (440)
Note: Results are based on empirical centiles.
(n) number of subjects assessed.
* n is too small to estimate lower centiles.
97
Annex 4
Indicators for assessing infant and

young child feeding practices1
Core Indicators
Breastfeeding initiation
1. Early initiation of breastfeeding: Proportion of children born in the last 24 months who were put to the breast
within one hour of birth.
Children born in the last 24 months who were put to the breast within one hour of birth
Children born in the last 24 months
Exclusive breastfeeding
2. Exclusive breastfeeding under 6 months: Proportion of infants 0–5 months of age who are fed exclusively with
breast milk.
Infants 0–5 months of age who received only breast milk during the previous day
Infants 0–5 months of age
Continued breastfeeding
3. Continued breastfeeding at 1 year: Proportion of children 12–15 months of age who are fed breast milk.
Children 12–15 months of age who received breast milk during the previous day
Children 12–15 months of age
Introduction of complementary foods

4. Introduction of solid, semi-solid or soft foods: Proportion of infants 6–8 months of age who receive solid, semi-
solid or soft foods.
Infants 6–8 months of age who received solid, semi-solid or soft foods during the previous day
Dietary diversity
5. Minimum dietary diversity: Proportion of children 6–23 months of age who receive foods from 4 or more food
groups.
Children 6–23 months of age who received foods from ≥ 4 food groups during the previous day
Reference: WHO, UNICEF, IFPRI, UC Davis, USAID, FANTA,

1
Macro International. Indicators for assessing infant and young

child feeding practices. Geneva: World Health Organization,
2008.
Meal frequency
6. Minimum meal frequency: Proportion of breastfed and non-breastfed children 6–23 months of age who receive
solid, semi-solid, or soft foods (but also including milk feeds for non-breastfed children) the minimum
number of times or more.
The indicator is calculated from the following two fractions:
Breastfed children 6–23 months of age who received solid, semi-solid or soft foods
the minimum number of times or more during the previous day
Breastfed children 6–23 months of age
and
Non-breastfed children 6–23 months of age who received solid, semi-solid or soft foods or milk feeds
the minimum number of times or more during the previous day
Non-breastfed children 6–23 months of age
Summary infant and young child feeding indicator

7. Minimum acceptable diet: Proportion of children 6–23 months of age who receive a minimum acceptable diet
(apart from breast milk).
This composite indicator will be calculated from the following two fractions:
Breastfed children 6–23 months of age who had at least the minimum dietary diversity and
the minimum meal frequency during the previous day
Breastfed children 6–23 months of age
and
Non-breastfed children 6–23 months of age who received at least 2 milk feedings and had at least
the minimum dietary diversity and the minimum meal frequency during the previous day
Consumption of iron-rich or iron-fortified foods

8. Consumption of iron-rich or iron-fortified foods: Proportion of children 6–23 months of age who receive an iron-
rich food or iron-fortified food that is specially designed for infants and young children, or that is fortified
in the home.
Children 6–23 months of age who received an iron-rich food or a food
that was specially designed for infants and young children and was fortified with iron,
or a food that was fortified in the home with a product that included iron during the previous day
Annex 4. Core indicators for assessing infant and young child feeding practices 99
Optional Indicators
Considering the need to limit the number of indicators and quantity of data to be collected to a minimum,
it is proposed that the indicators described above are the most critical for population-based assessment and
programme evaluation. However, to ensure continuity in monitoring of previously used indicators and recog-
nizing that some programmes may wish to measure additional indicators, the following optional indicators are
recommended:
Breastfeeding
9. Children ever breastfed: Proportion of children born in the last 24 months who were ever breastfed.
Children born in the last 24 months who were ever breastfed
Children born in the last 24 months
10. Continued breastfeeding at 2 years: Proportion of children 20–23 months of age who are fed breast milk.
Children 20–23 months of age who received breast milk during the previous day
11. Age-appropriate breastfeeding: Proportion of children 0–23 months of age who are appropriately breastfed.
The indicator is calculated from the following two fractions:
Infants 0–5 months of age who received only breast milk during the previous day
and
Children 6–23 months of age who received breast milk, as well as solid, semi-solid or soft foods, during the previous day
12. Predominant breastfeeding under 6 months: Proportion of infants 0–5 months of age who are predominantly
breastfed
Infants 0–5 months of age who received breast milk as the predominant source of nourishment during the previous day
Duration of breastfeeding
13. Duration of breastfeeding: Median duration of breastfeeding among children less than 36 months of age.
The age in months when 50% of children 0–35 months did not receive breast milk during the previous day
Bottle feeding of infants
14. Bottle feeding: Proportion of children 0–23 months of age who are fed with a bottle.
Children 0–23 months of age who were fed with a bottle during the previous day
Milk feeding frequency for non-breastfed children

15. Milk feeding frequency for non-breastfed children: Proportion of non-breastfed children 6–23 months of age who
receive at least 2 milk feedings.
Non-breastfed children 6–23 months of age who received at least 2 milk feedings during the previous day
Useful resource materials
WHO/UNICEF. Global strategy for infant and young child feeding. Geneva, World Health Organization, 2003
http://www.who.int/child_adolescent_health/documents/9241562218/en/index.html
http://webitpreview.who.int/entity/nutrition/publications/gs_infant_feeding_text_eng.pdf
WHO/UNICEF. Planning Guide for national implementation of the Global Strategy for Infant and Young Child
Feeding. Geneva, World Health Organization, 2007
WHO. The International Code of Marketing of Breast-milk Substitutes. Geneva, World Health Organization, 1981
http://www.who.int/nut/documents/code_english.PDF
WHO. The International Code of Marketing of Breast-milk Substitutes: frequently asked questions. Geneva,
World Health Organization, 2008
WHO/UNICEF. Baby-friendly Hospital Initiative: revised, updated and expanded for integrated care. Geneva,
World Health Organization, 2009. http://www.who.int/nutrition/topics/bfhi/en/index.html
WHO. The optimal duration of exclusive breastfeeding: report of an expert consultation. Geneva, World Health
Organization, 2001
http://www.who.int/nutrition/publications/optimal_duration_of_exc_bfeeding_report_eng.pdf
WHO. Optimal feeding of low-birth-weight infants: a review. Geneva, World Health Organization, 2006
WHO. Evidence on the long-term effects of breastfeeding. Geneva, World Health Organization, 2007
PAHO. Guiding principles for complementary feeding of the breastfed child.
Washington: Pan American Health Organization, World Health Organization, 2003
http://www.who.int/child_adolescent_health/documents/a85622/en/index.html
WHO. Guiding principles for feeding non-breastfed children 6–24 months of age. Geneva, World Health
Organization, 2005. http://www.who.int/child_adolescent_health/documents/9241593431/en/index.html
WHO, UNICEF, UNFPA, UNAIDS, FAO, UNHCR, WFP, WB, IAEA. HIV and infant feeding: a framework for
priority action. Geneva, World Health Organization, 2003
WHO, UNICEF, UNFPA, UNAIDS. HIV and infant feeding: Update. Geneva, World Health Organization, 2007
WHO, UNICEF, UNFPA, UNAIDS. HIV transmission through breastfeeding: A review of available evidence, 2007
update. Geneva, World Health Organization, 2008
WHO, UNICEF, WFP, UN-SCN. Community-based management of severe acute malnutrition:
A joint statement. Geneva, World Health Organization, 2007
http://www.who.int/child_adolescent_health/documents/a91065/en/index.html
WHO, UNICEF, IFPRI, UC Davis, USAID, FANTA, Macro International. Indicators for assessing infant and
young child feeding practices. Geneva, World Health Organization, 2008
For more information, please consult
http://www.who.int/child_adolescent_health/en/ and http://www.who.int/nutrition/en/
The Model Chapter on Infant and Young Child Feeding is intended for
use in basic training of health professionals. It describes essential
knowledge and basic skills that every health professional who
works with mothers and young children should master. The Model
Chapter can be used by teachers and students as a complement to
textbooks or as a concise reference manual.
For further information, please contact:

Department of Child and Adolescent Health and Development ([email protected])
Department of Nutrition for Health and Development ([email protected])
World Health Organization
20 Avenue Appia, 1211 Geneva 27, Switzerland
Web site: http://www.who.int
ISBN 978 92 4 159749 4

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List of boxes, figures and tables

Box 7 How to express breast milk by hand 32

Figure 20 Preparing and using a syringe for treatment of inverted nipples 68

ARA Arachidonic acid

O ptimal infant and young child feeding practices

1.1 Growth, health and Figure 1

Protein K whey proteins (lysozyme and lactoferrin) which

Baby suckling • More prolactin

Secreted after feed to produce next feed

Figure 8 Sometimes much of the areola is outside the baby’s

2.9 Effective suckling

K the baby’s lower lip points forward or is turned

K the baby may be very hungry and continue suck-

2.10 Causes of poor attachment

2.11 Positioning the mother and baby for good

2.12 Breastfeeding pattern References

child_adolescent_health/documents/a91064/en/, 22. Uvnas Moberg K. The neuroendocrinology of the

K Remember that feeding times are periods of learning

Box 3 Table 1 summarizes the amount of food required at

extra assistance with feeding to ensure adequate

months is 6 months or older (≥ 180 days) but is not yet 9 months

Percentage of daily needs (%)

ful, and cannot be expected to eat more than that 0

A Guiding Principle 8. Feed a variety of nutrient-rich

an extra portion at each meal or add an extra meal or Iodine

Obtain feedback on what works best in their

References 12. Bern C et al. The magnitude of the global problem

4.1 The Baby-friendly Hospital Initiative Box 5

References to the Code generally imply also subsequent relevant

Health Assembly resolutions.

(14,16). This early contact stimulates the flow of oxy- Box 6

A Step 8: Encourage breastfeeding on demand

Box 8 easily organised by health workers already based in

4.7 Follow-up support 3. WHO. The international code of marketing of

5.1 Support for mothers in the community Box 9

Use good communication and support skills: Box 10

Note: If a child has oedema of both feet, fluid retention

Length/height-for-age down, while standing height is measured for children 2 years of

direction (for example, close to the 3 or −3 z-score Low weight-for-age

Length/height-for-age Weight-for-age Weight-for-length/height

Above 3 See note 1 See note 2 Obese

faltering. Growth faltering is common in the first 2 Box 11

5.4.2 Taking a feeding history

Simple open questions can generate a great deal of Box 12

Signs that breastfeeding is going well: Signs of possible difficulty:

Assess the situation

Refer urgently Help with difficulties and poor Support good

If the child: If you find: If you find:

message to help you decide what information to give Mother’s health

K have a breast condition that does not respond to Box 14

Follow-up of the infant or young child with feeding Continuing management:

Low-birth-weight babies may require additional support, in

K At 3 and 4 months of age: continue assessing References

6.1 Low-birth-weight babies 6.1.1 What to feed?

K infant formula: Figure 16

2000–2500 g 1500–2000 g 1000–1500 g

3 days, the quantity of milk should be increased by Figure 18

3  days, the quantity of milk should be increased by Figure 18