During the postnatal period, counselling the mother of a normal healthy newborn baby focuses on many issues, including those already covered in earlier study sessions, such as infection prevention, nutrition for the mother, and family planning. In this study session, we return in detail to two topics that have been touched on previously: how to begin and maintain optimum breastfeeding, and how to keep the baby warm using the ‘warm chain principle’. The first part of this study session is about feeding the normal weight, healthy, full-term baby. Then we will look at the special counselling that HIV-positive mothers need about feeding babies who are full term and normal weight. Study Session 8 will cover the special care needed to feed and maintain the body temperature of preterm or low birth weight babies.
When you have studied this session, you should be able to:
7.1 Define and use correctly all of the key words printed in bold. (SAQ 7.2)
7.2 Explain the benefits of breast milk for the newborn and the advantages of exclusive breastfeeding for the mother and newborn. (SAQ 7.1)
7.3 Describe the steps in establishing optimum breastfeeding through good positioning of the mother and good attachment of the baby to the breast. (SAQ 7.2)
7.4 Describe how to counsel the mother who is HIV-positive on feeding options for her baby to reduce the risk of transmitting HIV through breast milk. (SAQ 7.1)
7.5 Describe how newborns lose heat and how to prevent hypothermia by using the ‘warm chain principle’. (SAQ 7.3)
It is always advisable to provide counselling about newborn feeding during the antenatal period and continue reinforcing it during the postnatal period. This teaching should focus on establishing and maintaining optimum breastfeeding. The criteria for achieving this are summarised in Box 7.1.
When you arrive for a postnatal visit, ask the mother to put the baby to the breast to check for good positioning and good attachment (we describe how you do this below). If the baby was fed recently, wait for at least an hour before putting him or her back to the breast. This will allow you to observe how the baby is breastfeeding and identify if there are any breastfeeding problems, which you can help the mother to overcome. Before you leave the house, ensure the mother understands how to breastfeed her baby optimally.
To begin with, the mother should sit comfortably (see Figure 7.1a), maintaining the four signs of good positioning:
If the mother has had a caesarean delivery, or her abdomen is sore for some other reason, she may be more comfortable supporting the baby as shown in Figure 7.1(b). It keeps the baby’s weight off her abdomen. She can feed twins this way too, with one on each breast. At night, or if she is tired and needs to rest, she can feed the baby while lying down (Figure 7.1c), but only if she stays awake.
Giving breastfeeding in the lying down position (Figure 7.1c) is not advisable unless the mother is awake. Can you suggest why not?
If the mother is falling asleep she may roll onto the newborn, who may be unable to breathe and asphyxiate (die from lack of oxygen).
Once good positioning is established, show the mother how to help the newborn to attach to the nipple. She should:
The four signs of good attachment are:
Advise the mother to empty one breast before switching to the other, so that the newborn gets the nutrient-rich hind milk (last milk), which is produced when the breast is almost empty.
Good signs of effective suckling are if the newborn takes slow, regular and deep sucks, sometimes pausing. The mother should tell you that she is comfortable and pain free.
If you observe that the attachment and suckling are inadequate, ask the mother to try again and reassess how well the baby is feeding. If they still cannot establish optimum breastfeeding, then you should assume that the newborn has a feeding problem and/or the mother has breast problems that make attachment difficult. If so refer the baby and the mother to a health facility for further advice and care.
Breastfeeding provides many benefits to both the newborn and mother. You should encourage mothers to breastfeed exclusively for at least the first six months by explaining the benefits to them.
Breast milk is the ideal feed for full term newborns as it provides all the nutrients in the correct amount and proportion for normal growth and development until the age of six months. It is easily digested and absorbed. Also, breast milk is clean and warm, and avoids the dangers of feeding formula milk which comes as a powder and has to be made up with water and fed in a bottle.
Can you suggest the sources of risk to the newborn from badly made formula milk?
There is a risk of infection from making the milk with contaminated water, or if the bottles and teats are not properly sterilised. If the mother makes several feeds at one time, and she cannot keep them cold because she has no refrigeration facilities, bacteria may grow in the warm milk. Also, if she puts too little or too much milk powder in each bottle, the baby will suffer from malnourishment if the formula is too weak, or it will get an excessive load on its organs from too concentrated formula.
Breast milk contains many anti-infective factors, such as antibodies, living cells and molecules that help the baby's body to fight infection. It also encourages the growth of beneficial bacteria in the newborn's bowel. These properties of breast milk help to prevent diarrhoeal diseases, the major cause of death of newborns in poor communities.
Breast milk also decreases the risk of allergy in the newborn. Allergies are adverse reactions of the body against components of the diet, pollen from plants, animals and other harmless things that touch the body or get into it through the nose, mouth or eyes. Newborns are more at risk of allergies if there is a strong family history of allergy.
Breastfeeding is (almost) free – the mother needs additional food while she is breastfeeding, but the cost is much cheaper than buying formula feeds, bottles and teats. It is instantly available at all times, so the mother does not have the trouble of sterilising bottles and teats, and preparing formula feeds many times every day. It is emotionally satisfying for the mother to successfully breastfeed her baby and the close contact helps to form a strong bond between mother and newborn.
The hormone (oxytocin) that triggers the milk to spurt from the breast by contracting the tiny muscles around the nipple, also makes the muscles in the uterus contract. So breastfeeding helps the uterus to return to its normal size.
What other benefit can you suggest results from the contractions of the myometrieum (the muscle layer in the uterus) during breastfeeding?
The contractions help to close the torn blood vessels where the placenta detached from the uterine wall, and this reduces the amount of normal vaginal bleeding during the puerperium, and decreases the risk of postpartum haemorrhage.
Breastfeeding helps the mother to lose excessive weight if she gained too much during the pregnancy. Pregnancy, not breastfeeding, alters the shape of a woman’s breasts.
Exclusive breastfeeding (feeding only breast milk to the baby and no other fluids or foods) greatly reduces the chance of the mother becoming pregnant again if it is begun early (within an hour of the birth), and maintained for the recommended first six months. Explain to the mother and her partner that if a woman has sex and is not exclusively breastfeeding, she can become pregnant as soon as four weeks after delivery. Therefore, information on when to start a contraceptive method will vary depending on whether the woman is breastfeeding or not.
In Ethiopia it is recommended that you try to convince mothers to put their babies on exclusive breastfeeding for six months for many reasons, including that it will suppress her menstrual cycle, but only if she fulfills the following criteria:
Emphasise that after six months, she will not be protected from becoming pregnant by breastfeeding alone. She should choose another family planning method. You will learn all about this in the Module on Family Planning in this curriculum. Table 7.1 summarises the benefits to the mother and the newborn of exclusive breastfeeding.
|It is much cheaper than formula||It is fully nutritious|
|Always available (ready)||Easily digested and absorbed|
|Mental satisfaction||It is clean and warm|
|Reduced bleeding||It contains anti-infective substances|
|Can be used as birth control||Prevents diarrhoeal disease|
|Helps lose excessive weight||Decreases allergy risk|
|Increases bonding with the newborn||Increases bonding with the mother|
HIV-testing and counselling and PMTCT is covered in detail in the Communicable Diseases Module, and also in the Antenatal Care Module.
Mothers who are HIV-positive and their babies need special care before, during and after labour and delivery. Therefore, if the mother is counselled and HIV-tested before or during pregnancy, and she knows that she is HIV-positive, you should try to convince her to deliver her baby in a health facility. That way she and her baby will get special care from health professionals with special training in delivering babies from HIV-positive mothers, and preventing maternal to child transmission (PMTCT of HIV).
In the postnatal period, she may need to take antiretroviral (ARV) drugs prescribed for her by the HIV clinic, and your support is vital in helping her to keep to her drug regimen. Maintain confidentiality about her status and conduct frequent visits to this woman as she may require a lot of psycho-social support immediately after the delivery. If it is available link her with the community social support group. Always make sure her partner is counselled and HIV-tested and also involved in the whole care process.
In this study session our focus is on the risk of HIV being transmitted from the mother to her newborn baby in her breast milk, and how you can support and counsel her about feeding options. If 20 HIV-positive mothers breastfeed their HIV-negative babies exclusively for the first six months, on average one to three of the babies will become infected with HIV through its mother’s breast milk. So the mother has a difficult choice to make. She has to balance the risk to her baby from HIV transmission during breastfeeding, against the risk of not breastfeeding and losing all the benefits described above. Formula feeding also exposes the baby to increased risk of infection from unsterilised bottles and malnutrition from incorrectly made feeds.
Exclusive breastfeeding is NOT recommended for the babies of HIV-positive women, since the only way to protect the baby completely from HIV transmission from its mother is to feed it on formula milk. This is known as replacement feeding. However, many families cannot afford to buy milk formula to feed the baby, and bottle feeding may be socially unacceptable in some communities. With all these issues in mind the World Health Organisation (WHO) has set the following criteria (known as the AFASS criteria), which need to be met before counselling an HIV-positive mother to use formula milk:
The AFASS criteria are illustrated in Figure 7.4. When replacement feeding fulfils the AFASS criteria, avoidance of all breastfeeding by HIV-positive mothers is recommended.
If replacement feeding is rejected by the HIV-positive mother, for whatever reasons, there are some things that she can do to reduce the risk of HIV transmission during breastfeeding. Counsel her to:
At six months, if replacement feeding is still not acceptable, feasible, affordable, sustainable and safe, counsel her to continue breastfeeding, but with additional complementary foods. All breastfeeding should stop once a nutritionally adequate and safe diet without breast milk can be provided.
Newborn babies cool down or heat up much quicker than older children or adults because they cannot regulate their body temperature as easily. They are particularly vulnerable to hypothermia, which means excessive cooling of the baby, so the body temperature falls below 35.5oC measured in the baby’s armpit (or use a rectal thermometer). If this low temperature continues even for a short time, it will cause the baby’s body systems to stop functioning properly and this is life-threatening. Hypothermia is a major cause of morbidity and mortality in a newborn baby, particularly pre-term babies (born before 36 weeks of gestation) and those with low birth weight (below 2,500 gm). Study Session 8 will teach you all about the problems and management of these early or tiny babies.
Hypothermia is usually caused more by the mother’s lack of knowledge rather than lack of covers and clothes to keep the baby warm. So make sure you explain to the mother the importance of keeping the baby warm all the time to ensure that a normal body temperature of above 36.5°C and below 37.5°C can be maintained.
Place the thermometer in the newborn's armpit (or rectum if you have a rectal thermometer) for two to three minutes, then read the temperature according to the type of thermometer you have. (You learned how to use different types of thermometer in Study Session 9 of the Antenatal Care Module.) Thermometers should be stored dry when not in use. Before and after you take anyone’s temperature, the thermometer should be cleaned with antiseptic to prevent carrying infection from one person to another. It is important to notice when the temperature is even a little bit lower than normal, before it reaches as low as 35.5oC.
Newborns that have particular problems in producing enough heat in their bodies, or who lose too much heat because of poor care by the mother, are at the greatest risk.
Newborns who may not produce enough heat include those who are:
Newborns that lose too much heat include those who are:
The mechanisms of how the newborn loses heat are summarised in Figure 7.5, and described below.
Convection. This is the loss of heat from the newborn's skin to the surrounding air. Newborns lose a lot of heat by convection when exposed to cold air or draughts.
Conduction. This is the loss of heat when the newborn lies on a cold surface. Newborns lose heat by conduction when placed naked on a cold table, weighing scale or are wrapped in a cold blanket or towel.
Evaporation. This is the loss of heat from a newborn's wet skin to the surrounding air. Newborns lose heat by evaporation after delivery or after a bath. Even a newborn in a wet nappy can lose heat by evaporation.
Radiation. This is the loss of heat from a newborn's skin to distant cold objects, such as a cold window or wall etc.
Finally, knowing that the newborn can lose heat by the four mechanisms described above, you should counsel the mother to avoid exposing the baby to drafts. Counsel her that before she removes the baby's clothes for a bath, close all doors and windows; cover the wet baby and dry him or her quickly.
Stop reading for a moment and think of your own experience in your community. Have you seen situations when mothers were in danger of letting their baby lose heat in any of the ways described above?
The mother should understand that keeping the baby warm is not a one-time job; it is rather a continuous job which means adhering to the warm chain principle. A warm chain is a system of keeping a baby warm immediately after delivery, wherever it occurs (at a health facility or the mother’s home), during transportation and while feeding and caring for the baby. The components of the warm chain are listed in Box 7.2.
The warm chain principle has to be maintained for all babies, but special care should be taken to keep preterm and low birth weight babies warm, as you will see in the next study session.
In Study Session 7 you have learned that:
Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the questions below. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.
You are wondering what to say to an HIV-positive mother who is particularly keen on breastfeeding. How would you advise her?
There are many ways in which you might have made notes on this difficult situation. You would have sympathised with the mother’s wish to breastfeed and probably pointed out the benefits for the baby (e.g. protection from infection, correct nutrients, reduction in risk of allergy), and the benefits for the mother (breast milk is cheaper, breastfeeding helps the uterus to contract, it is useful for birth control, etc). But you would also have told her of the risk of transmitting HIV to the baby via breastfeeding.
When you discuss formula feed as the alternative you would have explained the critical importance of clean water, and proper sterilisation of the bottles and teats, as well as the need to measure everything accurately so the baby gets the correct nourishment.
Then you would go through the AFASS criteria and the questions in Figure 7.4. If she answered ‘yes’ to them all, you would encourage her to use formula or animal milk, and also counselled her about birth control. If she answered ‘no’ and she really wants to breastfeed, you would have explained how she can reduce the risk of HIV transmission by feeding at very short intervals (no longer than three hours), and stop feeding from a breast that has a cracked nipple. You should have reminded her to check the baby’s mouth for sores, and seek urgent treatment for herself and her baby if either of them feels ill.
Which of the following definitions is incorrect? In each case, give the correct definition.
A Exclusive breastfeeding is only feeding one baby at a time.
B Good positioning for breastfeeding is when the mother is sitting comfortably.
C Good attachment means the baby has ‘a good mouthful of breast’.
D Early breastfeeding requires the mother to get up around dawn for the first feed.
E The principle of the warm chain means that you pay attention to keeping the baby warm at all times, so as to avoid hypothermia.
A False: Exclusive breastfeeding is giving nothing to the baby other than breast milk for the first six months.
B True. But look back to Section 7.1.1 and check you are clear about how to maintain the mother in good positioning.
C True: Look back to Section 7.1.2 and check you remember precisely the four signs of good attachment.
D False: Early breastfeeding is initiation of breastfeeding within one hour after birth.
E True: The warm chain principle means taking action to keep the baby warm at all times.
You are visiting a new mother and you notice that the baby feels very cold. You are worried about hypothermia. What do you do?