Which of the following interventions would be helpful to a breastfeeding mother who is experiencing and gorge breast?

This section has details on breastfeeding, care of the baby, treatments, immunization, routine and follow-up visits and urgent referral to hospital.
Table of Contents Show
General principles are found in the section on good care A1-A6.
If mother HIV-infected, see also G7-G11.

INCLUDE PARTNER OR OTHER FAMILY MEMBERS IF POSSIBLE

Explain to the mother that:

Breast milk contains exactly the nutrients a baby needs
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is easily digested and efficiently used by the baby's body.
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protects a baby against infection.
Babies should start breastfeeding within 1 hour of birth. They should not have any other food or drink before they start to breastfeed.
Babies should be exclusively breastfed for the first 6 months of life.
Breastfeeding
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helps baby's development and mother/baby attachment.
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can help delay a new pregnancy (see D27 for breastfeeding and family planning).

For counselling if mother HIV-infected, see G7.

Encourage mothers who are breastfeeding not to drink alcohol or smoke tobacco.

Help the mother to initiate breastfeeding within 1 hour, when baby is ready

After birth, let the baby rest comfortably on the mother's chest in skin-to-skin contact.
Tell the mother to help the baby to her breast when the baby seems to be ready, usually within the first hour. Signs of readiness to breastfeed are:
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baby looking around/moving
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mouth open
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searching.
Check that position and attachment are correct at the first feed. Offer to help the mother at any time K3.
Let the baby release the breast by her/himself; then offer the second breast.
If the baby does not feed in 1 hour, examine the baby J2-J9. If healthy, leave the baby with the mother to try later. Assess in 3 hours, or earlier if the baby is small J4.
If the mother is ill and unable to breastfeed, help her to express breast milk and feed the baby by cup K6. On day 1 express in a spoon and feed by spoon.
If mother cannot breastfeed at all, use one of the following options:
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donated heat-treated breast milk.
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If not available, then commercial infant formula.
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If not available, then home-made formula from modified animal milk.

Keep the mother and baby together in bed or within easy reach. Do not separate them.
Encourage breastfeeding on demand, day and night, as long as the baby wants.
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A baby needs to feed day and night, 8 or more times in 24 hours from birth. Only on the first day may a full-term baby sleep many hours after a good feed.
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A small baby should be encouraged to feed, day and night, at least 8 times in 24 hours from birth.
Help the mother whenever she wants, and especially if she is a first time or adolescent mother.
Let baby release the breast, then offer the second breast.
If mother must be absent, let her express breast milk and let somebody else feed the expressed breast milk to the baby by cup.

DO NOT force the baby to take the breast.

DO NOT interrupt feed before baby wants.

DO NOT give any other feeds or water.

DO NOT use artificial teats or pacifiers.

Advise the mother on medication and breastfeeding
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Most drugs given to the mother in this guide are safe and the baby can be breastfed.
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If mother is taking cotrimoxazole or fansidar, monitor baby for jaundice.

Show the mother how to hold her baby. She should:
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make sure the baby's head and body are in a straight line
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make sure the baby is facing the breast, the baby's nose is opposite her nipple
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hold the baby's body close to her body
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support the baby's whole body, not just the neck and shoulders
Show the mother how to help her baby to attach. She should:
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touch her baby's lips with her nipple
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wait until her baby's mouth is opened wide
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move her baby quickly onto her breast, aiming the infant's lower lip well below the nipple.
Look for signs of good attachment:
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more of areola visible above the baby's mouth
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mouth wide open
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lower lip turned outwards
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baby's chin touching breast
Look for signs of effective suckling (that is, slow, deep sucks, sometimes pausing).
If the attachment or suckling is not good, try again. Then reassess.
If breast engorgement, express a small amount of breast milk before starting breastfeeding to soften nipple area so that it is easier for the baby to attach.

If mother is HIV-infected, see G7 for special counselling to the mother who is HIV-infected and breastfeeding.

If mother chose replacement feedings, see G8.

COUNSEL THE MOTHER:

Reassure the mother that she can breastfeed her small baby and she has enough milk.
Explain that her milk is the best food for such a small baby. Feeding for her/him is even more important than for a big baby.
Explain how the milk's appearance changes: milk in the first days is thick and yellow, then it becomes thinner and whiter. Both are good for the baby.
A small baby does not feed as well as a big baby in the first days:
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may tire easily and suck weakly at first
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may suckle for shorter periods before resting
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may fall asleep during feeding
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may have long pauses between suckling and may feed longer
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does not always wake up for feeds.
Explain that breastfeeding will become easier if the baby suckles and stimulates the breast her/himself and when the baby becomes bigger.
Encourage skin-to-skin contact since it makes breastfeeding easier.

HELP THE MOTHER:

Initiate breastfeeding within 1 hour of birth.
Feed the baby every 2-3 hours. Wake the baby for feeding, even if she/he does not wake up alone, 2 hours after the last feed.
Always start the feed with breastfeeding before offering a cup. If necessary, improve the milk flow (let the mother express a little breast milk before attaching the baby to the breast).
Keep the baby longer at the breast. Allow long pauses or long, slow feed. Do not interrupt feed if the baby is still trying.
If the baby is not yet suckling well and long enough, do whatever works better in your setting:
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Let the mother express breast milk into baby's mouth K5.
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Let the mother express breast milk and feed baby by cup K6. On the first day express breast milk into, and feed colostrum by spoon.
Teach the mother to observe swallowing if giving expressed breast milk.
Weigh the baby daily (if accurate and precise scales available), record and assess weight gain K7.

COUNSEL THE MOTHER:

Reassure the mother that she has enough breast milk for two babies.
Encourage her that twins may take longer to establish breastfeeding since they are frequently born preterm and with low birth weight.

HELP THE MOTHER:

Start feeding one baby at a time until breastfeeding is well established.
Help the mother find the best method to feed the twins:
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If one is weaker, encourage her to make sure that the weaker twin gets enough milk.
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If necessary, she can express milk for her/him and feed her/him by cup after initial breastfeeding.
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Daily alternate the side each baby is offered.

Express breast milk

The mother needs clean containers to collect and store the milk. A wide necked jug, jar, bowl or cup can be used.
Once expressed, the milk should be stored with a well-fitting lid or cover.
Teach the mother to express breast milk:
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To provide milk for the baby when she is away. To feed the baby if the baby is small and too weak to suckle
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To relieve engorgement and to help baby to attach
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To drain the breast when she has severe mastitis or abscesses.
Teach the mother to express her milk by herself. DO NOT do it for her.
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Wash her hands thoroughly.
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Sit or stand comfortably and hold a clean container underneath her breast.
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Put her first finger and thumb on either side of the areola, behind the nipple.
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Press slightly inwards towards the breast between her finger and thumb.
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Express one side until the milk flow slows. Then express the other side.
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Continue alternating sides for at least 20-30 minutes.
If milk does not flow well:
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Apply warm compresses.
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Have someone massage her back and neck before expressing.
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Teach the mother breast and nipple massage.
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Feed the baby by cup immediately. If not, store expressed milk in a cool, clean and safe place.
If necessary, repeat the procedure to express breast milk at least 8 times in 24 hours. Express as much as the baby would take or more, every 3 hours.
When not breastfeeding at all, express just a little to relieve pain K5.
If mother is very ill, help her to express or do it for her.

Hand express breast milk directly into the baby's mouth

Teach the mother to express breast milk.
Hold the baby in skin-to-skin contact, the mouth close to the nipple.
Express the breast until some drops of breast milk appear on the nipple.
Wait until the baby is alert and opens mouth and eyes, or stimulate the baby lightly to awaken her/him.
Let the baby smell and lick the nipple, and attempt to suck.
Let some breast milk fall into the baby's mouth.
Wait until the baby swallows before expressing more drops of breast milk.
After some time, when the baby has had enough, she/he will close her/his mouth and take no more breast milk.
Ask the mother to repeat this process every 1-2 hours if the baby is very small (or every 2-3 hours if the baby is not very small).
Be flexible at each feed, but make sure the intake is adequate by checking daily weight gain.

Explain carefully and demonstrate how to heat treat expressed breast milk. Watch the mother practice the heat treating expressed breast milk. Check mother's understanding before she leaves.

Express breast milk (50 to 150 ml) in a clean glass jar of 450 ml and close it with a lid.
Label the jar with baby's name, the date and time.
Place jar in a pot (around 1 litre) and pour boiling water in the pot - 450 ml or 2 cm below pot brim. If the jar is floating put weight on top of jar.
Leave standing for ½hr. Remove milk, cool, administer to baby or store in fridge.

Cup feeding expressed breast milk

Teach the mother to feed the baby with a cup. Do not feed the baby yourself. The mother should:
Measure the quantity of milk in the cup
Hold the baby sitting semi-upright on her lap
Hold the cup of milk to the baby's lips:
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rest cup lightly on lower lip
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touch edge of cup to outer part of upper lip
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tip cup so that milk just reaches the baby's lips
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but do not pour the milk into the baby's mouth.
Baby becomes alert, opens mouth and eyes, and starts to feed.
The baby will suck the milk, spilling some.
Small babies will start to take milk into their mouth using the tongue.
Baby finishes feeding when mouth closes or when not interested in taking more.
If the baby does not take the calculated amount:
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Feed for a longer time or feed more often
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Teach the mother to measure the baby's intake over 24 hours, not just at each feed.
If mother does not express enough milk in the first few days, or if the mother cannot breastfeed at all, use one of the following feeding options:
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donated heat-treated breast milk
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home-made or commercial formula.
Feed the baby by cup if the mother is not available to do so.
Baby is cup feeding well if required amount of milk is swallowed, spilling little, and weight gain is maintained.

Start with 80 ml/kg body weight per day for day 1. Increase total volume by 10-20 ml/kg per day, until baby takes 150 ml/kg/day. See table below.
Divide total into 8 feeds. Give every 2-3 hours to a small size or ill baby.
Check the baby's 24 hour intake. Size of individual feeds may vary.
Continue until baby takes the required quantity.
Wash the cup with water and soap after each feed.

Signs that baby is receiving adequate amount of milk

Baby is satisfied with the feed.
Weight loss is less than 10% in the first week of life.
Baby gains at least 160 g in the following weeks or a minimum 300 g in the first month.
Baby wets every day as frequently as baby is feeding.
Baby's stool is changing from dark to light brown or yellow by day 3.

WEIGH THE BABY

Monthly if birth weight normal and breastfeeding well. Every 2 weeks if replacement feeding or treatment with isoniazid.
When the baby is brought for examination because not feeding well, or ill.

WEIGH THE SMALL BABY

Every day until 3 consecutive times gaining weight (at least 15 g/day).
Weekly until 4-6 weeks of age (reached term).

Daily/weekly weighing requires precise and accurate scale (10 g increment):

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Calibrate it daily according to instructions.

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Check it for accuracy according to instructions.

Simple spring scales are not precise enough for daily/weekly weighing.

(Mother or baby ill, or baby too small to suckle)

Teach the mother to express breast milk K5. Help her if necessary.
Use the milk to feed the baby by cup.
If mother and baby are separated, help the mother to see the baby or inform her about the baby's condition at least twice daily.
If the baby was referred to another institution, ensure the baby gets the mother's expressed breast milk if possible.
Encourage the mother to breastfeed when she or the baby recovers.

If the baby does not have a mother

Give donated heat treated breast milk or home-based or commercial formula by cup.
Teach the carer how to prepare milk and feed the baby K6.
Follow up in 2 weeks; weigh and assess weight gain.

(Baby died o<r stillborn, mother chose replacement feeding)

Breasts may be uncomfortable for a while.
Avoid stimulating the breasts.
Support breasts with a well-fitting bra or cloth. Do not bind the breasts tightly as this may increase her discomfort.
Apply a compress. Warmth is comfortable for some mothers, others prefer a cold compress to reduce swelling.
Teach the mother to express enough milk to relieve discomfort. Expressing can be done a few times a day when the breasts are overfull. It does not need to be done if the mother is uncomfortable. It will be less than her baby would take and will not stimulate increased milk production.
Relieve pain. An analgesic such as ibuprofen, or paracetamol may be used. Some women use plant products such as teas made from herbs, or plants such as raw cabbage leaves placed directly on the breast to reduce pain and swelling.
Advise to seek care if breasts become painful, swollen, red, if she feels ill or temperature greater than 38°C.

Pharmacological treatments to reduce milk supply are not recommended.

The above methods are considered more effective in the long term.

AT BIRTH AND WITHIN THE FIRST HOUR(S)

Warm delivery room: for the birth of the baby the room temperature should be 25-28°C, no draught.
Dry baby: immediately after birth, place the baby on the mother's abdomen or on a warm, clean and dry surface. Dry the whole body and hair thoroughly, with a dry cloth.
Skin-to-skin contact: Leave the baby on the mother's abdomen (before cord cut) or chest (after cord cut) after birth for at least 2 hours. Cover the baby with a soft dry cloth.
If the mother cannot keep the baby skin-to-skin because of complications, wrap the baby in a clean, dry, warm cloth and place in a cot. Cover with a blanket. Use a radiant warmer if room not warm or baby small.

SUBSEQUENTLY (FIRST DAY)

Explain to the mother that keeping baby warm is important for the baby to remain healthy.
Dress the baby or wrap in soft dry clean cloth. Cover the head with a cap for the first few days, especially if baby is small.
Ensure the baby is dressed or wrapped and covered with a blanket.
Keep the baby within easy reach of the mother. Do not separate them (rooming-in).
If the mother and baby must be separated, ensure baby is dressed or wrapped and covered with a blanket.
Assess warmth every 4 hours by touching the baby's feet: if feet are cold use skin-to-skin contact, add extra blanket and reassess (see Rewarm the newborn).
Keep the room for the mother and baby warm. If the room is not warm enough, always cover the baby with a blanket and/or use skin-to-skin contact.

AT HOME

Explain to the mother that babies need one more layer of clothes than other children or adults.
Keep the room or part of the room warm, especially in a cold climate.
During the day, dress or wrap the baby.
At night, let the baby sleep with the mother or within easy reach to facilitate breastfeeding.

Do not put the baby on any cold or wet surface.

Do not bath the baby at birth. Wait at least 6 hours before bathing.

Do not swaddle - wrap too tightly. Swaddling makes them cold.

Do not leave the baby in direct sun.

Keep a small baby warm

The room for the baby should be warm (not less than 25°C) with no draught.
Explain to the mother the importance of warmth for a small baby.
After birth, encourage the mother to keep the baby in skin-to-skin contact as long as possible.
Advise to use extra clothes, socks and a cap, blankets, to keep the baby warm or when the baby is not with the mother.
Wash or bath a baby in a very warm room, in warm water. After bathing, dry immediately and thoroughly. Keep the baby warm after the bath. Avoid bathing small babies.
Check frequently if feet are warm. If cold, rewarm the baby (see below).
Seek care if the baby's feet remain cold after rewarming.

Rewarm the baby skin-to-skin

Before rewarming, remove the baby's cold clothing.
Place the newborn skin-to-skin on the mother's chest dressed in a pre-warmed shirt open at the front, a nappy (diaper), hat and socks.
Cover the infant on the mother's chest with her clothes and an additional (pre-warmed) blanket.
Check the temperature every hour until normal.
Keep the baby with the mother until the baby's body temperature is in normal range.
If the baby is small, encourage the mother to keep the baby in skin-to-skin contact for as long as possible, day and night.
Be sure the temperature of the room where the rewarming takes place is at least 25°C.
If the baby's temperature is not 36.5°C or more after 2 hours of rewarming, reassess the baby J2-J7.
If referral needed, keep the baby in skin-to-skin position/contact with the mother or other person accompanying the baby.

Always wash hands before and after taking care of the baby. DO NOT share supplies with other babies.

Wash hands before and after cord care.
Put nothing on the stump.
Fold nappy (diaper) below stump.
Keep cord stump loosely covered with clean clothes.
If stump is soiled, wash it with clean water and soap. Dry it thoroughly with clean cloth.
If umbilicus is red or draining pus or blood, examine the baby and manage accordingly J2-J7.
Explain to the mother that she should seek care if the umbilicus is red or draining pus or blood.

DO NOT bandage the stump or abdomen.

DO NOT apply any substances or medicine to stump.

Avoid touching the stump unnecessarily.

Sleeping

Use the bednet day and night for a sleeping baby.
Let the baby sleep on her/his back or on the side.
Keep the baby away from smoke or people smoking.
Keep the baby, especially a small baby, away from sick children or adults.

Only remove blood or meconium.

DO NOT remove vernix.

DO NOT bathe the baby until at least 6 hours of age.

LATER AND AT HOME

Wash the face, neck, underarms daily.
Wash the buttocks when soiled. Dry thoroughly.
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Ensure the room is warm, no draught
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Use warm water for bathing
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Thoroughly dry the baby, dress and cover after bath.

Use cloth on baby's bottom to collect stool. Dispose of the stool as for woman's pads. Wash hands.

DO NOT bathe the baby before 6 hours old or if the baby is cold.

DO NOT apply anything in the baby's eyes except an antimicrobial at birth.

SMALL BABIES REQUIRE MORE CAREFUL ATTENTION

The room must be warmer when changing, washing, bathing and examining a small baby.

If the baby is not breathing or is gasping for breath, start resuscitation within 1 minute of birth.

Observe universal precautions to prevent infection A4.

Keep the baby warm

Transfer the baby to a dry, clean and warm surface.
Inform the mother that the baby has difficulty initiating breathing and that you will help the baby to breathe.
Keep the baby wrapped and under a radiant heater if possible.

Open the airway

Position the head so it is slightly extended. Place a folded towel no more than 2 cm thick under the baby's shoulders.
Only if the amniotic fluid was stained with meconium or if mouth or nose full of secretion, suction first the mouth and then the nose.
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Introduce the suction tube into the newborn's mouth 5 cm from lips and suck while withdrawing.
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Introduce the suction tube 3 cm into each nostril and suck while withdrawing until no mucus, no more than 10 seconds in total.

If still no breathing, VENTILATE

Place mask to cover chin, mouth, and nose.
Squeeze bag attached to the mask with 2 fingers or whole hand, according to bag size, 5 times.
Observe rise of chest. If chest is not rising:
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reposition head
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check mask seal.
Squeeze bag harder with whole hand.
Once good seal and chest rising, ventilate for 1 minute at 40 squeezes per minute.
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if the heart rate is more than 100 per minute (HR>100/min.), continue ventilating until the newborn starts crying or breathing spontaneously.

Look at the chest for in-drawing.
Count breaths per minute.
If breathing more than 30 breaths per minute and no severe chest in-drawing:
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do not ventilate any more
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put the baby in skin-to-skin contact on mother's chest and continue care as on D19.
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monitor every 15 minutes for breathing and warmth
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tell the mother that the baby will probably be well.

DO NOT leave the baby alone

If heart rate less than 100 per minute (HR<100/min.) or breathing less than 30 per minute (RR<30/min.) or severe chest in-drawing

Take ventilation corrective steps
Arrange for immediate referral.
Reassess every 1 - 2 minutes
Explain to the mother what happened, what you are doing and why.
Ventilate during referral.
Record the event on the referral form and labour record.

If no breathing or gasping at all

Continue ventilating for 10 minutes.
Reassess heart rate every 60 seconds.
If heart rate remains slow (<60/min)
or not detectable, stop ventilating. The baby is dead.
Explain to the mother and give supportive care D24.
Record the event. Complete the perinatal death certificate N7.

Treat the baby

Determine appropriate drugs and dosage for the baby's weight.
Give 1 mg of vitamin K IM to all newborns, one hour after birth.
Tell the mother the reasons for giving the drug to the baby.
Give intramuscular antibiotics in thigh. Use a new syringe and needle for each antibiotic.

Give first dose of both ampicillin and gentamicin IM in thigh before referral for possible serious illness, severe umbilical infection or severe skin infection.
Give both ampicillin and gentamicin IM for 5 days in asymptomatic babies classified at risk of infection.
Give intramuscular antibiotics in thigh. Use a new syringe and needle for each antibiotic.

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Weight	Benzathine penicillin IM Dose: 50 000 units/kg onceAdd 5 ml sterile water to vial containing 1.2 million units= 1.2 million units/(6 ml total volume) = 200 000 units/ml
1.0 - 1.4 kg	0.35 ml
1.5 - 1.9 kg	0.5 ml
2.0 - 2.4 kg	0.6 ml
2.5 - 2.9 kg	0.75 ml
3.0 - 3.4 kg	0.85 ml
3.5 - 3.9 kg	1.0 ml
4.0 - 4.4 kg	1.1 ml

Teach the mother to give treatment to the baby at home

Explain carefully how to give the treatment. Label and package each drug separately.
Check mother's understanding before she leaves the clinic.
Demonstrate how to measure a dose.
Watch the mother practice measuring a dose by herself.
Watch the mother give the first dose to the baby.

TEACH MOTHER TO TREAT LOCAL INFECTION

Explain and show how the treatment is given.
Watch her as she carries out the first treatment.
Ask her to let you know if the local infection gets worse and to return to the clinic if possible.

TREAT SKIN PUSTULES OR UMBILICAL INFECTION

Do the following 3 times daily:
Wash hands with clean water and soap.
Gently wash off pus and crusts with boiled and cooled water and soap.
Dry the area with clean cloth.
Paint with gentian violet.

Do the following 6-8 times daily:

Wash hands with clean water and soap.
Wet clean cloth with boiled and cooled water.
Use the wet cloth to gently wash off pus from the baby's eyes.
Apply 1% tetracycline eye ointment in each eye 3 times daily.
Wash hands.

REASSESS IN 2 DAYS

Assess the skin, umbilicus or eyes.
If pus or redness remains or is worse, refer to hospital.
If pus and redness have improved, tell the mother to continue treating local infection at home.

If the mother is diagnosed as having tuberculosis and started treatment less than 2 months before delivery:

Give 5 mg/kg isoniazid (INH) orally once a day for 6 months (1 tablet = 200 mg).
Delay BCG vaccination until INH treatment completed, or repeat BCG.
Reassure the mother that it is safe to breastfeed the baby.
Follow up the baby every 2 weeks, or according to national guidelines, to assess weight gain.

Give BCG, OPV-0, Hepatitis B vaccine birth dose, within 24 hours after birth, preferably before discharge.
If un-immunized newborn first seen 1-4 weeks of age, give BCG only.
Record on immunization card and child record.
Advise when to return for next immunization.

Give ARV drugs to newborn

Give the first dose of ARV drugs to newborn 6–12 hours after birth G9, G12.
Give Nevirapine 2 mg/kg once only.
Give Zidovudine 4 mg/kg every 12 hours.
If the newborn spills or vomits within 30 minutes repeat the dose.

Teach mother to give oral ARV drugs at home

Explain and show how the drug is given.
Demonstrate how to use the syringe and how to measure the dose.
Ask the mother to begin breastfeeding or feed the baby by cup.
Give drug by the syringe into the baby's mouth before the end of the feed.
Watch the mother as she carries out the next treatment.
Explain to the mother that she should watch her baby after giving a dose of ARV drug. If baby vomits or spills within 30 minutes, she should repeat the dose.
Tell her to give the ARV drugs every day at the same time for 6 weeks.
Prescribe or give her enough ARV(s) until the next visit.

For maternal visits see schedule on D28.

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If the problem was:	Return in
Feeding difficulty	2 days
Red umbilicus	2 days
Skin infection	2 days
Eye infection	2 days
Thrush	2 days
Mother has either:
→ breast engorgement or	2 days
→ mastitis.	2 days

Low birth weight, and either
→ first week of life or	2 days
→ not adequately gaining weight	2 days

Low birth weight, and either
→ older than 1 week or	7 days
→ gaining weight adequately	7 days

Orphan baby	14 days
INH prophylaxis	14 days
Treated for possible congenital syphilis	14 days
Mother HIV-infected	14 days

Use the counselling sheet to advise the mother when to seek care, or when to return, if the baby has any of these danger signs:

RETURN OR GO TO THE HOSPITAL IMMEDIATELY IF THE BABY HAS

GO TO HEALTH CENTRE AS QUICKLY AS POSSIBLE IF THE BABY HAS

a cord stump which is red or draining pus.
feeds <5 times in 24 hours.

After emergency treatment, explain the need for referral to the mother/father.
Organize safe transportation.
Always send the mother with the baby, if possible.
Send referral note with the baby.
Inform the referral centre if possible by radio or telephone.

DURING TRANSPORTATION

Keep the baby warm by skin-to-skin contact with mother or someone else.
Cover the baby with a blanket and cover her/his head with a cap.
Protect the baby from direct sunshine.
Encourage breastfeeding during the journey.
If the baby does not breastfeed and journey is more than 3 hours, consider giving expressed breast milk by cup K6.