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Breast fed infants, are Healthy Infan Breast fed infants, are Healthy Infan

Breastfeeding effective practices, benefits to mothers and infants

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Page 1: Breastfeeding effective practices, benefits to mothers and infants

““Breast fed infants, are Healthy Infants.”Breast fed infants, are Healthy Infants.”

Page 2: Breastfeeding effective practices, benefits to mothers and infants

IntroductionIntroduction Anatomy and Physiology of LactationAnatomy and Physiology of Lactation Composition and Storage of Human Breast MilkComposition and Storage of Human Breast Milk Achieving Optimal BreastfeedingAchieving Optimal Breastfeeding Breastfeeding Techniques and PositionsBreastfeeding Techniques and Positions Benefits of Breastfeeding to Infants and MothersBenefits of Breastfeeding to Infants and Mothers Barriers to Effective BreastfeedingBarriers to Effective Breastfeeding Contraindication to BreastfeedingContraindication to Breastfeeding Reason for supplementationReason for supplementation Role of the Family PhysicianRole of the Family Physician ConclusionConclusion

BreastfeedingBreastfeedingEffective Practices, Benefits to Mothers and Effective Practices, Benefits to Mothers and

Infants and The Role of the Family Infants and The Role of the Family PhysicianPhysician

Page 3: Breastfeeding effective practices, benefits to mothers and infants

IntroductionIntroduction Breastfeeding is the optimal source of nutrition. The Human Breastfeeding is the optimal source of nutrition. The Human

Milk is specie specific and it provides all the essential nutrients Milk is specie specific and it provides all the essential nutrients necessary for the growth and development of the newborn necessary for the growth and development of the newborn infant.infant.

The AAP, AAFP and WHO recommend exclusive breastfeeding The AAP, AAFP and WHO recommend exclusive breastfeeding for the first six months of life , and continuous breastfeeding for the first six months of life , and continuous breastfeeding for at least 12 months of life.for at least 12 months of life.

The Target of USDHHS “Healthy People 2010” initiative is to The Target of USDHHS “Healthy People 2010” initiative is to achieve breastfeeding at birth of 75%, 50% at 6 month and achieve breastfeeding at birth of 75%, 50% at 6 month and 25% at 12 months of life.25% at 12 months of life.

2008 data published by the CDC shows that 77% of mothers in 2008 data published by the CDC shows that 77% of mothers in the US initiate breastfeeding at birth. Only about 30% of women the US initiate breastfeeding at birth. Only about 30% of women continue with breastfeeding of the infant to 6 months of age. continue with breastfeeding of the infant to 6 months of age.

Page 4: Breastfeeding effective practices, benefits to mothers and infants

Anatomy and Physiology of LactationAnatomy and Physiology of Lactation

Structure of the Human BreastStructure of the Human Breast

Source: Lactation Education Program Nutrition Policy and Education

Page 5: Breastfeeding effective practices, benefits to mothers and infants

Structure of the Human Structure of the Human BreastBreast

The Human breast are modified sweat glands The Human breast are modified sweat glands responsible for lactation (milk production).responsible for lactation (milk production).

The breast contains adipose tissue and fibrous The breast contains adipose tissue and fibrous connective tissue. connective tissue.

Different hormones are responsible for the Different hormones are responsible for the development of the breast and changes that occur development of the breast and changes that occur during pregnancy.during pregnancy.

The major hormones affecting breast development The major hormones affecting breast development and enlargement are estrogen, progesterone and and enlargement are estrogen, progesterone and prolactin.prolactin.

Page 6: Breastfeeding effective practices, benefits to mothers and infants

Structure of the Human Breast Structure of the Human Breast (Cont’d)(Cont’d)

Each breast contains about 20 lobes, each lobes Each breast contains about 20 lobes, each lobes contains several lobules which at the end have contains several lobules which at the end have alveolar in which milk is produced.alveolar in which milk is produced.

Milk production and secretion are responsive to two Milk production and secretion are responsive to two major hormones – prolactin and oxytocin; and the major hormones – prolactin and oxytocin; and the sucking reflex. sucking reflex.

After production of milk in the alveolus, the milk After production of milk in the alveolus, the milk moves through the ducts and are stored in the moves through the ducts and are stored in the lactiferous sinus. When the infant latches on the lactiferous sinus. When the infant latches on the breast, milk is expressed from the sinuses.breast, milk is expressed from the sinuses.

Page 7: Breastfeeding effective practices, benefits to mothers and infants

Suckling Hormonal Reflex ArcSuckling Hormonal Reflex Arc

Source: Lactation Education Program Nutrition Policy and Education

Page 8: Breastfeeding effective practices, benefits to mothers and infants

The sucking reflex arc is a hormonal positive feedback The sucking reflex arc is a hormonal positive feedback mechanism. mechanism.

The sucking of the breast by the infant stimulates the The sucking of the breast by the infant stimulates the nipple; this sends messages to the spinal cord and nipple; this sends messages to the spinal cord and subsequently to the brain. subsequently to the brain.

Prolactin is released from the anterior pituitary for milk Prolactin is released from the anterior pituitary for milk production and oxytocin from the posterior pituitary for production and oxytocin from the posterior pituitary for the milk let down. the milk let down.

Prolactin receptors are established within the first Prolactin receptors are established within the first eight days of delivery. eight days of delivery.

Suckling at breast increases prolactin levels, so at each Suckling at breast increases prolactin levels, so at each feeding, levels rise, hence more milk production.feeding, levels rise, hence more milk production.

Suckling Hormonal Reflex Arc Suckling Hormonal Reflex Arc (Cont’d)(Cont’d)

Page 9: Breastfeeding effective practices, benefits to mothers and infants

Types and Composition of Types and Composition of Human Breast MilkHuman Breast Milk

Types of Breast Milk:Types of Breast Milk: Colostrum or Early MilkColostrum or Early Milk Transitional MilkTransitional Milk Mature MilkMature Milk

Colostrum or Early Milk is produced in the late stage of Colostrum or Early Milk is produced in the late stage of pregnancy till 4 days after delivery; and is rich in antibodies.pregnancy till 4 days after delivery; and is rich in antibodies.

Transitional Milk produced from day 4 – 10 is lower in protein Transitional Milk produced from day 4 – 10 is lower in protein in comparison to Colostrum.in comparison to Colostrum.

Mature milk is produced from approximately ten days after Mature milk is produced from approximately ten days after delivery up until the termination of the breastfeeding. delivery up until the termination of the breastfeeding.

Page 10: Breastfeeding effective practices, benefits to mothers and infants

Types and Composition of Human Types and Composition of Human Breast Milk (Cont’d)Breast Milk (Cont’d)

Fat Fat - The main lipids found in human milk are the - The main lipids found in human milk are the triglycerides phospholipids and essential fatty acids. triglycerides phospholipids and essential fatty acids.

Protein Protein – Whey ; lactoferrin, lysozymes, – Whey ; lactoferrin, lysozymes, immunoglobulin , A- lactalbumin, Casein; lower immunoglobulin , A- lactalbumin, Casein; lower concentration in human milk.concentration in human milk.

Carbohydrate Carbohydrate – Include lactose and oligosaccharides. – Include lactose and oligosaccharides.

Leukocytes - Leukocytes - Include neutrophils, marcrophages , Include neutrophils, marcrophages , lymphocytes.lymphocytes.

Non protein nitrogen Non protein nitrogen – urea, uric acid– urea, uric acid

Other constituentsOther constituents : steroid hormones, peptides, : steroid hormones, peptides, insulins, growth factors, minerals, vitamins, lipase.insulins, growth factors, minerals, vitamins, lipase.

Page 11: Breastfeeding effective practices, benefits to mothers and infants

Storage of Breast MilkStorage of Breast Milk Human milk can be stored at room temperature for 6-8 Human milk can be stored at room temperature for 6-8

hours. hours.

Expressed milk can be stored in an insulated cooler bag Expressed milk can be stored in an insulated cooler bag with icepacks for 24hours. with icepacks for 24hours.

Breast milk can be stored in the refrigerator for about 5 Breast milk can be stored in the refrigerator for about 5 days at about 40° F.days at about 40° F.

It can also be kept in a freezer compartment of a fridge for It can also be kept in a freezer compartment of a fridge for up to two weeks at up to two weeks at 0 - 5°F

It can be stored in a deep freezer for about 3-12 months It can be stored in a deep freezer for about 3-12 months

Breast milk should be stored in BPA (Bisphenol A) free Breast milk should be stored in BPA (Bisphenol A) free containers.containers.

Page 12: Breastfeeding effective practices, benefits to mothers and infants

Achieving Optimal Achieving Optimal BreastfeedingBreastfeeding

Activities, attitudes and procedures during the Activities, attitudes and procedures during the delivery and post partum period have an impact on delivery and post partum period have an impact on breastfeeding . breastfeeding .

There is well documented evidence that skin to skin There is well documented evidence that skin to skin contact between infant and mother helps to contact between infant and mother helps to maintain the body temperatures, reduce risk of maintain the body temperatures, reduce risk of hypoglycemia, enhance oxytocin release and hypoglycemia, enhance oxytocin release and beneficial nutrition with intake of colostrum beneficial nutrition with intake of colostrum

Skin to skin contact should occur for about 1-2 Skin to skin contact should occur for about 1-2 hours after delivery. Procedures after delivery like hours after delivery. Procedures after delivery like weighing, administration of vitamin K, eye weighing, administration of vitamin K, eye prophylaxis and other procedures should be delayed prophylaxis and other procedures should be delayed

Page 13: Breastfeeding effective practices, benefits to mothers and infants

Breastfeeding should be started and fully established Breastfeeding should be started and fully established before discharge from the hospitalbefore discharge from the hospital

Physicians and health care professionals should Physicians and health care professionals should observe at least one feeding and ensure this is done observe at least one feeding and ensure this is done properly and breast milk is produced properly and breast milk is produced

Lactation specialist should also work with parents Lactation specialist should also work with parents that are having difficulty with breast feeding. that are having difficulty with breast feeding.

Early follow up after leaving the hospital is required. Early follow up after leaving the hospital is required.

Achieving Optimal Achieving Optimal Breastfeeding (Cont’d)Breastfeeding (Cont’d)

Page 14: Breastfeeding effective practices, benefits to mothers and infants

Signs of Effective Signs of Effective BreastfeedingBreastfeeding

Frequent feedings 8-12 times daily. Frequent feedings 8-12 times daily.

Intermittent episodes of rhythmic sucking with audible Intermittent episodes of rhythmic sucking with audible swallows should be heard while the infant is nursing.swallows should be heard while the infant is nursing.

Infant should have about 6-8 wet diapers in a 24 hour period Infant should have about 6-8 wet diapers in a 24 hour period once breast feeding is established.once breast feeding is established.

Infant should have minimum of 3-4 bowel movements every Infant should have minimum of 3-4 bowel movements every 24 hours.24 hours.

Stools should be about one tablespoon or larger and should Stools should be about one tablespoon or larger and should be soft and yellow after day 3.be soft and yellow after day 3.

Average daily weight gain of 15 -30g.Average daily weight gain of 15 -30g.

Infant has regained birth weight by day 10 of life.Infant has regained birth weight by day 10 of life.

Page 15: Breastfeeding effective practices, benefits to mothers and infants

Good Breastfeeding Good Breastfeeding TechniquesTechniques

The baby should be properly positioned to achieve effective The baby should be properly positioned to achieve effective latching. latching.

The mother should wear comfortable apparel, with the breast The mother should wear comfortable apparel, with the breast well exposed for the infant to be able to latch. well exposed for the infant to be able to latch.

The infant’s mouth, chin and umbilicus should be lined up with The infant’s mouth, chin and umbilicus should be lined up with the head in a neutral position. the head in a neutral position.

The infant is brought to the breast, with the nose touching or The infant is brought to the breast, with the nose touching or close to the breast. close to the breast.

The gum line should overlap the areola, and the nipple The gum line should overlap the areola, and the nipple straight back into the mouth. straight back into the mouth.

The tongue moves forward beyond the lower gum, cupped and The tongue moves forward beyond the lower gum, cupped and forming a reservoir. forming a reservoir.

Milk is removed for the lactiferous sinuses, the jaw moves Milk is removed for the lactiferous sinuses, the jaw moves down creating a negative pressure gradient that helped down creating a negative pressure gradient that helped transfer milk to the pharynx. transfer milk to the pharynx.

Page 16: Breastfeeding effective practices, benefits to mothers and infants

Good Breastfeeding Good Breastfeeding TechniquesTechniques

Page 17: Breastfeeding effective practices, benefits to mothers and infants

Breastfeeding PositionsBreastfeeding Positions

Cradle HoldCradle Hold

This is the most common This is the most common position used by mothers.position used by mothers.

Infant’s head is supported Infant’s head is supported in the elbow, the back and in the elbow, the back and buttock is supported by the buttock is supported by the arm and lifted to the arm and lifted to the breast.breast.

Adapted from AAFP Journal September 2001

Page 18: Breastfeeding effective practices, benefits to mothers and infants

Football Hold PositionFootball Hold Position

The infant’s is placed under The infant’s is placed under the arm, like holding a the arm, like holding a footballfootball

Baby’s body is supported with Baby’s body is supported with the forearm and the head is the forearm and the head is supported with the hand. supported with the hand.

Many mothers are not Many mothers are not comfortable with this positioncomfortable with this position

Good position after operative Good position after operative proceduresprocedures

Adapted from AAFP Journal September 2001

Breastfeeding PositionsBreastfeeding Positions

Page 19: Breastfeeding effective practices, benefits to mothers and infants

Side Lying PositionSide Lying Position

The mother lies on her side The mother lies on her side propping up her head and propping up her head and shoulder with pillows. shoulder with pillows.

The infant is also lying down The infant is also lying down facing the mother. facing the mother.

Good position after Caesarean Good position after Caesarean section. section.

Allows the new mother some Allows the new mother some rest. rest.

Most mothers are scared of Most mothers are scared of crushing the baby. crushing the baby.

Breastfeeding PositionsBreastfeeding Positions

Adapted from AAFP Journal September 2001

Page 20: Breastfeeding effective practices, benefits to mothers and infants

Cross Cradle Hold Cross Cradle Hold PositionPosition

Ideal for early breastfeeding. Ideal for early breastfeeding.

Mother holds the baby Mother holds the baby crosswise in the crook of the crosswise in the crook of the arm opposite the breast the arm opposite the breast the infant is to be fed. infant is to be fed.

The baby's trunk and head The baby's trunk and head are supported with the are supported with the forearm and palm. forearm and palm.

The other hand is placed The other hand is placed beneath the breast in a U-beneath the breast in a U-shaped to guide the baby's shaped to guide the baby's mouth to your breast. mouth to your breast.

Breastfeeding PositionsBreastfeeding Positions

Adapted from AAFP Journal September 2001

Page 21: Breastfeeding effective practices, benefits to mothers and infants

Australian Hold Australian Hold PositionPosition

This is also called the saddle This is also called the saddle hold hold

Usually used for older Usually used for older infants infants

Not commonly used by Not commonly used by mothers.mothers.

Best used in older infants Best used in older infants with runny nose, ear with runny nose, ear infection.infection.

Breastfeeding PositionsBreastfeeding Positions

Adapted from AAFP Journal September 2001

Page 22: Breastfeeding effective practices, benefits to mothers and infants

Benefits of Breastfeeding to Benefits of Breastfeeding to InfantsInfants

Helps in Gastrointestinal development and functionHelps in Gastrointestinal development and function

Helps in development of the immune systemHelps in development of the immune system

Helps in cognitive development of the infantHelps in cognitive development of the infant

Infants who are breastfed have reduced risk of Infants who are breastfed have reduced risk of infection compared to formula fed infants.infection compared to formula fed infants.

Page 23: Breastfeeding effective practices, benefits to mothers and infants

Breastfed infants have reduced risk of obesity later in Breastfed infants have reduced risk of obesity later in life compared to formula fed infants.life compared to formula fed infants.

Reduced risk of sudden infant death syndrome, Reduced risk of sudden infant death syndrome, Hodgkin's lymphoma, Leukemia and Type 1 Hodgkin's lymphoma, Leukemia and Type 1 Diabetes.Diabetes.

Lower risk of infections e.g. otitis media, Lower Lower risk of infections e.g. otitis media, Lower respiratory tract infection, Diarrheal diseases, respiratory tract infection, Diarrheal diseases, Allergies , eczema, Meningitis and inflammatory Allergies , eczema, Meningitis and inflammatory bowel diseases.bowel diseases.

Benefits of Breastfeeding to Benefits of Breastfeeding to InfantsInfants

Page 24: Breastfeeding effective practices, benefits to mothers and infants

Benefits of Breastfeeding to Benefits of Breastfeeding to MothersMothers

Enhance early maternal – infant bond.Enhance early maternal – infant bond.

Aids involution of the uterus.Aids involution of the uterus.

Long term breastfeeding helps in loss of the excess Long term breastfeeding helps in loss of the excess weight acquired during pregnancy.weight acquired during pregnancy.

Prolonged Breastfeeding prolongs anovulation. Prolonged Breastfeeding prolongs anovulation.

Documented long term effect of breastfeeding include Documented long term effect of breastfeeding include reduced risk of breast, ovarian and endometrial reduced risk of breast, ovarian and endometrial cancers.cancers.

Page 25: Breastfeeding effective practices, benefits to mothers and infants

Supplements that increase Supplements that increase lactationlactation

Herbal dietary Herbal dietary supplementsupplement

- Fennel fruit- Fennel fruit- Aniseed fruit- Aniseed fruit- Coriander fruit- Coriander fruit- Fenugreek seed- Fenugreek seed- Blessed thistle herb- Blessed thistle herb

- Not FDA approved.Not FDA approved.

Page 26: Breastfeeding effective practices, benefits to mothers and infants

Socio-economic Benefits of Socio-economic Benefits of BreastfeedingBreastfeeding

Income savings – average of $1000 - $1200 per infant Income savings – average of $1000 - $1200 per infant per year.per year.

Reduced risk of infections and diseases hence Reduced risk of infections and diseases hence reduced hospital visits and attendant medical cost.reduced hospital visits and attendant medical cost.

Mothers are more economically productive since they Mothers are more economically productive since they will spend less time caring for a sick child.will spend less time caring for a sick child.

Page 27: Breastfeeding effective practices, benefits to mothers and infants

Barriers To Effective Barriers To Effective BreastfeedingBreastfeeding

Lack of confidence in motherLack of confidence in mother

Belief that breast milk is not sufficientBelief that breast milk is not sufficient

Lack of adequate support systemLack of adequate support system

History of previous breast surgeryHistory of previous breast surgery

Breast engorgement, cracked and sore nipplesBreast engorgement, cracked and sore nipples

Retractile nipplesRetractile nipples

Page 28: Breastfeeding effective practices, benefits to mothers and infants

Barriers To Effective BreastfeedingBarriers To Effective Breastfeeding

Embarrassment by motherEmbarrassment by mother

Jealousy by Partner and siblingsJealousy by Partner and siblings

Chronic illness in mother; psychosis, Cancer.Chronic illness in mother; psychosis, Cancer.

Page 29: Breastfeeding effective practices, benefits to mothers and infants

Contraindication to BreastfeedingContraindication to Breastfeeding HIV , HLTV 1 & 11 infections.HIV , HLTV 1 & 11 infections.

Active Tuberculosis.Active Tuberculosis.

Herpes lesions on mother’s breast.Herpes lesions on mother’s breast.

Infant with Inborn error of metabolism; galactosemia, Infant with Inborn error of metabolism; galactosemia, phenylketonuria.phenylketonuria.

Mothers on certain medications ; anticancer therapy, Mothers on certain medications ; anticancer therapy, radioactive isotope etc.radioactive isotope etc.

Page 30: Breastfeeding effective practices, benefits to mothers and infants

Reason for SupplementationReason for Supplementation Birth weight < 1500 g or GA < 32 weeksBirth weight < 1500 g or GA < 32 weeks

Severe hypoglycemiaSevere hypoglycemia

Acute water lossAcute water loss

Hyperbilirubinemia related to poor intakeHyperbilirubinemia related to poor intake

Delayed bowel movement or dark stools at day 5Delayed bowel movement or dark stools at day 5

Delayed milk productionDelayed milk production

Weight loss >8% of birth weight.Weight loss >8% of birth weight.

Page 31: Breastfeeding effective practices, benefits to mothers and infants

Role of the Family PhysicianRole of the Family Physician

Provide education about breastfeeding at first Provide education about breastfeeding at first prenatal visitprenatal visit

Physical exam should include breast examPhysical exam should include breast exam

Ensure rooming-in after deliveryEnsure rooming-in after delivery

Ensure breastfeeding is started and established Ensure breastfeeding is started and established before discharge after delivery.before discharge after delivery.

Observe at least a session of breastfeeding to ensure Observe at least a session of breastfeeding to ensure it is done correctlyit is done correctly

Page 32: Breastfeeding effective practices, benefits to mothers and infants

Role of the Family PhysicianRole of the Family Physician

Office should be breastfeeding friendlyOffice should be breastfeeding friendly

Staff should be well trained and willing to answer Staff should be well trained and willing to answer questions mothers might havequestions mothers might have

Prenatal package should have literatures and patient Prenatal package should have literatures and patient hand out that outlines benefit of breastfeedinghand out that outlines benefit of breastfeeding

Prenatal records should have a checklist that ensure Prenatal records should have a checklist that ensure all question are addressed.all question are addressed.

Page 33: Breastfeeding effective practices, benefits to mothers and infants

Conclusion

Breastfeeding is the best source of nutrition for a Breastfeeding is the best source of nutrition for a healthy term infant. healthy term infant.

AAP, AAFP and WHO recommends exclusive AAP, AAFP and WHO recommends exclusive breastfeeding for the first six month of life and for at breastfeeding for the first six month of life and for at least twelve month of life.least twelve month of life.

Human milk is human specific and contains nutrients Human milk is human specific and contains nutrients that are essential for the proper growth and that are essential for the proper growth and development of the newborn.development of the newborn.

Breast milk is beneficial to both infant and mother.Breast milk is beneficial to both infant and mother.

Page 34: Breastfeeding effective practices, benefits to mothers and infants

Conclusion

Proper positioning on the breast helps ensure Proper positioning on the breast helps ensure adequate latching on and subsequently adequate adequate latching on and subsequently adequate breastfeeding.breastfeeding.

Breast milk can be stored away, and utilized later Breast milk can be stored away, and utilized later when needed.when needed.

There are absolute contraindications to There are absolute contraindications to breastfeeding, these include HIV, 1 and 11 , HTLV 1 breastfeeding, these include HIV, 1 and 11 , HTLV 1 and 11, active TB and active herpes simplex lesions and 11, active TB and active herpes simplex lesions on the breast.on the breast.

The family physician has a significant role in The family physician has a significant role in promoting breastfeeding.promoting breastfeeding.

Page 35: Breastfeeding effective practices, benefits to mothers and infants

ReferencesReferences Riordan J, Auerbach KG.Riordan J, Auerbach KG. Breastfeeding and Human LactationBreastfeeding and Human Lactation. 2nd edition, Sudbury, . 2nd edition, Sudbury,

Mass: Jones and Bartlett, 1999Mass: Jones and Bartlett, 1999 American Academy of Pediatrics Journals & Periodicals American Academy of Pediatrics Journals & Periodicals Pediatrics in ReviewPediatrics in Review

www.aappublications.org Gartner LM, Morton J, Lawrence RA. et alGartner LM, Morton J, Lawrence RA. et al Breastfeeding and the Use of Human Breastfeeding and the Use of Human

MilkMilk, Pediatrics 2005 Feb;115 (2): 496 – 506, Pediatrics 2005 Feb;115 (2): 496 – 506 United States Department of Health and Human ServicesUnited States Department of Health and Human Services . Healthy People 2010: . Healthy People 2010:

Volume II. Objectives for Improving Health. Retrieved March 2009 from Volume II. Objectives for Improving Health. Retrieved March 2009 from http://www.healthypeople.gov/Document/tableofcontents.htm#volume1

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Wright AL.Wright AL. The rise of breastfeeding in the United States.The rise of breastfeeding in the United States. Pediatric Clinics of North Pediatric Clinics of North America 2001; pp1-12. America 2001; pp1-12.

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Lawrence RA and Lawrence RM.Lawrence RA and Lawrence RM. Breastfeeding, A Guide for the Medical Profession,Breastfeeding, A Guide for the Medical Profession, 6th Ed. Elsevier Mosby, Philadelphia PA. 20056th Ed. Elsevier Mosby, Philadelphia PA. 2005

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ReferencesReferences Nancy G, Powers, Wendelin SNancy G, Powers, Wendelin S. . Breastfeeding Update 2Breastfeeding Update 2: Clinical : Clinical

Lactation Management. Pediatrics In Review: May 1997; pp147-15Lactation Management. Pediatrics In Review: May 1997; pp147-15

Ali Z, Lowry M.Ali Z, Lowry M. Early maternal-child contact: effects on later Early maternal-child contact: effects on later behaviour.behaviour. Dev Med Child Neurol. Vol. 23 June 1981; pp337-345 Dev Med Child Neurol. Vol. 23 June 1981; pp337-345

Sinusas K, Gagliardi ASinusas K, Gagliardi A. . Initial Management of BreastfeedingInitial Management of Breastfeeding American Family Physician, Journal of the AAFP; September 15, 2001American Family Physician, Journal of the AAFP; September 15, 2001

Moreland J, Coombs JMoreland J, Coombs J. . Promoting and supporting BreastfeedingPromoting and supporting Breastfeeding. . American Family Physician, Journal of the AAFP; April 1, 2000American Family Physician, Journal of the AAFP; April 1, 2000

Agency for Healthcare Research and QualityAgency for Healthcare Research and Quality Breastfeeding and Breastfeeding and Maternal and Infant HealthMaternal and Infant Health Outcomes in Developed CountriesOutcomes in Developed Countries; April ; April 2007; #153; Retrieved March 15 2009 from 2007; #153; Retrieved March 15 2009 from http://www.ahrq.gov/downloads/pub/evidence/pdf/brfout/brfout.pdf

Protecting, promoting and supporting breastfeeding: the special role of Protecting, promoting and supporting breastfeeding: the special role of maternity services. A Joint WHO/UNICEF statement. Int J Gynecol Obstet maternity services. A Joint WHO/UNICEF statement. Int J Gynecol Obstet 1990; 31(suppl 1):171-83.1990; 31(suppl 1):171-83.

Moreland J, Coombs J Moreland J, Coombs J Promoting and Supporting Breast Feeding Promoting and Supporting Breast Feeding American Family Physician 2000; 61:2093-100, 2103-4American Family Physician 2000; 61:2093-100, 2103-4