Assessment of breast feeding. (5 Marks) (VALMED)*** *What is complementary feeding? How will you counsel a young primipara mother for optimal feeding of her baby from 6 months to 12 months. (5 Marks) (KMCRI) *Describe the 10 steps of Baby Friendly Hospital Initiative policy of successful Breast feeding. (5 Marks)(GMC)

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Breastfeeding - Comprehensive Examination Notes

Q1. Assessment of Breastfeeding (5 Marks - VALMED)

Assessment of breastfeeding involves evaluating the mother, the infant, and the feeding process systematically using the LATCH scoring system and clinical indicators.

A. LATCH Score (Standard Assessment Tool)

Letter	Parameter	0	1	2
L	Latch	Too sleepy / no latch	Repeated attempts, holds briefly	Grasps breast, rhythmic suckling
A	Audible swallowing	None	A few with stimulation	Spontaneous & intermittent
T	Type of nipple	Inverted	Flat	Everted (protractile)
C	Comfort (breast/nipple)	Engorged, cracked	Filling, reddened, small blisters	Soft, no tenderness
H	Hold (positioning)	Full assist needed	Minimal assist	No assist needed

Score 0-10: Score ≥7 = satisfactory breastfeeding. Score <7 = intervention needed.

B. Assessment of the Baby (Signs of Adequate Intake)

Baby feeding 8-12 times in 24 hours
Adequate wet diapers (at least 6 per day after Day 4)
Passage of yellow stools in breastfed infant
Weight gain: regain birth weight by Day 10-14; gain ~500-1000 g/month thereafter
Baby appears satisfied after feeds, with relaxed hands and arms
Urine is pale yellow (not dark)

C. Assessment of the Mother

Breasts: Check for engorgement, mastitis, inverted/flat nipples, cracked nipples
Let-down reflex: Milk dripping from opposite breast during feeding
Nipple condition: Soreness often means poor latch - assess and correct
Milk supply: Evaluate by infant's weight gain, not expressed volume

D. Assessment of Positioning and Attachment (4 Key Signs of Good Attachment)

Baby's mouth is wide open
More areola visible above than below the baby's mouth
Baby's lower lip is turned outward (everted)
Baby's chin touches the breast

E. Signs of Effective Feeding

Audible swallowing heard
Breast becomes softer after feed
Baby releases breast spontaneously
Mother feels uterine cramps (early days) due to oxytocin

F. Assessment of Common Problems

Problem	Sign	Action
Poor latch	Nipple pain, clicking sounds	Re-latch, check positioning
Insufficient milk	Poor weight gain, <6 wet diapers	Increase feeding frequency
Mastitis	Tender, hot, red lump with fever	Continue feeding + antibiotics
Engorgement	Both breasts hard, painful	Feed frequently, warm compresses
Inverted nipples	Nipple retracts on palpation	Nipple shields, Hoffman exercises antenatally

Q2. Complementary Feeding & Counseling a Primipara Mother (6-12 Months) (5 Marks - KMCRI)

Definition of Complementary Feeding

Complementary feeding is the process of introducing safe, nutritionally adequate solid or semi-solid foods to complement (not replace) breast milk when breast milk alone is no longer sufficient to meet the nutritional requirements of an infant - typically starting at 6 months of age, while continuing breastfeeding up to 2 years or beyond.

Also called "weaning" (though the WHO prefers the term complementary feeding, as it implies addition, not withdrawal)
Per Park's Preventive & Social Medicine: "Weaning is not sudden withdrawal of child from the breast. It is a gradual process starting around the age of 6 months because the mother's milk alone is not sufficient to sustain growth beyond 6 months."

Key Principles of Complementary Feeding (WHO - AFASS criteria)

Foods should be: Affordable, Feasible, Acceptable, Sustainable, Safe.

Counseling a Young Primipara: Feeding 6-12 Months

Continue breastfeeding - breast milk remains a critical source of nutrition and immunity. Do NOT stop.

Month-by-Month Guide

Age	Texture	Frequency	Amount	Examples
6 months	Smooth puree / mashed	2-3 times/day	2-3 tbsp per meal	Rice water, suji (semolina) porridge, mashed banana, dal water
7-8 months	Thick mash / soft lumps	3-4 times/day	Gradually increase	Mashed rice+dal, mashed potato, cooked vegetables, curd
9-10 months	Finely chopped / finger foods	4 times/day + 1-2 snacks	~half a cup per meal	Soft chapati pieces, khichdi, boiled egg, soft fruit
11-12 months	Family foods - soft chopped	4-5 times/day	Approx. ¾ to full cup	Whatever the family eats (soft), cow's milk introduced

Counseling Points (CAMP mnemonic)

C - Continue breastfeeding

Breast milk + complementary foods = optimal nutrition
Feed breast milk first for babies <9 months, then solids

A - Amount & Age-appropriate texture

Start with 2-3 small spoonfuls; increase gradually
Progress texture from pureed → mashed → chopped → family foods
Avoid forced feeding; respect hunger/satiety cues

M - Meal frequency & energy density

Feed 2-3 times at 6 months; increase to 4-5 times by 12 months
Energy-dense foods preferred (add ghee/oil to increase caloric density)
Include all 5 food groups: cereals, pulses, dairy, fruits/vegetables, fats

P - Protein, micronutrients & hygiene

Include pulses (dal), egg, fish/meat for protein
Green leafy vegetables for iron, folate
Vitamin C-rich foods (tomato, lemon) to enhance iron absorption
Wash hands before feeding; use clean utensils; avoid bottle feeding
No salt/sugar/honey in first year; no whole cow's milk <12 months (may use in cooking)

Foods to AVOID (under 12 months)

Honey (risk of infant botulism)
Whole nuts/hard raw vegetables (choking hazard)
Excess salt or sugar
Tea/coffee
Bottle feeding (promotes dental caries, overfeeding)

Warning Signs to Watch For

Refusal to feed for >24 hours
No weight gain
Persistent diarrhoea after introducing new food
Signs of allergy: rash, vomiting, wheezing

Q3. 10 Steps of Baby Friendly Hospital Initiative (BFHI) for Successful Breastfeeding (5 Marks - GMC)

The Baby Friendly Hospital Initiative (BFHI) was launched by WHO and UNICEF in 1991 and revised in 2018. It applies to all facilities providing maternity and newborn services. The revised 2018 guidelines restructured the original 10 steps into the following:

Step 1 (Policy) - Three Sub-steps (1a, 1b, 1c):

Step 1a: Comply fully with the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly (WHA) resolutions. (No promotion of formula, bottles, or pacifiers)

Step 1b: Have a written infant feeding policy that is routinely communicated to all staff and parents.

Step 1c: Establish an ongoing monitoring and data management system to assess compliance.

Step 2 - Staff Training:

Ensure that all staff have sufficient knowledge, competence and skills to support breastfeeding. Regular training and competency assessment of all healthcare workers.

Step 3 - Antenatal Counseling:

Discuss the importance and management of breastfeeding with pregnant women and their families during antenatal visits. Include education about the benefits of breastfeeding, risks of formula, and practical guidance.

Step 4 - Immediate Skin-to-Skin Contact:

Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth (within the first hour - "Golden Hour"). Delays routine procedures (weighing, bathing) until after first feed.

Step 5 - Support Breastfeeding:

Support mothers to initiate and maintain breastfeeding and manage common difficulties such as engorgement, sore nipples, poor latch, and low milk supply. Lactation counselors should be available.

Step 6 - No Formula / Supplements Unless Medically Indicated:

Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated. No glucose water, formula, or plain water to be given routinely.

Step 7 - Rooming-In:

Enable mothers and their infants to remain together and to practice rooming-in 24 hours a day, 7 days a week. This promotes bonding, demand feeding, and milk production.

Step 8 - Responsive/Demand Feeding:

Support mothers to recognize and respond to their infant's cues for feeding (demand/responsive feeding). Feed the baby whenever hungry, not by schedule. Cues include: rooting, hand-to-mouth, crying (late sign).

Step 9 - No Bottles, Teats, or Pacifiers:

Counsel mothers on the use and risks of feeding bottles, teats, and pacifiers. Avoid nipple confusion. Bottle use undermines breastfeeding and is discouraged unless medically necessary.

Step 10 - Discharge Planning and Ongoing Support:

Coordinate discharge so that parents and their infants have timely access to ongoing support and care. Refer to community lactation support, mother support groups, and follow-up visits.

Summary Table - BFHI 10 Steps (2018)

Step	Key Action	Keyword
1a	Follow WHO Code on breast-milk substitutes	Policy compliance
1b	Written infant feeding policy	Written policy
1c	Monitoring system	Data management
2	Train staff	Education
3	Counsel pregnant women	Antenatal education
4	Skin-to-skin contact, early initiation	Golden hour
5	Support & manage difficulties	Lactation support
6	No supplemental feeds unless indicated	Exclusive BF
7	Rooming-in 24 hours	Mother-baby together
8	Respond to infant feeding cues	Demand feeding
9	No bottles/teats/pacifiers	No nipple confusion
10	Post-discharge follow-up and support	Continuity of care

Source: Park's Textbook of Preventive and Social Medicine (Baby Friendly Hospital Initiatives 2018 section); WHO/UNICEF BFHI 2018 revised guidelines.

Quick Exam Mnemonics:

BFHI Steps 1-10: "Policy Trains Counselors, Golden Support, No Supplementation, Room-in, Respond, No Bottles, Discharge"
Good Attachment (4 signs): WELT - Wide open mouth, Extra areola above, Lower lip everted, Touching chin
Complementary feeding starts: 6 months - never before 4 months, never delayed beyond 6 months

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