Legal Basis
- A.O. 2005-0014: “National Policy on Infant and Young Child Feeding”, created on May 23, 2005
- E.O. 51: National Code of Marketing of Breastmilk Substitutes, Breastmilk Supplements, and Other Related Products (Milk Code). It prohibits any advertising, promotion, or marketing that implies the superiority or equivalence of bottle milk/formula to breastmilk.
- R.A. 7600: Rooming-in and Breastfeeding Act. It encourages the practice of rooming-in i.e. placing the newborn in the same room as the mother right after delivery up to discharge. This facilitates mother-infant bonding and initiates breastfeeding. All government and private health institutions are given incentives for breastfeeding practice. They are accredited as “Mother and Baby-Friendly Health Institutions” (MBFHI).
- NSD babies (who are well regardless of AOG, even those with low birth weight, and can suck) shall be put to the breast of the mother immediately after birth and forthwith roomed-in within 30 minutes.
- CS babies shall be roomed-in and breast-fed within 3 to 4 hours after birth.
- Those infants who are ill, cannot breastfeed, or is not permitted for rooming-in as determined by the physician, and those infants whose mothers are either ill, contraindicated for breastfeeding, violently psychotic, or is otherwise not permitted to breastfeed or room-in as determined by the physician are exempted.
- This act states that the infant has a right to be breastfed and the mother has the right to breastfeed. It further specifies that the mother must be informed of the advantages of breastmilk, methodology in formula feeding, and opted in writing to adopt formula feeding before bottlefeeding is used.
No Milk Donation Policy
Breastfeeding is still the ideal method of feeding infants during a disaster. Wet nursing may be used. It is not encouraged to donate feeding bottles, milk formula/milk substances, and pacifiers during disasters.
- R.A. 10028: “Expanded Breastfeeding Promotion Act”; an Act Providing Incentives to All Government and Private Health Institutions with Rooming-In and Breastfeeding Practices. This involves lactation stations, break time for expressed feeding
- R.A. 8976: The Philippine Food Fortification Act; the fortification of staple foods (rice, flour, cooking oil, sugar) with micronutrients including iron (in rice and flour), iodine, and Vitamin A (sugar, flour, oil).
- This also instates the certification of food manufacturers who fortify their foods to have the Sangkap Pinoy Seal.
- R.A. 8172: Act of Salt Iodization Nationwide (ASIN) Law. All producers of food-based salt are mandated to iodize it.
- E.O. 382: the designation of November 7 as the National Food Fortification Day.
- A.O. 2011-0303: “Micronutrient Powder Supplementation for Children 6 to 23 months”; a micronutrient-rich powder added into meals to counteract malnutrition in children from 6 to 23 months, the age bracket under complementary feeding.
- A.O. 32, S2010: Expanded Garantisadong Pambata; the comprehensive integration of packages of services and communication on health, nutrition, and environment for children available everyday at various settings.
- Additionally, Millennium Development Goal 4, the reduction of neonatal and infant mortality, is a goal of the IYCF program.
Lactation Management is the general care of the mother-infant nursing couple during prenatal, immediate postpartum, and postnatal periods.
IYCF Feeding Practices
Feeding practices begin with Essential Intrapartal and Newborn Care (EINC), whose second principle promotes the early initiation of breastfeeding.
- Exclusive Breastfeeding: the limitation of consumption to only breastmilk, even prohibiting water. Breastfeeding is done on demand, alternating between the breasts.
- Extended Breastfeeding: the extension of breastfeeding past six months to complementary feeding and to two years or more, if possible.
- Complementary Feeding: the addition of solid foods into the breastfeeding schedule, done after the child is able to tolerate solid foods (6 months).
Different Milks
| Human Milk | Cow Milk |
|---|---|
| Greater in Vitamin C, more for protection | Greater in Vitamin D, more for energy |
| High in Whey, which is easier to digest | High in Casein, which is difficult to digest |
| Contains antibodies (anti-infective protein), taurine and cysteine for brain development, and lactalbumin and lactoglobulin, which are easily digested |
- Colostrum: thick, yellowish milk with more whey and antibodies. It also displays purgative effects, allowing the infant to pass meconium more frequently. It contains growth factors that help the intestines grow and is rich in Vitamin A.
- Foremilk: the first type of milk to be expressed when initiating breastfeeding, more watery than hindmilk.
- Hindmilk: expressed later in breastfeeding, which contains more fats. It is necessary to breastfeed in appropriate durations to allow hindmilk to be expressed.
Breastfeeding Techniques
Two important aspects in breastfeeding is positioning and attachment (latching). Positioning is how the infant is positioned relative to the mother’s body and breast. Ideally, the position is tummy-to-tummy. This can be achieved with different positions:
- Cradle Hold: the baby’s head is placed on the crook of the arm, with that arm’s hand holding the baby’s bottom. The baby is turned to the side to allow tummy-to-tummy contact, then the baby is raised to the breast for feeding. The other arm may also be used to support the baby.
- Cross Cradle/Crossover Hold: an inversion of the cradle hold; the baby’s head is supported by the hand, while the buttocks of the baby is set in the crook of the arm, and their back runs along the forearm. The other hand can hold the breast.
- Side-lying Hold: the mother lies on her side, and so does the baby. The head is supported to be able to reach the breast for feeding. The mother should not perform this while sleepy or sleeping, as there is a major risk for rolling over the baby.
- Football/Clutch/Underarm Hold: primarily used for twins, it is a cross cradle hold but with the target breast on the same side as the arm holding the baby. The legs of the babies are tucked under the arm. This allows both arms to support the babies’ heads and back while each baby feeds from each breast.
Breast size does not affect breastfeeding capabilities
However, nipple inversion can reduce the efficiency of breastfeeding. For this, the syringe method (pull plunger suction), C-hold, U-hold, or Scissor-hold method (breast shaping), nipple rolling, and proper positioning can aid in revealing the nipple.
Proper latching can be achieved in a series of steps: offer the breast (with C-/U-/Scissor-hold to the infant, utilizing the rooting reflex. Wait for the infant’s mouth to open, and move the infant to the breast quickly. The mother positions the infant’s mouth so that the lower lips are just below the nipple and the chin touches her breast. Good latching has specific outlined characteristics by the DOH:
- The infant mouth is wide open with the lower lip turned outward, and the chin touching the breast.
- Most of the mother’s areola should be inside of the baby’s mouth. There should be more areola visible above the infant’s mouth than below, and the nipple should not be visible. There should also be no nipple pain felt by the mother.
- The baby is relaxed and happy.
Breast Hygiene
There is no need to wash the breasts or nipple before and after feeding. The mother can follow a regular washing schedule (once a day) but should avoid using soap on the nipple, as it has a drying effect.
The use of exclusive breastfeeding improves involution, reduces uterine pain (via the let-down reflex), and can serve as a natural form of contraception for the first six months (Lactational Amenorrhea Method) if done immediately, exclusively and regularly.
Signs of Effective Feeding
The infant should be visibly or audibly swallowing breastmilk. During feeding, the cheeks become full rather than drawn inward, and the infant releases the breast by themself when content.
Signs of Ineffective Feeding
- Infrequent Urination: at less than six times a day. A normal infant should urinate six to eight times every 24 hours.
- Poor Weight Gain: a weight gain of less than 500 grams per month. A normal infant should gain at least 500 grams monthly in the first six months.
- Breast Engorgement: an imbalance between milk supply and infant demand. This is not necessarily caused by ineffective feeding, but it is relieved by breastfeeding. Manual milk expression with a breast pump can also be used.
Expressed Breastfeeding
Milk expression is the manual collection of breastmilk. Expressed breastmilk is fed to the infant through cup feeding, not with an artificial nipple. Expressed breastmilk requires proper storage to retain its effectiveness as feed for the infant:
| Storage Method | Duration of Viability |
|---|---|
| Room Temperature | 8 hours |
| Refrigerator Body | 24 hours |
| Refrigerator Freezer | 1 month |
| Chest Freezer | 1 year |
If the expressed milk has been cooled or frozen, it is first mixed with warm water before being given to the infant.
Complementary Feeding
Complementary Feeding is the addition of solid foods into the breastfeeding schedule, done after the child is able to tolerate solid foods (6 months). It follows four core characteristics:
- Timely: only start after six months of age (first day after six months)
- Adequate: provides sufficient energy, protein, and micronutrients to meet nutritional needs
- Safe: hygienically stored and prepared, prepared with clean hands and clean utensils.
- Properly Fed: given consistently with the child’s signs of hunger with meal frequency and method attuned to the child’s age.
Bottle feeding is contraindicated
A bottle with nipple/teats increase the occurrence of diarrhea, morbidity, and mortality.
| Time Span | Recommended Food | Amount | Frequency |
|---|---|---|---|
| 6 to 9 months | Breastfeed as often. Thick porridge/well-mashed foods with animal sources and vitamin A rich fruits and vegetables | 2 tbsp, gradually raised to 125 mL (1/2 cup) | 2 to 3 meals a day, with 1 to 2 snacks between meals if hungry. |
| 9 to 12 months | Breastfeed as often. Food remains the same but can be mashed or finely chopped. | 1/2 cup per meal | 3 to 4 meals a day, with 1 to 2 snacks between meals if hungry. |
| Replacement Feeding is avoided as much as possible, but if necessary, the recommended milk to replace breastmilk is infant formula, full cream milk, or fortified milk. |
Nutritional Assessment
Nutritional assessment of the infant and young child utilizes various methods to determine the adequacy of nutrition for children:
- Anthropometry: the measurement of body dimensions, composition, and proportions to determine normal growth. Normal growth is determined with percentiles. - Weight-for-Age: determines an underweight status based on a growth chart with normalized values. - Weight-for-Height: determines wasting, the lack of growth in mass in relation to vertical growth. - Length and Height-for-Age: determines stunting due to undernutrition or repeated illness. Stunting is the lack of growth in relation to the population and heredity.
- Mid-Upper Arm Circumference: the measurement of arm circumference for children and comparison with a normalized table to determine inadequate growth. This is a rapid method of determining malnutrition in children.
- <115 mm for children aged 6 to 59 months is considered as severe malnutrition
| Classification | MUAC |
|---|---|
| Nutrition OK | >13.5 cm |
| Malnourished | <12.5 cm |
| Severely Malnourished | <11.5 cm |
- Physical Examination:
- Eye examination: night blindness (common in those with vitamin A deficiency; reversible, preventable)
- Marasmus: skin and bones; old man’s face with baggy pants. An example of a condition resulting in marasmus is helminthic infection.
- Kwashiorkor: protein deficiency resulting in edema, especially in the belly and the face (moon face).
- Biochemical Examination: the assessment of blood or urine samples as measures of measurement.
- Iron via a hemoglobin count
- Iodine via a urine analysis
- Retinol via a serum analysis