Slide 4a

UNICEF BHFI Breastfeeding policy

What should it cover?
At a minimum, it should include:
The 10 steps to successful breastfeeding
An institutional ban on acceptance of free or low cost supplies of breast-milk
substitutes, bottles, and teats and its distribution to mothers
A framework for assisting HIV positive mothers to make informed infant
feeding decisions that meet their individual circumstances and then support
for this decision

Slide 4.1.3
Improved exclusive breast-milk feeds while in the birth hospital
after implementing
the Baby-friendly Hospital Initiative

Exclusive Breastfeeding Infants

40%
33.50%
35%
Percentage 30%
25%
20%
15%
10% 5.50%
5%
0%
1995 Hospital with minimal 1999 Hospital designated as
lactation support Baby friendly
Adapted from: Philipp BL, Merewood A, Miller LW et al. Baby-friendly Hospital Initiative improves
breastfeeding initiation rates in a US hospital setting. Pediatrics, 2001, 108:677-681.

Slide 4.1.5
Antenatal education should include:
Benefits of breastfeeding
Early initiation
Importance of rooming-in (if
new concept)
Mechanisms of lactation and
suckling
Importance of feeding on
demand
Importance of exclusive
breastfeeding
How to assure enough
breastmilk
Risks of artificial feeding and
use of bottles and pacifiers
(soothers, teats, nipples, etc.)
Basic facts on HIV
Prevention of mother-to-child
transmission of HIV
Voluntary testing and
counselling for HIV and infant
feeding counselling for HIV+
women
How to assess a breastfeed
How to resolve breastfeeding
difficulties
Focus on changing negative
attitudes which set up barriers
Slide 4.3.2
 Effect of breastfeeding training
for hospital staff on exclusive breastfeeding rates at hospital
discharge
Exclusive Breastfeeding Rates at Hospital Discharge

90%
77%
80%
70%
Percentage

60%
50% 41%
40%
30%
20%
10%
0%
Pre-training, 1996 Post-training, 1998

Adapted from: Cattaneo A, Buzzetti R. Effect on rates of breast feeding of training for the Baby
Friendly Hospital Initiative. BMJ, 2001, 323:1358-1362.

Slide 4.2.4
 Breastfeeding counselling
increases exclusive breastfeeding
Age: 3 months 4 months 2 weeks after
100 diarrhoea treatment

Exclusive breastfeeding (%) 80 72 75

56.8 58.7 Control

60
Counselled

40

20 12.7
6
0
Brazil '98 Sri Lanka '99 Bangladesh '96
(Albernaz) (Jayathilaka) (Haider)
All differences between intervention and control groups are significant at p<0.001.
From: CAH/WHO based on studies by Albernaz, Jayathilaka and Haider.
Slide 4.2.5
steps to successful
breastfeeding

Inform all pregnant women

about the benefits of
breastfeeding.

A JOINT WHO/UNICEF STATEMENT (1989)

Slide 4.3.1
 Advantages of Breast Feeding

Breast milk has the exact combination of protein, fats,

vitamins, minerals, enzymes, and sugars needed for the
human infant at various stages of his growth.
Contain optimum percentage of carbohydrates, protein
and fat.
Due to the digestibility of breast milk, breastfed babies
are rarely constipated.
Breastfed babies tend to have less incidence of ear
infections, respiratory illness, allergies, diarrhea, and
vomiting.
The stools of breastfed babies are mild-smelling.
 He has easily digestible protein component (Whey to
casein ratio of 60:40
Contain an easily digested carbohydrate (Lactose) in a
higher concentration
Rich in sources of linoleic acid an essential fatty acid.
The calcium phosphorus ratio is 2:1
Protects against infection and allergies
It contains 90% of humoral secretary iga that provides
mucosal protection.
Is hygenic safe readily available at right temperature
needs no preparation and comes free of cost.
Sucking process helps in the development of the facial
muscles of the baby.
11/1/2017 9
 Exposed to a variety of tastes through their mother's milk.
Breastfed children are at less risk for chrohn's disease and
juvenile diabetes.
They also seem to have better overall dental health than
formula-fed children.
IQ levels are an average of 8 points higher in children who
were breastfed.
Adult daughters who were breastfed are at less risk for breast
cancer.
Adults who were breastfed have a lower risk for high
cholesterol and asthma.
The bond between mother and child seems to be enhanced
with breastfeeding.
 For Mothers
1.Causes the uterus to contract lessening the risk of postpartum
hemorrhage.
2. The uterus of a breastfeeding mother shrinks to its pre-
pregnancy size more quickly.
3. Calories are burned while breastfeeding. It takes approximately
20 calories to produce an ounce of milk.
4. Women who nurse their babies for at least 6 months lessen their
chances of pre-menopausal breast cancer.
5. Osteoporosis and cervical cancer are less common in women
who breastfed.
6. The return of fertility is delayed with breastfeeding.
7. Breastfeeding is more economical than formula feeding.
8. Breast milk is always available, clean, and the right temperature.
9. Many mothers feel a special satisfaction in knowing that they
alone are meeting the nutritional needs of their babies.
 Disadvantages of Breastfeeding
1. There can be discomfort involved with breastfeeding.
When you first start breastfeeding,
2. You may experience sore nipples, your breasts may feel
swollen or engorged.
3. You may leak milk at times that are inconvenient or
embarrassing. When the baby cries, you almost
immediately start producing milk. If you arent prepared
for this properly, it can be inconvenient or embarrassing.
4. Feeding your baby in public may be more difficult.
5. Everything you consume is being passed on to your baby.
Any food you eat, medication you use, or anything that you
are applying to your skin can and most likely will be
passed onto your baby through breastfeeding.
6. Prolonged breast feeding without complementary feeding
can result in poor weight gain and deficiency disorders
like rickets, vitamin K deficiency, iron deficiency etc.
7. Smoking and alcohol intake of mothers during breast
feeding can pose threat to the child.
 Contraindications of Breast Feeding

Mothers suffering from HIV infection

Mothers with open pulmonary tuberculosis

11/1/2017 14
Types of Milk

Colostrum, Foremilk and Hindmilk

There are essentially 3 types of breastmilk. These are

colostrum, foremilk and hindmilk.

Colostrum is the yellowish breastmilk that is produced in the

first few days after baby's birth and before normal lactation
begins. Colostrum is especially rich in nutrients and antibodies,
and is the perfect food for a newborn baby.
Foremilk is the milk which is first drawn during a feeding. It
is generally thin and lower in fat content, satisfying the
baby's thirst and liquid needs.

Hindmilk is the milk which follows foremilk during a feeding.

It is richer in fat content and is high in calories. The high fat
and calorie content of this milk is important for your baby's
health and continuing growth.
Slide 4e
Slide 4f
 Step 3: The influence of antenatal care
on infant feeding behaviour
70 No prenatal BF information
58 Prenatal BF information
60

50 43
Percentage
40
30 27
18
20

10
0
Colostrum BF < 2 h
Adapted from: Nielsen B, Hedegaard M, Thilsted S, Joseph A, Liljestrand J. Does antenatal care
influence postpartum health behaviour? Evidence from a community based cross-sectional study in
rural Tamil Nadu, South India. British Journal of Obstetrics and Gynaecology, 1998, 105:697-703.

Slide 4.3.3
 Step 3: Meta-analysis of studies
of antenatal education
and its effects on breastfeeding
50%
39%
40%
Initiation
(8 studies)
Percentage

30%
23% Short-term BF
(10 studies)
20%
Long-term BF
(7 studies)
10%
4%

0%
Increase in selected behaviours
Adapted from: Guise et al. The effectiveness of primary care-based interventions to
promote breastfeeding: Systematic evidence review and meta-analysis Annals of
Family Medicine, 2003, 1(2):70-78.

Slide 4.3.4
steps to successful
breastfeeding

Help mothers initiate

breastfeeding within a half-
hour of birth.

A JOINT WHO/UNICEF STATEMENT (1989)

Slide 4.4.1
revised BFHI Global Criteria (2006) stated that helping mother to
breastfeed mean:

Place babies in skin-to-skin contact with their

mothers immediately following birth for at least an
hour and encourage mothers to recognize when
their babies are ready to breastfeed, offering help
if needed.

Slide 4.4.2
Early initiation of breastfeeding
for the normal newborn
Why?
Increases duration of breastfeeding
Allows skin-to-skin contact for warmth and
colonization of baby with maternal organisms
Provides colostrum as the babys first
immunization
Takes advantage of the first hour of alertness
Babies learn to suckle more effectively
Improved developmental outcomes

Slide 4.4.3
Early initiation of breastfeeding
for the normal newborn
How?

Keep mother and baby together

Place baby on mothers chest
Let baby start suckling when ready
Do not hurry or interrupt the process
Delay non-urgent medical routines for at least one
hour

Slide 4.4.4
Slide 4g
Slide 4h
Slide 4i
Slide 4j
 Impact on breastfeeding duration
of early infant-mother contact
70%

Percent still breastfeeding at 3 months

58% Early contact: 15-20 min suckling and
60% skin-to-skin contact within
first hour after delivery
50%
Control: No contact within first
hour
40%

30% 26%

20%

10%

0%
Early contact (n=21) Control (n=19)

Adapted from: DeChateau P, Wiberg B. Long term effect on mother-infant behavior of extra
contact during the first hour postpartum. Acta Peadiatr, 1977, 66:145-151.

Slide 4.4.5
 Temperatures after birth in infants
kept either skin-to-skin with mother or in cot

Adapted from: Christensson K et al. Temperature, metabolic adaptation and crying in healthy
full-term newborns cared for skin-to-skin or in a cot. Acta Paediatr, 1992, 81:490.
Slide 4.4.6
 Protein composition of human colostrum
and mature breast milk (per litre)
Constituent Measure Colostrum Mature Milk
(1-5 days) (>30 days)
Total protein G 23 9-10.5
Casein mg 1400 1870
-Lactalbumin mg 2180 1610
Lactoferrin mg 3300 1670
IgA mg 3640 1420

From: Worthington-Roberts B, Williams SR. Nutrition in Pregnancy and Lactation, 5th ed. St. Louis,
MO, Times Mirror/Mosby College Publishing, p. 350, 1993.

Slide 4.4.7
 Effect of delivery room practices
on early breastfeeding
Successful sucking pattern
70%
60%
Percentage 50% 63%
P<0.001
40%
30%
20%
21%
10%
P<0.001
0%
Continuous contact Separation for procedures
n=38 n=34

Adapted from: Righard L, Alade O. Effect of delivery room routines on success of first
breastfeed .Lancet, 1990, 336:1105-1107.

Slide 4.4.8
steps to successful
breastfeeding

Show mothers how to

breastfeed and how to
maintain lactation, even if
they should be separated
from their infants.

A JOINT WHO/UNICEF STATEMENT (1989)

Slide 4.5.1
 Contrary to popular belief,
attaching the baby on the breast
is not an ability with which a mother is
[born]; rather it is a learned skill
which she must acquire by
observation and experience.
From: Woolridge M. The anatomy of infant sucking. Midwifery, 1986, 2:164-171.

Slide 4.5.2
Breast Feeding Techniques
And Positions

35
 Successful lactation is determined by early
initiation of breastfeeding and continuation of
lactation and again that is determined by
positioning.

Positioning is key to get Latch on.

36
Factors Influencing Breast Feeding

Position

Factors

Attitude
of the
Mother

37
 Bringing hands to mouth
Rooting
Suckling
Licking
Nuzzling
Lip smacking

38
 Preparation

Wash hands
Position comfortably and correctly use pillows or towels for support.
Uncover the breast.

39
 Side-lying Position

Lie on one side

Use pillows
Tummy to tummy
Babys mouth in line
with nipple.

40
 When side-lying position

Cesarean birth

Uncomfortable sitting

No assistance for latch

on in sitting

41
 The football Position

Infant legs are under

mothers arm, with hand
at the base of the head
and neck.
Use pillows
Help infant in latching on

42
 When Football hold

Cesarean birth
To see the latch on position
Large breast
Small baby
Infant is sleepy

43
 The cradle position

Hold the infant in upright

position on mothers lap
Infant head in crook of
mothers elbow on the same
side close to the breast, the
neck is slightly extended.
Infant ear, shoulder and hips in
straight line
Tummy to Tummy
Chest to chest of mother and
infant

44
 The Cross cradle Position

Same of cradle position

but just the opposite hand was
used to support the infant and
the same side hand was used to
hold the breast.

45
 When Cross Cradle

To learn Latching
To maintain comfortness of the mother

46
Various other positions to feed twins

47
48
49
50
 Latch on

Mother holds the baby in upright position on her lap.

Mouth is wide open and the chin touches the breast.
Mother guide the nipple and areola into the babys mouth for
effective milk transfer
Peristaltic action from the tip of the tongue to the base.

51
Step 1

52
Step 2

11/1/2017 53
Step 3

11/1/2017 54
Step 3

11/1/2017 55
Step 4

11/1/2017 56
57
58
 How to find poor attachment

1. Mother feels pain

2. Clicking sound heard
by mother
3. Eager to suck

59
 Process of Nursing

Sucks
Swallow
Pause

60
 Cuddle and fiddle with the baby by stroking and
tickling behind his or her ears or on the soles so that
infant does not lapse into sleep without adequate
feeds.

11/1/2017 61
De latching

Watch baby for cues that he

/she is finished
May spontaneously come off
the breast
May fall sleep
If mother wants to stop the
feeding early, break suction by
inserting finger into corner of
infants mouth.

62
 Burping

Propped up with babys tummy against shoulder of

the mother.

Sitting up, leaning forward on one hand of the mother

with the other hand burps at back of infant.

63
 Burping and de latching

11/1/2017 64
Importance of good Position and Attachment

65
Sign of successful Breast feeding
One or two wet diapers during the first few days.
Six to eight wet cloth diapers (5 - 6 wet disposable
diapers) per
day (24 hours).
At least two to five bowel movements every 24
hours.
6 - 10 feedings per24-hours.
Babys swallowing sounds are audible.
Gain at least 120 210 g per week after the fourth
day of life.
Appear healthy, have good colour, firm skin, and
will be growing in length and head circumference.
Sound sleep followed by feed.

66
If breastfeed baby presenting with no bowel
movement:
Discontinue the iron formula, it may be
constipating.
Give 1 tsp of mineral oil per day until he goes.
Give a suppository each day until he goes.
Add cereal to the bottle to help his bowels and to
sleep.
Dilute the formula to give more water.
Give 1 oz apple juice per day until he goes.
Do nothing, breast fed infants may not have a
bowel movement for up to 7 days.
 Effect of proper attachment
on duration of breastfeeding
Correct sucking technique at discharge
100% Incorrect sucking technique at discharge

Percentage

50%

P<0.001 P<0.01 P<0.01 P<0.01

0%
5 days 1 month 2 months 3 months 4 months
exclusive
breastfeeding Any breastfeeding
Adapted from: Righard L, Alade O. (1992) Sucking technique and its effect on success of
breastfeeding. Birth 19(4):185-189.
Slide 4.5.3
 Step 5: Effect of health provider encouragement of
breastfeeding in the hospital
on breastfeeding initiation rates

Breastfeeding initiation rates p<0.001

80% 74.6%
70%
60%
Percentage

50% 43.2%
40%
30%
20%
10%
0%
Encouraged to breastfeed Not encouraged to
breastfeed
Adapted from: Lu M, Lange L, Slusser W et al. Provider encouragement of breast-feeding: Evidence
from a national survey. Obstetrics and Gynecology, 2001, 97:290-295.

Slide 4.5.4
Supply and demand

Milk removal stimulates milk production.

The amount of breast milk removed at each

feed determines the rate of milk production in
the next few hours.

Milk removal must be continued during

separation to maintain supply.

Slide 4.5.6
Slide 4m
steps to successful
breastfeeding

Give newborn infants no

food or drink other than
breast milk unless
medically indicated.

A JOINT WHO/UNICEF STATEMENT (1989)

Slide 4.6.1
Slide 4n
Slide 4o
 The perfect match:
quantity of colostrum per feed
and the newborn stomach capacity

Adapted from: Pipes PL. Nutrition in Infancy and Childhood, Fourth Edition. St. Louis, Times
Mirror/Mosby College Publishing, 1989.

Slide 4.6.3
Impact of routine formula supplementation

Decreased frequency or effectiveness of suckling

Decreased amount of milk removed from breasts

Delayed milk production or reduced milk supply

Some infants have difficulty attaching to breast if
formula given by bottle

Slide 4.6.4
 Medically indicated
There are rare exceptions during
which the infant may require other
fluids or food in addition to, or in place
of, breast milk. The feeding
programme of these babies should be
determined by qualified health
professionals on an individual basis.

Slide 4.6.7
Acceptable medical reasons for supplementation or replacement

Infant conditions:
Infants who cannot be BF but can receive BM include those
who are very weak, have sucking difficulties or oral
abnormalities or are separated from their mothers.
Infants who may need other nutrition in addition to BM
include very low birth weight or preterm infants, infants at
risk of hypoglycaemia, or those who are dehydrated or
malnourished, when BM alone is not enough.
Infants with galactosemia should not receive BM or the usual
BMS. They will need a galactose free formula.
Infants with phenylketonuria may be BF and receive some
phenylalanine free formula.

UNICEF, revised BFHI course and assessment tools, 2006 Slide 4.6.8
Maternal conditions:
BF should stop during therapy if a mother is taking anti-
metabolites, radioactive iodine, or some anti-thyroid
medications.
Some medications may cause drowsiness or other side effects
in infants and should be substituted during BF.
BF remains the feeding choice for the majority of infants even
with tobacco, alcohol and drug use. If the mother is an
intravenous drug user BF is not indicated.
Avoidance of all BF by HIV+ mothers is recommended when
replacement feeding is acceptable, feasible, affordable,
sustainable and safe. Otherwise EBF is recommended during
the first months, with BF discontinued when conditions are
met. Mixed feeding is not recommended.

Slide 4.6.9
Maternal conditions (continued):

If a mother is weak, she may be assisted to position her baby

so she can BF.
BF is not recommended when a mother has a breast abscess,
but BM should be expressed and BF resumed once the breast
is drained and antibiotics have commenced. BF can continue
on the unaffected breast.
Mothers with herpes lesions on their breasts should refrain
from BF until active lesions have been resolved.
BF is not encouraged for mothers with Human T-cell
leukaemia virus, if safe and feasible options are available.
BF can be continued when mothers have hepatitis B, TB and
mastitis, with appropriate treatments undertaken.

Slide 4.6.10
steps to successful
breastfeeding

Practice rooming-in allow

mothers and infants to
remain together
24 hours a day.

A JOINT WHO/UNICEF STATEMENT (1989)

Slide 4.7.1
 Rooming-in
A hospital arrangement where a
mother/baby pair stay in the same room
day and night, allowing unlimited
contact between mother and infant

Slide 4.7.2
Slide 4p
Slide 4q
Rooming-in
Why?
Reduces costs
Requires minimal equipment
Requires no additional personnel
Reduces infection
Helps establish and maintain breastfeeding
Facilitates the bonding process

Slide 4.7.3
 Effect of rooming-in on frequency
of breastfeeding per 24 hours

Adapted from: Yamauchi Y, Yamanouchi I . The relationship between rooming-in/not rooming-in

and breastfeeding variables. Acta Paediatr Scand, 1990, 79:1019.
Slide 4.7.5
steps to successful
breastfeeding

Encourage breastfeeding
on demand.

A JOINT WHO/UNICEF STATEMENT (1989)

Slide 4.8.1
Breastfeeding on demand:
Breastfeeding whenever the baby or
mother wants, with no restrictions on
the length or frequency of feeds.

Slide 4.8.2
On demand, unrestricted breastfeeding
Why?

Earlier passage of meconium

Lower maximal weight loss
Breast-milk flow established sooner
Larger volume of milk intake on day 3
Less incidence of jaundice

From: Yamauchi Y, Yamanouchi I. Breast-feeding frequency during the first 24 hours after birth in full-
term neonates. Pediatrics, 1990, 86(2):171-175.

Slide 4.8.3
Slide 4r
Slide 4s
 Breastfeeding frequency during the first 24 hours after birth and
incidence of hyperbilirubinaemia (jaundice) on day 6

30% 28.1%
24.5%

20%
Incidence

15.2%
11.8%
10%
9 12 5 2 0
32 49 33 17 9

0.0%
0%
0-2 3-4 5-6 7-8 9-11
Frequency of breastfeeding/24 hours

From: Yamauchi Y, Yamanouchi I. Breast-feeding frequency during the first 24 hours after birth
in full-term neonates. Pediatrics, 1990, 86(2):171-175.

Slide 4.8.4
 Mean feeding frequency during the
first 3 days of life and serum bilirubin
12 10.7

Serum Bilirubin, mg/dl 10

7.5
8 6.7
6 4.8
4
2
0
5 to 6 7 to 8 9 to 10 11+
Feeding frequency/24 hr

From: DeCarvalho et al. Am J Dis Child, 1982; 136:737-738.

Slide 4.8.5
steps to successful
breastfeeding

Give no artificial teats or pacifiers (also

called dummies and soothers) to
breastfeeding infants. Studies show
that artificial teats may cause nipple
confusion or bottle preference to the
newborn.

A JOINT WHO/UNICEF STATEMENT (1989)

Slide 4.9.1
Slide 4t
Slide 4u
Alternatives to artificial teats
cup
spoon
dropper
Syringe

Slide 4.9.2
Cup-feeding a baby

Slide 4.9.3
Slide 4v
 Proportion of infants who were breastfed up to 6 months
of age according to frequency of pacifier use at 1 month

Non-users vs part-
time users:
P<<0.001
Non-users vs. full-
time users:
P<0.001

From: Victora CG et al. Pacifier use and short breastfeeding duration: cause, consequence or
coincidence? Pediatrics, 1997, 99:445-453.
Slide 4.9.4
steps to successful
breastfeeding

Foster the establishment of

breastfeeding support
groups and refer mothers
to them on discharge from
the hospital or clinic.

A JOINT WHO/UNICEF STATEMENT (1989)

Slide 4.10.1
 The key to best breastfeeding
practices is continued day-to-day
support for the breastfeeding
mother within her home and
community.

From: Saadeh RJ, editor. Breast-feeding: the Technical Basis and Recommendations for
Action. Geneva, World Health Organization, pp.:62-74, 1993.

Slide 4.10.2
Support can include:
Early postnatal or clinic Mother support groups
checkup Help set up new groups
Home visits Establish working
relationships with
Telephone calls those already in
Community services existence
Outpatient Family support system
breastfeeding clinics
Peer counselling
programmes

Slide 4.10.3
Types of breastfeeding mothers support groups
extended family
Traditional culturally defined doulas
village women
Modern, non-traditional
by mothers
Self-initiated
by concerned health professionals
Government planned through:

networks of national development groups, clubs, etc.

health services -- especially primary health care (PHC)
and trained traditional birth attendants (TBAs)

From: Jelliffe DB, Jelliffe EFP. The role of the support group in promoting breastfeeding in developing
countries. J Trop Pediatr, 1983, 29:244.

Slide 4.10.4
Slide 4w
Slide 4x
 Step 10: Effect of trained peer counsellors on the
duration of exclusive breastfeeding

80%
70%
70%
60%
Percentage 50%
Exclusively
40% breastfeeding 5
30% month old infants

20%
10% 6%

0%
Project Area Control

Adapted from: Haider R, Kabir I, Huttly S, Ashworth A. Training peer counselors to promote and
support exclusive breastfeeding in Bangladesh. J Hum Lact, 2002;18(1):7-12.

Slide 4.10.5
 Home visits improve
exclusive breastfeeding
90%
80%

Exclusive reastfeeding
80%
70%
67% Six-visit group
62%
60% Three-visit group
50%
(%) 50% Control group
40%
30% 24%
20% 12%
10%
0%
2 weeks 3 months

Infant's age

From: Morrow A, Guerrereo ML, Shultis J, et al. Efficacy of home-based peer counselling to
promote exclusive breastfeeding: a randomised controlled trial. Lancet, 1999, 353:1226-31

Slide 4.10.6
 Effect of baby-friendly changes
on breastfeeding at 3 & 6 months
50%
Experimental Group n = 8865
43.3%
Control Group n = 8181

Percentage 40%

30%

20%

10% 7.9%
6.4%

0.6%
0%
Exclusive BF 3 months Exclusive BF 6 months

Adapted from: Kramer et al. (2001)

Slide 4.11.3
 Impact of baby-friendly changes
on selected health conditions
25% Experimental Group n=8865
Control Group n=8181
20%

Percentage 15% 13.2%

10% 9.1%

6.3%
5% 3.3%

0%
Gastro-intestinal tract infections Atopic eczema

Note: Differences between experimental and control groups for various respiratory
tract infections were small and statistically non-significant.

Adapted from: Kramer et al. (2001)

Slide 4.11.4
Additional topics for BFHI training in the
context of HIV
Train all staff in:
Basic facts on HIV and on Prevention of Mother-to-Child
Transmission (PMTCT)
Voluntary testing and counselling (VCT) for HIV
Locally appropriate replacement feeding options
How to counsel HIV + women on risks and benefits of
various feeding options and how to make informed choices
How to teach mothers to prepare and give feeds
How to maintain privacy and confidentiality
How to minimize the spill over effect (leading mothers
who are HIV - or of unknown status to choose replacement
feeding when breastfeeding has less risk)

Slide 4.2.3