Initiate breastfeeding within one hour of birth.

Breastfeed exclusively for the first six months of age (180 days).

Thereafter give nutritionally adequate and safe complementary foods to all children.

Continue breastfeeding for up to two years of age or beyond.

The aim of the Global Strategy is to improve – through optimal feeding – the nutritional status, growth and development, health, and thus

the survival of infants and young children. It also supports maternal nutrition, and social and community support.

WHO’s infant and young child feeding recommendations

(Adapted from the 2002 WHO/UNICEF Global Strategy for Infant and Young Child Feeding)

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Skin to Skin Contact and Early Breastfeeding

No water necessary

Country Temperature

°C Relative

Humidity %

Urine osmolarity (mOsm/l)

Argentina 20-39 60-80 105-199

India 27-42 10-60 66-1234

Jamaica 24-28 62-90 103-468

Peru 24-30 45-96 30-544

(Normal osmolarity: 50-1400 mOsm/l)

Breastfeeding on demand:Breastfeeding whenever the baby or

mother wants, with no restrictions on the

length or frequency of feeds.

• 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

Infant Feeding Recommendation for HIV-positive Women

When replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS), avoidance of all breastfeeding by HIV-infected mothers is recommended.

Otherwise, exclusive breastfeeding is recommended during the first months of life and then should be discontinued as soon as it is feasible.

Prolactin reflex

Oxytocin reflex

Helping and hindering the oxytocin reflex

Good feelings or thinking lovingly of baby and feeling confident that her milk is the best for baby

Bad feelings, such as pain, or worry, or doubt that she has enough milk

Help the oxytocin reflex

Hinder the oxytocin reflex

Inhibitor in breastmilk

If a lot of milk is left in a breast, the inhibitor stops cells from secreting any more.

Inhibitor

Reflexes in the baby

Rooting reflexWhen something touches a baby’s lips or cheek, he opens his mouth and may turn his head to find it. He puts his turns down

and forward.

Sucking reflexWhen something touches a baby’s

palate, he starts to suck it.

Swallowing reflex When baby’s mouth fills with milk, he swallows.

Good and poor attachment

Results of poor attachment

Nipple fissure

The breasts may become engorged.

The baby may be unsatisfied because the breastmilk

comes slowly.

The baby may become frustrated and refuse feeding

The baby may fail to gain weight.

The breasts make less milk because the milk is not

removed.

The may cry a lot or feed often or for a very long time

at each feed.

Pain and damage to the nipple

The milk is not removed effectively

Breastfeeding PositionsIn line, Close, Supported, Facing

Hospital practices assisting BF Early initiation of BF

Compliance with the International Code

Antenatal education On demand, exclusive BF

Rooming in No artificial teats or pacifiers

Acceptable medical reasons for use of breast-milk substitutes/Infant

Conditions WHO 2009

• Infants who should not receive breast milk or any other milk except specialized formula

Infants with classic galactosemia: a special galactose-free formula is needed.Infants with maple syrup urine disease: a special formula free of leucine,

isoleucine and valine is needed.Infants with phenylketonuria: a special phenylalanine-free formula is needed

(some breastfeeding is possible, under careful monitoring).• Infants for whom breast milk remains the best feeding option but who

may need other food in addition to breast milk for a limited periodInfants born weighing less than 1500 g (very low birth weight).Infants born at less than 32 weeks of gestational age (very pre-term).Newborn infants who are at risk of hypoglycaemia by virtue of impaired

metabolic adaptation or increased glucose demand (such as those who are preterm, small for gestational age or who have experienced significant intrapartum hypoxic/ischaemic stress, those who are ill and those whose mothers are diabetic) (5) if theirblood sugar fails to respond to optimal breastfeeding or breast-milk feeding.

Acceptable medical reasons for use of breast-milk substitutes/Maternal Conditions WHO 2009

Mothers who are affected by any of the conditions mentioned below should receive treatment according to standard guidelines.

Maternal conditions that may justify permanent avoidance of breastfeeding

HIV infection1: if replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS) (6).

Maternal conditions that may justify temporary avoidance of breastfeeding

Severe illness that prevents a mother from caring for her infant, e.g sepsis. Herpes simplex virus type 1 (HSV-1): direct contact between lesions on the

mother’s breasts and the infant’s mouth should be avoided until all active lesions have resolved.

Maternal medication:

Acceptable medical reasons for use of breast-milk substitutes/Maternal Conditions

WHO 2009

Maternal medication:o sedating psychotherapeutic drugs, anti-epileptic drugs and opioids and

their combinations may cause side effects such as drowsiness and respiratory depression and are better avoided if a safer alternative is available (7);

o radioactive iodine-131 is better avoided given that safer alternatives are available - a mother can resume breastfeeding about two months after receiving this substance;

o excessive use of topical iodine or iodophors (e.g., povidone-iodine), especially on open wounds or mucous membranes, can result in thyroid suppression or electrolyte abnormalities in the breastfed infant and should beavoided;

o cytotoxic chemotherapy requires that a mother stops breastfeeding during therapy.

Maternal conditions during which breastfeeding can still continue, although health problems may be of concern

Breast abscess: breastfeeding should continue on the unaffected breast; feeding from the affected breast can resume once treatment has started

Hepatitis B: infants should be given hepatitis B vaccine, within the first 48 hours or as soon as possible thereafter

Hepatitis C Mastitis: if breastfeeding is very painful, milk must be removed by expression to prevent

progression of the condition Tuberculosis: mother and baby should be managed according to national tuberculosis

guidelines Substance useo maternal use of nicotine, alcohol, ecstasy, amphetamines, cocaine and related stimulants has been

demonstrated to have harmful effects on breastfed babies;o alcohol, opioids, benzodiazepines and cannabis can cause sedation in both the mother and the baby.

Mothers should be encouraged not to use these substances, and given opportunities and support to abstain.

Acceptable medical reasons for use of breast-milk substitutes/Maternal Conditions WHO 2009

Replacement (artificial) feeding options

Commercial infant formulas- most of them are based on cow’s milk and have been designed to mimic the nutrient composition of human milk The concentration of protein and electrolytes such as sodium, potassium and chloride are lower than in cow’s milk, while the levels of certain minerals, primarily iron and to a lesser extent zinc are higher.

Formula from cow’s milk may be processed to be high in whey proteins. This formula may be easier for the young infant to digest. Formula that is high in casein protein can be more difficult for the young infant to digest as it forms thick curds in the infant’s stomach.

Formula lucks the non-nutritional , bioactive components of human milk (protective and trophic factors), and the quality of their proteins and lipids are not optimal for the infant. Nevertheless, it provide satisfactory alternative sole source of nutrition for infants of up to 6 months of age in the absence of BF.

Formula is usually available as a milk powder and needs only to be mixed with the correct amount of water.

Compositional guidelines for formula have been agreed in the Codex Allimentarius (energy density is 65 kcal/100 ml is typical)

Specialised formulaSoy infant formula uses processed soybeans as the source of protein. Usually it is lactose-free and has a different sugar added instead. Infants who are intolerant of cows’ milk protein may also be intolerant of soy protein. Soy milk is not a good milk for young children as it does not include sufficient calcium and other animal products for good growth and contains excessive amount of fitoestrogens.Low birth weight or preterm formula is manufactured with higher levels of protein and certain minerals and a different mixture of sugars and fats than ordinary formula for full-term infants. Low birth weight formula is not recommended for healthy, full term infants. The nutritional needs of low birth weight infants should be individually assessed.Specialised formulas are available to use in conditions such as reflux, high-energy need, lactose intolerance, allergic conditions and metabolic diseases like phenylketonuria. These formulas are altered in one or more nutrients and should only be used for infants with the specific conditions under medical/nutritional supervision.Follow-on (or follow-up) milks are marketed for older infants (over six months). They contain higher levels of protein and are less modified than infant formula. Follow-on milks are not necessary.

Home-prepared formulaThe milk used as the base for home-prepared formula may be: Fresh milk that is heat-treated at home, Commercially heat-treated whole milk (such as UHT or sterilized milk), Powdered full cream milk, or Non-sweetened evaporated milk.o The animal milks used may be from cows, buffalo, goat, ewe, camel or

other animal. o In full strength full cream milk, the level of protein and some minerals is too

high, and it is difficult for an infant's immature kidneys to excrete the extra waste. These milks require some modification to make the proportions more appropriate.

o WHO recommends the following recipe for home prepared formula: Boil 70 ml of water Add 130 ml of boiled cow’s milk to make 200 ml of feed Add 1 level teaspoonful (5g) of sugar For sheep’s milk the milk and water amounts should be 100 ml to100 ml

Products that are not suitable for making infant formula

Skimmed milk – fresh or dried powderCondensed milkCreamers used for ‘whitening’ tea or coffee

Unsuitable breast-milk substitutes • Infants should not be given unmodified cow’s milk as a

drink before the age of 9 months. Cow’s milk can be gradually introduced into the diet of formula fed infants between the ages of 9 and 12 months.

• Skimmed, semiskimed, condenced milks • Yogurt, matzuni, Narine • Fruit juices, sugar-water, and dilute cereal gruels

Calculation of breast-milk substitutes daily requirements

Volumetric methodThe daily volume of breastmilk sunstitute for infants from 10 days to 2 months of age makes 1/5 of body weight, 2-4 months -1/6, 4-6 months - 1/72-6 old child should get 150 ml of breastmilk suntitute per kg of body weight

Calorimetric methodPremature infants up to 3-4 months demand about 120-140 kcal per kg of weight per day Term infants up to 3-4 months demand 110-120 kcal per kg per day As the infant grows the demand per body weight decreases and for the one years old infant is about 100 kcal per kg per day The daily volume of the milk (ml) = weight (kg) x caloric requirment (kcal/kg/day) / 0. 7 The calculated amount should not be more than one litre and has only orientational meaning.

Recomendations on safe prepatration of breastmilk substitutes

Check the expiration date on the formula can. Discard expired formula.Follow the instructions on the lable.Overdilution and underdilution are dangerous for infant health. Cup feeding and spoon feeding are more recomended than bottle feeding. Mother should always wash hands with soap before preparing feed. Feeding utilensis should be carefully cleaned and boiled. The water for preparing feed should also be boiled and then cooled to the temperature needed.Powdered formula may be contaminated with micro-organisms (such as E. sakazakii and Salmonella) during the manufacturing process or may become contaminated during preparation and that it is therefore necessary to discard any unused formula immediately after every feed.Artificially fed infant should also be fed on demand.

Artificially fed infant may need extra water.

Complementary Feeding Complementary feeding means

givingother foods in addition to breast milk.

After 6 months of age to meet their evolving nutritional requirements, all infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues until up to 2 years of age or beyond.

Energy required and the amount from breast milk

The iron requirment of infant and the amount received from breastmilk and the storages

Daily nutritional requirements of infants and the amounts received from breastmilk in the second

year of life

Risks of starting complementary foods too early

Take the place of breast milk, making it difficult to meet the child’s nutritional needs and result in a low nutrient diet

Increase risk of illness because less of the protective factors in breast milk are consumed;

Increase the risk of diarrhoea because the complementary foods may not be as clean or as easy to digest as breast milk;

Increase the risk of wheezing and other allergic conditions because the baby cannot yet digest and absorb other foods well;

Increase the mother’s risk of another pregnancy if breastfeeding is less frequent.

Risks of starting complementary foods too late

Delaying the introduction of complementary foods for too long is also not advisable because:

Breast milk alone may not provide enough energy and nutrients and may lead to growth faltering and malnutrition.

Breast milk alone may not meet the infant’s growing requirements of some micronutrients, especially iron and zinc.

The optimal development of oral motor skills, such as the ability to chew, and the infant’s ready acceptance of new tastes and textures may be adversely affected.Infants should, therefore, be started on

complementary foods at around six months of age.

Introducing complementary foods Complementary foods can be subdivided into:• Transitional (puréed, mashed, semi-solid) foods, which are foods

specifically selected from the main food groups and adapted to meet the particular nutritional and physiological needs of the infant.

• Family foods, largely based on a normal well-balanced varied family diet, with some minor adaptations.

• Between 6-8 months these should be given 2-3 times a day, increasing to 3-4 times daily after nine months of age, with additional nutritious snacks offered 1-2 times per day, as desired, after 12 months.

• Breastmilk, however, should remain the primary source of nutrition for the whole of the first year of life. During the second year of life, family foods should gradually become the primary source of nutrition.

Examples of age-appropriate foods for different ages and stages of development

Age(mo.)

Reflexes/skills Types of food that can be consumed

Examples of foods

0–6 Suckling/sucking and swallowing

Liquids Breast milk only

4-7 Appearance of early “munching”; movement of gag reflex from mid to posterior third of tongue

Puréed foods (only if the individual child’s nutritional requirements call for addition of complementary foods)

Breast milk plus cooked puréed meat; vegetable (e.g. carrot) or fruit purées (e.g. banana); mashed potato; gluten-free cereals (e.g. rice)

7–12

Clearing spoon with lips; biting and chewing; lateral movements of tongue and movement of food to teeth. Fine motor skills developing to facilitate self-feeding.

Increasing variety of mashed or chopped foods and finger foods-combining new and familiar foods. Give three meals per day with two snacks in between.

Breast milk plus cooked minced meat; mashed cooked vegetables and fruit; chopped raw fruit and vegetable (e.g. banana, melon, tomato); cereal (e.g. wheat, oats) and bread

12–24

Rotary chewing movements; jaw stability

Family foods Breast milk + family food, provided the family diet is healthy and well-balanced

Daily energy intake of infants Age of the

infantCalories

received from complementary

food

The volume of food during

each feeding

The amount of

complementary feeds

6-8 mo. 280 kcaL 160 ml 2-3 feedings

9-10 mo. 450 kcal 180 ml 3-4 feedings

11-12 mo. 500-600 kcal 250 ml 4-5 feedings

Main food groups

1.Milk and diary products

2.Meat and alternatives

3.Wheat and cereals

4.Fruits and vegetables

Feeding practices The way in which caregivers facilitate feeding and encourage eating plays a major role in the food intake of infants and young children. There are four dimensions of appropriate feeding:1. Adaptation of the feeding method to the

psychomotor abilities of the child (ability to hold a spoon, ability to chew).

2. Responsiveness of the caregiver, including encouragement to eat, by offering additional foods.

3. Interaction with the caregiver, including the conveying of affection.

4. The feeding situation, including the organization, frequency, duration and regularity of feeding