Factors Influencing Maternal Decision on Infant Feeding Methods

*Infant Feeding - Breast versus Formula*

of insulin-like growth factor-II in maternal and cord blood. European Journal of Clinical Nutrition.

[81] Anderson CM, Gillespe SL, Thiele DK, et al. Effects of maternal vitamin D supplementation on maternal and infant epigenome. Breastfeeding

[82] Eid A, Zawai N. Consequences of lead exposure, and its emerging role as an epigenetic modifier in the aging brain. Neurotoxicology. 2016;**56**:254-261

Fry RC. Effects of prenatal exposure to endocrine disruptors and toxic metals on the fetal epigenome. Epigenomics.

[84] Heijmans BT, Tobi EW, Stein AD, et al. Persistent epigenetic differences associated with prenatal exposure to famine in humans. PNAS. 2008;**105**:17046-17049

[85] DeVries A, Donata V. The neonatal methylome as a gatekeeper in the trajectory to childhood asthma.

Epigenetics. 2017;**9**:585-593

Medicine. 2018;**13**:371-380

[83] Bommarito P, Martin E,

2017;**9**:333-350

2011;**65**:480-485

**16**

**19**

**Chapter 2**

**Abstract**

be prevented.

**1. Introduction**

Basic Concepts

*Jayashree Purkayastha*

Breastfeeding in Normal Newborn:

Breastfeeding is a complete nutrition for the baby and beneficial to the baby and the mother. Mothers should be prepared for breastfeeding and motivated antenatally. Breastfeeding should be initiated within 1 h of normal delivery and 4 h of Caesarean section. In the first 2 days, colostrum is secreted which is highly immunogenic to the baby. Mature milk comes by day 10 of life. Foremilk is rich in protein and vitamins, while hindmilk is rich in fat. Proper technique should be followed for successful breastfeeding. Reflexes in the mother while breastfeeding are prolactin and oxytocin reflexes, while reflexes in the baby are rooting, sucking and swallowing. In case of early discharge from the hospital, adequacy of breastfeeding should be checked at 3–5 days of life. Breastfeeding develops bonding between the baby and the mother and promotes brain growth of the baby. Human milk is suitable for the baby and contains less protein and minerals than cow's milk and has less solute load for immature kidneys of the baby. Breastfeeding should be on demand, minimum eight times per day. The common feeding problems in the mother are flat or inverted nipple, sore nipple, engorgement of breasts, and mastitis which should

**Keywords:** breastfeeding, breastmilk, benefits, term baby, mother

tender loving care to the child and keeps the mother happy.

Breastfeeding is a birthright of every baby, and also it is the right of every mother to breastfeed her baby. Breastfeeding is a complete nutrition for the baby and has several advantages to the baby and the mother. Breastfeeding (colostrum) has so much benefit for the baby especially immunologically that it is called the first vaccine for the baby. Breastfeeding is hypoallergenic and safe to the baby. It is sterile, hygienic and also economical. Breastfeeding is the saviour of the infant from respiratory and diarrhoeal morbidity and mortality especially in the developing and underdeveloped countries. It relieves a lot of economic burden for the poor countries [1]. In low-income and middle-income countries, only 37% of the babies less than 6 months are exclusively breastfed [2]. Breastfeeding helps in brain growth and improves the intelligence quotient (IQ ) of the children and thus benefits the country as a whole [3]. Breastfeeding reduces mortality and morbidity of children under 5 years of age especially in developing and underdeveloped countries. Breastfeeding enhances the bond between the mother and the child, provides

#### **Chapter 2**

## Breastfeeding in Normal Newborn: Basic Concepts

*Jayashree Purkayastha*

#### **Abstract**

Breastfeeding is a complete nutrition for the baby and beneficial to the baby and the mother. Mothers should be prepared for breastfeeding and motivated antenatally. Breastfeeding should be initiated within 1 h of normal delivery and 4 h of Caesarean section. In the first 2 days, colostrum is secreted which is highly immunogenic to the baby. Mature milk comes by day 10 of life. Foremilk is rich in protein and vitamins, while hindmilk is rich in fat. Proper technique should be followed for successful breastfeeding. Reflexes in the mother while breastfeeding are prolactin and oxytocin reflexes, while reflexes in the baby are rooting, sucking and swallowing. In case of early discharge from the hospital, adequacy of breastfeeding should be checked at 3–5 days of life. Breastfeeding develops bonding between the baby and the mother and promotes brain growth of the baby. Human milk is suitable for the baby and contains less protein and minerals than cow's milk and has less solute load for immature kidneys of the baby. Breastfeeding should be on demand, minimum eight times per day. The common feeding problems in the mother are flat or inverted nipple, sore nipple, engorgement of breasts, and mastitis which should be prevented.

**Keywords:** breastfeeding, breastmilk, benefits, term baby, mother

#### **1. Introduction**

Breastfeeding is a birthright of every baby, and also it is the right of every mother to breastfeed her baby. Breastfeeding is a complete nutrition for the baby and has several advantages to the baby and the mother. Breastfeeding (colostrum) has so much benefit for the baby especially immunologically that it is called the first vaccine for the baby. Breastfeeding is hypoallergenic and safe to the baby. It is sterile, hygienic and also economical. Breastfeeding is the saviour of the infant from respiratory and diarrhoeal morbidity and mortality especially in the developing and underdeveloped countries. It relieves a lot of economic burden for the poor countries [1]. In low-income and middle-income countries, only 37% of the babies less than 6 months are exclusively breastfed [2]. Breastfeeding helps in brain growth and improves the intelligence quotient (IQ ) of the children and thus benefits the country as a whole [3]. Breastfeeding reduces mortality and morbidity of children under 5 years of age especially in developing and underdeveloped countries. Breastfeeding enhances the bond between the mother and the child, provides tender loving care to the child and keeps the mother happy.

#### **2. Physiology of lactation**

**Stage 1**: The mammary gland is developed to produce milk as colostrum 12 weeks prior to parturition, but colostrum secretion is inhibited by the raised progesterone levels.

**Stage 2**: Milk production occurs after delivery due to the decrease in progesterone and the increase in prolactin levels. By the second or third day, milk production depends on suckling of the baby.

**Stage 3**: Mature milk production starts after 10 days of delivery and is the third stage of lactogenesis. The lactogenic effect of prolactin is modulated by the complex interplay of pituitary, thyroid, ovarian, adrenal and pancreatic hormones [4].

#### **2.1 Preparing mothers for breastfeeding**

During the last trimester of antenatal care, the mother's nipples should be checked. In case of flat nipple or retracted nipple, oil massage and manipulation to make the nipples conducive to breastfeeding should be done. The mother should be given healthy diet, green leafy vegetables, fruits, eggs, fish (omega 3 fatty acid) and plenty of fluids. She should take extra 300 cal and 15 g of protein during the antenatal period and extra 500 cal and 25 g of protein during the lactation period [5].

#### **2.2 Initiation of breastfeeding**

Breastfeeding should be initiated as early as possible after delivery preferably within 1 h after normal delivery and 4 h after Caesarean section [5]. The baby is biologically active immediately after delivery after which the baby goes into sleep and there is difficulty in establishment of breastfeeding; hence breastfeeding should be initiated early. Immediately after delivery, he/she should be put on the mother's abdomen, crawl to the breast and suckle at the breast; this method helps in early initiation of breastfeeding. Early skin-to-skin contact, putting the baby in mother's abdomen helps in early initiation of breastfeeding [6]. Keeping the baby with the mother in the same room is called 'rooming in', keeping him/her in the same bed with his/her mother is called 'bedding in' and keeping him/her in his/her mother's abdomen is called 'mothering in' [5].

#### **2.3 Types of breastmilk**

In the first 2 days, colostrum is secreted which is rich in lymphocytes, IgA and antibodies; the colostrum secreted is 10–40 ml/day which is sufficient for a term baby and does not require any supplementation. No prelacteal feeds should be given because these can cause infection and delay in establishment of breastfeeding. The baby should be well supported while breastfeeding, and the mother may require help in the first few days. Both the mother and the baby should be comfortable while breastfeeding. A healthy baby will empty the breast within 20 min, and alternating the breasts used for each feed is advised. The baby should completely empty the breast on the one side in order to get adequate hindmilk. Foremilk is the initial milk which is rich in vitamins, proteins, sugar, mineral and fluid, while hindmilk contains fat. Hence foremilk only satisfies the thirst, and the baby needs to get adequate hindmilk to get adequate calories and to satisfy hunger. If a baby does not empty the breast each feed, he/she does not get hindmilk and hence does not get nutritional requirement and feels hungry very fast and does not gain adequate

**21**

**Figure 1.**

*Correct technique of breastfeeding (cradle hold).*

*Breastfeeding in Normal Newborn: Basic Concepts DOI: http://dx.doi.org/10.5772/intechopen.92250*

secreted is 500–800 ml/day [5].

**2.4 Technique of breastfeeding**

lactiferous sinuses [5].

weight. Transitional milk is secreted in the first 10 days followed by mature milk. Milk production increases for the first 6 months and then plateaus off. Average milk

The correct technique should be followed for successful breastfeeding. The mother should touch the angle of the baby's mouth with the nipple; rooting reflex causes the

baby to open the mouth and take in the nipple and the areola into the mouth. **Good attachment**: Signs of good attachment are as follows: the baby's chin should be touching the breast, the mouth should be wide open, the lower lip should be turned outwards, the upper areola should be visible and the lower areola covered (**Figure 1**). He/she should suckle at the areola and not at the nipple so that the tongue is under the lactiferous sinuses and the nipple against the palate. He/she should form an adequate seal around the nipple and areola to eject the milk from

**Good positioning**: The baby should be turned towards the mother; his/her head, body and buttocks should be well supported and in straight line; his/her

**Burping**: When the baby sucks the breast, air goes in which causes colic, regurgitation and abdominal distension; hence burping is necessary. Burping is done by putting the baby on the left shoulder and gently patting his/her back or by making him/her sit on his/her mother's lap with support and gently patting the back [7].

abdomen should be against his/her mother's abdomen [7].

weight. Transitional milk is secreted in the first 10 days followed by mature milk. Milk production increases for the first 6 months and then plateaus off. Average milk secreted is 500–800 ml/day [5].

#### **2.4 Technique of breastfeeding**

*Infant Feeding - Breast versus Formula*

**2. Physiology of lactation**

depends on suckling of the baby.

**2.2 Initiation of breastfeeding**

**2.3 Types of breastmilk**

mother's abdomen is called 'mothering in' [5].

**2.1 Preparing mothers for breastfeeding**

progesterone levels.

period [5].

**Stage 1**: The mammary gland is developed to produce milk as colostrum 12 weeks prior to parturition, but colostrum secretion is inhibited by the raised

**Stage 2**: Milk production occurs after delivery due to the decrease in progesterone and the increase in prolactin levels. By the second or third day, milk production

**Stage 3**: Mature milk production starts after 10 days of delivery and is the third stage of lactogenesis. The lactogenic effect of prolactin is modulated by the complex interplay of pituitary, thyroid, ovarian, adrenal and pancreatic hormones [4].

During the last trimester of antenatal care, the mother's nipples should be checked. In case of flat nipple or retracted nipple, oil massage and manipulation to make the nipples conducive to breastfeeding should be done. The mother should be given healthy diet, green leafy vegetables, fruits, eggs, fish (omega 3 fatty acid) and plenty of fluids. She should take extra 300 cal and 15 g of protein during the antenatal period and extra 500 cal and 25 g of protein during the lactation

Breastfeeding should be initiated as early as possible after delivery preferably within 1 h after normal delivery and 4 h after Caesarean section [5]. The baby is biologically active immediately after delivery after which the baby goes into sleep and there is difficulty in establishment of breastfeeding; hence breastfeeding should be initiated early. Immediately after delivery, he/she should be put on the mother's abdomen, crawl to the breast and suckle at the breast; this method helps in early initiation of breastfeeding. Early skin-to-skin contact, putting the baby in mother's abdomen helps in early initiation of breastfeeding [6]. Keeping the baby with the mother in the same room is called 'rooming in', keeping him/her in the same bed with his/her mother is called 'bedding in' and keeping him/her in his/her

In the first 2 days, colostrum is secreted which is rich in lymphocytes, IgA and antibodies; the colostrum secreted is 10–40 ml/day which is sufficient for a term baby and does not require any supplementation. No prelacteal feeds should be given because these can cause infection and delay in establishment of breastfeeding. The baby should be well supported while breastfeeding, and the mother may require help in the first few days. Both the mother and the baby should be comfortable while breastfeeding. A healthy baby will empty the breast within 20 min, and alternating the breasts used for each feed is advised. The baby should completely empty the breast on the one side in order to get adequate hindmilk. Foremilk is the initial milk which is rich in vitamins, proteins, sugar, mineral and fluid, while hindmilk contains fat. Hence foremilk only satisfies the thirst, and the baby needs to get adequate hindmilk to get adequate calories and to satisfy hunger. If a baby does not empty the breast each feed, he/she does not get hindmilk and hence does not get nutritional requirement and feels hungry very fast and does not gain adequate

**20**

The correct technique should be followed for successful breastfeeding. The mother should touch the angle of the baby's mouth with the nipple; rooting reflex causes the baby to open the mouth and take in the nipple and the areola into the mouth.

**Good attachment**: Signs of good attachment are as follows: the baby's chin should be touching the breast, the mouth should be wide open, the lower lip should be turned outwards, the upper areola should be visible and the lower areola covered (**Figure 1**). He/she should suckle at the areola and not at the nipple so that the tongue is under the lactiferous sinuses and the nipple against the palate. He/she should form an adequate seal around the nipple and areola to eject the milk from lactiferous sinuses [5].

**Good positioning**: The baby should be turned towards the mother; his/her head, body and buttocks should be well supported and in straight line; his/her abdomen should be against his/her mother's abdomen [7].

**Burping**: When the baby sucks the breast, air goes in which causes colic, regurgitation and abdominal distension; hence burping is necessary. Burping is done by putting the baby on the left shoulder and gently patting his/her back or by making him/her sit on his/her mother's lap with support and gently patting the back [7].

**Figure 1.** *Correct technique of breastfeeding (cradle hold).*

#### **2.5 Various positions of breastfeeding**

**Cradle hold:** Mother positions the infant's head at or near the antecubital space at the level of her nipple with her arm supporting the infant's body and her other hand is free to hold the breast (**Figure 2**).

**Cross cradle hold**: Useful in preterm and babies with fractured clavicle. Mother holds the head with the hand opposite the side on which the infant will feed and supports the infant's body across her lap with her arm. The other hand is free to hold the breast.

**Football hold**: This method avoids pressure on Caesarean incision and helps in heavy breasts. Mother supports the infant's head and neck with her hand with the infant's body resting on pillows alongside her hip.

**Side lying position**: This position avoids pressure on episiotomy or abdominal incision and helps the mother to rest while feeding. She lies on her side and her upper hand is used to position her breast. Pillows can be put behind her back and between her legs to provide comfort. A small blanket or towel can be placed over the abdominal incision to protect from the infants' movement (**Table 1**) [8].

#### *2.5.1 Reflexes in the mother while breastfeeding*

**Prolactin reflex**: This is the milk production reflex; when the baby suckles at the breast, it causes sensory nerves to be stimulated which stimulates the anterior pituitary to secrete prolactin which helps in the production of milk for the next feed.

**Oxytocin reflex**: When the baby suckles at the breast, stimulation of posterior pituitary secretes oxytocin which contracts the myoepithelial cells and helps in the ejection of milk; this reflex is also called **let down reflex** because when the mother feeds the baby from one breast and this reflex is acting, then there will be breastmilk secretion from the other breast also, which is called drip milk. This

**23**

happy [5].

**Table 1.**

reflex.

*2.5.2 Reflexes in the baby*

*Various positions for breastfeeding.*

are put inside the mouth.

**2.6 Adequacy of breastmilk**

and establishment of lactation [10].

*Breastfeeding in Normal Newborn: Basic Concepts DOI: http://dx.doi.org/10.5772/intechopen.92250*

Football or clutch hold For LBW, minimum head control,

reflex if present tells us that mother's milk is adequate. Oxytocin reflex is usually affected by the mother's mental status; if she is relaxed, calm and happy, oxytocin reflex is augmented on the other hand; if she is depressed and sad, oxytocin reflex is inhibited; for successful breastfeeding, the mother should be relaxed, calm and

**Positions Elements positive Elements negative** Cradle hold Classic position Head tends to wobble Cross cradle hold Provides good head control Least familiar

avoids Caesarean incision

Side lying Minimises fatigue Chances of smothering

Teaching required

**Rooting reflex**: When the mother's nipple touches the angle of the mouth and then the baby opens the mouth and tries to latch at the breast, this is called rooting

**Sucking reflex**: The baby suckles at the areola when the nipple and the areola

How to know if breastmilk is sufficient or not? In the first week of life, there will be weight loss; in an exclusively breastfed term baby, about 5–7% of birthweight is lost in the first week especially by 48–72 h of birth [9]. A term baby usually regains birthweight, on average, by 8.3 days of life [9] and starts gaining minimum ½ ounce/day for the first 3 months [10]. Hence after the first week of life, we know that breastmilk is adequate by observing adequate weight gain, five to six times, pale-coloured urine per day and golden yellow colour stools, and then baby should sleep after each feed. Also when the mother is breastfeeding from one breast, if milk drips from the other breast, it is suggestive of adequacy of milk, and the milk that drips from the other breast is called drip milk. Drip milk is low in energy and fat content. If the baby is not gaining adequate weight and urine output is less after the third day of life, it is suggestive of inadequate breastmilk; the baby needs to attend a paediatrician to prevent complications like hypernatraemic dehydration [10]. However it should be remembered that in the first 2 days of life, only colostrum is secreted which is less in amount; hence urine output may be very less so much so that we can wait for 48 h for the first passage of urine. There is no need to give any complementary feeds to the baby in the first 2–3 days when colostrum is less because whatever colostrum is there, it is enough to meet the nutritional needs of a term baby, and a term baby also contains enough stores of glycogen. In case of early discharge from the hospital exclusively, breastfed babies should be seen by a paediatrician on the third to fifth day of life to check the adequacy of breastmilk

**Swallowing reflex**: The baby sucks and then swallows. The synchrony of respiration with sucking and swallowing takes place at 34 weeks of gestation. Babies born at or after 34 weeks of gestation can only successfully breastfeed. The rhythm

is usually suck, suck, suck, pause and then swallow [5].

**Figure 2.** *Various positions of breastfeeding (taken from toko.semuada.com).*


#### **Table 1.**

*Infant Feeding - Breast versus Formula*

the breast.

**2.5 Various positions of breastfeeding**

hand is free to hold the breast (**Figure 2**).

infant's body resting on pillows alongside her hip.

*2.5.1 Reflexes in the mother while breastfeeding*

**Cradle hold:** Mother positions the infant's head at or near the antecubital space at the level of her nipple with her arm supporting the infant's body and her other

**Cross cradle hold**: Useful in preterm and babies with fractured clavicle. Mother holds the head with the hand opposite the side on which the infant will feed and supports the infant's body across her lap with her arm. The other hand is free to hold

**Football hold**: This method avoids pressure on Caesarean incision and helps in heavy breasts. Mother supports the infant's head and neck with her hand with the

**Side lying position**: This position avoids pressure on episiotomy or abdominal incision and helps the mother to rest while feeding. She lies on her side and her upper hand is used to position her breast. Pillows can be put behind her back and between her legs to provide comfort. A small blanket or towel can be placed over the abdominal incision to protect from the infants' movement (**Table 1**) [8].

**Prolactin reflex**: This is the milk production reflex; when the baby suckles at the breast, it causes sensory nerves to be stimulated which stimulates the anterior pituitary to secrete prolactin which helps in the production of milk for the next feed. **Oxytocin reflex**: When the baby suckles at the breast, stimulation of posterior pituitary secretes oxytocin which contracts the myoepithelial cells and helps in the ejection of milk; this reflex is also called **let down reflex** because when the mother feeds the baby from one breast and this reflex is acting, then there will be breastmilk secretion from the other breast also, which is called drip milk. This

**22**

**Figure 2.**

*Various positions of breastfeeding (taken from toko.semuada.com).*

*Various positions for breastfeeding.*

reflex if present tells us that mother's milk is adequate. Oxytocin reflex is usually affected by the mother's mental status; if she is relaxed, calm and happy, oxytocin reflex is augmented on the other hand; if she is depressed and sad, oxytocin reflex is inhibited; for successful breastfeeding, the mother should be relaxed, calm and happy [5].

#### *2.5.2 Reflexes in the baby*

**Rooting reflex**: When the mother's nipple touches the angle of the mouth and then the baby opens the mouth and tries to latch at the breast, this is called rooting reflex.

**Sucking reflex**: The baby suckles at the areola when the nipple and the areola are put inside the mouth.

**Swallowing reflex**: The baby sucks and then swallows. The synchrony of respiration with sucking and swallowing takes place at 34 weeks of gestation. Babies born at or after 34 weeks of gestation can only successfully breastfeed. The rhythm is usually suck, suck, suck, pause and then swallow [5].

#### **2.6 Adequacy of breastmilk**

How to know if breastmilk is sufficient or not? In the first week of life, there will be weight loss; in an exclusively breastfed term baby, about 5–7% of birthweight is lost in the first week especially by 48–72 h of birth [9]. A term baby usually regains birthweight, on average, by 8.3 days of life [9] and starts gaining minimum ½ ounce/day for the first 3 months [10]. Hence after the first week of life, we know that breastmilk is adequate by observing adequate weight gain, five to six times, pale-coloured urine per day and golden yellow colour stools, and then baby should sleep after each feed. Also when the mother is breastfeeding from one breast, if milk drips from the other breast, it is suggestive of adequacy of milk, and the milk that drips from the other breast is called drip milk. Drip milk is low in energy and fat content. If the baby is not gaining adequate weight and urine output is less after the third day of life, it is suggestive of inadequate breastmilk; the baby needs to attend a paediatrician to prevent complications like hypernatraemic dehydration [10]. However it should be remembered that in the first 2 days of life, only colostrum is secreted which is less in amount; hence urine output may be very less so much so that we can wait for 48 h for the first passage of urine. There is no need to give any complementary feeds to the baby in the first 2–3 days when colostrum is less because whatever colostrum is there, it is enough to meet the nutritional needs of a term baby, and a term baby also contains enough stores of glycogen. In case of early discharge from the hospital exclusively, breastfed babies should be seen by a paediatrician on the third to fifth day of life to check the adequacy of breastmilk and establishment of lactation [10].

#### **2.7 Benefits of breastmilk**

#### *2.7.1 Benefits to the baby*


#### *2.7.2 Benefits to the mother*

1.Breastfeeding releases oxytocin which helps in involution of the uterus which leads to less chance of postpartum haemorrhage.

**25**

*Breastfeeding in Normal Newborn: Basic Concepts DOI: http://dx.doi.org/10.5772/intechopen.92250*

temperature.

take care of their baby.

**2.8 Breastmilk and brain growth**

during lactation.

of the human brain [3].

**2.10 Breastfeeding schedule**

conception during lactational amenorrhea.

cancer and ovarian cancer [5, 11–13].

**2.9 Composition of breastmilk and cow's milk**

2.Mothers who breastfeed have lactational amenorrhoea and have less chance of conception during that period. Night feeds especially help in preventing

3.Breastfeeding is convenient, economical and readily available at the desired

4.Mothers develop a close bond with the baby; they feel relaxed and happy to

5.Mothers regain their prepregnancy weight earlier than in those mothers who formula feed their babies because the energy stored during pregnancy is lost

6.Mothers who breastfeed their babies have less chance of developing breast

Breastmilk contains arachidonic acid (AHA), docosahexaenoic acid (DHA), high contents of amino acids like cysteine and taurine, choline, iodine, zinc, lactose and oligosaccharides which promotes maturation, myelination and synaptogenesis

Breastmilk contains less protein and solute load which are suitable for the baby and their immature kidneys. Cow's milk protein is predominantly casein, whereas breastmilk contains whey protein which is easily digestible. It is mainly lactalbumin and lactoferrin. Casein to whey protein ratio is 40:60 in human milk and 80:20 in cow's milk. Cow's milk contains lactoglobulin which is the cause of intolerance to cow's milk. Lactobacilli and lactic acid are probiotics which help in digestion in human milk. Nonprotein nitrogen in human milk like urea, amino acids, choline, creatinine, uric acid, ammonia and N-acetylglutamine are bioactive factors which are not present in cow's milk. Breastmilk is rich in long-chain polyunsaturated fatty acid (PUFA) like eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Cow's milk is rich in saturated fats. The polyunsaturated/saturated fat ratio is 1.2:1 in breastmilk compared to 1:2 in cow's milk. Carbohydrate in breastmilk is lactose which is double in content in breastmilk than in cow's milk and is suitable for brain growth and for the development of normal GI flora in babies. Vitamins like K and D are deficient in breastmilk. Especially in vitamin D-deficient mothers, breastmilk contains less vitamin D, and hence vitamin D supplementation in normal newborn exclusively breastfed babies is essential. Vitamin K is given to all babies after birth to prevent haemorrhagic disease of newborn. Minerals are less in breastmilk, but bioavailability is better in breastmilk than in cow's milk. Cow's milk contains high levels of electrolytes and hence high solute load and is not suitable for immature kidneys of babies [5, 12] (**Table 2**).

In a normal term baby, breastfeeding should be done as and when baby demands.

Usually after every 2–3 h, the baby will wake up and cry for feeds; this is called demand feeding. Some babies might sleep for a long duration usually in the first few *Infant Feeding - Breast versus Formula*

and necrotizing enterocolitis.

1.It is a complete nutrition for the baby till 6 months of age. It is easily digestible

2.Breastmilk contains anti-infective properties, antibodies, IgA and lactobacilli which protect the baby from diarrhoea, respiratory tract infection, otitis media

3.Breastmilk is hypoallergenic and reduces disorders like asthma and eczema in

tryptophan which is a precursor of serotonin and plays an important role as neurotransmitter. Lactoferrin helps in the absorption of iron and zinc and is bacteriostatic. Calcium phosphorus ratio is more than 2 and helps in calcium absorption. Protein content is less which provides less solute load to the

5.**Microbiological benefits:** It is sterile and there is less chance of contamination. Lactoferrin is bacteriostatic and inhibits E. coli growth in gut; lactoferrin binds with iron and makes it unavailable to E. coli. Peroxidases and lipases kill bacteria. The bifidus factor promotes the growth of lactobacilli. Bile salt-stimulated lipase (BSSL) kills amoeba and Giardia. Deficiency of paraaminobenzoic acid (PABA) in breastmilk prevents the growth of malarial

6.**Immunological benefits:** Breastmilk supplies passive immunity to the baby. It contains macrophages, lysozymes and complements, T lymphocytes and B lymphocytes. Secretory IgA provides surface immunity to GI tract and respira-

7.**Psychological benefits:** Breastfeeding promotes bonding between the mother and the baby. Breastfeeding provides maternal warmth, closeness and comfort

8.**Better IQ:** Breastfed babies have higher intelligence quotient than formula-fed babies and have enhanced visual development. Breastmilk contains long-chain fatty acids like arachidonic acid (AHA) and docosahexaenoic acid (DHA), lactose and sialic acid which promote brain growth. Breastmilk contains choline,

9.Breastfed babies have less risk of developing diabetes mellitus, high blood pressure, obesity, heart attack and certain cancers in adult life [5, 11–13].

1.Breastfeeding releases oxytocin which helps in involution of the uterus which

taurine and iodine which promote brain growth.

leads to less chance of postpartum haemorrhage.

4.**Biochemical benefits:** Protein is predominantly whey protein which contains alpha lactalbumin and lactoferrin. Lactalbumin is rich in

due to the presence of lipase and whey proteins.

**2.7 Benefits of breastmilk**

breastfed babies.

baby's kidneys.

parasite.

tory tract.

to the baby.

*2.7.2 Benefits to the mother*

*2.7.1 Benefits to the baby*

**24**


#### **2.8 Breastmilk and brain growth**

Breastmilk contains arachidonic acid (AHA), docosahexaenoic acid (DHA), high contents of amino acids like cysteine and taurine, choline, iodine, zinc, lactose and oligosaccharides which promotes maturation, myelination and synaptogenesis of the human brain [3].

#### **2.9 Composition of breastmilk and cow's milk**

Breastmilk contains less protein and solute load which are suitable for the baby and their immature kidneys. Cow's milk protein is predominantly casein, whereas breastmilk contains whey protein which is easily digestible. It is mainly lactalbumin and lactoferrin. Casein to whey protein ratio is 40:60 in human milk and 80:20 in cow's milk. Cow's milk contains lactoglobulin which is the cause of intolerance to cow's milk. Lactobacilli and lactic acid are probiotics which help in digestion in human milk. Nonprotein nitrogen in human milk like urea, amino acids, choline, creatinine, uric acid, ammonia and N-acetylglutamine are bioactive factors which are not present in cow's milk. Breastmilk is rich in long-chain polyunsaturated fatty acid (PUFA) like eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Cow's milk is rich in saturated fats. The polyunsaturated/saturated fat ratio is 1.2:1 in breastmilk compared to 1:2 in cow's milk. Carbohydrate in breastmilk is lactose which is double in content in breastmilk than in cow's milk and is suitable for brain growth and for the development of normal GI flora in babies. Vitamins like K and D are deficient in breastmilk. Especially in vitamin D-deficient mothers, breastmilk contains less vitamin D, and hence vitamin D supplementation in normal newborn exclusively breastfed babies is essential. Vitamin K is given to all babies after birth to prevent haemorrhagic disease of newborn. Minerals are less in breastmilk, but bioavailability is better in breastmilk than in cow's milk. Cow's milk contains high levels of electrolytes and hence high solute load and is not suitable for immature kidneys of babies [5, 12] (**Table 2**).

#### **2.10 Breastfeeding schedule**

In a normal term baby, breastfeeding should be done as and when baby demands. Usually after every 2–3 h, the baby will wake up and cry for feeds; this is called demand feeding. Some babies might sleep for a long duration usually in the first few


**Table 2.**

*Human milk versus cow's milk composition per 100 ml [5, 12].*

days after birth; these babies should be awakened and fed if the gap exceeds more than 3 h. Some babies sleep off after few minutes of suckling; they should be aroused by tickling at the ears and flicking the sole, or the mother should try to withdraw the nipple and then the baby starts suckling again [12]. Usually a normal term baby requires 15–20 min to empty one breast; he/she should be allowed to completely empty one breast so that he/she gets both foremilk and the hindmilk, which is required for the satiety of hunger and weight gain. If the baby sleeps off after a few mins, he/she should be aroused and then start suckling again and complete the feed [12]. Breastfeeding should be continued till 2 years of age because the maximum growth

**27**

*Breastfeeding in Normal Newborn: Basic Concepts DOI: http://dx.doi.org/10.5772/intechopen.92250*

**2.11 Immunobiology of breastmilk**

antiviral and anti-staphylococcal factors [12].

*2.12.2 Prevention of engorgement of breasts*

*2.12.1 Flat or inverted nipple*

relieve the congestion [8].

*2.12.3 Prevention of sore nipples*

**2.12 Common feeding problems in the mother**

and myelination of the brain take place in the first 2 years of life [5]. After 6 months of age, weaning should be started which is done by introducing semisolids or complementary feeds to the diet along with breastfeeding. After 6 months of life, the baby becomes interested in his/her surroundings and shows interest when adults take food; breastmilk output of the mother is not sufficient to meet the needs of the baby, and hence semisolid diet according to the regional availability may be introduced. If weaning is not started by 6 months of age, it might lead to malnutrition. An exclusively breastfed term baby does not require multivitamin supplementation; however the baby may be given vitamin D supplementation for a period of 6 months [10].

Colostrum is very rich in secretory IgA (sIgA) which protects the mucosal lining

If the nipple is flat, the areola and the nipple should be brought out to form the teat; otherwise the baby cannot latch a flat nipple. Occasionally while trying to pull out the nipple, it goes deeper into the breast and this is called inverted nipple; in this case the baby finds difficulty in latching. Nipple protractility test (nipple should be capable of being pulled out) should be done in the last trimester of pregnancy [14]. The nipple might get corrected as the baby sucks. In case of problem, syringe technique should be tried (**Figure 3**). Supple cups or silicone nipple can be

used over flat or inverted nipple to form a teat so that the baby can suckle.

Usually by days 2–3, milk production increases, and if the baby is not put for suckling, the breasts get engorged. If the breasts get engorged, then the nipple and areola becomes hard and baby does not suck at the breast. To relieve breast engorgement, breasts have to be emptied; this can be done by putting the baby for frequent suckling at the breast or by emptying the breast using breast pump. Warm packs applied to breasts or a warm shower before feeding combined with massage helps to

This may occur from strong sucking action of the baby if his/her position is not correct, i.e. if he/she sucks at the nipple instead of the areola; correct breastfeeding

of GI tract and respiratory tract and contains lymphocytes and macrophages. After 2–3 days, colostrum is replaced by transitional breastmilk which contains less amount of sIgA than colostrum. SIgA are produced in the mammary gland by the plasma cells that are derived from gut-associated lymphoid tissue (GALT) and bronchus-associated lymphoid tissue (BALT) [5]. Breastmilk contains sIgA and also IgM antibodies. IgM antibodies are transmitted from the mother to the baby by breastmilk; IgM antibodies usually do not cross the placenta and are not transferred from the mother to the baby via the placenta [12]. Breastmilk also contains IgG antibodies, lymphocytes, polymorph, macrophages and plasma cells and nonspecific humoral factors like lysozyme, oligosaccharides, lactoferrin and lactoperoxidase. Probiotics in breastmilk protects the gut from enteric pathogens. It also contains

*Breastfeeding in Normal Newborn: Basic Concepts DOI: http://dx.doi.org/10.5772/intechopen.92250*

*Infant Feeding - Breast versus Formula*

Electrolytes (meq/L)

Vitamins

**Nutrition Human milk Cow's milk** Calories 65 67 Protein 1.1 g 3.5 g Lactose 7.4 g 4.5 g Fat 3.5 g 3.5 g Calcium 35 mg 140 mg Phosphorus 15 mg 90 mg Magnesium 4 mg 12 mg

Sodium 6.5 25 Chloride 12 29 Potassium 14 35 Osmolality (mosm/L) 290 350

Vitamin A (μg) 53 34 Vitamin D (IU) 0.4–10 0.3–4

Vitamin K1 (μg) 0.3 0.7 Vitamin C (mg) 4.3 1.8 Thiamine (B1) (μg) 16 42 Riboflavin (B2) (μg) 43 157 Niacin (μg) 172 85 Vitamin B6 (μg) 11 58 Folic acid (μg) 0.18 0.23 Vitamin B12 (μg) 0.18 0.4 Biotin (μg) 2 22 Choline (mg) 1.3 1.2 Taurine (mg) 5 0.5 Carnitine (mg) 0.8 1 Iron (mg) 0.05–0.2 0.1–0.3 Iodine (mg) 7 21 Copper (mg) 0.04 0.03 Zinc (mg) 0.53 0.38

Vitamin E (mg) 0.2

*Human milk versus cow's milk composition per 100 ml [5, 12].*

**26**

**Table 2.**

days after birth; these babies should be awakened and fed if the gap exceeds more than 3 h. Some babies sleep off after few minutes of suckling; they should be aroused by tickling at the ears and flicking the sole, or the mother should try to withdraw the nipple and then the baby starts suckling again [12]. Usually a normal term baby requires 15–20 min to empty one breast; he/she should be allowed to completely empty one breast so that he/she gets both foremilk and the hindmilk, which is required for the satiety of hunger and weight gain. If the baby sleeps off after a few mins, he/she should be aroused and then start suckling again and complete the feed [12]. Breastfeeding should be continued till 2 years of age because the maximum growth

and myelination of the brain take place in the first 2 years of life [5]. After 6 months of age, weaning should be started which is done by introducing semisolids or complementary feeds to the diet along with breastfeeding. After 6 months of life, the baby becomes interested in his/her surroundings and shows interest when adults take food; breastmilk output of the mother is not sufficient to meet the needs of the baby, and hence semisolid diet according to the regional availability may be introduced. If weaning is not started by 6 months of age, it might lead to malnutrition. An exclusively breastfed term baby does not require multivitamin supplementation; however the baby may be given vitamin D supplementation for a period of 6 months [10].

#### **2.11 Immunobiology of breastmilk**

Colostrum is very rich in secretory IgA (sIgA) which protects the mucosal lining of GI tract and respiratory tract and contains lymphocytes and macrophages. After 2–3 days, colostrum is replaced by transitional breastmilk which contains less amount of sIgA than colostrum. SIgA are produced in the mammary gland by the plasma cells that are derived from gut-associated lymphoid tissue (GALT) and bronchus-associated lymphoid tissue (BALT) [5]. Breastmilk contains sIgA and also IgM antibodies. IgM antibodies are transmitted from the mother to the baby by breastmilk; IgM antibodies usually do not cross the placenta and are not transferred from the mother to the baby via the placenta [12]. Breastmilk also contains IgG antibodies, lymphocytes, polymorph, macrophages and plasma cells and nonspecific humoral factors like lysozyme, oligosaccharides, lactoferrin and lactoperoxidase. Probiotics in breastmilk protects the gut from enteric pathogens. It also contains antiviral and anti-staphylococcal factors [12].

#### **2.12 Common feeding problems in the mother**

#### *2.12.1 Flat or inverted nipple*

If the nipple is flat, the areola and the nipple should be brought out to form the teat; otherwise the baby cannot latch a flat nipple. Occasionally while trying to pull out the nipple, it goes deeper into the breast and this is called inverted nipple; in this case the baby finds difficulty in latching. Nipple protractility test (nipple should be capable of being pulled out) should be done in the last trimester of pregnancy [14]. The nipple might get corrected as the baby sucks. In case of problem, syringe technique should be tried (**Figure 3**). Supple cups or silicone nipple can be used over flat or inverted nipple to form a teat so that the baby can suckle.

#### *2.12.2 Prevention of engorgement of breasts*

Usually by days 2–3, milk production increases, and if the baby is not put for suckling, the breasts get engorged. If the breasts get engorged, then the nipple and areola becomes hard and baby does not suck at the breast. To relieve breast engorgement, breasts have to be emptied; this can be done by putting the baby for frequent suckling at the breast or by emptying the breast using breast pump. Warm packs applied to breasts or a warm shower before feeding combined with massage helps to relieve the congestion [8].

#### *2.12.3 Prevention of sore nipples*

This may occur from strong sucking action of the baby if his/her position is not correct, i.e. if he/she sucks at the nipple instead of the areola; correct breastfeeding

**Figure 3.** *Syringe technique for flat and inverted nipple (taken from Wikihow.com).*

technique can prevent sore nipples. The baby should not be forcefully removed from sucking at the breast, but instead a finger can be introduced to break the suction and then remove him/her; he/she should not be allowed to suck for a long time after the breast is emptied; the nipple should not be allowed to remain wet from leaking milk. The mother can keep the nipple exposed to air for 10–15 min after breastfeeding or apply vitamin E lotion, coconut oil and lanolin to prevent soreness. While cleaning the nipples, she should avoid using soap and use only warm water. In case of sore nipple or cracked nipple, nipple shells or nipple shields can be used to allow the baby to suckle and to prevent the mother from pain [7].

#### *2.12.4 Blocked ducts*

Sometimes a segment of the breast becomes hard due to blocked ducts; in this case proper massage and warm packs with emptying of the breast helps, and if blocked ducts are not treated, it leads to mastitis [5]. Sometimes due to incorrect technique and engorgement of breasts if not treated, the mother may develop mastitis (non-infective); in this condition mothers should be given analgesia (paracetamol) prior to feeds, and the baby should be put for suckling; if baby cannot be put for suckling at the breast due to pain, breasts must be emptied by using breast pump; the mother should take bed rest and plenty of fluids orally. In case the mother develops breast abscess, antibiotics should be given for 10–14 days. Breastfeeding can be continued from the affected breast if there is no pus discharge from the nipple [15]. Breast abscess might require drainage. Candidal infection: sometimes mothers may experience excruciating pain while feeding the baby; if the baby has oral thrush, 1% gentian violet clotrimazole mouth paint may be applied over the nipple and inside the baby's mouth. Mothers may require systemic antifungal like fluconazole in severe cases [16]. Psychological counselling for the mother is necessary in these cases of feeding problems. A mother needs constant support and guidance in these cases [5].

#### **2.13 Breastfeeding when the mother is ill**

A mother can breastfeed her baby in case of fever, rhinitis, respiratory tract infection, diarrheal diseases and asthma provided she is not very sick and unable to breastfeed. In case of respiratory tract infections, she should wear mask while breastfeeding. If the mother is unable to breastfeed, expressed breastmilk (EBM) can

**29**

*Breastfeeding in Normal Newborn: Basic Concepts DOI: http://dx.doi.org/10.5772/intechopen.92250*

**2.14 Contraindications to breastfeeding**

**2.15 Breastfeeding-associated problems**

for breastfeeding [5].

*2.15.1 Regurgitation of feeds*

slight elevation of the head.

out and relieve the colic [12].

started along with breastfeeding.

**2.16 Breastfeeding in working mothers**

*2.15.2 Gastrocolic reflex*

*2.15.3 Evening colic*

be given through cup and spoon. Breastmilk can be expressed using manual or electric breast pump. Bottle feeds should not be used because it creates nipple confusion in the baby and the baby will refuse to take breastfeeding. Bottle feeding is easier and needs less energy, and henceforth the baby becomes lazy and refuses breastfeeding [12]. If the mother has mastitis, she can breastfeed from the unaffected breast and also from the affected breast if there is no pus discharge from the nipple of affected site [15]. In case of UTI and tuberculosis (if sputum is negative), breastfeeding can be given. In case of hepatitis B-positive mother, the baby should be given hepatitis B immunoglobulin and hepatitis B vaccine after birth, and breastfeeding can be continued [5]. In case of HIV-positive mother, the **WHO** recommends to continue breastfeeding in developing countries because in developing countries morbidity and mortality is high if the baby is not breastfed due to other infections like respiratory and diarrhoeal diseases. However in the case of higher socioeconomic status, breastfeeding can be stopped and formula feeds may be given in HIV-positive mothers. **CDC** recommends to stop breastfeeding in HIV-positive mothers [17]. In

postpartum psychosis, breastfeeding may be allowed under supervision.

Galactosemia, congenital lactose intolerance, chemotherapy, antithyroid drugs except propylthiouracil and antipsychotic drugs like lithium are contraindications

Some babies regurgitate some curdy milk precipitates (fermented milk from the stomach) after each feed; the mother should be advised to burp the baby properly to eructate the swallowed air and to make the baby lie in right lateral position with

Some breastfed babies may pass stool after each feed; this is not diarrhoea, and if urine output is good, then there is no dehydration and no treatment required; it is a phenomenon due to gastrocolic reflex. If the urine output is good then it is normal*.*

Some breastfed babies cry during the evening hours due to aerophagia. These babies can be put prone, and burping can be done which will help the air to come

Usually working mothers get 6 months of maternity leave. In the first 6 months,

Ideally there should be a crèche near the working place for the mother to go and feed in between. There should be a private place in the working area for the mother to express her milk and give to her baby in the crèche. Expressed breastmilk can be

exclusive breastfeeding can be given and then complementary feeds should be

given to the baby if the mother is away by cup and spoon [5].

*Breastfeeding in Normal Newborn: Basic Concepts DOI: http://dx.doi.org/10.5772/intechopen.92250*

*Infant Feeding - Breast versus Formula*

technique can prevent sore nipples. The baby should not be forcefully removed from sucking at the breast, but instead a finger can be introduced to break the suction and then remove him/her; he/she should not be allowed to suck for a long time after the breast is emptied; the nipple should not be allowed to remain wet from leaking milk. The mother can keep the nipple exposed to air for 10–15 min after breastfeeding or apply vitamin E lotion, coconut oil and lanolin to prevent soreness. While cleaning the nipples, she should avoid using soap and use only warm water. In case of sore nipple or cracked nipple, nipple shells or nipple shields can be used to

Sometimes a segment of the breast becomes hard due to blocked ducts; in this case proper massage and warm packs with emptying of the breast helps, and if blocked ducts are not treated, it leads to mastitis [5]. Sometimes due to incorrect technique and engorgement of breasts if not treated, the mother may develop mastitis (non-infective); in this condition mothers should be given analgesia

(paracetamol) prior to feeds, and the baby should be put for suckling; if baby cannot be put for suckling at the breast due to pain, breasts must be emptied by using breast pump; the mother should take bed rest and plenty of fluids orally. In case the mother develops breast abscess, antibiotics should be given for 10–14 days. Breastfeeding can be continued from the affected breast if there is no pus discharge from the nipple [15]. Breast abscess might require drainage. Candidal infection: sometimes mothers may experience excruciating pain while feeding the baby; if the baby has oral thrush, 1% gentian violet clotrimazole mouth paint may be applied over the nipple and inside the baby's mouth. Mothers may require systemic antifungal like fluconazole in severe cases [16]. Psychological counselling for the mother is necessary in these cases of feeding problems. A mother needs constant support and guidance in these cases [5].

A mother can breastfeed her baby in case of fever, rhinitis, respiratory tract infection, diarrheal diseases and asthma provided she is not very sick and unable to breastfeed. In case of respiratory tract infections, she should wear mask while breastfeeding. If the mother is unable to breastfeed, expressed breastmilk (EBM) can

allow the baby to suckle and to prevent the mother from pain [7].

*Syringe technique for flat and inverted nipple (taken from Wikihow.com).*

**28**

*2.12.4 Blocked ducts*

**Figure 3.**

**2.13 Breastfeeding when the mother is ill**

be given through cup and spoon. Breastmilk can be expressed using manual or electric breast pump. Bottle feeds should not be used because it creates nipple confusion in the baby and the baby will refuse to take breastfeeding. Bottle feeding is easier and needs less energy, and henceforth the baby becomes lazy and refuses breastfeeding [12]. If the mother has mastitis, she can breastfeed from the unaffected breast and also from the affected breast if there is no pus discharge from the nipple of affected site [15]. In case of UTI and tuberculosis (if sputum is negative), breastfeeding can be given. In case of hepatitis B-positive mother, the baby should be given hepatitis B immunoglobulin and hepatitis B vaccine after birth, and breastfeeding can be continued [5]. In case of HIV-positive mother, the **WHO** recommends to continue breastfeeding in developing countries because in developing countries morbidity and mortality is high if the baby is not breastfed due to other infections like respiratory and diarrhoeal diseases. However in the case of higher socioeconomic status, breastfeeding can be stopped and formula feeds may be given in HIV-positive mothers. **CDC** recommends to stop breastfeeding in HIV-positive mothers [17]. In postpartum psychosis, breastfeeding may be allowed under supervision.

#### **2.14 Contraindications to breastfeeding**

Galactosemia, congenital lactose intolerance, chemotherapy, antithyroid drugs except propylthiouracil and antipsychotic drugs like lithium are contraindications for breastfeeding [5].

#### **2.15 Breastfeeding-associated problems**

#### *2.15.1 Regurgitation of feeds*

Some babies regurgitate some curdy milk precipitates (fermented milk from the stomach) after each feed; the mother should be advised to burp the baby properly to eructate the swallowed air and to make the baby lie in right lateral position with slight elevation of the head.

#### *2.15.2 Gastrocolic reflex*

Some breastfed babies may pass stool after each feed; this is not diarrhoea, and if urine output is good, then there is no dehydration and no treatment required; it is a phenomenon due to gastrocolic reflex. If the urine output is good then it is normal*.*

#### *2.15.3 Evening colic*

Some breastfed babies cry during the evening hours due to aerophagia. These babies can be put prone, and burping can be done which will help the air to come out and relieve the colic [12].

#### **2.16 Breastfeeding in working mothers**

Usually working mothers get 6 months of maternity leave. In the first 6 months, exclusive breastfeeding can be given and then complementary feeds should be started along with breastfeeding.

Ideally there should be a crèche near the working place for the mother to go and feed in between. There should be a private place in the working area for the mother to express her milk and give to her baby in the crèche. Expressed breastmilk can be given to the baby if the mother is away by cup and spoon [5].

#### **2.17 Breastmilk storage**

Expressed breastmilk (EBM) should be stored in a stainless steel, food grade hard plastic or glass container having a tight fitting lid. EBM can be stored at room temperature for 6 h and in the refrigerator for 24 h and in the freezer compartment of the refrigerator for 2 weeks. EBM should be thawed before feeding by running tap or lukewarm water over the container; never use boiling or hot water to thaw the milk. EBM should never be heated or microwaved because the antibodies get destroyed [18].

#### **2.18 Medications to the lactating mothers**

All drugs taken by the mother will be excreted in the milk, but the concentration of drugs in the breastmilk is less, usually less than 1%. Propylthiouracil and warfarin are safe and can be taken during breastfeeding. Antibiotics taken by the mother may cause increased stooling of the baby. Laxatives taken by the mother can cause diarrhoea in the baby; however milk of magnesia, liquid paraffin and glycerine suppositories are safe. Oral contraceptives, pyridoxine, nicotine and bromocriptine suppress lactation [5].

#### **2.19 Delayed lactation**

Some mothers with obesity, diabetes mellitus, stress, polycystic ovarian disease, postpartum haemorrhage and retained placenta may have delayed lactation. In these cases galactogogues can be given like domperidone and metoclopramide tablets. However it should be kept in mind that these drugs can cause extra pyramidal symptoms (EPS) in the mother. Domperidone has less chance of EPS and is well tolerated and can be given for 7–10 days at length [5].

#### **2.20 Baby-friendly hospital initiative (BFHI)**

The Baby-friendly Hospital Initiative (BFHI) was started in the year 1992 organised by the UNICEF and WHO. The World Alliance for Breastfeeding Action (WABA) is the global agency for the promotion of breastfeeding. The 10 steps of BFHI are as follows [5]:


**31**

*Breastfeeding in Normal Newborn: Basic Concepts DOI: http://dx.doi.org/10.5772/intechopen.92250*

8.Encourage breastfeeding on demand.

**2.21 Breastfeeding week celebration**

ment and non-government organisations [19].

edge the mother for allowing me to take the picture.

The author declares no conflict of interest.

them on discharge from the hospital or clinic.

day.

**3. Conclusion**

countries.

**Acknowledgements**

**Conflict of interest**

feeding infants.

7.Practise rooming-in and allow mothers and infants to remain together 24 h a

9.Give no artificial teats or pacifiers (also called dummies or soothers) to breast-

10. Foster the establishment of breastfeeding support groups, and refer mothers to

Every year breastfeeding week is celebrated from August 1 to August 7. It commemorates the Innocenti Declaration in August 1990 when the WHO, UNICEF and several other organisations came together to protect, promote and support breastfeeding. Every year there is a theme based on which it is celebrated. Breastfeeding week celebrations are organised by the WABA, UNICEF, WHO and several govern-

All mothers should be antenatally motivated for breastfeeding. Breastfeeding should be initiated within 1 h of birth. Early skin-to-skin contact helps in early initiation of breastfeeding. Correct technique of breastfeeding should be taught to the mother. Exclusive breastfeeding should be given for 6 months of age and then complementary feeds should be introduced. In low- and middle-income countries, breastfeeding not only benefits the mother and the baby but also reduces economic burden of the country. Hence we should protect, promote and support breastfeeding not only in low- and middle-income countries but also in developed

I would like to acknowledge Dr. Sneha Andrade and Veronica sister for helping me take the picture of the mother while breastfeeding. I would also like to acknowl-


#### **2.21 Breastfeeding week celebration**

Every year breastfeeding week is celebrated from August 1 to August 7. It commemorates the Innocenti Declaration in August 1990 when the WHO, UNICEF and several other organisations came together to protect, promote and support breastfeeding. Every year there is a theme based on which it is celebrated. Breastfeeding week celebrations are organised by the WABA, UNICEF, WHO and several government and non-government organisations [19].

### **3. Conclusion**

*Infant Feeding - Breast versus Formula*

**2.18 Medications to the lactating mothers**

tolerated and can be given for 7–10 days at length [5].

**2.20 Baby-friendly hospital initiative (BFHI)**

communicated to all healthcare staff.

separated from their infants.

Expressed breastmilk (EBM) should be stored in a stainless steel, food grade hard plastic or glass container having a tight fitting lid. EBM can be stored at room temperature for 6 h and in the refrigerator for 24 h and in the freezer compartment of the refrigerator for 2 weeks. EBM should be thawed before feeding by running tap or lukewarm water over the container; never use boiling or hot water to thaw the milk. EBM should never be heated or microwaved because the antibodies get

All drugs taken by the mother will be excreted in the milk, but the concentration of drugs in the breastmilk is less, usually less than 1%. Propylthiouracil and warfarin are safe and can be taken during breastfeeding. Antibiotics taken by the mother may cause increased stooling of the baby. Laxatives taken by the mother can cause diarrhoea in the baby; however milk of magnesia, liquid paraffin and glycerine suppositories are safe. Oral contraceptives, pyridoxine, nicotine and bromocriptine

Some mothers with obesity, diabetes mellitus, stress, polycystic ovarian disease,

postpartum haemorrhage and retained placenta may have delayed lactation. In these cases galactogogues can be given like domperidone and metoclopramide tablets. However it should be kept in mind that these drugs can cause extra pyramidal symptoms (EPS) in the mother. Domperidone has less chance of EPS and is well

The Baby-friendly Hospital Initiative (BFHI) was started in the year 1992 organised by the UNICEF and WHO. The World Alliance for Breastfeeding Action (WABA) is the global agency for the promotion of breastfeeding. The 10 steps of

1.Every hospital should have a written breastfeeding policy that is routinely

5.Show mothers how to breastfeed and how to maintain lactation even if they are

6.Give newborn infants no food or drink other than breastmilk, unless medically

2.Train all healthcare staff in skills necessary to implement this policy.

3.Inform all pregnant women about the benefits and management of

4.Help mothers to initiate breastfeeding within an hour of birth.

**2.17 Breastmilk storage**

destroyed [18].

suppress lactation [5].

**2.19 Delayed lactation**

BFHI are as follows [5]:

breastfeeding.

indicated.

**30**

All mothers should be antenatally motivated for breastfeeding. Breastfeeding should be initiated within 1 h of birth. Early skin-to-skin contact helps in early initiation of breastfeeding. Correct technique of breastfeeding should be taught to the mother. Exclusive breastfeeding should be given for 6 months of age and then complementary feeds should be introduced. In low- and middle-income countries, breastfeeding not only benefits the mother and the baby but also reduces economic burden of the country. Hence we should protect, promote and support breastfeeding not only in low- and middle-income countries but also in developed countries.

#### **Acknowledgements**

I would like to acknowledge Dr. Sneha Andrade and Veronica sister for helping me take the picture of the mother while breastfeeding. I would also like to acknowledge the mother for allowing me to take the picture.

### **Conflict of interest**

The author declares no conflict of interest.

*Infant Feeding - Breast versus Formula*

#### **Author details**

Jayashree Purkayastha Kasturba Medical College, MAHE, Manipal, Karnataka, India

\*Address all correspondence to: jayashreepurkayastha@yahoo.com

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**33**

*Breastfeeding in Normal Newborn: Basic Concepts DOI: http://dx.doi.org/10.5772/intechopen.92250*

> and formula fed infants. Archives of Disease in Childhood. Fetal and Neonatal Edition. 2003;**88**(6):F472-F476

[11] Grummer-Strawn LM, Rollins N. Summarising the health effects of breastfeeding. Acta Paediatrica. 2015;**104**(467):1-2. DOI: 10.1111/

[12] Singh M. Feeding and nutrition. In: Care of the Newborn. 7th ed. New Delhi: Sagar Publications; 2010. pp. 168-182

[13] Guideline: Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services. Geneva: WHO; 2017 Licence: CCBY-NC-SA3.0IGO. Available from: http://www.ncbi.nlm.nih.gov/

[10] Hurst N, Poupolo KM. Breastfeeding and maternal medications. In: Eichenwald EC, Hansen AR, Martin CR, Stark AR, editors. Cloherty and Stark's Manual of Neonatal Care. 8th ed. Philadelphia: Wolters Kluwer; 2017. pp. 285-288

apa-13136

books/NBK487819

1997;**6**(2):72-78

[14] Alexander J, Campbell M. Prevalence of inverted and non protractile nipples in antenatal women who intend to breastfeed. The Breast.

Mallikarjuna RH, Kalliath A, Rao KT, Verghese J, et al. Successful management of breast abscess with ongoing breastfeeding. Indian

Pediatrics. 1995;**32**:488-490

[16] Lawrence RA, Lawrence RM. Medical complications of the mother. In: Breastfeeding: A Guide for the Medical Profession. 6th ed. Philadelphia: Elsevier Mosby; 2005. pp. 562-568

[17] World Health Organization, United Nations Children's Fund. Updates

[15] Banapurmath RC, Banapurmath CS,

**References**

[1] Rollins NC, Bhandari N,

Hajeebhoy N, Horton S, Lutter CK, Martines JC, et al. Why invest, and what it will take to improve breastfeeding practices? Lancet. 2016;**387**:491-504. DOI: 10.1016/s0140-6736(15)01044-2

[2] Victoria CG, Bahl R, Barros AJ, Franca GV, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: Epidemiology, mechanisms,

2016;**387**(10017):475-490. DOI: 10.1016/

and lifelong effect. Lancet.

[3] Horta BL, Loret de Mola C, Victoria CG. Breastfeeding and intelligence: A systematic review and meta-analysis. Acta Paediatrica. 2015;**104**(467):14-19. DOI: 10.1111/

[4] Lawrence RA, Lawrence RM. Physiology of lactation. In:

[6] Moore ER, Bergman N, Anderson GC, Medley N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews. 2016;(11):CD003519. DOI: 10.10002/14651858.CD003519pub4

[7] Novan JC, Broom BL. Ingalls and Salerno's Maternal and Child Health Nursing. 9th ed. Missouri: Mosby; 1999

[9] MacDonald DP, Ross RS, Grant L, Young D. Neonatal weight loss in breast

[8] Murray SS, McKinney ES. Foundations of Maternal-Newborn and Women's Health Nursing. 5th ed. Saunders Elsevier: Missouri; 2010

Breastfeeding: A Guide for the Medical Profession. 6th ed. Philadelphia: Elsevier Mosby; 2005. pp. 68-100

[5] Elizabeth KE. Infant and young child feeding (IYCF). In: Nutrition and Child Development. 4th ed. New Delhi: Paras Medical Publisher; 2010. pp. 1-22

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#### **References**

*Infant Feeding - Breast versus Formula*

**32**

**Author details**

Jayashree Purkayastha

Kasturba Medical College, MAHE, Manipal, Karnataka, India

provided the original work is properly cited.

\*Address all correspondence to: jayashreepurkayastha@yahoo.com

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

[1] Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, et al. Why invest, and what it will take to improve breastfeeding practices? Lancet. 2016;**387**:491-504. DOI: 10.1016/s0140-6736(15)01044-2

[2] Victoria CG, Bahl R, Barros AJ, Franca GV, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. Lancet. 2016;**387**(10017):475-490. DOI: 10.1016/ s0140-6736(15)01024-7

[3] Horta BL, Loret de Mola C, Victoria CG. Breastfeeding and intelligence: A systematic review and meta-analysis. Acta Paediatrica. 2015;**104**(467):14-19. DOI: 10.1111/ apa-13139

[4] Lawrence RA, Lawrence RM. Physiology of lactation. In: Breastfeeding: A Guide for the Medical Profession. 6th ed. Philadelphia: Elsevier Mosby; 2005. pp. 68-100

[5] Elizabeth KE. Infant and young child feeding (IYCF). In: Nutrition and Child Development. 4th ed. New Delhi: Paras Medical Publisher; 2010. pp. 1-22

[6] Moore ER, Bergman N, Anderson GC, Medley N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews. 2016;(11):CD003519. DOI: 10.10002/14651858.CD003519pub4

[7] Novan JC, Broom BL. Ingalls and Salerno's Maternal and Child Health Nursing. 9th ed. Missouri: Mosby; 1999

[8] Murray SS, McKinney ES. Foundations of Maternal-Newborn and Women's Health Nursing. 5th ed. Saunders Elsevier: Missouri; 2010

[9] MacDonald DP, Ross RS, Grant L, Young D. Neonatal weight loss in breast and formula fed infants. Archives of Disease in Childhood. Fetal and Neonatal Edition. 2003;**88**(6):F472-F476

[10] Hurst N, Poupolo KM. Breastfeeding and maternal medications. In: Eichenwald EC, Hansen AR, Martin CR, Stark AR, editors. Cloherty and Stark's Manual of Neonatal Care. 8th ed. Philadelphia: Wolters Kluwer; 2017. pp. 285-288

[11] Grummer-Strawn LM, Rollins N. Summarising the health effects of breastfeeding. Acta Paediatrica. 2015;**104**(467):1-2. DOI: 10.1111/ apa-13136

[12] Singh M. Feeding and nutrition. In: Care of the Newborn. 7th ed. New Delhi: Sagar Publications; 2010. pp. 168-182

[13] Guideline: Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services. Geneva: WHO; 2017 Licence: CCBY-NC-SA3.0IGO. Available from: http://www.ncbi.nlm.nih.gov/ books/NBK487819

[14] Alexander J, Campbell M. Prevalence of inverted and non protractile nipples in antenatal women who intend to breastfeed. The Breast. 1997;**6**(2):72-78

[15] Banapurmath RC, Banapurmath CS, Mallikarjuna RH, Kalliath A, Rao KT, Verghese J, et al. Successful management of breast abscess with ongoing breastfeeding. Indian Pediatrics. 1995;**32**:488-490

[16] Lawrence RA, Lawrence RM. Medical complications of the mother. In: Breastfeeding: A Guide for the Medical Profession. 6th ed. Philadelphia: Elsevier Mosby; 2005. pp. 562-568

[17] World Health Organization, United Nations Children's Fund. Updates

on HIV and Infant Feeding: The Duration of Breastfeeding and Support from Health Services to Improve Feeding Practices among Mothers Living with HIV. Geneva. World Health Organization; 2016. Available from: http://apps.who.int/iris/bitstr eam/10665/246260/1/9789241549707 eng.pdf?ua=1 [Accessed: 20 September 2017]

[18] Lawrence RA, Lawrence RM. The storage of human milk. Academy of breastfeeding medicine-human milk storage information for home use for healthy full term infants. In: Breastfeeding: A Guide for the Medical Profession. 6th ed. Philadelphia: Elsevier Mosby; 2005. pp. 1018-1020

[19] World Breastfeeding Week. 2019. Available from: www.waba.org.my

**35**

**Chapter 3**

**Abstract**

**1. Introduction**

breastfeeding.

practices is crucial.

the WHO's recommendations [1].

ing to at least 50% by the year 2025 [1].

**Key Points**

Factors Influencing Maternal

The decision to formula feed or breastfeed a child typically begins with an established prenatal intention. This chapter will examine the multiple dimensions influencing maternal decision-making in regards to the feeding practices of infants including 1) individual maternal characteristics, 2) organizational factors, 3) hospital/provider recommendations, and 4) systematic/policy factors. The chapter will also examine the impact of infant feeding practices on early infant and childhood health outcomes. Research has demonstrated the benefits of breastfeeding on infants and early childhood which includes but is not limited to protection against common illnesses and infections, improved IQ, and even increased school attendance. Moreover, the World Health Assembly global nutrition objectives focus on encouraging breastfeeding support across all sectors in addition to implementing tailored community-based approaches, limiting the excessive marketing of infant formula, and enforcing supportive breastfeeding legislation. The aim of this chapter is to provide an overview of the dynamic interplay between individual, interpersonal, community, and societal factors, such as policies

that impact breastfeeding rates and more specifically the health of infants.

• The World Health Organization recommends mothers exclusively breastfeed their children for the first 6 months of life and thereafter, supplement nutritious foods and breastmilk for up to 2 years and beyond in order for children and mothers to reap the optimal health benefits associated with

• Despite the known health and economic benefits of breastfeeding, global breastfeeding prevalence remains an underachieved target, where less than 40% of infants are globally breastfed according to

• The World Health Assembly (WHA) has a goal of increasing the prevalence of exclusive breastfeed-

• In order to increase global breastfeeding prevalence understanding and addressing the individual maternal characteristics, community, organizational, and political factors affecting breastfeeding

**Keywords:** infant feeding, breastfeeding, health outcomes

Decision-Making on Infant

Feeding Practices

*Whitney N. Hamilton*

#### **Chapter 3**

*Infant Feeding - Breast versus Formula*

on HIV and Infant Feeding: The Duration of Breastfeeding and Support from Health Services to Improve Feeding Practices among Mothers Living with HIV. Geneva. World Health Organization; 2016. Available from: http://apps.who.int/iris/bitstr eam/10665/246260/1/9789241549707 eng.pdf?ua=1 [Accessed: 20 September

[18] Lawrence RA, Lawrence RM. The storage of human milk. Academy of breastfeeding medicine-human milk storage information for home use for healthy full term infants. In: Breastfeeding: A Guide for the Medical Profession. 6th ed. Philadelphia: Elsevier Mosby; 2005. pp. 1018-1020

[19] World Breastfeeding Week. 2019. Available from: www.waba.org.my

2017]

**34**

## Factors Influencing Maternal Decision-Making on Infant Feeding Practices

*Whitney N. Hamilton*

#### **Abstract**

The decision to formula feed or breastfeed a child typically begins with an established prenatal intention. This chapter will examine the multiple dimensions influencing maternal decision-making in regards to the feeding practices of infants including 1) individual maternal characteristics, 2) organizational factors, 3) hospital/provider recommendations, and 4) systematic/policy factors. The chapter will also examine the impact of infant feeding practices on early infant and childhood health outcomes. Research has demonstrated the benefits of breastfeeding on infants and early childhood which includes but is not limited to protection against common illnesses and infections, improved IQ, and even increased school attendance. Moreover, the World Health Assembly global nutrition objectives focus on encouraging breastfeeding support across all sectors in addition to implementing tailored community-based approaches, limiting the excessive marketing of infant formula, and enforcing supportive breastfeeding legislation. The aim of this chapter is to provide an overview of the dynamic interplay between individual, interpersonal, community, and societal factors, such as policies that impact breastfeeding rates and more specifically the health of infants.

**Keywords:** infant feeding, breastfeeding, health outcomes

#### **1. Introduction**

#### **Key Points**


Breastfeeding is a child's first barrier against death and disease, providing protection against respiratory infection, gastrointestinal illness, and other adverse health outcomes [1–3]. Breastfeeding has also been associated with increased IQ, school attendance, as well as higher income in adult life [2, 3] The World Health Organization recommends infants exclusively receive breastmilk for the first 6 months of life and consume nutritionally adequate foods in addition to breastmilk for 2 years and beyond in order for children and mothers to reap the optimal health benefits associated with breastfeeding [1]. Nearly 1 million deaths of children under the age of 5 worldwide could be averted through breastfeeding alone, if families adhered to the World Health Organization's breastfeeding recommendation [2]. Improving maternal compliance to optimal breastfeeding recommendations can also reduce a mother's risk of ovarian cancer, heart disease, and diabetes and prevent approximately 20,000 maternal deaths from breast cancer alone. Breastfeeding also delays the return of the menstrual cycle which can help with birth spacing. Global adherence to optimal breastfeeding practices can lead to an array of health benefits coupled with economic benefits contributing to a worldwide economic savings of 300 billion U.S. dollars [1, 2].

**The World Health Assembly (WHA),** which is the governing body of the World Health Organization, recognizes the benefits of breastfeeding and has set a goal of increasing the prevalence of exclusive breastfeeding to at least 50% by the year 2025. In addition to the WHA breastfeeding objective, the **Global Breastfeeding Collective**, a partnership of non-governmental organizations, academic institutions, and donors, led by UNICEF and WHO, seeks to work alongside WHA to accelerate progress toward reaching the breastfeeding targets and improve overall rates of breastfeeding initiation and continuation for 2 years [4]. The World Bank Investment Framework for Nutrition estimates that by reaching the WHA breastfeeding targets in 2025, would prevent over 500,000 child deaths as well as save approximately \$300 billion as a result of improved child development and survival rates [5].

Despite the recognized benefits of breastfeeding, only 38% of infants worldwide are exclusively breastfed for 6 months [4]. The maternal decision on infant feeding practices begins with an established prenatal intention to breast or formula feed. Macro-level factors such as media broadcasting, infant formula marketing, and breastfeeding legislation interact with the micro-level factors which include hospitals, workplaces, and cultural norms that are supportive or discouraging to a woman's intent to breastfeed [6].

**37**

**Table 1.**

*Key breastfeeding terminology.*

*Factors Influencing Maternal Decision-Making on Infant Feeding Practices*

experiences a continued breastfeeding duration of 2 years [4].

the significance of breastfeeding (see **Table 1**) [11].

The prevalence of breastfeeding remains variable around the world due to the lack of necessary support for a mother to sustain breastfeeding [7]. Economic pressures, societal factors, and the lack of positive media coverage on breastfeeding has resulted in a cultural shift that does not fully support breastfeeding and are cited reasons for reduced breastfeeding rates globally [8]. The excessive marketing, support of, and reliance on infant formula has created a new culture and standard for infant feeding practices [8].

As aforementioned, the overall rate of exclusive breastfeeding for infants under 6 months of age is slightly less than 40% despite the known benefits of breastfeeding [4]. However, the least developed countries have experienced the greatest improvement in exclusive breastfeeding rates, where exclusive breastfeeding prevalence at 6 months increased from 38% in 2000 to 50% in 2012 [9]. In such developing countries a majority of infants are also still breastfeeding at 1 year in contrast to the approximate 20% in developed countries and the less than 1% still breastfeeding in the UK [3, 4]. According to the World Health Organization, only 23 countries have achieved at least 60% of infants less than 6 months being exclusively breastfed and nearly 40% of countries have breastfeeding initiation rates above 80%. In Africa, approximately 70% of countries have extended duration rates of continued breastfeeding for at least 1 year. In contrast, only four countries in the Americas have reached such high rates of breastfeeding duration at 1 year. The duration of breastfeeding for 2 years dramatically drops to 45% and no country in the Americas

The high initiation rate and reduced duration rate suggest many mothers intend to breastfeed but may face barriers to continue breastfeeding. The most commonly cited breastfeeding barriers as indicated in research include misinformation regarding the specific benefits of breastfeeding, social norms, lack of spousal and family support, child-birth complications, maternal employment, and lack of healthcare provider breastfeeding recommendations [10]. **The Global Breastfeeding** 

**Collective's Call to Action** highlights seven priorities to improve global breastfeeding prevalence including 1) funding breastfeeding programs, 2) eliminating the promotion of infant formula, 3) enacting legislation to protect the rights of breastfeeding women, 4) providing breastfeeding support and maternity services, 5) improving community support for breastfeeding, 6) developing systems to monitor and improve breastfeeding programs and 7) disseminating accurate information on

Exclusive breastfeeding The practice of giving an infant only breastmilk for the first

Optimal breastfeeding Exclusively breastfeeding an infant for the first 6 months of life

6 months of life (no additional food or water) [1].

food for 2 years of age and beyond [1].

followed by continued breastfeeding supplementary to nutritious

*DOI: http://dx.doi.org/10.5772/intechopen.91325*

**2. Breastfeeding prevalence**

*Factors Influencing Maternal Decision-Making on Infant Feeding Practices DOI: http://dx.doi.org/10.5772/intechopen.91325*

The prevalence of breastfeeding remains variable around the world due to the lack of necessary support for a mother to sustain breastfeeding [7]. Economic pressures, societal factors, and the lack of positive media coverage on breastfeeding has resulted in a cultural shift that does not fully support breastfeeding and are cited reasons for reduced breastfeeding rates globally [8]. The excessive marketing, support of, and reliance on infant formula has created a new culture and standard for infant feeding practices [8].

#### **2. Breastfeeding prevalence**

As aforementioned, the overall rate of exclusive breastfeeding for infants under 6 months of age is slightly less than 40% despite the known benefits of breastfeeding [4]. However, the least developed countries have experienced the greatest improvement in exclusive breastfeeding rates, where exclusive breastfeeding prevalence at 6 months increased from 38% in 2000 to 50% in 2012 [9]. In such developing countries a majority of infants are also still breastfeeding at 1 year in contrast to the approximate 20% in developed countries and the less than 1% still breastfeeding in the UK [3, 4]. According to the World Health Organization, only 23 countries have achieved at least 60% of infants less than 6 months being exclusively breastfed and nearly 40% of countries have breastfeeding initiation rates above 80%. In Africa, approximately 70% of countries have extended duration rates of continued breastfeeding for at least 1 year. In contrast, only four countries in the Americas have reached such high rates of breastfeeding duration at 1 year. The duration of breastfeeding for 2 years dramatically drops to 45% and no country in the Americas experiences a continued breastfeeding duration of 2 years [4].

The high initiation rate and reduced duration rate suggest many mothers intend to breastfeed but may face barriers to continue breastfeeding. The most commonly cited breastfeeding barriers as indicated in research include misinformation regarding the specific benefits of breastfeeding, social norms, lack of spousal and family support, child-birth complications, maternal employment, and lack of healthcare provider breastfeeding recommendations [10]. **The Global Breastfeeding Collective's Call to Action** highlights seven priorities to improve global breastfeeding prevalence including 1) funding breastfeeding programs, 2) eliminating the promotion of infant formula, 3) enacting legislation to protect the rights of breastfeeding women, 4) providing breastfeeding support and maternity services, 5) improving community support for breastfeeding, 6) developing systems to monitor and improve breastfeeding programs and 7) disseminating accurate information on the significance of breastfeeding (see **Table 1**) [11].


#### **Table 1.** *Key breastfeeding terminology.*

**37**

### **3. Determinants of breastfeeding in developing and developed countries**

Unique factors exist in developing and developed countries that influence breastfeeding behaviors. Research illustrates child and maternal morbidities such as infant colic and maternal infection are critical factors influencing breastfeeding in developing countries in contrast to developed countries. In developing countries, mothers who experience breast infections, swelling, pain, and/or chronic conditions or had infants with congenital or acquired disease were less likely to breastfeed [12, 13]. Environmental factors also have a great influence on breastfeeding in developing countries due to the limited availability of electricity to refrigerate breastmilk and the fear of contamination due to unsanitary feeding environments prevalent in some underdeveloped areas [12, 13]. Unlike developing countries that face major challenges associated directly with maternal and child health, major influences of breastfeeding practices in developed countries stem from health systems, political, and societal factors. However, in both developing and developed countries there is an interaction between individual maternal characteristics, interpersonal, community, and societal factors, such as policies and legislation that impact a mother's decision to start and continue breastfeeding [12, 13]. It may be difficult for mothers to sustain breastfeeding even after initiating due to sociodemographic, socialcultural, and systematic factors that are not supportive of breastfeeding practices (see **Figure 1** below).

#### **3.1 Maternal characteristics**

Correlates of breastfeeding initiation and duration as indicated in research include maternal marital status, vaginal delivery, previous live birth, multiple live birth (plurality), smoking and drinking habits, prenatal care within the first trimester, conversation with a healthcare provider about breastfeeding, and birth intendedness [14, 15]. Additional factors associated with breastfeeding behaviors include maternal age, race and ethnicity, level of educational

**39**

the infant [15].

*Factors Influencing Maternal Decision-Making on Infant Feeding Practices*

attainment, employment status, annual household income, and Body Mass Index (BMI) [14, 15]. Teenage mothers, specifically those who had a cesarean section, experienced postpartum depression, and/or perceived an inadequate supply of breastmilk reported a shorter duration of exclusive breastfeeding. The ethnicity of mothers also has a significant association with duration of exclusive breastfeeding, which could be related to the traditions of various ethnicities in addition to religious recommendations and views [14, 15]. For example, in the U.S., black women have the lowest breastfeeding initiation and duration rates of all ethnicities [14]. The racial breastfeeding disparity among black women in the U.S. persists due to several cultural misperceptions. For instance, a common cultural belief prevalent in the black community is that the addition of cereal to an infant's bottle will help the infant sleep longer [16]. Furthermore, a mother's pre-existing health issues including obesity, experiencing multiple pregnancy complications, or giving birth to a premature child were also associated with a shorter duration of exclusive breastfeeding [15]. A mother's lack of knowledge regarding breastfeeding, limited breastfeeding guidance, poor family and social

support are also associated with a lack or shorter duration of exclusive

In contrast, the likelihood of breastfeeding is higher among mothers who received a high school diploma, married, and older at childbirth. Married mothers are more likely to breastfeed because they are more likely to receive spousal support that helps overcome breastfeeding challenges. Other factors that significantly improve the duration of exclusive breastfeeding include a singleton pregnancy, breastfeeding friendly birthing facility, natural vaginal delivery, babies' proper weight gain during breastfeeding, and the calmness of

*DOI: http://dx.doi.org/10.5772/intechopen.91325*

breastfeeding.

**Figure 1.** *Social determinants of breastfeeding.*

#### *Factors Influencing Maternal Decision-Making on Infant Feeding Practices DOI: http://dx.doi.org/10.5772/intechopen.91325*

attainment, employment status, annual household income, and Body Mass Index (BMI) [14, 15]. Teenage mothers, specifically those who had a cesarean section, experienced postpartum depression, and/or perceived an inadequate supply of breastmilk reported a shorter duration of exclusive breastfeeding. The ethnicity of mothers also has a significant association with duration of exclusive breastfeeding, which could be related to the traditions of various ethnicities in addition to religious recommendations and views [14, 15]. For example, in the U.S., black women have the lowest breastfeeding initiation and duration rates of all ethnicities [14]. The racial breastfeeding disparity among black women in the U.S. persists due to several cultural misperceptions. For instance, a common cultural belief prevalent in the black community is that the addition of cereal to an infant's bottle will help the infant sleep longer [16]. Furthermore, a mother's pre-existing health issues including obesity, experiencing multiple pregnancy complications, or giving birth to a premature child were also associated with a shorter duration of exclusive breastfeeding [15]. A mother's lack of knowledge regarding breastfeeding, limited breastfeeding guidance, poor family and social support are also associated with a lack or shorter duration of exclusive breastfeeding.

In contrast, the likelihood of breastfeeding is higher among mothers who received a high school diploma, married, and older at childbirth. Married mothers are more likely to breastfeed because they are more likely to receive spousal support that helps overcome breastfeeding challenges. Other factors that significantly improve the duration of exclusive breastfeeding include a singleton pregnancy, breastfeeding friendly birthing facility, natural vaginal delivery, babies' proper weight gain during breastfeeding, and the calmness of the infant [15].

#### **3.2 Community factors (cultural values and norms)**

#### *3.2.1 Common misperceptions and attitudes toward breastfeeding*

The following are actual quotes from various members of global communities illustrating common misconceptions associated with breastfeeding [17].

Cultural attitudes, lack of public acceptance, and social norms which sexualize breasts may discourage women from breastfeeding in public [10]. Interventions promoting behavior change with regards to breastfeeding should focus on dispelling the negative cultural beliefs and practices that result in suboptimal breastfeeding practices. Infant feeding practices are strongly influenced by family members and spouses who may not be well informed about optimal breastfeeding practices. In some communities, breastfeeding in public is perceived as a culturally unacceptable practice. Therefore, disseminating tailored communication messages addressing prevailing misperceptions that build on the positive aspects of breastfeeding while involving spouses and other family members is also critical in shifting the negative perceptions of breastfeeding.

#### **3.3 Organizational factors**

#### *3.3.1 Hospital/provider recommendations*

Pediatricians, obstetricians, and other healthcare workers are usually the most trusted and credible source on infant health and nutrition [18]. The practices of maternity hospitals regarding breastfeeding and the recommendation of health providers contribute to a mother's decision to breastfeed. New mothers may lack the confidence or relevant knowledge regarding breastfeeding and health workers

**41**

**Table 2.**

feed is established.

programs.

a "Baby-friendly" facility [1] (**Table 3**).

2.Regulate the promotion of infant formula.

families into breastfeeding advocacy campaigns.

6.Develop systems to monitor and improve breastfeeding programs.

*The World Health Assembly call to action to support breastfeeding [11].*

7. Disseminate accurate information on the value and significance of breastfeeding.

*Factors Influencing Maternal Decision-Making on Infant Feeding Practices*

can play an important role by providing lactation guidance and helping to resolve challenges [1]. Lactation issues that may arise can be addressed through breastfeeding support and counseling. Thus, healthcare workers should be adequately trained to support breastfeeding and help mothers manage common lactation barriers and challenges. The support of healthcare providers enables women to attain the confidence and skills needed to successfully and optimally breastfeed.

However, when health care workers provide expectant and/or new mothers with infant formula promotion materials they mistakably reduce an infant's likelihood of being breastfeed. Studies show mothers who receive discharge packages containing items useful for breastfeeding are more likely to breastfeed than mothers who receive discharge packages including free formula samples and coupons [18]. The sooner a mother opts out of breastfeeding, the more formula is purchased, which creates an incentive for formula companies to market infant formula to women even before giving birth which is usually when prenatal intention to breast or formula

The practices of maternity hospitals regarding breastfeeding as well as the attitudes and information provided by healthcare workers regarding infant feeding largely influences infant feeding behaviors. Health providers and maternity facilities that disseminate information regarding the benefits of breastfeeding as well as provide useful breastfeeding resources have the potential to significantly increase breastfeeding prevalence [18]. In 1991, the WHO and UNICEF initiated the Baby-Friendly Hospital Initiative, with the goal of improving maternity facilities to better support and promote breastfeeding. A facility must follow the "Ten Steps to Successful Breastfeeding" (described in **Table 2** below) in order to be designated as

1.Fund breastfeeding programs that will build advocacy and garner political support for breastfeeding.

3.Enact legislation to protect the rights of breastfeeding women and advocate for paid maternity leave. 4.Provide breastfeeding support and maternity services, including lactation counseling and peer support

5.Improve community support for breastfeeding and integrate the voices of mothers, spouses and their

*DOI: http://dx.doi.org/10.5772/intechopen.91325*

#### *Factors Influencing Maternal Decision-Making on Infant Feeding Practices DOI: http://dx.doi.org/10.5772/intechopen.91325*

can play an important role by providing lactation guidance and helping to resolve challenges [1]. Lactation issues that may arise can be addressed through breastfeeding support and counseling. Thus, healthcare workers should be adequately trained to support breastfeeding and help mothers manage common lactation barriers and challenges. The support of healthcare providers enables women to attain the confidence and skills needed to successfully and optimally breastfeed.

However, when health care workers provide expectant and/or new mothers with infant formula promotion materials they mistakably reduce an infant's likelihood of being breastfeed. Studies show mothers who receive discharge packages containing items useful for breastfeeding are more likely to breastfeed than mothers who receive discharge packages including free formula samples and coupons [18]. The sooner a mother opts out of breastfeeding, the more formula is purchased, which creates an incentive for formula companies to market infant formula to women even before giving birth which is usually when prenatal intention to breast or formula feed is established.

The practices of maternity hospitals regarding breastfeeding as well as the attitudes and information provided by healthcare workers regarding infant feeding largely influences infant feeding behaviors. Health providers and maternity facilities that disseminate information regarding the benefits of breastfeeding as well as provide useful breastfeeding resources have the potential to significantly increase breastfeeding prevalence [18]. In 1991, the WHO and UNICEF initiated the Baby-Friendly Hospital Initiative, with the goal of improving maternity facilities to better support and promote breastfeeding. A facility must follow the "Ten Steps to Successful Breastfeeding" (described in **Table 2** below) in order to be designated as a "Baby-friendly" facility [1] (**Table 3**).


#### **Table 2.**

*The World Health Assembly call to action to support breastfeeding [11].*

1.Have a written breastfeeding policy that is communicated to all health care staff.

2.Train all health care staff in the skills necessary to implement this policy.

3.Inform all new mothers about the benefits of exclusive breastfeeding

4.Assist mothers in initiating breastfeeding within a half hour of an infant's birth

5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.

6.Do not give infants any food or drink other than breastmilk, unless supplemental food is medically necessary

7. Allow mothers and infants to room-in or stay in the same room at all times during their stay in the facility

8.Encourage breastfeeding on demand.

9.Do not give pacifiers or artificial nipples to breastfeeding infants.

10. Foster the establishment of breastfeeding support groups and refer mothers to them upon discharge from the hospital or birth center

#### **Table 3.**

*Ten steps to successful breastfeeding [1].*

#### **3.4 Societal factors**

#### *3.4.1 Legislation*

Policies that protect and support breastfeeding are necessary in order to enable a mother's decision to initiate and sustain breastfeeding. A majority of the approximate 1 million women who are employed full-time around the world do not benefit from supportive workplace policies regarding breastfeeding [2, 4]. The large prevalence and increase of women working outside the home is often cited for the low rates of breastfeeding indicating the necessity of workplace policies to support working mothers [7]. It is necessary that a woman has the time, space, privacy, and place to express milk in the workplace and in public areas [10]. Legislation in support of a women's choice to breastfeed can help overcome employment barriers and aid in the return of breastfeeding becoming the societal norm and standard feeding practice [10].

**43**

can offer [20].

*Factors Influencing Maternal Decision-Making on Infant Feeding Practices*

The lack of legislative accommodation in the workplace is a significant predictor of shorter duration of exclusive breastfeeding. Key workplace barriers include the lack of flexibility for milk expression in the work schedule, lack of accommodations such as a nursing room equipped to enable mothers to pump or store breastmilk, and concerns about employer or co-worker support [10]. Additional workplace barriers include the perception that breastfeeding may hinder a mothers' job performance, lack of privacy for expressing breast milk or for breastfeeding, and the inability to find a child care facility near the workplace, the high cost of day care, insurance regulations, employer building codes, and other rules that may limit infants and children in the workplace. Studies illustrate that supportive work site environments that provide a private place to express milk and access to a quality breast pump helps women to continue breastfeeding upon return to

Workplace policies such as paid breaks for expressing milk, the provision of lactation rooms, and public awareness of the breastfeeding policies, have the ability to improve the ability of mothers to sustain breastfeeding while working. Using data from 182 countries, Atabay and colleagues (2015) found the prevalence of exclusive breastfeeding among infants 6 months and younger was nearly 9 percentage points higher in countries with guaranteed paid breastfeeding work breaks compared to those without paid breaks [9]. Another study conducted in 2014, found 136 out of 176 countries, or approximately 71% of the world, provided mothers the right to take paid breaks during the workday in order to provide breastmilk for their child until 6 months following birth while four countries permitted shorter or unpaid breastfeeding breaks. However, 51 countries, the remaining 29% of the world, did not have policies that protected the right of

Further, research illustrates extended maternity leave is associated with higher prevalence of exclusive breastfeeding because women are able to continue breastfeeding without choosing between employment and providing breastmilk for her child. A report by the International Labor Organization found that in most developed countries 75–100% of pay was guaranteed for up to 16 weeks of maternity leave. In over 70 countries, employers are paid through social security systems in order to decrease cost burdens [20]. The United States does not have a universal policy that guarantees paid maternity leave and also has one of the lowest rates of breastfeeding and one of the highest rates of infant mortality among developed countries. A study examining 16 countries found maternity leave policies increase breastfeeding prevalence and prevent one to two neonatal deaths per 2000 live births [21]. In Norway, mothers can take up to 42 weeks of maternity leave with full pay or receive 80% pay for 52 weeks. More than 97% of Norwegian women initiate breastfeeding and 80% continue to do so until at least 3 months; this is largely different from the 79% of American women who initiate breastfeeding and the 41% who still exclusively breastfeed at 3 months [20, 22]. Other interventions implemented in Norway to encourage breastfeeding include the availability of breastfeeding informational material, training health workers to help mothers have positive breastfeeding experiences, and establishing support groups where mother are able collectively share breastfeeding experiences [22]. Norwegian mothers who are employed are entitled to 60- to 90-minute daily breaks and can even leave to breastfeed their infant or have their infant brought to work. Supportive policies workplace policies are needed in order to improve breastfeeding rates and achieve the maximum benefits breastfeeding

*DOI: http://dx.doi.org/10.5772/intechopen.91325*

work [19].

mothers to breastfeed [9].

#### *Factors Influencing Maternal Decision-Making on Infant Feeding Practices DOI: http://dx.doi.org/10.5772/intechopen.91325*

The lack of legislative accommodation in the workplace is a significant predictor of shorter duration of exclusive breastfeeding. Key workplace barriers include the lack of flexibility for milk expression in the work schedule, lack of accommodations such as a nursing room equipped to enable mothers to pump or store breastmilk, and concerns about employer or co-worker support [10]. Additional workplace barriers include the perception that breastfeeding may hinder a mothers' job performance, lack of privacy for expressing breast milk or for breastfeeding, and the inability to find a child care facility near the workplace, the high cost of day care, insurance regulations, employer building codes, and other rules that may limit infants and children in the workplace. Studies illustrate that supportive work site environments that provide a private place to express milk and access to a quality breast pump helps women to continue breastfeeding upon return to work [19].

Workplace policies such as paid breaks for expressing milk, the provision of lactation rooms, and public awareness of the breastfeeding policies, have the ability to improve the ability of mothers to sustain breastfeeding while working. Using data from 182 countries, Atabay and colleagues (2015) found the prevalence of exclusive breastfeeding among infants 6 months and younger was nearly 9 percentage points higher in countries with guaranteed paid breastfeeding work breaks compared to those without paid breaks [9]. Another study conducted in 2014, found 136 out of 176 countries, or approximately 71% of the world, provided mothers the right to take paid breaks during the workday in order to provide breastmilk for their child until 6 months following birth while four countries permitted shorter or unpaid breastfeeding breaks. However, 51 countries, the remaining 29% of the world, did not have policies that protected the right of mothers to breastfeed [9].

Further, research illustrates extended maternity leave is associated with higher prevalence of exclusive breastfeeding because women are able to continue breastfeeding without choosing between employment and providing breastmilk for her child. A report by the International Labor Organization found that in most developed countries 75–100% of pay was guaranteed for up to 16 weeks of maternity leave. In over 70 countries, employers are paid through social security systems in order to decrease cost burdens [20]. The United States does not have a universal policy that guarantees paid maternity leave and also has one of the lowest rates of breastfeeding and one of the highest rates of infant mortality among developed countries. A study examining 16 countries found maternity leave policies increase breastfeeding prevalence and prevent one to two neonatal deaths per 2000 live births [21]. In Norway, mothers can take up to 42 weeks of maternity leave with full pay or receive 80% pay for 52 weeks. More than 97% of Norwegian women initiate breastfeeding and 80% continue to do so until at least 3 months; this is largely different from the 79% of American women who initiate breastfeeding and the 41% who still exclusively breastfeed at 3 months [20, 22]. Other interventions implemented in Norway to encourage breastfeeding include the availability of breastfeeding informational material, training health workers to help mothers have positive breastfeeding experiences, and establishing support groups where mother are able collectively share breastfeeding experiences [22]. Norwegian mothers who are employed are entitled to 60- to 90-minute daily breaks and can even leave to breastfeed their infant or have their infant brought to work. Supportive policies workplace policies are needed in order to improve breastfeeding rates and achieve the maximum benefits breastfeeding can offer [20].

#### *3.4.2 Infant formula marketing*

Women entering the labor force and the promotion of large-scale infant formula brands have drastically altered infant feeding practices. The provision of free infant formula samples in maternity facilities and the promotion of breastmilk substitutes by the media and healthcare providers have been shown to reduce breastfeeding prevalence [23]. Research indicates the use of infant formula is twice as high among mothers who have viewed and recalled an infant formula advertisement compared to mothers who had not viewed the advertisements [23].

The media, including marketing and advertisements, influence social norms, which are the shared beliefs regarding the acceptable behaviors within a social group [23]. The media also influences the attitudes toward behaviors and tend to appeal to prevalent values and perceptions in order to generate views and boost profits. For example, in 1997, Tabitha Walrond, a young black mother, was convicted of negligent homicide after her 2-month old child died from malnutrition. The mother was unaware that her breast reduction surgery from years prior would result in an insufficient supply of breastmilk. Years later, Walrond's case was depicted on a popular TV show, "Chicago Hope," which depicted breastfeeding to be potentially fatal. However, the episode portrayed white and middle-class parents (a more "appealing" demographic) who were being criminally investigated following the death of a breastfed child as a result of malnutrition. Rather than illustrating the -Friendly Hospital Initiative as an effort to enable successful breastfeeding the episode suggested the initiative was forcing mothers to breastfeed leading to infant deaths as a result of malnourishment. Alarmingly, the episode was also found to be a ploy by pharmaceutical companies to inform the public of the risks associated with breastfeeding [24].

Infant formula advertisements also appeal to common maternal experiences and concerns often suggesting breastmilk substitutes have ingredients that improve infant intelligence, solve digestive issues, and even help infants sleep through the night. Such claims have not been substantiated by research. However, research has recognized the association of breastfeeding with higher intelligence and reduced risk of gastrointestinal illness among many other health benefits. Digestive issues such as colic are no less prevalent in formula fed than breastfed infants and formula fed infants have not been found to sleep more than breastfed infants. Hunger is one of many reasons infants cry, thusly, infant formula is not associated with a reduced response of infant crying [23].

Further, media is often driven by profits and audience appeals. The external pressures stemming from the aggressive marketing of infant formula and media messages regarding formula can affect a mother's intent to breastfeed and provide the most optimal form of nutrition to her child [25]. The excessive marketing of infant formula and inaccurate portrayal of breastfeeding can undermine the significance of breastfeeding by spreading biased information and diminishing a mother's confidence in her ability to breastfeed. Infant formula is often portrayed to be as good as breastfeeding and a viable solution to a convenient lifestyle for working mothers. The labels displayed on infant formula often include descriptions such as "gold standard" and images depicting happy infants. This type of labeling implies positive health and developmental benefits, while ignoring the potential economic and health consequences associated with formula feeding [23]. However, families of breastfed infants can experience economic advantages in addition to health benefits. Infant formula can cost over \$1500 throughout an infant's first year of life, however, women who breastfeed

**45**

*Factors Influencing Maternal Decision-Making on Infant Feeding Practices*

avoid the substantial cost burden [10]. Breastfed infants also require less medical attention rendering decreased medical expenses and fewer missed days of work for parents. A study found that a group of formula-fed infants had accrued \$68,000 in health care costs over a 6-month timeframe, while an equal number of breastfeeding babies accrued only \$4000 of similar medical expenses [26]. Breastfeeding is also better for the environment because less waste is produced compared to the waste created by formula products and bottle supplies. The media can play an integral role in disseminating such accurate and positive messages regarding breastfeeding. Media campaigns that are short, tailored to the needs and values of the audience, and displayed through the appropriate channel (e.g., radio, television, social media) that reaches and appeals to the target audi-

However, formula companies tend to make unsubstantiated claims regarding breastmilk substitutes and use trusted healthcare workers to promote infant formula. The provision of free infant formula samples in maternity facilities and the promotion of breastmilk substitutes by the media and healthcare providers have also been shown to reduce breastfeeding prevalence [23]. Infant formula companies attract new consumers by providing free samples and information on breastmilk substitutes to expectant and new mothers through providers and hospital facilities. Physicians are usually the most undisputed consultant on infant health and nutrition, making them a prime vehicle for promoting infant formula. Formula companies give doctors free or discounted products in exchange for physicians recommending and encouraging their brand of infant formula to expectant and new mothers. Many hospitals provide new mothers with packages containing free infant formula and coupons upon hospital

The marketing tactics employed by formula companies sparked international disapproval based on the assertion formula marketing led to preventable infant deaths. The international opposition prompted the WHO and UNICEF to develop the International Code of Marketing of Breastmilk Substitutes. The Code prohibits the unethical marketing of infant formula as equal to or superior to breastmilk and restricts the promotion of infant formula by medical practices [18]. Distributing accurate, unbiased information regarding the benefits of and importance of breastfeeding through the media as well as healthcare workers is critical to improving breastfeeding prevalence and reducing the dispersion of false information and misperceptions regarding the significance of

Breastfeeding is considered the single most effective solution to preventing deaths of children under the age of five globally [26]. Considering the substantial economic and health savings that breastfeeding alone provides, exclusive breastfeeding should be supported and promoted within families, communities, workplaces, and hospital facilities that provide care to mothers and their infants. Understanding and addressing the dynamic interplay between individual, interpersonal, community, organizational and societal factors, such as policies and legislation that impact breastfeeding rates and the health of infants is key to improving breastfeeding prevalence. Below is an example of evidence-informed approaches used to improve the prevalence of exclusive breastfeeding that can be adapted and

applied in both developing and developed countries.

*DOI: http://dx.doi.org/10.5772/intechopen.91325*

ence are most successful.

discharge [23].

breastfeeding.

**4. Conclusion**

#### *Factors Influencing Maternal Decision-Making on Infant Feeding Practices DOI: http://dx.doi.org/10.5772/intechopen.91325*

avoid the substantial cost burden [10]. Breastfed infants also require less medical attention rendering decreased medical expenses and fewer missed days of work for parents. A study found that a group of formula-fed infants had accrued \$68,000 in health care costs over a 6-month timeframe, while an equal number of breastfeeding babies accrued only \$4000 of similar medical expenses [26]. Breastfeeding is also better for the environment because less waste is produced compared to the waste created by formula products and bottle supplies. The media can play an integral role in disseminating such accurate and positive messages regarding breastfeeding. Media campaigns that are short, tailored to the needs and values of the audience, and displayed through the appropriate channel (e.g., radio, television, social media) that reaches and appeals to the target audience are most successful.

However, formula companies tend to make unsubstantiated claims regarding breastmilk substitutes and use trusted healthcare workers to promote infant formula. The provision of free infant formula samples in maternity facilities and the promotion of breastmilk substitutes by the media and healthcare providers have also been shown to reduce breastfeeding prevalence [23]. Infant formula companies attract new consumers by providing free samples and information on breastmilk substitutes to expectant and new mothers through providers and hospital facilities. Physicians are usually the most undisputed consultant on infant health and nutrition, making them a prime vehicle for promoting infant formula. Formula companies give doctors free or discounted products in exchange for physicians recommending and encouraging their brand of infant formula to expectant and new mothers. Many hospitals provide new mothers with packages containing free infant formula and coupons upon hospital discharge [23].

The marketing tactics employed by formula companies sparked international disapproval based on the assertion formula marketing led to preventable infant deaths. The international opposition prompted the WHO and UNICEF to develop the International Code of Marketing of Breastmilk Substitutes. The Code prohibits the unethical marketing of infant formula as equal to or superior to breastmilk and restricts the promotion of infant formula by medical practices [18]. Distributing accurate, unbiased information regarding the benefits of and importance of breastfeeding through the media as well as healthcare workers is critical to improving breastfeeding prevalence and reducing the dispersion of false information and misperceptions regarding the significance of breastfeeding.

#### **4. Conclusion**

Breastfeeding is considered the single most effective solution to preventing deaths of children under the age of five globally [26]. Considering the substantial economic and health savings that breastfeeding alone provides, exclusive breastfeeding should be supported and promoted within families, communities, workplaces, and hospital facilities that provide care to mothers and their infants. Understanding and addressing the dynamic interplay between individual, interpersonal, community, organizational and societal factors, such as policies and legislation that impact breastfeeding rates and the health of infants is key to improving breastfeeding prevalence. Below is an example of evidence-informed approaches used to improve the prevalence of exclusive breastfeeding that can be adapted and applied in both developing and developed countries.

#### **5. Key strategies employed to increase global exclusive breastfeeding prevalence**

#### **Conflict of interest**

The author declares no conflict of interest.

#### **Author details**

Whitney N. Hamilton Middle Georgia State University, Macon, United States

\*Address all correspondence to: whitney.hamilton@mga.edu

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**47**

ajph.2009.185280

*Factors Influencing Maternal Decision-Making on Infant Feeding Practices*

for breastfeeding promotion. Health Promotion International. 2002;**17**(3):205-214 https://doi. org/10.1093/heapro/17.3.205

[9] Atabay E, Moreno G, Nandi A, Kranz G, Vincent I, Assi TM, et al. Facilitating working mothers' ability to breastfeed: Global trends in guaranteeing breastfeeding breaks at work, 1995-2014. Journal of Human Lactation. 2015;**31**(1):81-88. DOI: 10.1177/0890334414554806

[10] Office of the Surgeon, Centers for Disease Control and Prevention, & Office on Women's Health. Publications and reports of the surgeon general. In: The Surgeon General's Call to Action to Support Breastfeeding. Rockville (MD): Office of the Surgeon General (US); 2011

[11] WHO/UNICEF. Breastfeeding and gender equality. Breastfeeding Advocacy Brief [Internet]. 2019. Available from: https://www.unicef.org/nutrition/ files/6.\_Advocacy\_Brief\_on\_BF\_and\_ Gender\_Equality.pdf [Accessed:

04 December, 2019]

DOI: 10.1111/mcn.12180

[13] Reeta B. Breast feeding in developing countries: Is there a scope for improvement. Journal of Neonatal Biology. 2016;**5**(1):2-5. DOI:

10.4172/2167-0897.1000208

[14] Sparks PJ. Differences in breastfeeding initiation in the United States. Journal of Human Lactation. 2010;**26**(2):118-129. DOI:

10.1177/0890334409352854

[12] Balogun OO, Dagvadorj A, Anigo KM, Ota E, Sasaki S. Factors influencing breastfeeding exclusivity during the first 6 months of life in developing countries: A quantitative and qualitative systematic review. Maternal & Child Nutrition. 2015;**11**:433-451.

*DOI: http://dx.doi.org/10.5772/intechopen.91325*

[1] WHO/UNICEF. Global Nutrition Targets 2025: Breastfeeding Policy Brief [Internet]. 2014. Available from: https:// www.who.int/nutrition/publications/ globaltargets2025\_policybrief\_ breastfeeding/en/ [Accessed: 04

[2] WHO/UNICEF. Nurturing the health and wealth of nations: The investment case for breastfeeding. Global Breastfeeding Collective - Executive Summary [Internet]. 2017. Available from: https://www.who.int/ nutrition/publications/infantfeeding/ global-bf-collective-investmentcase/en/

[Accessed: 04 December 2019]

[5] Breastfeeding: Achieving the new normal. The Lancet. 2016;**387**(10017):404. DOI: 10.1016/

[6] Bentley ME, Dee DL, Jensen JL. Breastfeeding among low income, African-American women: Power, beliefs and decision making. The Journal of Nutrition. 2003;**133**(1): 305S-309S. DOI: 10.1093/jn/133.1.305S

[7] Murtagh L, Moulton AD. Working mothers, breastfeeding, and the law. American Journal of Public Health. 2011;**101**(2):217-223. DOI: 10.2105/

[8] Earle S. Factors affecting the

initiation of breastfeeding: Implications

S0140-6736(16)00210-5

[3] Victora CG, Bahl R, Barros AJ, Franca GV, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. Lancet. 2016;**387**(10017):475-490. DOI: 10.1016/s0140-6736(15)01024-7

[4] WHO/UNICEF. Tracking Progress for Breastfeeding Policies and Programmes [Internet]. 2017. Available from: https:// www.who.int/nutrition/publications/ infantfeeding/global-bf-scorecard-2017. pdf [Accessed: 08 December 2019]

**References**

December 2019]

*Factors Influencing Maternal Decision-Making on Infant Feeding Practices DOI: http://dx.doi.org/10.5772/intechopen.91325*

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[2] WHO/UNICEF. Nurturing the health and wealth of nations: The investment case for breastfeeding. Global Breastfeeding Collective - Executive Summary [Internet]. 2017. Available from: https://www.who.int/ nutrition/publications/infantfeeding/ global-bf-collective-investmentcase/en/ [Accessed: 04 December 2019]

[3] Victora CG, Bahl R, Barros AJ, Franca GV, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. Lancet. 2016;**387**(10017):475-490. DOI: 10.1016/s0140-6736(15)01024-7

[4] WHO/UNICEF. Tracking Progress for Breastfeeding Policies and Programmes [Internet]. 2017. Available from: https:// www.who.int/nutrition/publications/ infantfeeding/global-bf-scorecard-2017. pdf [Accessed: 08 December 2019]

[5] Breastfeeding: Achieving the new normal. The Lancet. 2016;**387**(10017):404. DOI: 10.1016/ S0140-6736(16)00210-5

[6] Bentley ME, Dee DL, Jensen JL. Breastfeeding among low income, African-American women: Power, beliefs and decision making. The Journal of Nutrition. 2003;**133**(1): 305S-309S. DOI: 10.1093/jn/133.1.305S

[7] Murtagh L, Moulton AD. Working mothers, breastfeeding, and the law. American Journal of Public Health. 2011;**101**(2):217-223. DOI: 10.2105/ ajph.2009.185280

[8] Earle S. Factors affecting the initiation of breastfeeding: Implications for breastfeeding promotion. Health Promotion International. 2002;**17**(3):205-214 https://doi. org/10.1093/heapro/17.3.205

[9] Atabay E, Moreno G, Nandi A, Kranz G, Vincent I, Assi TM, et al. Facilitating working mothers' ability to breastfeed: Global trends in guaranteeing breastfeeding breaks at work, 1995-2014. Journal of Human Lactation. 2015;**31**(1):81-88. DOI: 10.1177/0890334414554806

[10] Office of the Surgeon, Centers for Disease Control and Prevention, & Office on Women's Health. Publications and reports of the surgeon general. In: The Surgeon General's Call to Action to Support Breastfeeding. Rockville (MD): Office of the Surgeon General (US); 2011

[11] WHO/UNICEF. Breastfeeding and gender equality. Breastfeeding Advocacy Brief [Internet]. 2019. Available from: https://www.unicef.org/nutrition/ files/6.\_Advocacy\_Brief\_on\_BF\_and\_ Gender\_Equality.pdf [Accessed: 04 December, 2019]

[12] Balogun OO, Dagvadorj A, Anigo KM, Ota E, Sasaki S. Factors influencing breastfeeding exclusivity during the first 6 months of life in developing countries: A quantitative and qualitative systematic review. Maternal & Child Nutrition. 2015;**11**:433-451. DOI: 10.1111/mcn.12180

[13] Reeta B. Breast feeding in developing countries: Is there a scope for improvement. Journal of Neonatal Biology. 2016;**5**(1):2-5. DOI: 10.4172/2167-0897.1000208

[14] Sparks PJ. Differences in breastfeeding initiation in the United States. Journal of Human Lactation. 2010;**26**(2):118-129. DOI: 10.1177/0890334409352854

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**49**

Section 3

Breast Feeding: Ocular and

Hematopoietic Effects

### Section 3
