Overview

Breastfeeding remains the unequalled way of providing ideal food for the healthy growth and development of infants. Breastmilk provides all the energy and nutrients that the infant needs for the first six months of life, and it continues to provide up to half or more of a child's nutritional needs during the second-half of the first year, and up to one-third during the second year of life. Breastmilk contains unique immunological properties which protect against both infectious and chronic diseases. Breastfeeding's positive contribution to the health and well-being of mothers, child-spacing, family and national economics, food security and a safe environment makes it a key aspect of primary health care and an important aspect of sound socio-economic development. To achieve optimal growth, development and health, infants should be exclusively breastfed for the first 6 months of life. Thereafter, to meet their evolving nutritional requirements, infants should begin to receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond.

Breastfeeding is a fundamental right of the child, its role in infant nutrition has been underplayed in the name of modernization. Efforts are on, both nationally and globally to protect and promote breastfeeding.

Health care providers have a major role to play in this effort. The advice they give mothers has great bearing on the rate of exclusive breastfeeding, the time of initiation and duration of breastfeeding, prevention and management of common breastfeeding problems, and the appropriate and timely introduction of complementary foods. If they fail to provide support for exclusive breastfeeding at the time of birth, and at times even encourage artificial feeding, breastfeeding is more likely to fail and decline.

Inappropriate infant and young child feeding practices may be attributable to the lack of adequate training in the practical aspects of breastfeeding and lactation management, as well as lack of understanding of the needs of women who are breastfeeding. Training all of the present lot of health professionals though very much needed would be difficult and expensive. A more practical and useful strategy however, would be to effectively educate new graduates and post graduates (pediatrics and Ob Gynae.)of medical colleges, who could support breastfeeding from the beginning of their professional careers. Strengthening pre-service education is more sustainable than training and continuing education and has the potential to reach the maximum number of health care providers and thus the communities. It would be cost-effective as well. Continuing education would only be necessary to prepare faculty and to provide updates as a part of a comprehensive education plan.

Integrating breastfeeding and lactation management information into already existing courses of doctors and nurses can be easily done by inserting appropriate modules such as including information on the protective functions of breastmilk during biochemistry or physiology, trends and practices during preventive and social medicine, case studies on breast conditions in surgery, and discussing the health benefits of breastfeeding to the mother and subject of lactation amenorrhea during obstetrics could be possible. During practical training /internship or residency, stress should also be laid on clinical practice in breastfeeding and its management and counselling.

The problem/gaps/Inadequacy of current undergraduate curricula

Scrutiny of the basic curriculum for medical and nursing school students reveals a surprising and disappointing inadequacy of material for preparing them to support mothers to breastfeed successfully. The content is incomplete, even incorrect, when compared with the standard teaching of breastfeeding and lactation management .Global Strategy for Infant and Young Child Feeding being Developed jointly by WHO and UNICEF[1] and likely to be public in 2002 has identified several difficulties that persist in this area. One of the main difficulties has been cited , "inadequate training of health workers, who receive too little pre-service instruction about infant feeding, and who subsequently work in non-supportive health care environments.

The National Health Policy 2001[2] also recognizes that the current syllabus is theoretical making it difficult for the fresh graduate to meet even the primary health care needs. NHP 2001 recognizes the need to revise medical education curricula and prescribes, " a need based skill oriented syllabus, with a more significant component of practical training, would make fresh graduates useful immediately after graduation."

Strengthening pre-service education curriculum has been identified among the main areas of intervention to improve infant and young child feeding. Revising and reforming pre-service curricula for all health professionals, nutritionists and related professions to provide objective and consistent information, and practical skills related to infant and young child feeding would be logical step forward and one of the most appropriate long-term strategy intervention to protect, promote and support breastfeeding.

Suggested curricula

A curriculum for undergraduate and postgraduate teaching for doctors and for nurses is suggested in Appendix 1 .This is based on our findings, thinking through several findings and their solutions and recommendations of the group of 35 experts met and discussed about strategies for infant and young child feeding in June 2000[3].

Conclusion

            Mothers, other caregivers and families should have access to skilled support to initiate and sustain optimal feeding practices and to prevent difficulties, and to overcome them when they occur. All health care providers working with mothers and infants should not only be convinced that breastfeeding and breastmilk have distinct advantages, but also understand the basic physiology of lactation and be able to provide skilled assistance for successful initiation and maintenance of breastfeeding. They should recognize that breastfeeding can continue during many situations and that early supplementation with formula is not the first step, but the last.

A sustainable curriculum, based on scientifically sound information, is needed at both the pre-service and postgraduate level of medical and nursing education. All medical/nursing students should be prepared to promote breastfeeding and to avoid practices that interfere with it. Pre-clinical and clinical curricula suggested here could be implemented and present the breastfed infant and the breastfeeding mother as the norm and not an exception.

Dr. Arun Gupta MD (Ped) FIAP

National Coordinator, Breastfeeding Promotion Network of India (BPNI) and

South Asia Representative International Baby Food Action Network (IBFAN)

BP-33 Pitampura, Delhi 110034.

Phone: 7457936, 7443445

Email: agupta@bpni.org

 Analysis of books

  To analyze the content matter with regard to breastfeeding and lactation management, six of the most commonly used books (Nelson 1996, Park 1997, Williams 1993, Dutta 1992, Holland and Brews 1998 and Ghai, 1996) by students of MBBS and MD were reviewed. Two books each of pediatrics and obstetrics, one manual of obstetrics and one of preventive and social medicine was included. The books we identified were the most commonly read by students during their education. As you would be able to conclude from our analysis or by reading the relevant books, the content matter of all books does not fully cover practical aspects of breastfeeding and lactation management. It is evident that most books do not fully prepare a doctor to promote, protect and support breastfeeding. Analysis revealed that the three books (Ghai, 1996; Dutta, 1992 and Park, 1997) used for undergraduate courses were good at detailing the advantages of breastmilk and breastfeeding. The practical aspects of breastfeeding and lactation management including physiology of lactation management, problems during breastfeeding and the factors interfering with breastfeeding were either inadequately or incorrectly covered. Ironically, even all the books combined could not provide complete and accurate information on practical aspects of breastfeeding and lactation management. (Table-I)

The situation was found to be better when the three books for postgraduate students (Nelson, 1996; Williams, 1993 and Holland &Brews, 1998) were analyzed, however, in the dealing of practical aspects of lactation management, it was still disappointing.

Marking criteria in the evaluation grid

1. Adequate                                         +

2. Inadequate                                       +

3. Missing                                             -

4. Incorrect information                         x

Following books are analyzed:

Book No. 1: Ghai OP. Ghai Essential Pediatrics. 4^th Edition 1996.

Book No. 2: Dutta DC. Text Book of Obstetrics including Perinatology and Contraception. 3^rd Edition 1995.

Book No. 3: Park K. Textbook of Preventive and Social Medicine. 15^th Edition

Book No. 4: Nelson WE and Behrman RE, Kliegman RM and Arvin AM. Nelson Textbook of Pediatrics. 15^th Edition. 1996.

Book No. 5: Cunningham FG et al. Williams Obstetrics. 19^th Edition

Book No. 6: Daftary SN, Chakravarti S and Daftary GS. Holland and Brews Manual of Obstetrics. 16^th Edition. 1998.

Table I: Evaluation of  books of medical doctors with respect to the adequacy of specific aspects of Breastfeeding and lactation management

* "Ten Steps to Successful Breastfeeding", are the foundation of WHO/UNICEF Baby Friendly Hospital Initiative (BFHI)

**Infant Milk substitutes, Feeding Bottles and Infant foods (Regulation of Production, Supply and Distribution) Act 1992.

***International Code of Marketing of Breast-Milk Substitutes. World Health Assembly (WHA) Resolution1981.

Bibliography

1.        Armstrong HC. Breastfeeding promotion: training of mid-level and outreach health workers. Int J Gynaecol Obstet 31: Suppl. No. 1, 91-103.1990.

2.        Gupta A.  Human Lactation Management Training (HLMT), a course for Doctors, Nurses and Breastfeeding Counselors, 1994.Breastfeeding Promotion Network of India. New Delhi, India.

3.        Haider R, Islam A, Hamadani J et al. Breast-feeding counselling in a diarrhoeal disease hospital. Bull WHO 74: 173-179,1996.

4.        WHO/UNICEF, Breastfeeding Counselling: training Course. World Health Organization, Geneva., and UNICEF ,New York,1993

5.        Wood CBS and WalkerSmith JA.  Mackeith's infant feeding and feeding difficulties, 6^th edition.1981. Churchill Livingstone.

6.        King FS and Anand RK. Helping Mothers to Breastfeed. 1994. Association for consumers action on safety and health, Mumbai. India.

Part II - Nurses

Following books are analyzed:

Book No. 1: Pediatric Nursing. R.S. Tambulwadkar. 2^nd Edition 1999.

Book No. 2: Myles Text Book for Midwives. V. Ruth Bennett. 13^th Edition 1999.

Part II

Table I: Evaluation of textbooks with respect to the adequacy of specific aspects of Breastfeeding and lactation management

* "Ten Steps to Successful Breastfeeding", are the foundation of WHO/UNICEF Baby Friendly Hospital Initiative (BFHI)

**Infant Milk substitutes, Feeding Bottles and Infant foods (Regulation of Production, Supply and Distribution) Act 1992.

***International Code of Marketing of Breast-Milk Substitutes. World Health Assembly (WHA) Resolution1981.

Suggested curricula for breastfeeding and lactation management education

Core curriculum

·        Need and significance of exclusive breastfeeding

·        Concept, conviction of adequacy of exclusive breastfeeding optimal growth and development

·        Concept of exclusive breastfeeding without even water

·        Concept of appropriate intervals frequency of breastfeeding, night feeds etc.

·        Concept of adequacy of colostrum/ milk for first 72 hours

·        Problems of nipple pain/sore nipples, breast engorgement etc,

·        Pitfalls/misconceptions/myths related to crying, loose stools, constipation etc,

·        Awareness /appreciation and offering solutions to questions of mothers/mothers in-law

·        Information related to normal behavior of the bay in early period

·        Concept of not enough milk(pseudo or real)

·        Appreciation of special situations like LBW HIV etc

·        Concepts of BFHI and ten steps

·        Awareness of promotional stratifies of infant milk food companies

·        Need and method of adequate and appropriate complementary foods

·        DO's and DONT's of standard messages of all categories of health functionaries

Essential elements

Basic Objectives

The student should be ..

Learning Objectives

For the Undergraduate Medical Student

At the end of undergraduate course, a medical student should be able to:

Theory ( Subject for Integration is suggested in brackets)

1.      Describe the benefits of breastmilk and superiority of breastfeeding and appropriate complementary feeding to the infant and the mother.(Ped)

2.      Describe the benefits of breastfeeding to the family and the community.(Community Med)

3.      Identify anatomical breast structures involved in milk production and transfer.(Anatomy /Phys)

4.      Describe the process of milk production and transfer from breast to the baby.(Ped)

5.      Describe the process of suckling and how does it differ from feeding at a bottle.(Ped)

6.      Describe the hormones prolactin and oxytocin and their functions and clinical applications.(Phys)

7.      Describe the advantages of early initiation and demand feeding, and the ten steps to successful breastfeeding.(OBG)

8.      Describe the problems during breastfeeding(Ped)

9.      Describe the effect of maternal nutrition on lactation.(Ped)

10.  Describe the factors interfering and not interfering with breastfeeding(OBG)

11.  Describe the salient features of the Infant Milk Substitutes, Feeding Bottles and Infant Foods(Regulation of Production, Supply and Distribution) Act 1992, No.41 of 1992.(IMS Act)(Ped)

Skill building and field practice.

1.      Identify factors that favor or hinder breastfeeding and appropriate complementary feeding(Ped)

2.      Take breastfeeding history, conduct examination of breasts and use the breast examination as an opportunity to reassure the woman that she can breastfed her infant(OBG)

3.      Define components of antenatal counselling for women.(OBG)

4.      Recognize the effect of procedures/medications on breastfeeding success.(OBG)

5.      Help women to initiate lactation early and encourage exclusive breastfeeding(OBG)

6.      Recognize correct and incorrect position of breast and the baby during  suckling (Ped)

7.      Demonstrate expression of breastmilk and its needs and discuss how to maintain lactation during separation.(Ped/Neonatology)

8.      Discuss the causes and prevention of breastfeeding problems(Ped)

9.      Prescribe drugs that are compatible with breastfeeding.(Ped)

10.  Discuss breastfeeding in the pre-term/low birth weight babies and infants with special needs.(Ped)

11.  Provide counselling for complementary foods.(Community Med)

Learning Objectives

For the Post graduate student

In addition to what a undergraduate should know, at the end of the course, should be able to,

Theory

1.      Describe the unique properties of human milk including cellular components and immune factors and how it is advantageous to the preterm baby.

2.      Discuss the effect of lactation amenorrhea method of contraception and its impact on fertility.

3.      Describe the synthesis of human milk at the cellular level and describe in detail the physiology of milk production and transfer.

4.      Describe the specific impact of maternal diet and nutritional status on the quantity and quality of the milk produced and review the current literature on the impact of maternal nutrition on lactation.

5.      Describe the factors to consider and how to select a maternal medication during lactation.

6.      Identify local sources of data on breastfeeding trends.

7.      Identity cultural and psychosocial factors that impact breastfeeding rates.

8.      Describe the pattern of growth of breastfed infants.

9.      Describe the ways how socio-cultural factors influence breastfeeding

Skill building and field practice

1.      Provide technical and routine support for the successful initiation and maintenance of lactation and the prevention and management of common breastfeeding problems.

1.      Develop protocols for successful initiation and maintenance of lactation in high risk/complicated situations and provide support to them.

2.      Provide anticipatory guidance to pregnant women with unusual or high risk conditions

3.      Provide prenatal, intra-partum and immediate postpartum care that supports successful lactation.

4.      Develop and implement intra-partum care protocols that facilitate breastfeeding for high-risk mother-infant couple.

5.      Provide consultation regarding the banking and use of human milk in special circumstances

6.      Assess and manage the breastfeeding mother with complicated nutritional needs

7.      Assess and manage complex dysfunctional suckling  patterns

8.      Assess complicated issues regarding complementary feeding

9.      Counsel women about contraceptive use and LAM

10.  Help women how to maintain lactation while at work using expression techniques

11.  Help and counsel women who complain of not enough milk, and manage lactation in the event of persistent slow growth in the infant with help to increase breastmilk supply.

12.  Provide consultations to colleagues and breastfeeding mothers regarding exposure to contaminants during lactation.

13.  Able to lead the implementation of lactation management programme in the institution and support policies which promote breastfeeding

14.  Develop policies/positions on breastfeeding-related issues

Learning objectives For the Nursing  students

At the end of undergraduate course, a nursing  student should be able to:

Theory

1.      Describe the benefits of breastmilk and superiority of breastfeeding and appropriate complementary feeding to the infant and the mother

2.      Describe the benefits of breastfeeding to the family and the community.

3.      Identify anatomical breast structures involved in milk production and transfer.

4.      Describe the process of milk production and transfer from breast to the baby.

5.      Describe the process of suckling and how does it differ from feeding at a bottle.

6.      Describe the hormones prolactin and oxytocin and their functions and clinical applications.

7.      Describe the advantages of early initiation and demand feeding, and the ten steps to successful breastfeeding.

8.      Describe the problems during breastfeeding.

9.      Describe the salient features of the Infant Milk Substitutes, Feeding Bottles and Infant Foods(Regulation of Production, Supply and Distribution) Act 1992, No.41 of 1992.(IMS Act)

Skill building and field practice.

1.      Identify factors that favor or hinder breastfeeding and appropriate complementary feeding

2.      Take breastfeeding history, conduct examination of breasts and use the breast examination as an opportunity to reassure the woman that she can breastfed her infant

3.      Define components of antenatal counselling for women.

4.      Help women to initiate lactation early and encourage exclusive breastfeeding.

5.      Recognize correct and incorrect position of breast and the baby during  suckling

6.      Demonstrate expression of breastmilk and its needs and discuss how to maintain lactation during separation.

7.      Discuss the causes and prevention of breastfeeding problems.

8.      Discuss breastfeeding in the pre-term/low birth weight babies

9.      Provide counselling support for women during antenatal and postnatal period.