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CM5.{12,16-17} | CM5.{12,16-17} | Breastfeeding Skills and Counselling — SDL Guide (Part 2)

Counselling Skills — Structured Support for Breastfeeding Mothers

Breastfeeding counselling is a structured clinical skill that combines technical knowledge, communication technique, and emotional support. The WHO/UNICEF counselling approach uses four steps: listen (without judgment), praise (acknowledge effort), give information (relevant, specific), and suggest (one or two practical changes — not an overwhelming list).

Baby-Friendly Hospital Initiative (BFHI): WHO/UNICEF programme designating hospitals that implement the Ten Steps to Successful Breastfeeding. Key steps:
1. Have a written breastfeeding policy communicated to all staff
2. Train all staff in the skills necessary to implement this policy
3. Inform all pregnant women about the benefits and management of breastfeeding
4. Help mothers initiate breastfeeding within half an hour of birth
5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants
6. Give newborn infants no food or drink other than breast milk unless medically indicated
7. Practice rooming-in: allow mothers and infants to remain together 24 hours a day
8. Encourage breastfeeding on demand
9. Give no artificial teats or pacifiers to breastfeeding infants
10. Foster the establishment of breastfeeding support groups

Common breastfeeding problems and solutions:

Engorgement: Bilateral, painful, hard breasts — usually in the first few days when milk 'comes in' (day 3-5). Management: frequent, effective feeds (8-12 times per day); warm compress before feeding to promote milk letdown; cold compress after feeding to reduce oedema; gentle breast massage before feeding; if latch is painful due to firmness, hand-express a small amount first to soften the areola. Severe engorgement → mastitis risk if not resolved.

Sore nipples: Almost always from incorrect latch. First intervention: correct the latch. Secondary: allow a few drops of breast milk to air-dry on the nipple after each feed (antimicrobial, moisturising); avoid soap on nipples; use lanolin cream if severe cracking. If fissures are infected (erythema, discharge, fever): treat for mastitis or Candida (white patches on nipple = thrush).

Mastitis: Breast infection — usually unilateral, in a wedge-shaped segment; fever, erythema, warmth, severe pain. Management: do NOT stop breastfeeding (stopping → abscess formation); frequent, complete emptying of the affected breast; antibiotics (flucloxacillin 500 mg QID for 10 days, or dicloxacillin — targeting Staphylococcus aureus); ibuprofen for pain/inflammation.

Perceived insufficient milk (PIM): The most common reason mothers stop breastfeeding. In most cases, milk supply is adequate but the mother perceives it as insufficient because the infant is fussing (normal infant behaviour) or the breasts feel soft (normal after initial days of engorgement). Signs of adequate milk intake: infant gaining weight, 6+ wet nappies per day, 2-3 yellow seedy stools per day, content after feeds. True insufficient milk supply is rare and usually related to infrequent feeding, poor latch, or insufficient glandular tissue. Management: increase feeding frequency, correct latch, skin-to-skin contact (promotes oxytocin release and letdown), involve a peer counsellor or lactation consultant.

Support systems: ASHA workers and Anganwadi workers are trained in IYCF counselling and make home visits in the first 42 days after delivery (HBNC — Home-Based Newborn Care). They can observe feeds and provide first-line latch support. Peer counsellors (trained mothers who have successfully breastfed) have strong evidence for improving EBF rates in community settings. The Maternity Benefit Act 2017 ensures 26 weeks of paid maternity leave for the first two children — a legal and structural support for EBF.

Monitoring Breastfeeding Outcomes at Community Level

Community-level monitoring of breastfeeding practices uses standardised IYCF indicators developed by WHO/UNICEF to track progress toward breastfeeding recommendations. These indicators are collected through NFHS surveys, NNMB dietary surveys, and HMIS data from ICDS/HBNC registers.

Key IYCF breastfeeding indicators:
1. Early initiation of breastfeeding: Proportion of infants born in the previous 24 months who were put to the breast within 1 hour of birth — national rate 41.8% (NFHS-5).
2. Exclusive breastfeeding: Proportion of infants 0-5 months who received only breast milk in the previous 24 hours — national rate 63.7% (NFHS-5).
3. Continued breastfeeding at 1 year: Proportion of children 12-15 months who received breast milk in the previous 24 hours — 85.9% (NFHS-5).
4. Continued breastfeeding at 2 years: Proportion of children 20-23 months who received breast milk — 60.5% (NFHS-5).

At the Anganwadi level, the AWW maintains an IYCF register recording breastfeeding status of all children under 2 in her catchment. Home visits (HBNC visits at days 3, 7, 14, 21, 28, 42 post-delivery by ASHA and AWW) include observation of breastfeeding, correction of latch problems, and recording of breastfeeding status.

Identifying breastfeeding failure early: Warning signs that require medical review: infant has lost >10% of birth weight by day 3 (normal physiological loss is up to 7-10%), weight gain <20 g/day in the first weeks (expected is 20-30 g/day in term infants), <6 wet nappies/day by day 5, concentrated dark urine (dehydration), persistently jaundiced at day 5-7 (breastfeeding jaundice from poor milk intake vs breastmilk jaundice from EBF in a healthy infant — important distinction: the former requires more frequent feeding and potentially supplementation; the latter is managed by continuing breastfeeding).

Applying Breastfeeding Counselling in Clinical Practice

Effective breastfeeding support requires different clinical actions at different points in the care pathway — from antenatal counselling through postnatal support to community follow-up.

Antenatal (ANC visits, 28+ weeks): Discuss breastfeeding plans; explain the importance and evidence base (briefly — she is not yet in the feeding moment, so a brief motivational explanation is sufficient); confirm that the mother plans to breastfeed; explain what to expect in the first hours post-delivery. Examine breasts for inverted or flat nipples — these can be managed with nipple shells or Hoffman's exercises during pregnancy, but do not predict breastfeeding failure.

Postnatal — first hour (delivery room or postnatal ward): Facilitate skin-to-skin contact immediately after birth (even for caesarean births where possible). The infant placed skin-to-skin will self-attach within 30-60 minutes using primitive feeding reflexes (rooting, stepping). Avoid unnecessary separation. Assist with first feed: use the cross-cradle hold for teaching; confirm wide gape, lower lip flange, chin-to-breast contact, no pain. Do NOT give formula, glucose water, or water unless medically indicated.

Postnatal — subsequent days (postnatal ward rounds): At each clinical encounter, ask: 'How is feeding going? How many times in the last 24 hours? Is there any pain?' A brief observation of one feed is the gold standard but is often overlooked. Ensure the mother knows: feeding 8-12 times per day is normal; night feeds are essential for milk supply; soft, non-engorged breasts after initial days are normal and do not indicate low milk supply.

Contraindications to breastfeeding:
- Absolute (infant should not receive the mother's milk): Galactosaemia (infant enzyme deficiency — breast milk's lactose is harmful)
- Maternal conditions requiring temporary cessation: Active pulmonary tuberculosis (until 2 weeks of effective treatment; expressed breast milk can be given); herpes simplex lesions ON the nipple/areola (express and discard from affected side; other side can feed); certain chemotherapy agents and radioactive diagnostic agents
- HIV: In high-income countries — replacement feeding is recommended; in low-income/resource-limited settings (India) — WHO recommends exclusive breastfeeding with antiretroviral therapy (ART) coverage for both mother and infant, as replacement feeding risks from contaminated water, diarrhoea, and pneumonia exceed transmission risk from breastfeeding with ART. India's NACO guidelines follow this approach.
- NOT a contraindication: Hepatitis B (infant should receive HBIg + hepatitis B vaccine within 12 hours of birth; breastfeeding can then proceed); Hepatitis C; common minor maternal illnesses (fever, cold, mild mastitis); jaundice in the infant.