WHO advises

28 World Health • 50th Year, No. 2, March-Aprill997 WHO advises ••• The practice of rooming-in, which allows mothers and infants to be together 24 hours a day, actively supports and promotes breastfeeding. Photo: WHO/ UNICEF/ R. Lemoyne. Ten steps to successful breostfeeding The baby-friendly hospital initiative formally began in 1991 . launched by WHO and UNICEF, the initiative aims to give babies the best start in life by creating an environment where breasrleeding is the norm. The basis of the initiative is a joint WHO/ UNICEF statement on breasrleeding and maternity services (Protecting, promoting and supporting breastfeeding*). Maternity wards and hospitals that apply the principles described in the statement are designated "baby-friendly". So far there are more than 8000 of them in 171 countries. To be truly "baby-friendly", every facility providing maternity services and care for newborn infants should do the following: 1. Have a written breasrleeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breasrleeding. 4. Help mothers initiate breasrleeding within a half-hour of birth. 5. Show mothers how to breasrleed, and how to maintain lactation even if they should be separated from their infants. 6. Give newborn infants no food or drink other than breast milk, unless medically indicated. 7. Practise rooming-in - allow mothers and infants to remain together- 2 4 hours a day. 8. Encourage breasrleeding on demand. 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breasrleeding infants. 1 0. Foster the establishment of breasrleeding support groups and refer mothers to them on discharge from the hospital or clinic. lt is estimated that worldwide only some 34% of infants under four months of age are exclusively breasrled. *Protecting, promoting and supporting breastfeeding: the special role of maternity services. A joint WHO/ UNICEF statement. Geneva, World Health Organization, 1989. Order no. I 1503 26, costs Sw. fr. 6.-/US $5.40 {Sw.fr. 4.20 in developing countries}, and is available from Distribution and Sales, WHO, 12 I I Geneva 27, Switzerland. Most deaths of newborn infants con be avoided Every year more than 8 million infants die before their first birthday. More than half survive for less than a month -while they are still classed as newborn. Almost all the 5.1 million deaths in the neonatal period (the 28 days after birth) take place in developing countries. Nearly two-thirds (3.3 million) of them occur within a few days of birth. World Health • 50th Year, No. 2, March- Aprill997 The causes of neonotol deaths ore not always easy to assess but WHO estimates that 85% of them ore due to infections, birth asphyxia, birth injury and problems linked with preterm (or premature) birth. Similarly, nearly half of all stillborn babies die os o result of complications during labour and delivery. With appropriate core, most of these deaths could be avoided. Although congenital anomalies ore often thought to be the main cause of death in babies, in fact they account for o relatively small percentage. WHO's Maternal Health and Safe Motherhood Programme stresses that all newborn babies, wherever they may be born, need o certain level of basic core to ensure their welfare. This basic core includes cleanliness, warmth, early and exclusive breosrleeding, eye core, immunization, and resuscitation when necessary. Cleanliness Cleanliness at birth prevents infections. The birth attendant's hands and fingernails should be clean, the delivery should take place on o clean surface, and the umbilical cord should be cut with o sterile instrument and should be kept clean. Nothing should be applied to the cord, and it should be left uncovered so that it con dry and fall off by itself. The baby's first contact after birth should be with the mother. The newborn will be colonized by microorganisms and it is preferable if these come from the mother rather than from the environment. Having mothers take core of their babies, even if the birth takes place in o hospital or health centre, cuts the risk of cross-infection. Warmth Newly born babies come from the warmth of the mother's womb into o room that is often too cold for them. They lose heat rapidly, particularly if they ore very small or premature. The first thing that should be done is to give the baby to the mother- her skin is the warmest and the cleonest surface for the newborn. Then the baby should be dried to prevent loss of heat. After drying, and following cord and eye core, the baby should spend o peaceful hour or two with the mother. This will keep it worm and will encourage early breosrleeding. Bathing should be postponed for several hours after the birth and preferably foro day or two. Later the newborn should be wrapped loosely (not tightly!) in several layers of soft clean cloth or loose clothing and kept in o worm room with its mother. Requirements may vary according to climate and temperature. Immediately after the birth the baby should be dried and wrapped and put into close contact with its mother's body in order to ovoid heat loss. Photo: WHO/ P Abensur. 29 Breastfeeding Early skin·to·skin contact with the mother allows the baby to breosrleed early. This should happen os soon os possible after delivery and the first feed con easily take place within on hour of birth. The antibodies in colostrum and breast milk help immunize the infant against infection, and breast milk provides the best nutrition foro child's growth and development. Breast milk should be the young infant's only food and drink. If the baby is allowed to feed os often os it needs, it will hove no need of other fluids or food. Breosrleeding also reduces the risk of postpartum haemorrhage in the mother by stimulating uterine contractions. Eye care While the newborn baby is being dried and cleaned, both eyelids should be carefully wiped too. This will stop bacteria from getting into the baby's eyes and causing infection that con lead to blindness if left untreated. The baby of o mother with gonorrhoea has o 30%-50% chance of having gonococcal ophthalmia. A drop of special solution (l % silver nitrate) or o small amount of ointment (tetracycline) in the eyes within the first hour will prevent ophthalmia from occurring. Immunization All mothers should be immunized with at least two doses of tetanus toxoid to protect both themselves and their newborns from tetanus. Where there is o high risk of tuberculosis infection, WHO recommends that all babies should be given BCG immunization os soon os possible after birth. A single dose of oral polio vaccine is also recommended at birth or within the first two weeks to increase early protection. lt will not interfere with the normal immunization doses at 6, l 0 and 14 weeks. In areas where perinatal infections ore common, the first dose of hepatitis B vaccine should be given soon after birth. Diphtheria-pertussis-tetanus vaccine has little effect in the first month but con be given effectively after four weeks. Resuscitation, where necessary About 3% of newborns (3.6 million) in developing countries hove moderate or severe birth asphyxia. Of these, some 900 000 die and on equal number suffer moderate to severe disability. Most newborns start breathing spontaneously but those that do hove difficulty breathing need resuscitation. This does not require sophisticated equipment but timely recognition is crucial. If the baby does not cry within the first minute of life it needs to be helped to breathe. No oxygen is needed, just air. The mouth and nose must be cleaned but the most urgent need is ventilation (with o bog and mask if available) to get air into the lungs and to start the baby breathing. More than three-quarters of babies with breathing difficulties con be revived in this way. Core must be token to dry the baby first and to wrap it in o blanket to keep it worm. Special care Although most babies ore born healthy, problems do occur in some. Health workers and families must be able to recognize them and respond appropriately. The signs of infection ore often subfte: the baby stops suckling well, is unusually sleepy, does not woke up, moves little, has difficulty breathing or has convulsions. it may be too cold or too worm. 30 Umbilical infection is present if the skin around the cord stump is red, it has a foul smell and the stump is draining pus. If the eyelids become swollen and ore draining pus, the infection is probably caused by a gonococcus. Each of these conditions requires early recognition and immediate treatment. Care of preterm and low birth weight newborns WHO defines low birth weight os weight at birth of less than 2500g, whatever the gestational age. A preterm, or premature, baby is one that is born at less than 37 weeks. Low birth weight is usually caused by preterm birth or retarded growth in the uterus, or a combination of the two. Preterm and low birth weight babies are more prone to low body temperature (hypothermia), more susceptible to infections, more likely to need resuscitation and more difficult to feed. Above all, they need good basic care, but in addition they may need special treatment if they hove problems. The smaller or more preterm the baby, the more problems it will hove. Well trained personnel, and special equipment and supplies are needed for the core of these babies if they are to receive the extra attention they need with regard to warmth, cleanliness, breostfeeding and the early identification and management of infections. HIV and infant feeding: an interim statement Breast milk is the best possible milk for newborn babies. Unfortunately a mother who is infected with the human immunodeficiency virus (HIV) may pass the infection to her infant during breostfeeding. HIV is the virus that causes the acquired immunodeficiency syndrome (AIDS). Various studies conducted to dote indicate that worldwide between one-quarter and one·third of infants born to women infected with HIV become infected themselves. In most cases infection takes place during late pregnancy or delivery but studies suggest that up to one-third of HIV-infected infants ore infected through breostfeeding. Should a mother with HIV breostfeed her infant? lt depends on the situation in which she lives. In some circumstances the risk of HIV by breostfeeding may be low compared to the risk of other infections or diarrhoea that a baby is exposed to if it is not breostfed. In this situation the mother should breostfeed her infant even if she is infected with HIV or has AIDS. The Joint United Notions Programme on HIV / AIDS (UNAIDS) has issued on interim statement on HIV and infant feeding. WHO is one of the six cosponsors of UNAIDS and, together with UNDP, UNESCO, UNFPA, UNICEF and the World Bank, formulated the statement. lt contains four elements for establishing a policy on HIV and infant feeding, os follows: 1. Supporting breast-feeding As a general principle, in all populotions, irrespective of HIV infection rotes, breostfeeding should continue to be protected, promoted and supported. 2. Improving access to HIV counselling and testing Access to voluntary and confidential HIV counselling and testing should be facilitated for women and men of reproductive age, in port by ensuring a supportive environment that encourages individuals to be informed and counselled about their HIV status rather than one that discourages them out of fear of discrimination or stigmatization. World Health • 50th Year, No. 2, Morch-Aprill 997 As port of the counselling process, women and men of reproductive age should be informed of the implications of their HIV status for the health and welfare of their children. Counselling for women who are aware of their HIV status should include the best available information on the benefits of breostfeeding, on the risk of HIV transmission through breostfeeding, and on the risks and possible advantages associated with other methods of infant feeding. 3. Ensuring informed choice Because both parents hove a responsibility for the health and welfare of their children, and because the infant feeding method chosen has health and financial implications for the entire family, mothers and fathers should be encouraged to reach a decision together on this matter. However, it is mothers who are in the best position to decide whether to breostfeed, particularly when they alone may know their HIV status and wish to exercise their right to keep that information confidential. lt is therefore important that women be empowered to make fully informed decisions about infant feeding, and that they be suitably supported in carrying them out. This should include efforts to promote a hygienic environment, essentially clean water and sanitation, that will minimize health risks when a breast-milk substitute is used. When children born to women living with HIV can be ensured uninterrupted access to nutritionally adequate breast-milk substitutes that are safely prepared and fed to them, they are at less risk of illness and death if they are not breostfed. However, when these conditions are not fulfilled, in particular in on environment where infectious diseases and malnutrition ore the primary causes of death during infancy, artificial feeding substantially increases children's risk of illness and death. 4. Preventing commercial pressures for artificial feeding Manufacturers and distributors of products which fall within the scope of the International Code of Marketing of Breast-milk Substitutes (1981) should be reminded of their responsibilities under the Code and continue to take the necessary action to ensure that their conduct at every level conforms to the principles and aim of the Code. This report is based on on article in Safe motherhood {No. 2 I}, the newsletter of WHO's Maternal Health and Safe Motherhood Programme. To subscribe to Safe motherhood {3 issues a year}, contact Carlo AbouZahr, Maternal Health and Safe Motherhood Programme, Division of Family and Reproductive Health , WHO, CH-I 2 I I Geneva 27, Switzerland.