BREAST FEEDING AND HOSPITAL PRACTICES
S T Chen, Department of Paediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur

Introduction
Human milk is best suited to the human infant and there is no substitute which is equal to it. Nutritionally it provides optimal nourishment for growth including brain growth and causes minimal stress upon the immature systems of the young infant. Immunologically, it protects the infant against infections and allergy during the period of physiologically transient immune deficiency state. Early, frequent and prolonged breast feeding fosters maternal-infant bonding which is essential for the optimal development of the infant. Although some present day infant formulas overcome some of the nutritional difficulties associated with cow's milk feeding, such as higher content of protein and phosphorus and lower content of lactose and polyunsaturated fatty acids, the cost of such formulas is too high for the majority of people living in Malaysia. Besides, manipulation of infant formulas may lead to new problems, such vitamin E deficiency anaemia in preterm infant fed on high polyunsaturated infant formulas. Therefore it is essential that all newborn infants, as far as possible, should be breast-fed. Because of the importance of breast feeding, the medical profession is concerned with the decline in the incidence and duration of breast feeding, both in the rural and urban areas of Malaysia. A few concerted efforts to reverse this trend were carried out recently, for example the Breast-Feeding Campaign of 1976 and the Code of Ethics for Infant Formula Products in Malaysia, June 1979. However there is very little change in most hospital practices in Malaysia to actively support breast feeding.

Studies on Programmes Designed to Improve Breast-Feeding
Studies have shown that minor modification, in the functions and regimen of hospitals requiring little or no additional expense, has resulted in an increase in the incidence and/or duration of breast-feeding. For example, Salariya et al (1978) have shown that mothers, who breast-fed their infants within 10 minutes after delivery and at 2 hourly intervals, had a longer duration of breast feeding compared with those who breast-fed 4-6 hours after delivery and at 4 hourly intervals. Of the 2 factors, the early initiation of breast-feeding had a greater effect on the duration of breast-feeding. However 2 hourly feeding induced lactation at least 24 hours earlier than did 4 hourly feeding. Table I lists some of the studies. Studies have also shown that a number of traditional hospital practices have adverse effects on breast feeding. For example, Gueri et al (1977) demonstrated the adverse effect of prelacteal bottle feeding on the duration of breast feeding. Chen (1978) in a study of babies born in hospital in Kuala Lumpur and Petaling Jaya, found that most of the babies were put to the breast more than 24 hours after delivery and that babies were given bottle feeding before the initiation of breast-feeding. Consequently, 70% of these mothers breast-fed partially resulting in lactation failure in a short time ((51.6% stopped breast feeding by one month). Table II lists some of the hospital practices that interfere with the prolactin and let-down reflexes which are essential for successful lactation.

TABLE I
RESULTS FROM SELECTED HOSPITAL OR PRACTICE-BASED PROGRAMMES DESIGNED TO IMPROVE BREAST FEEDING (FROM JELLIFFEE & JELLIFFEE, 1978)

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TABLE II
PUERPERAL PRACTICES INTERFERING WITH LACTATION VIA THE PROLACTIN AND LET-DOWN REFLEXES (FROM JELLIFFEE & JELLIFFEE, 1978)

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Suggestion for Modification in Hospital Practices to Promote Breast Feeding
To encourage parents to breast feed and ensure successful lactation, hospital practices must plan their activities with breast feeding in mind. They should adopt minimal bottle feeding policy and practical health education concerning biological breast feeding (as opposed to token breast feeding). All categories of staff, dealing with mothers and children, should encourage, motivate and support mothers to breast feed. They should avoid promotion of unwanted commercial infant foods such as distribution of samples, brochures and calenders and display of posters.

During antenatal clinic sessions necessary information regarding breast feeding, maternal nutrition and labour should be given for both wife and husband. It is especially useful to have practical demonstration by those who are successfully breast feeding their babies.

In puerperal care, practices, which may interfere with prolactin or let down reflexes should be avoided (see Table II). For example, avoid maternal anxiety by having a relaxed atmosphere and allowing liberal visiting by relatives. On the other hand, those practices which will promote lactation should be actively encouraged. For example, stimulation of lactation by putting baby to the breast as soon as possible after delivery. When baby and mother are fit, the first breast feeding should be within 20-30 minutes after delivery. There are distinct advantages with early breast feeding. Firstly, suckling increases further secretion of oxytocin, which helps the uterus to contract and reduces postpartum bleeding. Secondary, the baby's sucking and rooting reflexes are strongest shortly (20-30 minutes) after birth and hence early suckling, which stimulates prolactin reflex and milk production, provides an excellent start to breast feeding. Besides, early contact between the infant and mother fosters maternal-infant bonding which is critical for the infant's survival and well-being, as he is entirely dependent on his mother as a source of nourishment, emotional support and protection. Finally colostrum is rich in antibodies and anti-infective factors which will protect the infant against infection.

In the postnatal wards, avoid unnecessary separation of mother and newborn and "rooming in" is the best arrangement. Mothers should be encouraged to breast feed frequently. Baby should be allowed to suckle on both breasts as often and for as long as he desires, usually every 2 to 3 hourly or more often. Early and frequent suckling encourages early milk production, sometimes within 36 hours, and prevents breast engorgement. There should be no prelacteal, complimentary or supplementary bottle feeding and hence no routine bottle rounds in the post-natal wards. Water may be necessary and this should preferably be given by spoons because the sucking mechanism of bottle feeding and breast feeding are different. For successful lactation it is important that constant encouragement and help be given to the mothers, preferably by staff, who have successfully breast fed previously.

Special care nurseries for sick or premature babies
Accommodation should be available nearby so that mothers can establish contact with babies and to feed babies with fresh expressed breast milk with earliest return to direct breast feeding.

Children's hospitals
These hospitals should be a centre for health education, not only breast feeding but also on various aspects of child care. Accommodation should be available for mothers to continue breast feeding. "Hospitalization induced lactation failure" should be prevented.

Conclusion
Mothers can be motivated to breast feed and maintain successful lactation through health education and modification in the activities of hospital practices dealing with mothers and children. Such hospital practices should plan their activities with breast feeding in mind.