Malnutrition

Chapter One

Define Nutrition

Nutrition is the entire process from obtaining food and consuming it, to
absorbing

The nutrients and energy from it. The intake of food, considered in relation to
the Body’s dietary needs, is one of the foundations of good health
throughout a person’s Lifetime. Nutrition encompasses the process by which
people:

 obtain adequate types and amounts of food required to meet the nutrient
needs

For the body’s maintenance, growth and activity.

 prepare food for consumption.

 consume food.

 absorb nutrients and energy from the food that was consumed.

Good nutrition is not just about getting enough food, but also about ensuring
the Right nutrients enter the body, for example through breastfeeding infant
and young Children, giving them a varied diet and ensuring that nutrients be
absorbed in the Body.

Good nutrition also emphasises food handling safety and hygiene to prevent

Diarrhoeal diseases.

• All food is made up of nutrients. The body uses nutrients to:

» build and repair damaged tissue.

» produce energy.

» perform bodily actions in order to remain healthy.

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For good nutrition, the body needs a combination of nutrients, distinguished
into two Categories:

Macronutrients include carbohydrates, proteins and fats. Macronutrients

are Consumed in relatively large quantities since they supply all the energy
needed by The body and form the bulk of the diet. The macro nutrients are:
Proteins help the Body to grow and repair worn out tissues.

The macro nutrients are: Proteins help the Body to grow and repair worn out
tissues. They are known as body-building foods.

Carbohydrates give the body energy to work and are known as energy-
giving Foods.

Fats are essential for the development of healthy cells. They give energy

And strength, so that people can work hard.

Micronutrients include vitamins and minerals, and trace elements. They

are Only needed in small amounts. The micro nutrients are: Minerals
perform different Functions like building strong bones and for proper
functioning of the brain. Some Minerals are used to make hormones or
maintain a normal heartbeat. Examples of Minerals are: calcium,
phosphorous, zinc and magnesium. Vitamins are needed in Small quantities
to sustain life. We get vitamins from food and other sources. For Example
sunlight is a source for Vitamin D. Vitamins help to strengthen bones, heal
Wounds, and boost the immune system. They also convert food into energy,

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and Repair cellular damage because the human body either may or may not
produce Enough vitamins required by the body.

The image below shows the various food sources of micronutrients.

Water is not a nutrient, but it is essential for normal body function. Our
bodies, the Cells, organs and tissues require water to regulate body
temperature and maintain Other bodily functions. The body loses water
through breathing, sweating and Digestion. We rehydrate by drinking fluids
and eating foods that contain water.

Malnutrition

• Malnutrition occurs when nutrient and energy intake does not meet or
exceeds, an Individual’s requirements to maintain growth, immunity and
organ function.

• Overnutrition is the over consumption of nutrients and energy to the point

where Health is adversely affected. Overnutrition can result in being
overweight and obesity, As well as suffering from nutrition-related non-
communicable disease.

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Example

If a person weight 65kg and the person’s height is 175cm

Calculate the BMI

Solvent

65kg/1.75m2

= 65kg/3.0625m²

21.224kg/m²

Undernutrition occurs when the intake or absorption of energy of one or

more Nutrients (protein and/or micro nutrients) is less than required.
Undernutrition can Result in chronic malnutrition, acute malnutrition and/or
micronutrient deficiencies.

Forms of undernutrition

Acute malnutrition occurs as a result of recent rapid weight loss (or, in

children,It may be the result of failure to gain weight. Acute malnutrition is
associated with Increased morbidity and mortality. Acute malnutrition is
further distinguished into Moderate acute malnutrition (MAM) and severe
acute malnutrition (SAM).

Chronic malnutrition develops as a result of inadequate nutrition, repeated

Infections, or both. It is associated with poor cognitive development, poor
learning And limited productivity. It accumulates over time, in particular
during the first 1 000 Days. Stunting is an indicator of chronic malnutrition.

Micronutrient deficiency (MND) is a shortage of essential vitamins or

minerals. People who suffer from MND may not show any signs or symptoms,
so it is sometimes Referred to as hidden hunger. Worldwide, iron, vitamin A
and iodine are the three Most common MNDs. Children and PLW are most
vulnerable to MNDs.

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 Chapter Two
INTRODUCTION
Malnutrition is a major public health problem of the world. It dramatically
increases the risk of early death, is responsible either directly or indirectly for
more than one third of all childhood deaths, and deprives children of the
opportunity to develop to their potential. Itis both a cause and a result of
poverty and underdevelopment.

Conceptual Framework for Malnutrition:

Malnutrition, whether acute or chronic, has multiple causes that usually work
in conjunction, reinforcing each other to the point that no single action or
intervention can prevent it.

Underlying Causes of Malnutrition

Three major underlying causes of malnutrition include:

1. Food: Inadequate household food security (limited access or

availability of food).

2. Care: Inadequate social and care environment in the household and

local community, especially with regard to women and children.

3. Health: Limited access to adequate health services and/or inadequate

environmental health conditions (including access to safe water and
sanitation facilities). All underlying causes of malnutrition are usually
the consequence of poverty.

Immediate Causes of Malnutrition

Inadequate dietary intake and disease are immediate causes of malnutrition
and create a vicious cycle in which disease and malnutrition exacerbate each
other.

Basic Causes of Malnutrition

The basic causes of malnutrition in a community originate at the regional
and national level, where strategies and policies that affect the allocation of
resources (human, economic, political 6 and cultural) influence what
happens at the community level.
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Pathophysiology of Severe Acute Malnutrition
Severe acute malnutrition can result in profound metabolic, physiological,
and anatomical changes. Virtually all physiological processes are altered due
to severe acute malnutrition. Every organ and system is involved in reductive
adaptation.

Reductive adaptation is the physiological response of the body to

undernutrition i.e. systems slowing down to survive on limited macro and
micro-nutrient intake.

The system reduces activity, to adapt to the lack of nutrients and energy.

The following table presents some of the main alterations in each of the
body systems. Knowing them can help understand the evolution and therapy
of severe acute malnutrition and its complications

Cardiovascular system

• Cardiac output and stroke volume are reduced.

• Infusion of saline may cause an increase in venous pressure.

• Any increase in blood volume can easily produce acute heart failure.

• Any decrease will further compromise tissue perfusion.

• Blood pressure is low.

• Renal perfusion and circulation time are reduced.

• Plasma volume is usually normal and red cell volume is reduced.

Genitourinary System
Production of gastric acid is reduced.

• Intestinal motility is reduced.

• Pancreas is atrophied and production of digestive enzymes is reduced.

• Small intestinal mucosa is atrophied.

• Secretion of digestive enzymes is reduced.

• Absorption of nutrients is reduced

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Liver Function
• Synthesis of all proteins is reduced.

• Abnormal metabolites of amino acids are produced.

• Capacity of liver to take up, metabolize, and excrete toxins is severely

reduced.

• Energy production from galactose and fructose is much slower than

normal.

• Gluconeogenesis is reduced, with a high risk of hypoglycaemia during

infection.

• Bile secretion is reduced.

Genitourinary System
• Glomerular filtration is reduced.

• Capacity of kidney to excrete excess acid or a water load is greatly

reduced.

• Urinary phosphate output is low.

• Sodium excretion is reduced.

• Urinary tract infection is common.

Circulatory System
• Basic metabolic rate is reduced by about 30%.

• Energy expenditure due to activity is very low.

• Both heat generation and heat loss are impaired.

• The child becomes hypothermic in a cold environment and hyperthermic in

a hot environment.

Endocrine System
Insulin levels are reduced and the child has glucose intolerance.

• Insulin growth factor 1 (IGF-1) levels are reduced.

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• Growth hormone levels are increased.

• Cortisol levels are usually increased.

Immune System
• All aspects of immunity are diminished.

• Lymph glands, tonsils and thymus are atrophied.

• Ig-A levels in secretions are reduced.

• Complement components are low.

• Phagocytes do not kill ingested bacteriaefficiently.

• Tissue damage does not result in inflammation or migration of white cells

to the affected area.

• Acute phase immune response is diminished and cell-mediated immunity is

severely depressed.

• Typical signs of infection, such as an increased white cell count and fever,
are frequently absent.

• Hypoglycaemia and hypothermia are signs of severe infection usually

associated with septic shock

PROGRAMME OVERVIEW
Components of the IMAM programme
The objectives of the IMAM programme are:

1. to prevent acute malnutrition,

2. to prevent the development of severe acute malnutrition in moderate
acute cases,

3. to establish links with other programmes/services to prevent future

relapse, and

4. to save the lives of individuals that have developed acute

malnutrition.

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 The core of the IMAM programme includes four distinct but integrated
components/services:

1. Community mobilization and sensitization

2. Targeted Supplementary Feeding Programme –TSFP

3. Outpatient Therapeutic Programme (Outpatient care) – OTP

4. Stabilisation Centre (Inpatient care) -SC

IMAM ENVIRONMENT
the causes of malnutrition are multiple which implies that prevention and
treatment of malnutrition equiresanintra-sectoralandmulti-sectoral approach.
The IMAM programme is not a stand-alone set of services and other
interventions are necessary; these can be “nutrition specific” or “nutrition
sensitive” interventions. All together can be referred to as the IMAM
environment, as indicated in the figure below, where

Nutrition specific interventions or programmes address the immediate

determinants of foetal and child nutrition and development—adequate food

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and nutrient intake; feeding; caregiving and parenting practices; and low
burden of infectious diseases.

Nutrition sensitive interventions or programmes address the underlying

determinants of foetal and child nutrition and development — food security

IMAM Services
Community mobilization

Targeted Supplementary Feeding Programme (TSFP) Outpatient

Therapeutic Programme (Outpatient care)– OTP

Stabilisation Centre (In-patient care) – SC

Community mobilisation
Objective:
To sensitize the population on the problem of malnutrition and how to
identify it in order to reach more children and women at an earlier stage in
their development of acute malnutrition, thereby increasing coverage and
recovery.

Activities:
Screening children through assessments of MUAC and nutritional oedema;
referring to the nearest health facilities; mobilising key community
stakeholder’s and organizations; education and sensitization on nutrition
health related topics as well as existing community services to enhance
understanding and acceptance by the community; following up with patients
that default or present recovery difficulties.

Targeted Supplementary Feeding Programme –TSFP

Objective:
To treat patients with Moderate Acute Malnutrition (MAM) and prevent the
development of Severe Acute Malnutrition (SAM).

Activities:

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Biweekly prescription of take-home rations in the form of Supplementary
Food commodities (e.g. CSB+ or Ready to Use Supplementary Foods
[RUSFs]) and routine medicines and nutritional monitoring of the patient.
Follow up of OTP children discharged as cured.

Outpatient Therapeutic Programme (Outpatient care) – OTP

Objective:
To treat patients with SAM who have a good appetite and no medical
complications and to prevent further deterioration of SAM cases.

Activities:
Weekly prescription of Ready to Use Therapeutic Foods (RUTFs) and routine
medicines and medical and nutritional monitoring of the patient. After
recovery and discharge, the child will be transferred to TSFP for two months
to consolidate the nutritional status and prevent relapse.

Stabilisation Centre (In-patient care)–SC

Objective:
To treat patients with SAM who have a poor appetite or medical
complications.

Activities:
Use of therapeutic milk and medical treatment in inpatient facility (hospital
or stand-alone centre). A child with complicated SAM will start treatment at
an SC (inpatient) and when the medical conditions are stabilized and/or the
appetite returns, he/she will continue treatment as an outpatient at the OTP.
After recovery and discharge the child will be transferred to TSFP for two
months to consolidate the nutritional status and prevent relapse.

Additional services linked to IMAM

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Chapter three
Topic2 Nutritional requirements for the child aged 0-6
month

Lesson objectives

By the end of this lesson, participants should be able to:

• define exclusive breastfeeding.

• state the risks of giving artificial feeding.

• state the benefits of early initiation of breastfeeding and exclusive

breastfeeding.

Training methodology

Important of breast feeding to the infant

Important of breast feeding to the mother
Important of breast feeding to the family

Defining exclusive breastfeeding

Exclusive breastfeeding means giving the infant no other food or drink, not
even water, except breast milk for the first 6 months of life. This includes
breast milk expressed by the mother or breast milk from a wet nurse.

Exclusive breastfeeding includes giving oral drops or syrups consisting of

vitamins, mineral supplements or medicines that are permitted.

Infants should be exclusively breastfed for 0-6 months (up to 180 days) of
life.

Defining artificial feeding

Artificial feeding refers to feeding the infant with formula feeds with no
breast milk

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Bottle-feeding

Bottle-feeding refers to feeding of the child using a bottle, no matter what is

in the bottle.

Pre-lacteals
Pre-lacteals refer to anything given to the newborn before introduction of
breast milk. This includes giving tea, honey, sugar waters given to the infant
before introduction of breastmilk.

Giving pre-lacteals means the child is not receiving colostrum and this could
hinder establishment of breastfeeding.

Mixed feeding
Mixed feeding refers to giving other liquids and/or other foods together with
breast milk to infants under 6 months of age.

Importance of breastfeeding

Importance of breastfeeding to the child

• Saves infants’ lives.

• Breast milk is a whole food that covers all nutritional and fluid needs of
the infant for the first 6 months and prevents stunting.

• Breast milk is clean, at the right temperature, easy to digest and

nutrients are well absorbed. • Colostrum is the golden first milk that
contains antibodies that protect against diseases, especially against
diarrhoea and respiratory infections.

• Breastfeeding helps in the development of the baby’s jaw and teeth. This
is because suckling develops facial and jaw structure.

• Long- term benefits include - reduced risk of obesity and diabetes

• Frequent skin-to-skin contact between the mother and infant leads to

bonding, better psychomotor, affective and social development of the
infant.

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 • Breast milk contains immunoglobulins therefore protecting the child from
infections, including respiratory infections, diarrhoeal disease, ear
infections, etc.

• Breast milk prevents children from having allergies and eczema.

Importance of breastfeeding to the mother

Exclusive breastfeeding is an effective natural contraceptive during the
baby’s first 6 months

. • Islam also expects that mothers breastfeed for up to 2 years which could
translate into child spacing. Consequently, the mother has more time for
herself, the other children and for her husband.

• Breastfeeding reduces the risk of bleeding after delivery. It facilitates the

expulsion of the placenta as the baby’s suckling stimulates uterine
contractions.

• Breastfeeding reduces the mother’s workload since there is no time

involved in buying and preparing food for the baby.

• Immediate and frequent suckling prevents breast engorgement.

• Helps prevent breast and uterine cancer

Importance of breastfeeding to the family

Mothers and the children are healthier.

• Minimal medical expenses due to the baby’s ill health because

breastfeeding prevents diseases by improving the immunity of the child.

• There are no expenses involved in buying other milk, firewood or other

fuel, or utensils for the baby.

• Births are spaced if the mother is exclusively breastfeeding for the first six
months, day and night, and if her menses have not returned.

• Time-saving since less time is used in purchasing and preparing other

milk, collecting water and firewood, and there is reduced incidences of illness
that may require trips for medical treatment.

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Risks of artificial feeding
Note: The younger the infant is, the greater these risks

Greater risk of death. A baby who is not breastfed is 14 times more likely to
die than a baby who has been exclusively breastfed for the first 6 months. •
Infant formula has no antibodies to protect the child against illness. The
mother’s body produces breast milk with antibodies that protect the child
from specific illnesses in their environment

• Newborn babies who are not breastfed do not receive their “first
immunisation” from colostrum.

• Such infants struggle to digest formula which is not the best food for
babies.

• The babies who undergo artificial feeding have frequent diarrhoea, and fall
ill more often and more seriously. Indeed, mixed-fed infants who are less
than 6 months old and who receive contaminated water, formula and foods
are at higher risk. • Such babies have frequent respiratory infections.

• They are at a greater risk of undernutrition, especially for younger infants.

• Children who undergo artificial feeding are more likely to become

malnourished because their family may not be able to afford enough
formula.

• This means that they are at an increased risk of underdevelopment, such

as retarded growth, being underweight, stunting, and wasting due to
infectious diseases such as diarrhoea and pneumonia.

• There is poor bonding between mother and infant, meaning that the infant
is likely to feel insecure.

• Infants who are artificially fed are more likely to score low on intelligence
tests and may have more difficulty learning at school.

• They are also more likely to be overweight.

• They also have greater risk of heart disease, diabetes, cancer, asthma and
dental decay later in life

Children who undergo mixed feeding

Have a higher risk of death.

• Fall ill more often and more seriously, especially with diarrhoea: due to
contaminated milk and water.
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• Are more likely to become malnourished because the gruel they are given
has little nutritional value, and the infant formula is often diluted. Both dis-
place the more nutritious breast milk.

• Tend to get less breast milk because they suckle less, which then causes
the mother to produce less milk.

• Suffer damage to their fragile guts from even small amounts of anything
other than breast milk.

• Are more likely to be infected with HIV if their mother is HIV-positive, than
an infant who is exclusively breastfed. This is because their guts are dam-
aged by other liquids and foods, thus allowing the HIV virus to enter their
systems more easily

Chapter four
Topic 3: Recommended breastfeeding practice
Lesson objectives
By the end of this lesson, participants should be able to:

• name at least six recommended breastfeeding practices.

• state four signs of good attachment of the child to the breast.

• state four signs of good positioning during breastfeeding

Prior preparation: Print out pictures of the anatomy of the human breast.
Write the 11 recommended breastfeeding practices on manilla paper of dif-
ferent colours or on flip chart paper

Anatomy of the human breast

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[Link] the newborn baby skin-to-skin with the mother im-
mediately after birth.
Placing the infant skin-to-skin helps in stimulating the “let down reflex” of
the colostrum/ first milk.

• Colostrum is the first, thick, yellowish milk that helps protect the baby
from illnesses.

• There may be no visible milk in the first hours. Some women can take a
day or two to experience the “let down reflex” and secrete the first milk. It is
important to continue putting the baby to the breast to stimulate milk pro-
duction.

• Frequent skin-to-skin contact between the mother and infant leads to

bonding, better psychomotor, effective and social development of the infant.

• When the mother holds her newborn skin-to-skin immediately after birth, it
helps the mother and baby to bond. It also stimulates the baby’s brain devel-
opment and helps the baby to reach the breast easily.

[Link] breastfeeding within the first hour of birth:

• The first milk is called colostrum. This milk is yellow and full of antibodies
which protect your baby from diseases.

• Colostrum provides the first immunisation against many diseases such as

diarrhoea, respiratory infections, ear infections

• Colostrum also aids in healing of the umbilical cord stump.

• Breastfeeding frequently from birth helps the baby to learn to attach and
helps prevent breast engorgement and other complications.

• Give the newborn baby only the breast. Do not give them any water, infant
formula, or other foods or liquids.

[Link] frequently, both day and night: for the first few
days, the baby may feed 2 to 3 times a day. If the baby is still
sleepy on day 2, the mother may express some colostrum and
give it to the baby using a cup.

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After the first few weeks, most newborns want to breastfeed frequently,
about 8 to 12 times a day. Frequent breastfeeding helps to produce lots of
breast milk.

• Once breastfeeding is well established, breastfeed 8 or more times, day

and night, to continue to produce plenty of breast milk. If the baby is well at-
tached, contented and gaining weight, the number of feeds is not important.

• More suckling, with good attachment, helps the mother to produce more
breast milk.

[Link] breastfeed (no other food or drink) from 0 to

6 months.
• Breast milk is all the food a baby needs for the first 6 months.

• Do not give anything else to the infant below 6 months, not even water.

• Breast milk contains all the water a baby needs, even in hot climate.

• Giving water will fill up the infant and cause less suckling, which in turn will
cause the mother to produce less breast milk.

• Water and other liquids and foods given to an infant less than 6 months
can cause diarrhoea.

5. Breastfeed frequently, both day and night

• Breastfeed at least 8-12 times in a day.

• The more the mother breastfeeds, the more breast milk is produced

[Link] on demand, every time the baby asks to

breastfeed
Crying is a late sign of hunger.

• The early signs that the baby wants to breastfeed include:

 restlessness

 opening the mouth and turning the head from side to side

 sticking the tongue in and out of the mouth

 sucking on fingers or fists.

7. Let the infant finish one breast and come off by them-
selves before switching to the other breast
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 • Switching back and forth from one breast to the other prevents the infant
from getting the nutritious “hind milk”.

• The fore milk has more water content and quenches the infant’s thirst,
whereas the hind milk has more fat content and satisfies the infant’s hunger.

8. Ensure good positioning and attachment.

The four signs of good positioning are:

a) The baby’s body should be straight.

b) The baby’s body should face the breast.
c) The baby should be close to the mother.
d) The mother should support the baby’s whole body and not just the
neck. She should use her hand and forearm.

The four signs of good attachment are:

1. The baby’s mouth is wide open

2. The baby’s lower lips is turned out
3. The baby’s chin is touching the breast.
4. More areola is showing above than below the nipple

Good attachment and poor attachment

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How to ensure good attachment:

• To begin attaching the baby, the mother’s nipple should be aimed at the
baby’s nose.

• When the baby opens their mouth wide, bring them onto the breast from
below, rather than approaching the breast straight on.

• Show the mother how to hold her breast with her fingers in a C-shape. The
thumb should be above the areola and the other fingers below. The fingers
need to be flat against the chest wall to avoid getting in the baby’s way.
Make sure that the fingers are not too close to the areola so that the baby
can get a mouthful of the breast. Fingers should not be in a “scissor hold” be-
cause this method tends to put pressure on the milk ducts and can take the
nipple out of the infant’s mouth.

• Explain how the mother should touch her baby’s lips with her nipple, so
that the baby opens their mouth

• Explain that the mother should wait until her baby’s mouth is wide open.

• Explain how to quickly move the baby to her breast. She should aim her
baby’s lower lip well below her nipple, so that the nipple goes to the top of
the baby’s mouth and the baby’s chin will touch her breast. The baby should
approach the breast with nose to nipple, not mouth to nipple

9. Continue breastfeeding until 2 years of age or longer

• Breast milk contributes a significant proportion of energy and nutrients dur-
ing the complementary feeding period, from 6 months up to 2 years and bey-
ond.

• This helps protect babies from illnesses.

10. Continue breastfeeding when the infant or mother is

ill.
• Breastfeed more frequently during and after a child’s illness, including
diarrhoea.

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 • The nutrients and immunological protection of breast milk are important to
the infant when the mother or infant is ill.

• Breastfeeding provides comfort to a sick infant.

11. Mother needs to eat and drink to satisfy her hunger

and thirst
• No single special food or diet is required to provide sufficient quantity or
quality of breast milk.

• No foods are forbidden.

• Mothers should be encouraged to eat more food to maintain their own

health, by having two extra meals or snacks each day.

Chapter Five
Common breastfeeding difficulties
By the end of this lesson, participants should be able to:

• name the common breastfeeding difficulties.

• explain some of the ways to prevent mastitis, sore or cracked nipples, and
breast engorgement.

• explain some of the ways to manage mastitis, sore or cracked nipples, and
breast engorgement.

Prior preparation: Print pictures in colour of engorged breasts, breasts suf-

fering from mastitis, sore or cracked nipples

Common breastfeeding difficulties

1. Breast engorgement

2. Sore or cracked nipples

3. Plugged ducts and mastitis

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Breastfeeding difficulty
1 Breast engorgement
Breast engorgement (also called early postpartum engorgement) is
swelling of your breast that occurs soon after giving birth.

Symptoms
• occurs in both breasts

• swelling of the breasts

• tenderness of the breasts

• The breast feels warm on touch.

• slight redness

• pain

• skin is shiny, tight and the nipple is flattened and difficult for the baby to
attach

• often occurs between the third and fifth day after birth (when milk produc-
tion increases dramatically and suckling is not yet established)

prevention
• Put baby skin-to-skin with mother

• Start breastfeeding within an hour of birth

• Ensure good attachment

• Breastfeed frequently on demand, day and night, 8 to 12 times a day.

Note: In the first day or two the baby may only feed 2 to 3 times a day

What to do
• Improve attachment
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• Breastfeed more frequently

• Gently stroke the breasts to help stimulate milk flow

• Press around the areola to reduce swelling, and to help baby to attach

• Offer both breasts to the infant

• Express milk to relieve pressure until the baby can suckle `

• Apply warm compresses to help the milk flow before expressing

• Apply cold compresses to breasts to reduce swelling after expression

2 Sore or cracked nipples

Symptoms

• breast or nipple pain

• cracks across the top of the nipple or around the base

• occasional bleeding of the nipple

• May become infected

Prevention
• Ensure good attachment

• Do not use feeding bottles (the suckling method is different from breast-
feeding so it can cause ‘nipple confusion’)

What to do

• Do not stop breastfeeding

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 • Improve attachment by ensuring that the baby comes onto the breast
from underneath and is held close.

• Begin to breastfeed on the side that hurts less.

• Change breastfeeding positions.

• Let the baby come off breast by themselves.

• Apply drops of breast milk to the nipples.

• Do not use soap or cream on the nipples.

• Do not wait until the breast feels full before breastfeeding.

• Do not use feeding bottles

3 Plugged ducts and mastitis

Plugged ducts are a common concern in breastfeeding moms

A plugged milk duct feels like a tender ,sore lump or knot in the [Link]
happens when a milk duct does not drain properly.

Mastitis

Mastitis is painful inflammation in your breast tissue that can lead to a bac-
terial infection

Symptoms of plugged ducts

• lumpy breasts

• tenderness of the breasts

• localized redness

• mother feels well, with no fever

Symptoms of mastitis

• hard swellings on the breasts

• severe pain

• redness in one area

• the mother generally does not feel well

• the mother has fever

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 • sometimes the baby refuses to breastfeed as the milk tastes more salty
than usually

prevention
Get support from the family to perform chores that do not include infant care

• Ensure good attachment

• Breastfeed on demand and let the infant come off the breast by them-
selves.

• Avoid holding the breast in a ‘scissor hold’.

• Avoid wearing tight clothing

What to do
Do not stop breastfeeding. If the breast milk is not removed the risk of abs-
cesses increases. Let the baby feed as often as they want to.

• Apply warm water or a hot towel on the breast.

• Hold the baby in different positions, so that the baby’s tongue or chin is
close to the site of the plugged duct.

The baby’s tongue or chin will massage the breast and release the milk from
that part of the breast.

• Ensure good attachment by the baby.

• For plugged ducts, apply gentle pressure to the breast with the palm,
rolling fingers towards the nipple.

Express milk or let the baby feed every 2-3 hours, day and night.

• The mother should rest.

• The mother should drink more liquids.

• If there is no improvement in 24 hours, refer patient to a health facility.

• If mastitis, express the breast if it’s too painful to suckle the baby

Breastfeeding Prevention What to do

difficulty
• First evaluate if the
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Not enough milk per- • Put the baby skin-to baby is getting enough
ceived by the mother • skin with the mother breast milk or not by
The mother believes • Start breastfeeding checking the baby’s
that she does not pro- within an hour of birth weight, urine and stool
duce enough milk. • • Ensure good attach- output. If the baby has
The baby is restless or ment poor weight gain, refer
unsatisfied • Encourage frequent both the mother and
demand feeding the baby to a health fa-
Real “not enough” • Let the baby come off cility.
breast milk • The baby the breast first • Listen to the
is not gaining weight. • Breastfeed exclus- mother’s concerns and
The trend line on the ively, day and night why she thinks she
growth chart for the in- • Encourage use of does not produce
fant who is less than 6 suitable family planning enough milk
months is flat or slopes methods • Assess if there is a
downward • Infants clear cause of difficulty
after day 4 up to 6 in breastfeeding, for in-
weeks should pass ur- stance having a poor
ine at least 6 times a breastfeeding pattern,
day, and pass stool 3-4 the mother’s mental
time a day condition, or if the baby
or mother is ill. • Build
the mother’s confid-
ence and reassure her
that she can produce
enough milk. • Explain
what the difficulty may
be due to growth spurts
that occur around 3
weeks, 6 weeks, and 3
months, or due to
cluster feeding instead
of feeding on demand.
• Explain the import-
ance of removing as
much breast milk as
possible from the
breast, • Check and im-
prove on the baby’s at-
tachment. • Suggest
stopping any supple-
ments being given to
the baby. Advise that
the baby should be
given no water, for-
mula, tea or liquids. •
Avoid separation of the
mother and baby, and

30
 extensive care of the
baby by others. The
mother should express
breast milk when away
from baby. • Suggest
improvements to the
baby’s feeding pattern.
Feed the baby fre-
quently on demand,
day and night.

Chapter six

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