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Protecting Babies: Breastfeeding and Sleeping


Learning Objectives

By the end of this presentation, participants will be able to:

1. State recommendations for breastfeeding initiation and duration rates of the American Academy of Pediatrics (AAP), the World Health Organization (WHO), and the breastfeeding goals of Healthy People 2010.

2. Provide anticipatory guidance on:

- importance of breastfeeding

- needs of babies

- benefits of breastfeeding exclusively for first six months


Learning Objectives

3.Discuss the risks and benefits of parent-infant bed

sharing.

4. Discuss the AAP safe sleeping recommendations for breastfeeding mothers.

5.Provide information on continuum of safe sleeping environments.


AAP Breastfeeding Recommendations

“…exclusive breastfeeding is sufficient to support optimal growth and development for approximately the first six months of life… Breastfeeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child.”

(AAP, 2005)


WHO Breastfeeding Recommendations

“…exclusive breastfeeding for six months is the optimal way of feeding infants. Thereafter infants should receive complementary foods with continued breastfeeding up to two years of age or beyond.”

(WHO, 2007)


Breastfeeding Definitions

  • Full Breastfeeding: Exclusive; almost exclusive.

  • Exclusive: No other liquid or solid given.

  • Almost exclusive: Not more than one or two swallows of vitamins, water, ritual food not more than 1-2 times a day.

  • Partial:

    • Low: supplementation of less than 20% of feeds

    • Medium: supplementation of 20-79% of feeds

    • High: supplementation of more than 80% of feeds

  • Token: “Breastfeeding episodes have insignificant caloric contribution.”

    (Modified from Labbok M, Krasovec K: Toward consistency in Breastfeeding definitions. Stud Fam Plan 21:226, 1990. Cited in Lawrence, 2005)


Healthy People 2010 Breastfeeding Goals

  • Seventy-five percent breastfeeding initiation rate.

  • Fifty percent continuing to breastfeed at six months.

  • Twenty-five percent continuing to breastfeed at one year.


Healthy People 2010 Exclusive Breastfeeding Goals

  • Sixty percent exclusively breastfeeding at three months.

  • Twenty-five percent exclusively breastfeeding at six months.

    (DHHS, Office of Disease Prevention and Health Promotion, 2005)


Breastfeeding Rates in Florida, 2005

  • Initiation: 71.1 %

  • 6 months: 35.0 %

  • 12 months: 16.0 %

  • 3 months exclusive: 33.1 %

  • 6 months exclusive: 11.5 %

    (CDC, National Immunization Survey, 2005)


Florida WIC Breastfeeding Rates, June 2007

  • Initiation: 70.02%

  • 6 months: 28.51%

  • 12 months: 23.15%

    (Statewide WIC Crystal Reports data, WIC Moms)


Risks of Not Breastfeeding: Infant Mortality

  • “Formula-fed Black infants are five times more likely to die than if breastfed.” (Black mothers were 2.5 times less likely to breastfeed than White mothers in this study.)

  • “Investigators found that breastfeeding accounts for as much of the race difference in infant mortality rates as does low birth weight.”

    (Forste R. et. al, Pediatrics, 2001. Cited by M. Biancuzzo, 2003)


Risks of Not Breastfeeding:Infant Mortality

  • “…postneonatal infant mortality rates in the United States are reduced by 21% in breastfed infants.” (Chen, Pediatrics, 2004. Cited by AAP, 2005)

  • “…a significant association (has been found) between breastfeeding and a lowered Sudden Infant Death Syndrome (SIDS) risk, especially when breastfeeding was…exclusive…during the first four months.” (Academy of Breastfeeding Medicine, 2003)


One Million Lives Might be Saved if Babies Breastfeed in the First Hour of Life

For rural Ghana:

  • Sixteen percent of newborn deaths could be prevented if newborns were breastfed exclusively from birth.

  • Twenty-two percent of newborn deaths could be prevented if newborns initiated breastfeeding within one hour of birth.

    (Edmond K et al (2006) Delayed Breastfeeding Initiation Increases

    Risk of Neonatal Mortality. Pediatrics, 117:380-386)


Invest in Breastfeeding

“In low resource areas…Improved breastfeeding alone could save the lives of more than 3,500 children every day, more than any other preventive intervention.”

(Innocenti Declaration, 2005. Cited in “Invest in Breastfeeding”, 2007. LLLI, WABA, WHO)


Breastfeeding in Emergencies

  • Nutritionally-perfect human milk is available without need for supplies.

  • Protects against infectious diseases.

  • Helps prevent hypothermia.

  • Hormone release relieves mother’s stress.

  • Provides security for mother and baby.

    (Adapted from AAP. “Infant Nutrition During a Disaster,” 2007)


Children Not Exclusively Breastfed for Six Months

Are about:

  • 40% more likely to develop Type 1 diabetes.

  • 25% more likely to become overweight or obese.

  • 60% more likely to suffer from recurrent ear infections.

    (National Breastfeeding Awareness Campaign Draft of Original Risk Statements from studies from developed countries. Cited by Walker, NABA, 2004.)


Children Not Exclusively Breastfed for Six Months

Are about:

  • 30% more likely to suffer from leukemia.

  • 100% more likely to suffer from diarrhea.

  • 250% more likely to be hospitalized for respiratory conditions and infections like asthma and pneumonia.

    (National Breastfeeding Awareness Campaign Draft of Original Risk Statements from studies from developed countries. Cited by Walker, NABA, 2004.)


Risks to Women if Not Breastfeeding

  • Increased postpartum bleeding and slower uterine involution.

  • Increased menstrual blood loss and closer child spacing without lactational amenorrhea (unless another form of contraception used).

  • Slower return to prepregnancy weight.

  • Increased risk of breast cancer.

  • Increased risks of ovarian cancer.

    (adapted from Breastfeeding and the Use of Human Milk, AAP 2005)


Risks to Women if Not Breastfeeding

  • Increased risk of osteoporosis.

  • Increased risk of long-term obesity.

  • Increased risk of weaker attachment to baby.

  • Increased risk of anxiety and lack of confidence.

    (Adapted from United States Breastfeeding Committee, 2002)


Global Frameworkof Protection and Support

  • International Code of Marketing of Breast milk Substitutes - WHO/United Nations Children’s Fund (UNICEF)

    (“WHO Code”).

  • Baby-Friendly Hospital InitiativeTM (BFHI)

    UNICEF/WHO.


WHO Code - Recommendation

  • Aim - “Contribute to the provision of safe and adequate nutrition for infants by the protection and promotion of breastfeeding and by ensuring the proper use of breast-milk substitutes, when these are necessary, on the basis of adequate information and thorough appropriate marketing and distribution.”

    (Biancuzzo, 2003)

  • Integration into County Health Departments and WIC Agencies: County Health Department Guidebook, TAG: Maternal 9

    (CHD Guidebook, TAG: Maternal 9.)


WHO Code - Summary of Provisions

  • Scope

    • Breast milk substitutes.

    • Feeding bottles and teats.

    • The quality, availability, and information concerning the use of above products.

      (ILCA, Core Curriculum…, 2007)


WHO Code - Promotion of Items Within Scope

  • “There should be no advertising or other form of promotion to the general public of products within the scope of this Code.”

  • “No facility of a health care system should be used for the purpose of promoting infant formula or other products within the scope of this Code.”

  • “No financial or material inducements to promote products should be offered by manufacturers or distributors to health workers or members of their families, nor should these be accepted by health care workers.” (Biancuzzo, 2003)


Baby-Friendly Hospital InitiativeTM (BFHI) - WHO/UNICEF

  • Purpose: Rid hospitals of dependence on breast milk substitutes; encourage maternity services to support breastfeeding.

  • Promote adoption of the, “Ten Steps to Successful Breastfeeding.”

  • Remove hospital barriers to breastfeeding “by creating a supportive environment with trained and knowledgeable health care workers.”

    (ILCA, Core Curriculum, 2007)


“Ten Steps to Successful Breastfeeding”

  • Have a written breastfeeding policy that is routinely communicated to all health care staff.

  • Train all health care staff in skills necessary to implement this policy.

  • Inform all pregnant women about the benefits and management of breastfeeding.


“Ten Steps to Successful Breastfeeding”

  • Help mothers initiate breastfeeding within a half hour (one hour in U.S.) of birth.

  • Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants.


“Ten Steps to Successful Breastfeeding”

  • Give newborn infants no food or drink other than breast milk unless medically indicated.

  • Practice rooming-in: enable mothers and infants to remain together 24 hours a day.


“Ten Steps to Successful Breastfeeding”

  • Encourage breastfeeding on demand.

  • Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.

  • Foster the establishment of breastfeeding support groups and refer mothers to them upon discharge from the hospital or clinic.

    (Division of Child Health and Development. Evidence for the ten steps to successful breastfeeding. Geneva: WHO. 1998- Cited in Core Curriculum, 2007.)


Breastfeeding - the NormNeeds of Babies

  • The human baby is the most neurologically immature of all mammals at birth and the slowest to develop.

  • Born with 25% of adult brain volume, 60% at one year, and 100% at 14-17 years. (McKenna, 2007)

  • Long chain polyunsaturated fatty acids, docosahexanoic acid (DHA) and arachidonic acid (ARA) found in human milk, are important for brain, nervous system, and visual development.


Breastfeeding - the NormNeeds of Babies

  • Automatic body contact - touch essential for survival and proper development. Increases “production of growth hormones and the immune system.”

    (Klaus, M. The Amazing Newborn, 1998. Cited in ILCA “Background Information” WBW 2007.)

  • Human milk is species-specific for normal growth and development. “Is extremely complex and composition is most likely programmed by chemical communication between the mother and infant, both pre- and postnatally.” Active and provides disease protection. Cannot be duplicated by artificial baby milk (ABM).

    (Walker, “Artificial Baby Milks” Core Curriculum, 2007)


Brain Food a Snuggle Away

  • DHA and ARA added to ABM are not equal to the complex fatty acid patterns in human milk.

  • Clinical studies have failed to show that the additives are effective regarding improved mental, motor, visual, or general development.

    (Simmer, 2003; Wright et al., 2006- cited in Mannel, Martens, Walker. ILCA, 2007)


Mother as EnvironmentNeeds of Babies

  • Composition of breast milk requires frequent feeding.

  • “Separation distress cry” when separated.

    (Christensson et al., 1995, cited by McKenna, 2007)

  • Levels of stress hormones rise and temperature, blood sugar, breathing, and heart rate become unstablewhenseparated.

    (Christensson et al., 1995, cited by McKenna, 2007)


Mother as EnvironmentNeeds of Babies

  • False expectation that babies should sleep through the night. Adaptive. Opinion is culturally based. Arousal mechanisms in baby ill-prepared for deep sleep.

  • Contact with mother helps with arousal.

    (McKenna, 2007)


Anticipatory Guidance: Early Breastfeeding

  • “Help mothers initiate breastfeeding within a half-hour of birth.”

    (Step 4 - Baby Friendly Hospital Initiative’s (BFHI), “Ten Steps to Successful Breastfeeding.”)

  • Encourage and support breastfeeding during the first hour of life.

    (ILCA.“Background Information, Breastfeeding: The 1st Hour-Welcome Baby Softly, WBW, 2007.)


Early Initiation ThroughSkin-to-Skin Contact

  • Facilitates infant’s self-attachment to breast within first two hours after birth if undisturbed and unmedicated. (Anderson et al, 2003)

  • Oxytocin released makes colostrum available to baby.

  • Increases milk production and infant weight gain. (Bier et al, 1996. cited by ILCA, WBW, 2007)


Early Initiation and Uninterrupted Skin-to-Skin Contact

  • Increases amount of milk pumped for premature baby.(Hurst N et al, 1997)

  • Increases breastfeeding duration.

  • Infant “quickly adapts to the visual, auditory, and touch stimuli, and physiological benefits are seen, including: improved infant state organization, thermal regulation, stabilized heart and breathing rates, and oxygen levels.” (Ferber, 2004; Bergman, 2004; Tornhage, 1999; cited by ILCA, WBW, 2007)


Skin-to-Skin ContactEarly Initiation of Breastfeeding

  • Babies like flavor of amniotic fluid and colostrum. (Mennella, 1991)

  • Searches for breast; taste and lick nipple. Helps baby learn to bring tongue down and protrude it for effective latch. (Mathieson, 2001)

  • Increases mother’s confidence in caring for baby.

  • Oxytocin aids mother in attachment with baby. (ILCA, WBW, 2007)


Skin-to-Skin Contact

  • Releases oxytocin, which has a sedative effect on infants.

    (Uvnas, 1998)

  • Causes babies to cry up to 10 times less than babies who do not receive skin-to-skin contact in the first hour of life.

    (Charpak, 2001. cited by ILCA, WBW, 2007)

  • Comforts baby and helps with breastfeeding when continued after early postpartum period.


Further Assistance with Breastfeeding

  • Room-in with baby 24/7.

  • Help prepare a plan to limit visitors to provide time alone with baby to snuggle and breastfeed, as mother desired.

  • Exclusively breastfeed, unless there is a rare medical contra-indication.

  • Giving ABM decreases the duration of breastfeeding.


Ongoing Breastfeeding Support

Step 9 – Baby Friendly Hospital Initiative’s (BFHI), “Ten Steps to Successful Breastfeeding states

  • “Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.”

    (

  • Soothe in other ways (e.g. by breastfeeding, changing, holding, skin-skin, rocking, singing, dancing, walking with, swaddling, burping, someone else holding, white noise, household noises, massaging, and going outside).


Breastfeeding Support

  • Refer to breastfeeding support group - WIC, La Leche League (LLL), hospital, birthing center, private - Step 10 (BFHI).

  • Breastfeed at least 8-12 times every 24 hours to prevent engorgement, produce and provide sufficient milk to baby.

  • The more milk removed from the breast, the more milk made.


Breastfeeding Support

  • Baby-led latch -baby well-supported and placed between mother’s breasts.

  • Mother-led latch - positioned comfortably, healthy baby can often latch by himself.

  • Breastfeed with early hunger cues - crying the latest cue, more difficult latch.

  • Refer to International Board Certified Lactation Consultant (IBCLC), LLL, or knowledgeable helper if having difficulty.


Breastfeeding Support

  • Baby-led beginning and ending of nursing session.

  • Watch baby, not clock, for hunger cues.

  • Drowsy, quiet-alert, active alert states.

  • Baby may need one or both breasts at each session - breast for comfort, thirst, as well as full meal - Analgesic.

  • Cluster feeding normal, often in evening.


Breastfeeding Support

“All breastfeeding newborn infants should be seen by a pediatrician or other knowledgeable and experienced health care professional at 3-5 days of age…and a second…visit at 2-3 weeks of age….”

(AAP Policy Statement, Section on Breastfeeding, 2005)


Signs of Effective Breastfeeding Baby

  • Weight loss less than seven percent of birth weight.

  • Three or more bowel movements per day after day one.

  • Seedy, yellow bowel movements by day five.

  • At least six wet diapers per day by day four.

  • Satisfied baby.

  • Audible swallowing.

  • No weight loss after day three; gaining weight by day five.

  • Back to birth weight by day 10.

    (Clinical Guidelines for the Establishment of Exclusive Breastfeeding, ILCA, 2005)


Signs of Effective Breastfeeding Mother

  • Noticeable increase in firmness, weight, and size of breast and noticeable increase in milk volume by day five.

  • Nipples not damaged.

  • Breast fullness relieved by breastfeeding.

  • Refer to IBCLC, LLL, or other knowledgeable helper if neither baby nor mother shows signs of effective breastfeeding.

    (Clinical Guidelines for the Estab. Excl Breastfeeding, ILCA, 2005)


Prenatal - Address Barriers

  • Fear of Pain

  • Lack of Confidence

  • Embarrassment

  • Time and Social Constraints

  • Lack of Social Support

    (Loving Support© Through Peer Counseling, 2005)


Talking with Mothers About Breastfeeding Prenatally

  • Open ended question:

    “What have you heard about breastfeeding?” Does not lock her into a choice.

    (“It hurts!!-I don’t want to do it.”)

    (Loving Support©Through Peer Counseling Curriculum, 2005)


Talking with Mothers About Breastfeeding Prenatally

  • Affirmation:

    “I don’t blame you, Latoya. Many women are worried about pain. No one wants to do something that hurts.”

    (May feel heard and open to new ideas.)

    (Loving Support©Through Peer Counseling Curriculum, 2005)


Talking with Mothers About Breastfeeding Prenatally

  • Targeted education:

    “How would you feel about breastfeeding if it didn’t hurt?” (Latoya: “I’d try it.”)

    “Breastfeeding isn’t supposed to hurt. When your baby takes enough of your breast far into her mouth, your nipple isn’t pinched and you are comfortable.”

    (Loving Support© Through Peer Counseling Curriculum, 2005)


Prenatal Breastfeeding Support

  • Refer to breastfeeding classes in community (e.g. WIC, LLL, birthing facility, childbirth educator, IBCLC, Healthy Start).

  • As mother is willing, discuss plan to limit visitors to provide time alone with baby to snuggle and breastfeed.


Prenatal Breastfeeding Support

  • Childbirth education classes discuss breastfeeding; may need little or no medication and/or birth interventions; a help to breastfeeding. Healthy Start may offer this service.

  • Doula or knowledgeable support person during labor and/or postpartum. Healthy Start perhaps.


Breastfeeding Resources

  • International Board Certified Lactation Consultants (IBCLC) http://www.ilca.org

  • La Leche League (LLL) http://www.laleche.org

    LLL, 24- hour toll- free hotline: 1-877-452-5324

  • WIC: IBCLC’s, peer counselors, registered dietitians, or licensed dietitians with breastfeeding training.


Bed Sharing and Breastfeeding

There is disagreement among health care professionals about the benefits and risks of parent-infant bed sharing.


Risks:

SIDS

Suffocation

Falling out of bed

Benefits:

Increased breastfeeding

Enhanced closeness

Increased awareness and response to infant needs

More infant arousals and less deep sleep for infant

Benefits and Risks of Bed Sharing


Bed Sharing

“When all known adverse bedsharing risks are avoided, breastfeeding and bedsharing infants are under represented in SIDS and SUID populations.”

(McKenna, 2007)


Recent Findings of SIDS In Breastfed Infants who Bed Shared

  • Netherlands study found bed sharing to be a serious risk factor for SIDS for babies less than 4 months old even after adjusting for breastfeeding and smoking.

  • ECAS study found that bed sharing doubled the risk of SIDS for both breastfed and bottle bed infants.

    Source: Ruys J Acta Paediatrica 2007

    Carpenter R Paediatr Child Health 2006


Sleep Environment

  • Co-sleeping:" The universal contextof infant sleep development - a generic sleeping arrangement in which mother and infant exchange and have access to each other’s sensory modalities (within arm’s reach).”

  • Bed Sharing: a form of co-sleeping.

    (McKenna, 2007)


Sleep Environment

  • Mother as baby’s environment (habitat), wherever they are.

  • Breastfeeding mothers have a drastically different sleep relationship with their babies than do mothers giving ABM. (Helen Ball, cited by McKenna, 2007)


Sleep Environment

  • Breastfeeding and co-sleeping are part of same adaptive complex: maximizes survival and parental reproductive success. Integrated, adaptive system, mutually reinforcing.

  • Biology of infant sleep development and breastfeeding intertwined. Both must be studied together. Babies immature system supported by mother.

    (McKenna, 2007)


Reasons Given for Bed Sharing

  • No crib.

  • Easier to breastfeed at night.

  • To avoid crib death.

  • Family tradition.

  • To spend quality time.

  • Too tired to get up.

  • To keep baby warm.

  • Baby sleeps better.

    (Survey conducted by Palm Beach County Health Department)


AAP Task Force on Sudden Infant Death Syndrome

In 2005 the task force came out with new recommendations for reducing the risk of SIDS in the general population.

They recommended that infants not bed share during sleep.

Many groups came out in opposition to this specific recommendation.


Safe Sleep for Babies AAP Task Force on SIDS

  • Bed sharing, “as practiced in the United States…is more hazardous than the infant sleeping on a separate surface…recommends that infant not bed share during sleep.”

  • “Infants may be brought into bed for nursing or comforting but should be returned to their own crib or bassinet when the parent is ready to return to sleep.”


Safe Sleep for Babies AAP Task Force on SIDS

  • Do not bed share if parent is excessively tired or using medications or substances that could impair his or her alertness.

  • Back to sleep - always, not on side. Inform other caregivers/day care.

  • Do not smoke during pregnancy – major risk. Avoid second-hand smoke.


Safe Sleep for Babies AAP Task Force on SIDS

  • Firm sleeping surface. A firm crib mattress, covered by sheet. No pillows, quilts, sheepskins, soft objects (toys). If bumper pads: thin, firm, well secured.

  • No loose bedding. Tucked in if used. Feet to foot as possibility. Sleep clothing - no other covering.


Safe Sleep for Babies AAP Task Force on SIDS

  • Pacifier - after breastfeeding is well established and does not interfere with breastfeeding - if mother chooses. AAP Task Force on SIDS says to “consider” offering one at nap and bedtime after one month.

    (Policy Statement, 2005)


Safe Sleep for Babies AAP Task Force on SIDS

A separate, but proximate sleeping environment: room share. Use cribs that meet current safety standards.


Safe Sleep for Babies AAP Task Force on SIDS

  • Place infant’s crib or bassinet in parents’ bedroom, close enough for convenient breastfeeding and contact.

  • Do not bed share with other children.

  • Very dangerous to sleep with an infant on couch or armchair. Never do this.

  • Avoid overheating. Infant lightly clothed for sleep. Bedroom temperature comfortable for lightly clothed adult. Should not feel hot to touch.


Provide Education During Postpartum Hospital Stay

  • Why back sleeping is important.

  • The advantages of back sleeping.

  • How infants sleep.

  • The risks associated with bed sharing.

  • Strategies to help infants learn to sleep on their own.

  • Benefits of breastfeeding.

  • Sensitive care giving.


Bed Sharing Environment

  • Exclusively breastfeeding.

    • Mother automatically sleeps facing infant. Place baby on back.

    • Increased arousals, often baby-led.

    • Lighter sleep for infant.

  • Large mattress on floor away from furniture.

  • Never use a couch. Most bed sharing deaths are due to furniture.

    (McKenna, 2007)


Academy of Breastfeeding Medicine Guidelines

  • Breastfeed your baby exclusively for six months.

  • Place the baby next to the mother and not between parents.

  • Place the baby on his back when sleeping.

  • Take precautions to prevent baby from rolling out of bed (do not leave baby alone).

    (Academy of Breastfeeding Medicine, 2005b)


Academy of Breastfeeding Medicine Guidelines

  • Use the largest adult bed you can afford, such as a king-sized mattress.

  • Make sure that there are no spaces between mattress, head board, walls, or rail slats in which baby’s head can be entrapped.

  • Use a thin blanket, not a heavy quilt or duvet in the parents’ bed, and adjust the room temperature for comfort.

    (Academy of Breastfeeding Medicine, 2005b)


AAP Section on Breastfeeding

“Mother and infants should sleep in proximity to each other to facilitate breastfeeding.”


“If your baby is not exclusively breastfed, roomsharing is the safest form of cosleeping for your family.”

(McKenna, 2007)


Never Bed Share When

  • Mom or partner smokes.

  • Mom or partner is obese.

  • Baby is premature or small for gestational age.

  • Mom or partner has been drinking alcohol or using drugs or medications.

  • Mom or partner is excessively tired.

  • Older siblings or pets are sharing the bed.

  • With someone other than parent (baby-sitter, grandparent).

    (Academy of Breastfeeding Medicine, 2005b; Sears, 2005; McKenna, 2007)


Never Bed Share On

  • Cushiony or soft surfaces (i.e. waterbeds, pillows, air mattresses, beanbags, or futons).

  • Couches, armchairs, or recliners.

  • Beds with pillows, comforters, or duvets.

  • Beds with spaces between mattress, head board, walls, or rail slats in which baby’s head can be entrapped.


“For the First Time in American History

all pediatric scientists agree that co-sleeping in the form of room sharing should be supported not only because it facilitates breastfeeding but because a mother sleeping proximate to her infant reduces the infant’s chances of SIDS.”

Source: McKenna J Sleeping With Your Baby, 2007


“An Island of Peace”

“The baby at the breast represents the common language of mothering. Babies have basic needs that do not change, regardless of when or where they are born. And the beautiful natural act of nursing your little one has this same timeless quality. It is a link to other mothers and sign, even, of womanly power. The ability of a mother’s body to nurture her child is a source of strength to her. And through breastfeeding’s gentling effect, an island of peace is secured. It is a small miracle, belonging rightfully to mothers, babies, and families the world over.”

(LLLI, The Womanly Art of Breastfeeding, 2004, cited in“Invest in Breastfeeding”, 2007. LLLI, WHO, WABA)


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