Breastfeeding in Working Mother Lalitawadee Tungsuputi, MD
Outline • กฎหมายท ี ่ เก ี ย่วขอ ้ งกบ ั การลามารดาหลง ั คลอด • Tips for working and breastfeeding • Planning during pregnancy • Preparing at home for your return • Returning to work
Maternity Protection Convention, 2000 • shall be entitled to a period of maternity leave of not less than 14 weeks. • The prenatal portion of maternity leave shall be extended by any period elapsing between the presumed date of childbirth and the actual date of childbirth, without reduction in any compulsory portion of postnatal leave. • A woman shall be provided with the right to one or more daily breaks or a daily reduction of hours of work to breastfeed her child.
Maternity Protection Convention, 2000 Only 43 countries ratifications
• การลาคลอดบต ุ รจะลาในวน ั ท ี ค่ลอด กอ่น หรอ ื หลง ั วน ั ท ี ค่ลอดบต ุ รก็ได้ แต่ เม ื อ่รวมวน ั ลาแลว ้ ตอ ้ งไม่เกน ิ 90 วัน (น ั บตอ่เน ื ่องรวมวน ั หย ุ ดราชการ) • ลาตอ่เน ื ่องจากการคลอดบต ุ รไดไม่ ้ เกิน 150 วันท าการ แต่จะไม่ได้รับ เงินเดือนระหว่างลา ระเบียบว่าด้วยการลาของข้าราชการ • ขยายวน ั ลาคลอดของแม่ท ี ่ เป็ น ข้าราชการหญิง โดยได้รับค่าจ้าง จากเดิมไม่เกิน 90 วัน เป็ น 98 วัน (เพ ิ ม่ข ึ น้ 8 วัน) • ลาเพ ิ ม่ ไดอ ้ ก ีไม่เกน ิ 90 วัน โดย ได้รับเงินเดือนในอัตรา 50% พ.ศ. 2555 พ.ศ. 2565 มาตรการดงักลา่วยงัไม่มผีลในขณะนี ้
• ลาไดค ้ ร ั ้งหน ึ ่งตด ิ ตอ่กน ัไม่เกิน 15 วัน ท าการ (จะลาเป็ นช่วง ๆ เว้นระยะ ไม่ได้) • ลาภายใน 30 วน ั น ั บต ั ้งแตว่น ั ท ีภริยา่ คลอดบุตร มีสิทธิได้รับเงินเดือน ระหว่างการลา ระเบียบว่าด้วยการลาไปช่วยภริยาคลอดบุตรของ ข้าราชการ • มีสิทธิลาได้ 15 วันท าการ เป็ น ช่วง ๆ ไม่ติดต่อกันจนครบวันลา พ.ศ. 2555 พ.ศ. 2565 มาตรการดงักลา่วยงัไม่มผีลในขณะนี ้
พระราชบัญญัติคุ้มครองแรงงาน (ฉบบ ั ท ี ่ 7) พ.ศ.2562 เร ื อ ่ ง ลาเพ ื อ ่ คลอดบ ุ ตร • หญงิมค ี รรภจ ์ ง ึสามารถลากอ่นคลอดเพ ื อ่ ไปตรวจครรภเ ์ป็ นระยะๆไดน ้ับแตว่นัตั ้งครรภ ์ และ เม ื อ่คลอดบตุรสามารถลาตอ่เน ื ่องไดโ้ ดยนับรวมวนัลาคลอดบตุรครรภห ์ น ึ ่งไมเกิน ่ 98 วัน ทั ้งน ี ้การนับวนัลาเพ ื อ่คลอดบตุร ใหน ้ับรวมวนัหยดุประจ าสปัดาห ์ วนัหยดุตามประเพณ ี ท ี ม่ี ระหว่างวันลาการคลอดบุตรด้วย • ลูกจ้างยังคงได้รับค่าจ้างจาก นายจ้างเท่ากับค่าจ้างในวันท างานตลอดระยะเวลาท ี ล่า แตไ่ม่ เกิน 45 วัน
Tips for Working & Breastfeeding
Planning during pregnancy Preparing at home for your return Returning to work
Planning during pregnancy 1. Communicating with supervisor and co-worker 2. Finding pumping space at work 3. Breastfeeding supportive childcare (ศูนย์เด็กเล็กน่าอยู่คู่นมแม่)
Planning during pregnancy 1. Communicating with supervisor and co-worker
2. Finding pumping space at work Planning during pregnancy คู่มือการจัดท ามุมนมแม่ในสถานประกอบกิจการ, มูลนิธินมแม่แห่งประเทศไทย
3. Breastfeeding supportive childcare (ศูนย์เด็กเล็กน่าอยู่คู่นมแม่) • Look for onsite-day care • Look for a baby-sitter near your workplace Planning during pregnancy
Preparing at home for your return 1. Practicing pumping 2. Get baby use to the bottle – but not to soon
Preparing at home for your return 1. Practicing pumping • Start pumping about 2-3 weeks before you plan to return to work • If you’re trying to build up your milk supply or stockpile milk, pump in between nursing sessions when you’re with your baby. • Aim to spend 15 to 20 minutes hooked up to the pump to net a good amount of breast milk • Some moms are able to pump from one breast while baby is nursing on the other
Preparing at home for your return 2. Get baby used to the bottle – but not too soon • Offering a bottle at the time your baby is learning the fine art of latch-on • If the bottle is introduced too soon, some babies develop nipple confusion • Most experts suggest waiting until your baby is 4 to 6 weeks old • If you're returning to work after maternity leave, start bottle-feeding several weeks before you go back. That way, you'll have plenty of time for them to adjust to the bottle
Returning to work 1. Get thing ready the night before 2. Pumping at work place 3. Breast milk handling and storage 4. Cleaning breast pump kit
Returning to work 1. Get thing ready the night before • Pack the baby’s bag • Pack pumping equipment • Prepare the amount of milk needed for tomorrow
How to thaw breast milk In a bowl of water (room temperature) 1-2 hours. In refrigerator (4°C) 24 hours. from the time it is completely thawed, not from the time when you took it out of the freezer “Never refreeze thawed milk” CDC, breastfeeding Guidelines and recommendations
Returning to work 2. Pumping at work place • Place: your desk, empty room, pumping room • Wash your hand before pumping • Every 2-3hours If you work an eight-hour day, this means pumping at mid-morning, at lunch, and at mid-afternoon • If you pump both breasts at the same time >>15 to 20 minutes • if you pump each breast separately >> 30 minutes
Returning to work 3. Breastmilk handling & storage • Use breast milk storage bags or clean, foodgrade containers to store expressed breast milk • Clearly label the breast milk with the date it was expressed • Breast milk can be stored in an insulated cooler with frozen ice packs for up to 24 hours when you are working. At your home, use the milk right away, store it in the refrigerator, or freeze it. CDC, breastfeeding Guidelines and recommendations
Ref. flipchart 10 steps breastfeeding in sick baby
Returning to work 4. Cleaning breast pump kit: after every use CDC, breastfeeding Guidelines and recommendations
Returning to work CDC, breastfeeding Guidelines and recommendations
For extra protection, Sanitize • Steam • Boil Boil for 10-15 minutes • Dishwasher with sanitize setting CDC, breastfeeding Guidelines and recommendations
The revised Baby-Friendly Hospital Initiative 2018: 10 Steps to Successful Breastfeeding Meera Khorana MBBS. Queen Sirikit National Institute of Child Health July 2023
study of preterm infants fed an exclusive human milk diet compared with those fed human milk supplemented with cow-milk-based infant formula products noted a 77% reduction in NEC.19 One case of NEC could be prevented if 10 infants received an exclusive human milk diet, and 1 case of NEC requiring surgery or resulting in death could be prevented if 8 infants received an exclusive human milk diet.19 Sudden Infant Death Syndrome and Infant Mortality Meta-analyses with a clear definition of degree of breastfeeding and adjusted for confounders and other known risks for sudden infant death syndrome (SIDS) note that breastfeeding is associated with a 36% reduced risk of SIDS.13 Latest data comparing any versus exclusive breastfeeding reveal that for any breastfeeding, the multivariate odds ratio (OR) is 0.55 (95% confidence interval [CI], 0.44–0.69). When computed for exclusive breastfeeding, the OR is 0.27 (95% CI, 0.27–0.31).20 A proportion (21%) of the US infant mortality has been attributed, in part, to the increased rate of SIDS in infants who TABLE 2 Dose-Response Benefits of Breastfeedinga Condition % Lower Riskb Breastfeeding Comments ORc 95% CI Otitis media13 23 Any — 0.77 0.64–0.91 Otitis media13 50 ≥3 or 6 mo Exclusive BF 0.50 0.36–0.70 Recurrent otitis media15 77 Exclusive BF ≥6 mod Compared with BF 4 to <6 mod 1.95 1.06–3.59 Upper respiratory tract infection17 63 >6 mo Exclusive BF 0.30 0.18–0.74 Lower respiratory tract infection13 72 ≥4 mo Exclusive BF 0.28 0.14–0.54 Lower respiratory tract infection15 77 Exclusive BF ≥6 mod Compared with BF 4 to <6 mod 4.27 1.27–14.35 Asthma13 40 ≥3 mo Atopic family history 0.60 0.43–0.82 Asthma13 26 ≥3 mo No atopic family history 0.74 0.6–0.92 RSV bronchiolitis16 74 >4 mo — 0.26 0.074–0.9 NEC19 77 NICU stay Preterm infants Exclusive HM 0.23 0.51–0.94 Atopic dermatitis27 27 >3 mo Exclusive BFnegative family history 0.84 0.59–1.19 Atopic dermatitis27 42 >3 mo Exclusive BFpositive family history 0.58 0.41–0.92 Gastroenteritis13, 14 64 Any — 0.36 0.32–0.40 Inflammatory bowel disease32 31 Any — 0.69 0.51–0.94 Obesity13 24 Any — 0.76 0.67–0.86 Celiac disease31 52 >2 mo Gluten exposure when BF 0.48 0.40–0.89 Type 1 diabetes13, 42 30 >3 mo Exclusive BF 0.71 0.54–0.93 Type 2 diabetes13, 43 40 Any — 0.61 0.44–0.85 Leukemia (ALL)13, 46 20 >6 mo — 0.80 0.71–0.91 Leukemia (AML)13, 45 15 >6 mo — 0.85 0.73–0.98 SIDS13 36 Any >1 mo — 0.64 0.57–0.81 ALL, acute lymphocytic leukemia; AML, acute myelogenous leukemia; BF, breastfeeding; HM, human milk; RSV, respiratory syncytial virus. a Pooled data. b % lower risk refers to lower risk while BF compared with feeding commercial infant formula or referent group specified.FROM THE AMERICAN ACADEMY OF PEDIATRICS PEDIATRICS Volume 129, Number 3, March 2012 Result of 28 systema3c reviews and meta-analyses Non-BreasNed infants ü Higher risk of all-cause and infec3on related mortality (< 2 years) ü Increased risk of diarrhea and respiratory infec3ons & hospital admission due to them ü Increased risk of acute o33s media (< 2 years) ü Increased risk of asthma in children 5-18 years ( low grade quality of evidence) ü Increased risk of AR in children up to 5 years, eczema up to 2 years ü Increased risk of dental malocclusion (but dental caries increased If breast fed> 1 year) ü Increased odds of overweight and obesity ü Increased risk of Type 2 DM , lower IQ
Meera Khorana M.B.B.S Queen Sirikit National Institute of Child Health 23rd May, 2016 Sankar MJ, Sinha B, Chowdhury R etal. Acta Pediatrica 2015; 104: 3-13
Lancet July 5 ,2003; 362: Dr Gareth Jones PhD, Richard W Steketee MD, et al The Bellagio Child Survival Study Group
WHO & UNICEF เสนอโครงการรพ.สายส ั มพน ั ธ ์ แม ่ ล ู ก(BabyFriendly Hospital Initiative) เพื6อผลักดันรพ.ทั6วโลกให้สงเสริม การเลย ี @ งล ู กด ้ วยนมแม ่ อย ่ าง เดย ี ว6เด ื อนและมก ี ารเลย ี @ งล ู กด ้ วยนม แม่รวมกับอาหารเสริมตามวัยจนถึงขวบปี ที6 2 หรือนานกวานั@น
บันได 10 ขั)นส ่ ◌ ู ความสําเร็จของการเลย ี ) งล ู กด ้ วยนมแม ่ Ten Steps to Successful Breastfeeding บันได 10 ขั้นสู่ความสําเร็จของการเลี้ยงลูกด้วยนมแม่
Overview 10 steps first published 1989 (BE 2532) The Innocenti Declaration on the protection, promotion and support of breastfeeding 1990 (BE 2533) WHO and UNICEF Baby Friendly Hospital Initiative (BFHI) 1991 (2534) Hospitals adhering to ALL the 10 steps: “Baby - friendly”
Overview Almost all countries in the world have implemented BFHI at some point Coverage has remained low In 2017, WHO estimated that 10% of babies in the world were born in “Baby – friendly” facilities Evidence shows that BFHI has potential to significantly influence success with breastfeeding
Strength and Impact of BFHI Adherence to 10 steps impacts rates of breastfeeding early initiation immediately after birth, exclusive breastfeeding total duration of any breast feeding Avoiding Supplementation demonstrated to be a crucial factor in determining breastfeeding outcomes Community support proved crucial to maintaining the improved breastfeeding rates Perez-Escamilla R, Martinez JL, Segura-Perez S. Impact of the BFHI on breastfeeding and child health outcomes: a systematic review. Matern Child Nutr. 2016;12: 402-17 Systematic review (58 studies)
30 26.9 21.5 15.5 13.7 6.2 3.2 0 5 10 15 20 25 30 35 0 1 2 3 4 5 6 Number of “Baby-friendly” practices reported Ann M.DiGiramo et al. pediatrics 2006; 122:S43-S49 % of mothers who Stopped breastfeeding before 6 week One study based in the United States of America (USA) found that adherence to six of the specific maternity care practices could reduce the odds of early termination of breastfeeding 13 –fold (see Fig.1) (43) Fig.1. Among women who initiated breastfeeding and intended to breastfeed for > 2 month, the percentage who stopped breastfeeding before 6 weeks, according to the number of Baby-friendly hospital practices they experienced (43) Dose - response relationship Number of BFHI steps the women were exposed to and likelihood of improved breastfeeding outcomes
5 12.3 23.1 14 28.6 0 5 10 15 20 25 30 35 2006 2013 2017 2019 2021 Percent Exclusive Breastfeeding rate at 6 Month Multiple Indicator Cluster Survey (MICS) UNICEF %
MICS 2017 2019 2022 Ever breastfed (%) 97.4 96.8 97.3 Exclusive 6 months (%) 23.1 (6.4 BKK) (40% Global) 14 (26.4 BKK) 28.6 Predominant BF(%) 42.1 (17.1 BKK) 40.7 (63.5 BKK) 45.3 BF within 1st hour (%) 39.9 (27.9 BKK) (44% Global) 34 (20.9 BKK) 29.4 BF with 1st DOL(%) 80.9 (54.7 BKK) 76.1 (63.9 BKK) --- Continues BF at 1yr(%) 33.3 (19.5 BKK) 24.6 (25.7 BKK) 31.3 Continued BF at 2 yr(%) 15.6 (14.5) (45% Global) 15 (3.7 BKK) 18.7 Thailand Multiple Indicator Cluster Survey (MICS) UNICEF
WHO and UNICEF recommend that breastfeeding be initiated within the first hour after birth, continued exclusively for the first 6 months of life and continued, with safe and adequate complementary foods, up to 2 years and beyond
Core Purpose of BFHI: Protect, Promote & Support Ensure that mothers and newborns receive timely and appropriate care before and during their stay in the facility providing maternal and newborn services Enable the establishment of optimal feeding of the newborns which promotes health and development Updated BFHI 2018: Implementation guidance. UNICEF & WHO
Health professional & BF • Breastfeeding is a biological norm, health professionals may perform inappropriate procedures that interfere with the initiation of breastfeeding; üSeparation of mother and infant üDelayed initiation of breastfeeding üUnnecessary supplementation
gBox 1. Ten Steps to Successful Breastfeeding (revised 2018) Critical management procedures 1. a. Comply fully with the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions. b. Have a written infant feeding policy that is routinely communicated to staf and parents. c. Establish ongoing monitoring and data-management systems. 2. Ensure that staf have sufcient knowledge, competence and skills to support breastfeeding. Key clinical practices 3. Discuss the importance and management of breastfeeding with pregnant women and their families. 4. Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth. 5. Support mothers to initiate and maintain breastfeeding and manage common difculties. 6. Do not provide breastfed newborns any food or fuids other than breast milk, unless medically indicated. 7. Enable mothers and their infants to remain together and to practise rooming-in 24 hours a day. 8. Support mothers to recognize and respond to their infants’ cues for feeding. 9. Counsel mothers on the use and risks of feeding bottles, teats and pacifers. 10. Coordinate discharge so that parents and their infants have timely access to ongoing support and care.
International Code of Marketing Written policy Monitoring STEP 1
1a Comply with the International Code of Marketing of Breast -milk Substitutes • Responsibility of the health care system NOT TO promote infant formula, feeding bottles or teats NOT TO display of any logos or brands on any products in the unit NOT TO give samples of infant samples to mothers to take home Acquire BM substitutes, feeding bottles, or teats through normal procurements
Code of marketing
1b. Have a written infant feeding policy Policy guarantees that appropriate care is equally provided to all mothers and babies Policies help sustain practices over time Communicate a standard set of expectations for all health workers Policy should also include guidance on clinical care practice implementation
1c. Monitoring & data – management system • Integrate recording and monitoring of clinical practices into quality improvement /monitoring system • Recommended indicators for facilitybased monitoring üEarly initiation of breastfeeding üExclusive breastfeeding • BFHI Committee to Review progress regularly (1, 6, 12 months)
Staff competency STEP 2 ฝึกอบรมบ ุ คลากรทางการ แพทย ์ และสาธารณส ุ ขท ุ กคน ให้มีทักษะที>จะนํานโยบายนีB ไปปฏิบัติ
2. Staff competency • Timely and appropriate care for BF mothers can be accomplished if staff have the knowledge, competence and skill • National üpre-service education system üon – service training • Didactic lectures, supervised clinical experience • Testing of competency