‘Complete Coverage & Covering Completely’ for Breastfeeding with Able, Bold, & Confident Mothers, for Sustainable Development, & Medical Education Excellence

Abstract

Complete coverage of all infants, everywhere with wonderful evidence, and covering completely with first six months of exclusive breastfeeding and thereafter proper weaning while continuing breastfeeding up to 2 years of age or beyond is desirable. Reaching all rightly and robustly is required. All this will contribute greatly towards the growth & development of infants and grandly towards the Sustainable Development Goals. We propose the “ABC mothers” plan. Progress for required practices for results possible with making mothers—“Able for practices advantageous, bold with pertinent awareness, and confident with propitious attitude”. Strong efforts on sound footing are necessary for health of all our infants and happiness all around with sustainable development. Scientific infant feeding will contribute to advance the attainment of this. Medical education teaching best beneficial practices is for excellence. One promoting breastfeeding is the best. The US Surgeon General’s Implementation Strategies elaborate “Education content”, “Enabling competency”, & “Education continuing”. Competency-based curriculum for Indian Medical Graduates includes “to promote and support optimal breast feeding”. Need for inclusion in teaching curriculum across US, UK, & internationally has been documented. Given all the evidence for breastfeeding benefits, it should be a consistent essential component of training in all medical schools worldwide.

1. Introduction

Infants and young children are the beginning of the ambitions of life. All health plans for them should be ambitious, vigorous, & vivacious. Breastfeeding is an excellent start for children. All babies should be breastfed, with the motto “cover all & cover completely”, motivating all concerned, & with the motive of achieving excellence, with complete coverage. Early initiation of breastfeeding, exclusive breastfeeding for first six months, followed by timely, adequate, safe, and appropriate complementary feeding, while continuing breastfeeding up to 2 years of age or beyond is recommended. Starting within the first hour of birth, longer-duration breastfeeding is associated with protection against childhood infections, increases in intelligence & reductions in the prevalence of overweight and diabetes [1]. Breastfeeding is associated with improved performance in intelligence tests 30 years later and might have an important effect in real life, by increasing educational attainment and income in adulthood [2]. Innovations are needed to accelerate progress for our children’s health & there is a need to involve everyone. For their future and the future of our world [3]. Best breastfeeding policies & practices will advance the attainment of the Sustainable Development Goals (SDGs). Medical education excellence is teaching best beneficial practices, which prominently includes breastfeeding.

2. Able, bold, & confident mothers

The success of breastfeeding initiation and continuation depends on multiple factors, such as education about breastfeeding, preparation for breastfeeding, hospital breastfeeding practices and policies, routine and timely follow-up care, and family and societal support. Maternal breastfeeding self-efficacy is a significant predictor of breastfeeding duration and level [4]. Mothers may need help to adopt better practices, or to overcome difficulties with their own health, nutrition, or family planning [5]. Mothers are at the center stage for breast & complementary feeding. Hence, we propose the ABC plan of breast and complementary feeding—Able, Bolder, and Confident mothers

2.1 Able

It is important to make all mothers able to breastfeed, with all the correct knowledge, positive attitude, and reinforced support for breast and complementary feeding. This should be done with all the promptness with which the CPR (Cardio-Pulmonary Resuscitation) is done, as this is the factor of core importance for preventing all morbidities and mortalities. This is the beginning of life and should be a healthy beginning.

To be ably breastfeed, mothers’ own health is important. Various aspects to be taken care of include nutritional status and food intake, any illness she may have, maternal medications, birth spacing, and family planning. Emotional & social support to the mothers is important.

The energy cost of breastfeeding should be catered for. A mother’s intake should be increased by around 10% in women not physically active. The increase should be 20% or more in moderately or very active women. Poor diet, quantitatively or qualitatively affects mothers’ energy and ability to breastfeed or to feed and care for their infant or child. A lactating mother needs around 500 kilocalories (roughly equivalent to one extra meal) each day for making 750 ml of breast milk. The required nutrients are supplied from body stores partly, laid down during pregnancy. The rest need to be supplied as an increased intake [6]. All this is ensured by greater amount and variety of foods. Pregnant and lactating women can eat any foods normally included in the local diet.

The Baby-Friendly Hospital Initiative (BFHI) comprehensively enables mothers to breastfeed, as systematic ten steps. Evidence exists for the effectiveness of individual steps, but even more so for full implementation of all steps together [7, 8, 9]. The ten steps to successful breastfeeding of BFHI are:

1. 1. Compliance: full to International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions.

   2. Written policy: on infant feeding routinely communicated to staff and parents.

   3. Ongoing monitoring and data-management systems: are in place.

2. Trained staff: having sufficient knowledge, competence, and skills to support breastfeeding.

3. Counselling: for importance and management of breastfeeding with pregnant women and their families.

4. Initiation: immediate and uninterrupted skin-to-skin contact is facilitated. Mothers are supported for initiation of breastfeeding as soon as possible after birth.

5. Support: for mothers to maintain breastfeeding and manage common difficulties.

6. Exclusive guidance: for not to provide breastfed newborns any food or fluids other than breast milk, unless medically indicated.

7. Rooming-in: enable mothers and their infants to remain together 24 hours a day.

8. Infant cues: teach mothers to recognize and respond to their infants’ cues for feeding.

9. Counselling additional: on the use and risks of feeding bottles, teats & pacifiers.

10. Care ongoing: coordination of discharge so that parents and their infants have timely access to ongoing support [10].

Baby-friendly and biological nurturing approach has been shown to be highly effective [11]. Biological nurturing is a neurobehavioral approach to breastfeeding support. It encourages women to breastfeed in a relaxed, laidback position. This approach is advantageous with reduction in breast problems (e.g., sore nipples), making good latch easier and thus facilitating the initiation of exclusive breastfeeding [12].

Social support is required and results in success contributing to making mothers able to breastfeed. These should include emotional, tangible, and educational components. Providers of these should include both informal social network members (male partner, mother, family/friends) and professional network members (health care professionals, lactation consultants). Also, negative social support may decrease breastfeeding [13].

Breastfeeding is an intimate process that requires psychosocial adjustment as well as technical skills. During these adjustments, psychological support will contribute to success [14].

Couples need to be advised to wait at least 24 months after a live birth and 6 months after a miscarriage before attempting the next pregnancy [15]. This ensures mothers' health, good birth weight, & ability to breast & complementary feed in the desired way.

Also, correct advice is required if mother becomes pregnant while breastfeeding. This mostly occurs when the breastfeeding infant is older than 6 months. After this age dependency on mother for nutritional needs is not total as weaning has started. Breastfeeding during pregnancy is thought to pose no increased risk to the pregnancy [16].

Mothers can face challenges in breastfeeding. Conquering the challenges is important for making them able to breastfeed. The American College of Obstetricians & Gynecologists (ACOG) has comprehensively made detailed recommendations and conclusions regarding breastfeeding challenges [17]. Obstetrician–gynecologists and other obstetric care professionals are uniquely positioned to support women in these situations [17].

Able mothers practicing correct breast & complementary feeding will help in achieving nutrition and health goals.

2.2 Bold

Making women bold is the way forward. Correct knowledge will make mothers bold & bold mothers will not deviate from correct practices. Antenatal counseling sessions giving knowledge & skills of scientific practices will make them ready for the very best implementation. Large-scale interventions focusing on educating mothers about breastfeeding have the potential to increase breastfeeding prevalence. A systematic review on breastfeeding interventions has concluded that combined individual and group counseling appeared to be superior to individual or group counseling alone [18]. This will ensure breastfeeding with desired confidence.

The logic of correct knowledge-making mothers bold is illustrated by following examples. The WHO Integrated Management of Neonatal and Childhood Illness (IMNCI) “feeding recommendations during sickness and health” are:

1. Up to 6 months of Age: Breastfeed as often as the child wants, day and night, at least 8 times in 24 hours.

2. 6 months up to 24 months: Breastfeed as often as the child wants.

Remember: Continue breastfeeding if the child is sick

If breastfeeding, exclusive and continued, in sickness is beneficial then mothers will definitely be bold for breastfeeding. IMNCI implementation in Real Life Situation is strongly recommended [19].

Another excellent example is hot conditions & deserts. It was generally, but wrongly, agreed that infants in a hot and dry climate need extra water. This assumption was based more on caution than on knowledge. An important study showed that breastfed infants in a hot and humid climate were found to do well without supplementary water [20]. Current recommendation is, breastfed infants do not require additional water. Correct knowledge will definitely empower mothers with boldness.

Working mother issues need to be addressed. ACOG recommends providing anticipatory guidance about how to continue breastfeeding after returning to work [17]. The Maternity Benefit Act 1961 (amended up to 2017) has provided for “Nursing breaks”—“Every woman delivered of a child who returns to duty after such delivery shall, in addition to the interval for rest allowed to her, be allowed in the course of her daily work two breaks of the prescribed duration for nursing the child until the child attains the age of fifteen months” [21].

Breastfeeding in public, when required, needs to be taken care of. Women should feel at home in the world, and we should ensure this. This will also make their babies feel at home in the world. Mother work in public should be free, safe, & as full citizens without harassment or surveillance. Bold mothers are a prerequisite for all this.

Newspaper articles report & reflect current trends. A newspaper in India has recently, in an article titled “Bold & Breastfeeding”, importantly reported “More and more Indian moms are confidently nursing in public and proudly sharing pictures online too” [22]. This is the right direction meeting the requirement to feed the baby when the baby wants and not disrupting mothers’ life or freedom. In today’s world Digital Communication aids reaching all and should contribute to popularizing right practices.

2.3 Confident

We need to infuse confidence into mothers that proper breast and complementary feeding will lead to healthier babies with bright futures. These practices rank among the most effective interventions to improve child health. The WHO systematic review of long-term effects of breastfeeding has concluded that there is strong evidence of a causal effect of breastfeeding on IQ [23]. All this positive evidence will infuse confidence for a propitious attitude and actions.

Confidence in the ability to breastfeed has been shown to be the most important predictor of full first six months of exclusive breastfeeding [24]

An increase in mothers’ confidence in themselves, in breastfeeding, and in their infants’ growth and development is simple & requires supporting mothers to respond in a variety of ways to behavioral cues for feeding, comfort, or closeness. This enables them to build caring, nurturing relationships with their infants. Ways to respond to infant cues include breastfeeding, skin-to-skin contact, cuddling, carrying, talking, singing, and so forth [25].

Alive & Thrive initiative addressed the multiple influences that can affect a mother’s confidence and ability to optimally breastfeed [26]. The interventions included provision of training, supportive supervision, job aids, & communications materials to both health workers working at the primary care level (local health centers) and the volunteer community health worker cadre [27]. Health education reinforcement for healthy practices is the key and gives mothers necessary confidence.

Media plays an important role in our lives, and definitely should play a positive role to raise community awareness about the benefits of breastfeeding for both the mother and her baby. All this will make mothers confident about breastfeeding.

Social media breastfeeding support groups (SMBSGs) have been found to be useful. These have been found to improve women's confidence, knowledge, and attitudes and, therefore, increase the potential for exclusive breastfeeding to 6 months [28].

3. Special situations

Covering all is important and special situations demand specific considerations.

3.1 Preterm babies feeding

Premature infants receive profound benefits from breastfeeding [29]. Maternal breast milk should be the preferred enteral feeding for premature infants, although its nutritional adequacy may be limited for several reasons [30]. Preterm mothers’ milk has greater protein content than that of mothers delivering at term, however, it is insufficient in meeting the needs of smaller and more immature preterm infants [31]. Human milk fortifier should be added once the premature infant is tolerating tube feeding, and its use should be continued until the infant has achieved all oral feedings, a weight of 1800 g, or is near to discharge from the hospital. Similarly, Very Low Birth Weight (VLBW) infants should receive a human milk fortifier. This meets their nutritional needs and prevents clinical deficiency diseases and growth failure.

3.2 Breastfeeding without birthing

Breastfeeding is all advantageous, and should also be done after surrogacy and adoption. There is a growing awareness that it is possible for women to breastfeed in these situations. Health care professionals should support these mothers. Breastfeeding can play a significant role in facilitating the development of the child-mother relationship in cases of adoption and surrogacy [32, 33]. This is besides all the physiological benefits.

Induction of lactation in the biological mother after gestational surrogacy and in cases of adoption is required. A combination of pharmacological and nonpharmacological methods is often used for the induction of lactation [34]. Medications to help induce lactation are useful. ACOG recommends that galactagogues may be helpful if a woman would like to produce milk for an adopted infant [17]. Various protocols for inducing lactation and maximizing milk production are there [35, 36].

4. Complementary feeding

The general principles of complementary feeding are:

1. Start: at six months

2. Responsive feeding: needs to be practiced, applying the principles of psychosocial care

3. Hygiene: good along with proper food handling

4. Quantity: start with small amounts of food and increase the quantity as the child gets older, while maintaining frequent breastfeeding

5. Food type: food consistency to be gradually increased and variety added as the infant grows older, adapting to the infant’s requirements and abilities. Introduce one food at a time

6. Frequency: increase the number of times that the child is fed complementary foods as the child gets older

7. Variety: feed a variety of nutrient-rich foods, ensuring that all nutrient needs are met.

8. Source: locally available & home food recommended

9. Energy density: should be more than that of breast milk

10. Technique: encourage cup and avoid bottle

11. Illness & recovery: increase fluid intake during illness, including more frequent breastfeeding, and encourage the child to eat soft, favorite foods. After illness, give food more often than usual and encourage the child to eat more.

12. Breastfeeding simultaneous: continue breastfeeding until 2 years of age or beyond.

Newborn babies have a right to survive and grow into childhood, and to experience life to their full potential [37]. With “ABC plan” mothers will be able to better and comprehensively contribute towards this. Proper nutrition is the first prerequisite for attaining full potential.

Overall, our ABC plan is summarized as:

‘Able, bold, & confident mothers, for

All advantageous, best beneficial, bolstering comprehensive care’

5. Sustainable development goals with breast & complementary feeding

The SDGs are a collection of 17 interlinked global goals as a plan of action for people, planet, and prosperity. These are people-centered, universal, and transformative [38].

Breastfeeding-achieving the new normal is based on consolidation of evidence for breastfeeding’s benefits in recent years, in particular, the economic gains to be reaped [39]. All advantages are contributory towards SDGs.

SDGs, adopted by the world leaders are expected to follow on from the Millennium Development Goals (MDGs). We need to accelerate our progress [3]. Breastfeeding and complementary feeding (BFCF) are important & the impact for attaining SDGs & all the MDGs is as follows:

• ‘Eradicate extreme poverty and hunger’ (SDG 1 & 2 / MDG 1)

Adequate and scientifically correct BFCF has tremendous potential for achieving progress in food and nutrition security in childhood, completely and comprehensibly. The savings from expenditure on other milk & its substitutes also contributes to “No poverty”. High returns on health investments can aid to eliminate poverty. Protection, promotion, and support for breastfeeding results in savings totaling US$302 billion annually [40], i.e. nearly 0.5 percent of the world gross national industry.

Breastfeeding is a natural and economical way of feeding. It does not burden household budgets. Savings will contribute to feeding other household members resulting in no hunger and ultimately eradication of poverty.

• ‘Good health & well-being’ (SDG 3)

Optimal breastfeeding & complementary feeding ensures this not only for the present but also for the future. Breastfeeding confers short-term and long-term benefits for both child and mother, including helping to protect children against a variety of acute and chronic disorders. The benefits of breastfeeding are confirmed in fewer infections, increased intelligence, probable protection against overweight and diabetes, and cancer prevention for mothers [23, 39]. The short-term as well as long-term, disadvantages of not breastfeeding are important [23, 41].

• ‘Quality education’ (SDG 4) / ‘Achieve universal primary education’ (MDG 2)

Free from disease means fit to attend school on all days. The benefits of breastfeeding on good health & in preventing childhood morbidities are well proven.

Breastfeeding and quality complementary foods significantly contribute to cognitive development, support appropriate neurological development and enhance later school performance. Adequately BFCF will boost universal primary education, aptly and appropriately. All this will enormously contribute to global learning targets.

• “Gender equality” (SDG 5) / “Promote gender equality and empower women” (MDG 3)

Women should receive equality at all levels of society. Women’s reproductive rights and productive roles require adequate support. Providing them with accurate information about BFCF will empower them, and provision of breastfeeding-friendly workplaces will make them practice it.

A study on breastfeeding has shown that interventions such as maternity leave, workplace support, and employment status of mothers led to a 30 percent increase in breastfeeding rates [42]. We all need to get the cycle going for best feeding practices for best goals accomplishments.

• “Reduce child mortality” (MDG 4)

For this, the importance of adequate BFCF practices is supported by a large body of scientific evidence. Breastfeeding provides protection against childhood infections along with other advantages. Early start and longer duration of breastfeeding as recommended are the most useful. Research has shown that scaling up breastfeeding up to near-universal levels will result in saving the lives of 823,000 children under age 5 in 75 low- and middle-income countries [1]. All this justifies implementation of breastfeeding recommendations with full devotion and diligently.

• ‘Improve maternal health’ (MDG 5)

Breastfeeding has a positive impact on the health of mothers. For nursing women, breastfeeding protects against breast cancer and improves birth spacing [1]. The more the mothers breastfeed, the greater are the benefits. These advantages of breastfeeding should be widely told simply and scientifically.

• “Combat HIV/AIDS, malaria and other diseases” (MDG 6)

The protective effects of breastfeeding against infections are well known. For HIV/AIDS, there is now enough evidence to recommend ARVs during breastfeeding. Research shows that HIV-positive mothers who receive effective ARV treatment can have a close to zero transmission rate of HIV to their babies during pregnancy, birth, and breastfeeding. Thus, breastfeeding will help reduce morbidity and mortality from infections dramatically and drastically.

• “Ensure access to affordable, reliable, sustainable, and modern energy for all” (SDG 7) / “Ensure environmental sustainability” (MDG 7)

The manufacture of breast milk substitute products and their packaging is a wasteful activity, which pollutes and damages the environment. The bottles not only degrade the health of the babies but are also non-biodegradable. Our recommended optimum BFCF will lead to environmental protection and preservation.

• “Decent work & economic growth” (SDG 8) & “Reduced inequalities” (SDG 10)

Breastfeeding is associated with adding US$302 billion annually in additional income to the world economy [40], in the healthiest way. All babies breastfed & given complementary feeding will definitely result in reduced inequalities.

• “Responsible consumption & production” (SDG 12)

Breastmilk does not require industry for the production and is created and consumed with a minimal ecological footprint. It is the healthiest consumption. Home-based locally available complementary feeds are again responsible for consumption & production.

• “Global partnerships for the goals” (SDG 17) / “Develop a global partnership for development” (MDG 8)

The promotion for optimum BFCF requires multi-sectoral collaboration. WHO, UNICEF, various government & non-government organizations cooperating for Infant feeding. This provides an opportunity for building on the existent international partnerships for support of development. A healthy start to life for all babies of the world is the best possible development which we should aim, support, and sustain.

All this is best summarized as:

‘Scientific, energetic, & strong efforts for sustainable excellence,

Breastfeeding is best and fruitful’

6. Medical education: Methodical excellence

Excellent medical education is one that teaches best beneficial practices. BFCF is of importance for all our infants for lifelong benefits. Promoting correct practices is an imperative duty & important obligation. Advanced methodical learning and optimized learning lead to better-trained doctors [43].

The US Surgeon General in its Call to Action to Support Breastfeeding (2011) remarked [44]:

“Inadequate education and training of clinicians has been identified as a major barrier to breastfeeding, and

education on breastfeeding is not a core element of most medical school or residency programs or of programs in nursing education.”

‘The US Surgeon General’s Call to Action to Support Breastfeeding’ describes in detail the Implementation Strategies:

1. Education content: Improvements in the breastfeeding content in undergraduate and graduate education and ongoing training for health professionals. Quality content recommended.

2. Enabling competency: Incorporation of competency in lactation care as minimum requirements for health professional credentialing, licensing, and certification processes.

3. Education continuing: Increase opportunities for continuing education on the management of lactation to ensure the maintenance of minimum competencies and skills [44].

The Medical Council of India (now National Medical Commission of India) has effective outcome-based strategies. The MCI Competency-based Undergraduate curriculum for the Indian Medical Graduate [45] requires the following competency:

‘To promote and support optimal Breastfeeding for Infants’

This simple straightforward statement is all favorable, for all the life, for all the liveliness throughout life, & is the amongst the foremost best duty doctors can do.

The General Medical Council (GMC), UK, in its ‘Outcomes for Medical Graduates’ mentions [46]:

“Newly qualified doctors must be able to apply biomedical scientific principles, methods, and knowledge to medical practice and integrate these into patient care. This must include principles and knowledge relating to immunology, nutrition, physiology, etc.”

Further in Health promotion and illness prevention GMC mentions:

“Newly qualified doctors must be able to apply the principles, methods and knowledge of population health and the improvement of health and sustainable healthcare to medical practice.

They must be able to:

Discuss the role and impact of nutrition to the health of individual patients and societies”.

Breast feeding is the start of nutrition, the best nutrition, & the start should be on best & sound scientific footing. Focused specific approach is desirable. “Currently there is no published data on the inclusion of breastfeeding education within the UK medical school curriculum” [47]. Biggs et al (2020) cross-sectional study in UK has suggested that UK medical schools are not adequately preparing students to support breastfeeding patients. Further studies should explore the competency of doctors to meet the needs of lactating women, and design optimal training for UK medical students. In this study, overall, 93% (381/411) students requested further breastfeeding education [47].

Taylor & Bell (2017) have commented that high quality training in breastfeeding during medical education is historically varied. The process of becoming a board-certified physician entails more than 20 years of education. Medical school and residency training timelines and courses are relatively standardized across the United States and even internationally, but breastfeeding education varies greatly across schools and programs [48]. In view of all this and given all the evidence of benefits of breast feeding, it should be a consistent essential component in all future training, as:

“Learned practices & policies for correct start of life with

Medical education rationalization,

Benefits immediate, short term, & long-term scientific basis foundation,

Basic & advanced competencies worldwide acceleration,

For holistic health & wonderful wellbeing facilitation”

7. Conclusion

Advancing on universal health coverage vision is required. For this, it is important that right things are taught to all mothers for feeding their babies, encouraging and enabling all, for the best start of life. For breastfeeding leaving out a single or even a few mothers are undesirable and the results of this can be unpardonable. Universal health coverage is not a one-time effort, and if we are not able to implement a scientifically proven natural intervention, breastfeeding, for its full period, then it is also not universal health coverage. Our efforts should be for Universal health coverage with the new meaning – “Cover all and cover completely”, a much refined and more rigorous approach [49].

“Be early to start, Be exclusive for first half of first year,

Be comprehensive with complementary feeding while also carrying on breastfeeding”

This is for all, for full recommended duration, for child’s full development, and

Leading to fulfillment of development goals”

Specific initiatives are definitely needed for the health of children so that they achieve their full growth potential [50]. We need to build health systems that can monitor the continued implementation of our scientific recommendations. This calls for continued efforts by all healthcare workers, unremitting and unrelenting. We should partner all in eliminating gross health inequalities and enhancing human welfare. Scientific evidence regarding the feeding of these most vulnerable age groups has revealed clear-cut policies for implementation, which should be done with precision and perfection.

We look forward to continued cooperation with renewed vigor and vitality from all the Paediatricians and health care providers for Able, Bold, & Confident mothers, & attaining the Sustainable Development Goals, for which optimum breast and complementary feeding practices are the most important and imperative. Methodical medical education will ensure all this.

“Breastfeeding is the firm foundation & is for favorable future, hence

Comprehensive policies & complete practice,

Wonderfully with,

Medical education for supportive, sophisticated & skilled doctors”

Acknowledgments

Thankful to the formulators of all regulatory policies and guidelines and to the authors of the references quoted.

Conflict of interest

“The authors declare no conflict of interest.”

Funding

Nil.