Comprehensive Breastfeeding Support and Feeding of Small and Sick Newborns in Low- and Middle-Income Countries: Programmatic Considerations

The World Health Organization (WHO) recommends breast milk feeding for all infants, including SSNBs requiring special care. The UNICEF/WHO Baby-Friendly Hospital Initiative (BFHI) 2018 provides guiding principles and steps to implement breastfeeding support for all babies. Optimal breast milk feeding practice is defined as early and uninterrupted skin-to-skin contact between mothers and infants, followed by exclusive breast milk feeding (EBF) for the first six months of life, and continued breastfeeding to two years of age or beyond. However, globally, only 44% of infants initiate breastfeeding within the first hour after birth, and 41% of all infants under six months of age are exclusively breastfed. The WHO- and UNICEF-led Global Breastfeeding Collective promotes key policy actions to strengthen the promotion, protection, and support of breastfeeding. The Global Breastfeeding Scorecard tracks countries' progress in meeting specific targets by 2030, including 70% of babies breastfed within an hour of birth, 70% of babies under six months old exclusively breastfed, 80% of children still breastfed at one year of age, and 60% of children still breastfed at two years of age. Breast milk feeding has been shown to reduce infant mortality due to common childhood illnesses, such as diarrhea or pneumonia. Delayed initiation of breastfeeding is associated with an increased risk of neonatal mortality. A review identified a dose-response relationship between the risk of neonatal mortality and the delay in breastfeeding initiation, with infants who initiated breastfeeding 24 hours after birth having a higher risk of neonatal mortality. Globally, approximately 10% of babies are born preterm, with higher rates in Low- and Middle-Income Countries (LMICs) compared to high-income countries. Preterm infants have differing needs for nutrition and immune protection, and breast milk-fed babies have lower mortality and lower incidence of infections and necrotizing enterocolitis. Breastfeeding has also been shown to have beneficial effects on neurodevelopment, with higher cognitive skills and behavioral scores reported among preterm infants. The World Health Organization recommends that mothers of SSNBs should be supported to provide exclusive breast milk feeding or alternative feeding, and that clinically stable preterm newborns should receive kangaroo mother care (KMC) to encourage breast milk feeding. Interventions that aid the initiation and establishment of breastfeeding, such as immediate skin-to-skin contact, early initiation of EBF, and rooming-in, are often interrupted during inpatient care, which can separate mothers from their babies and create a physiological barrier to breastfeeding. Comprehensive breastfeeding support and feeding support for SSNBs in LMICs require consideration of the special situations and requirements of these newborns. Existing systems for breastfeeding among healthy infants often fail to address the needs of SSNBs. Therefore, new approaches and guidelines are needed to support optimal feeding for SSNBs in LMICs.