Lactation Counseling for Maintaining Exclusive Breastfeeding in Adolescent Mothers: A Trial Protocol

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Current interventions target adult women, and little evidence is available for breastfeeding promotion among adolescents. This is a pilot study protocol with a parallel, single-blind, randomized, controlled trial design, to evaluate the effectiveness of the intervention “Lactation Counseling” in first-time adolescent mothers to maintain exclusive breastfeeding in the first six months of life. The control group will receive routine education in prenatal care and prenatal and childbirth classes and, the experimental group will receive additionally the intervention “Lactation Counseling”, for four weeks, both conducted by trained nurses. The primary outcome will be the exclusive breastfeeding rate; and the secondary, the breastfeeding knowledge. Measurements will be taken at baseline, post-intervention, and two, four and six months after childbirth. This study will allow the evaluation of the feasibility of an intervention in low-income, Latin American population adolescents. Sexual & Reproductive Medicine Breastfeeding Nursing Education Pregnancy in Adolescence Nursing Care Nursing Process (Source: DeCS-MeSH) Figures Figure 1 Introduction Breast milk is the natural and optimal source of nutrition for the newborn; it is associated with multiple health benefits (1,2), providing nutrients, hormonal immunoactives, and microbiomes necessary for growth and development (3). Furthermore, in the mother, it reduces the probability of breast and ovarian cancers, improves birth spacing, prevents type-2 diabetes, obesity and hypertension, among other benefits (4,5). Countries have made efforts to protect, promote and support exclusive breastfeeding (EB). It is expected that by 2025 the prevalence of EB will be 50% (6), although globally only about 38% of children benefit from it (7). The outlook is worse in developing countries, such as Colombia with a prevalence of 36.1% in children under 6 months, and only 52.2% of children 6 to 12 months continued to receive breastfeeding (8). Exclusive breastfeeding is one of the most important cost-effective strategies in the prevention of maternal and infant morbidity and mortality. An estimated 823,000 deaths of children under 5 years of age and 20,000 deaths of women from breast cancer could be prevented each year if breastfeeding were a universal practice (2). The optimal practice of breastfeeding in adolescent mothers is determined by a range of personal and cultural factors such as attitudes about breastfeeding, perceived benefit, knowledge, previous experiences, self-efficacy, and affective or social support. All these factors significantly influence the duration of breastfeeding in adolescent mothers (9). The development of educational strategies that intervene in the factors that influence breastfeeding in adolescent mothers is key. Therefore, nurses must acquire a commitment and responsibility in the implementation of educational interventions, motivating the mother to generate positive thoughts and commitments, as well as providing a support network and knowledge that contribute to the significant improvement of breastfeeding practices and indices of initiation, exclusivity and duration (10–14). The Global Breastfeeding Scorecard 2019 urges that primary care facilities offer individual advice on infant and child feeding, seeking the goal of 80% of countries whose health institutions provide this advice by 2030. It emphasizes in the importance of improving access to qualified breastfeeding counseling by providing specialized guidance that helps to make informed decisions and overcomes difficulties for breastfeeding, focusing on new mothers who have the greatest lack of knowledge and confidence (15). To carry out educational interventions, the nurse must implement the nursing care plan, as it provides patient-centered care and improves the expected results. To implement this care plan, the use of the Nursing Intervention Classification (NIC) (16) is recommended, which includes the nursing intervention “Lactation Counseling”; however, available evidence on the use of the classification in clinical trials is scarce especially in the adolescent maternal population (17). Purpose: This article describes the methodology of intervention design based on the nursing intervention “Lactation Counseling” that aims to determine the effectiveness of this intervention in first-time adolescent mothers for maintaining exclusive breastfeeding in the first six months of child-life. Materials And Methods Design: This is a pilot study protocol for a randomized controlled trial using a parallel-group design with a 1:1 allocation ratio, to evaluate the effect on exclusive breastfeeding rates of the intervention "Lactation Counseling" described in the Classification of Nursing Interventions (NIC) (16) (n=59), versus usual education and nursing interventions not related to breastfeeding (n=59) in first-time pregnant adolescents, attending the control prenatal, and followed-up with for up to 6 months after delivery. Participants: Eligible participants are first-time teenage mothers; between 14 and 19 years old, between 20 to 30 weeks gestation. Adolescents with psychiatric and/or communication disorders will be excluded and who have obtained a score less than or equal to 3.8 on the Knowledge outcome: Breastfeeding (1800), described in the Nursing Outcomes Classification (NOC) (18). Settings and locations: The study will be carried out in two public hospitals in the cities of Girón and Piedecuesta in Santander, Colombia, which mainly provide care for low-income people. The recruitment of participants began in 2019 and is expected to end in 2021 due to delays caused by quarantines and restrictions to control the COVID-19 pandemic. The protocol is approved by the research ethics board of the Industrial University of Santander and is covered by the inter-institutional agreement between the participating hospitals; it has obtained approval and funding from the university’s Research and Extension Directorate (#2453) and additional funding from young research program form the Ministry of Science, Technology and Innovation(#8009). Pregnant women attending prenatal controls will be invited to participate in the study. Pregnant women who meet the inclusion criteria will fill out a questionnaire designed based on the Knowledge outcome: Breastfeeding (1800). Adolescents who obtain a score on the knowledge test less than or equal to 3.8 points will be invited to participate in the intervention, with prior informed consent. Pregnant women scoring above 3.8 in breastfeeding knowledge will not be invited as they are considered to have extensive breastfeeding knowledge. Interventions: Control group: This group will receive the usual education given in prenatal control and maternity preparation classes, using the interventions: Infant Care (6820) and Prenatal Care (6960), taken from the Nursing Interventions Classification (16). This group will not receive specific interventions in breastfeeding and the information on this aspect will be that which is usually offered in prenatal control. This group will receive the interventions in four educational sessions with the following topics: physical-psychological changes and care during pregnancy, the process of labor, delivery and postpartum in its different stages, care of the newborn at home, and family planning. The sessions will be carried out in groups of a maximum of ten pregnant women, led by a nurse trained in maternal and perinatal care. The frequency of each session will be weekly, lasting between 45-60 minutes each. The sessions will be supported by audiovisual materials like slides, photography, videos, and educational games. Experimental group: In addition to the usual education given in prenatal control and maternity preparation classes, this group will receive the intervention “Lactation counselling” (5244) defined as “assisting in the establishment and maintenance of successful breastfeeding” (16). The intervention will consist of four educational sessions with seven topics (See Table 1). The frequency of each session will be weekly, lasting 45-60 minutes each. Each session contains three parts: 1) introduction to the topic where the objective of the session is explained and the pre-knowledge and usual practices in the community on the topic are explored, 2) development of the topic using PowerPoint presentations, audiovisual material such as photographs and videos, simulation material as well as strategies to encourage the participation of mothers such as games and challenges, and 3) end of the session reviewing the main lessons, addressing doubts and concerns and carrying out an evaluation with questions on the topic of the session. Participants will not receive educational material about interventions, neither will they be encouraged or prohibited from seeking information about breastfeeding by other means. All mothers will be called before each session to encourage their attendance and another phone call will be made near to childbirth to know the health status of mother-child binomial. Outcomes: The primary outcome will be the exclusive breastfeeding rate in the first 6 months postpartum. We use the WHO definition of exclusive breastfeeding: “exclusive breastfeeding for at least 6 months in all infants,” meaning that the infant receives only breast milk and no other liquids or solids, not even water, except for oral rehydration solution or drops/syrups of vitamins, minerals, or medicines(19). This result will be evaluated by phone call at 2, 4 and 6 months postnatal and a checklist will be applied to evaluate the following: offer exclusive breastfeeding, offer food or fluids other than breast milk, ensure breastfeeding even when separated from your child (express), describe correct breastfeeding technique, and recognize the importance of breastfeeding for the growth and development of the newborn. Additionally, mothers will be invited to continue breastfeeding and participating in the study. Secondary outcomes: The secondary outcome will be the level of knowledge about the breastfeeding process using a questionnaire based on the nursing Knowledge outcome: Breastfeeding (1800) defined as the “Extent of understanding conveyed about lactation and nourishment of an infant through breastfeeding”(18). For questionnaire design 7 indicators were selected for each topic taught in the 4 sessions, with a Likert-type scale with a score from 1 to 5 (1: no knowledge, 2: little knowledge, 3: moderate knowledge, 4: substantial knowledge and 5: extensive knowledge). Each of the indicators selected will be quantifiable constructing a questionnaire with a single answer, multiple choice question (Table 2). The internal consistency of the instrument was 0.8712 Cronbach's Alpha coefficient. At the end of the intervention, the level of knowledge acquired will be verified and a phone call will be made at 2, 4 and 6 months after the birth of the babies. Instrument 1 will be used again in each of the visits to evaluate the level of knowledge over time and Instrument 4 will be used to verify the adherence and maintenance of mothers to breastfeeding. Sample size: We used STATA-12 to calculate the sample size with the following statistical parameters: a rate of exclusive breastfeeding of 70% in the experimental group and 60% in the control group, a power of 80%, an alpha error of 5%, and the rate of abandonment of exclusive breastfeeding being 2.5 times higher in the control group compared to the experimental group. Additionally, for the knowledge level outcome, we considered a delta or expected difference of 0.4 in the knowledge assessment result score between both groups, a power of 95%, an alpha of 5%, a standard deviation of the result scores of 0.5, an average of correlations between the first and second assessment of 0.5. Finally, the sample size estimated was n=118 primigravidae mothers including 20% of the possible losses; distributed by simple randomization with a ratio of experimental group/control group 1:1 (n=59 pregnant women in the experimental group and n=59 pregnant women control group). Randomization and blinding: We will use simple randomization with an allocation ratio of 1:1. The generation of the allocation sequence will be carried out using a succession of true random numbers stored in tables of random digits. A person who does not know the participants will access this table to find out which group each participant belongs to, depending on whether the number was odd or even and will inform the nurses who will carry out the intervention. The nurse who will perform the intervention “Lactation Counselling” will only maintain contact with the experimental group, and the nurse who will carry out the initial and final measurements along with the person who will perform the data analysis will be blinded to the group assignment. Study participants, nurses conducting the interview and statistical analysis of data will be masked in group assignments. Ethical consideration: This research is based on the World Medical Association Declaration of Helsinki and the research guidelines in Colombia (Resolution 008430/1993 and Law 911/2004) and has the approval of the Ethics Committee in Scientific Research of the Industrial University of Santander. The parents of the participants must sign the informed consent, as well as a consent for those under 18 years of age because they are considered a population of minors. Statistical analysis: The information will be recorded in EPIDATA 3.1. An intention-to-treat analysis will be performed. The categorical and continuous variables will be compared according to the treatment group using chi-square tests or Fisher's exact tests and Student's T-test or Mann Whitney's U test, respectively. The exclusive breastfeeding rate will be calculated at 2, 4 and 6 months of follow-up with their respective confidence intervals. To evaluate the effect of the intervention on the level of Knowledge: Breastfeeding, two approximations will be made by different statistical methods: mean differences through an independent samples Student's t-test and repeated measures ANOVA. Additionally, the effect of the intervention on the abandonment of exclusive breastfeeding will be calculated in terms of relative risk by means of a binomial regression. Discussion We detail the design of a nursing intervention to standardize breastfeeding counseling, as well as the evaluation of its effect on adolescent mothers. This intervention has the advantage of having been designed using standardized language from the Nursing Intervention Classification and using the same standardized language to evaluate its effect through the Nursing Outcome Classification, using standardized language facilitates the use of interventions and the measurement of their effect in different populations, as well as consolidating the use of a specific nursing language. Educational interventions in first-time mothers has shown effectiveness in maintaining exclusive breastfeeding in the first six months of life (13) and an increase in the level of knowledge about breastfeeding (20,21). However, these interventions were not carried out on adolescent mothers, despite the fact that pregnancy at this stage of the life cycle is considered a global public health problem given that nearly 16 million adolescents give birth every year in the world. which is equivalent to 11% of all births worldwide, a figure that increases in developing countries. Likewise, Latin America and the Caribbean have the second highest adolescent fertility rate in the world, estimating 67 births per 1000 girls between the ages of 15 and 19 between 2010-2015 (22). The above figures denote the urgency of providing counseling support to sustain breastfeeding in these young mothers, with appropriate methodologies for these ages. Additionally, it should be considered that the adolescent mother is generally not prepared to carry out effective breastfeeding, and in developing countries it is working mothers who can put breastfeeding at risk. Different studies have established that adolescent mothers, compared to adult mothers, are less likely to initiate breastfeeding and those who initiate it are more likely to abandon it. Among the reasons for dropping out, causes such as hypogalactia, returning to school, medical indication, causes related to the nipple, maternal illness, maternal labor, and acid reflux in the newborn have been described (23). In a study carried out in adolescent mothers, 39.4% lactated for 6 months and 9.8% lactated for more than 6 months; the reasons why they do not feed their child with only breast milk are: 9.5% produce little milk, 12% the child is left hungry, and 20.7% other causes (24). On the other hand, a study in South Africa found that adolescent mothers knew the benefits of breastfeeding but abandoned it easily due to its lack of practicality when faced with the need to go to school (25) as was found by Acosta Silva in Ecuadorian adolescents (26), adding as a barrier the insufficient breastfeeding education during prenatal or in the early postpartum period (26,27). The foregoing highlights the importance of designing interventions that promote exclusive breastfeeding and therefore evaluating its effect. On the other hand, a review by Lumbiganon et al. in 2016 found that the majority of intervention studies to promote exclusive breastfeeding had been done in high-income countries (28). This is a pilot study that seeks to know the efficacy of a nursing intervention in low-income adolescent mothers in a developing country, considering that sustaining breastfeeding depends on social and cultural factors and in view of the need to explore an intervention that is low cost and easy to perform by nurses. Even though this pilot uses a randomized design, with the aim of preventing potential biases, some measures will be taken to reduce their appearance: Offer the possibility of participation to all adolescents in maternity classes, Have strict measures for the random assignment of mothers to groups. Ensure blinding of nurses who will assess the results and those who analyze the data. It is worth highlighting the importance of the intervention activities being standardized and supervised with prior training of the nursing staff. It is important to note that mothers will be able to access information or training on breastfeeding in a complementary way through different means and could bring the levels of knowledge about breastfeeding closer to those of the intervention group. There can also be a potential contamination of the groups in the event that some mothers who are in different intervention / control groups have a close relationship given the proximity of their homes and the similarity in age and share the learning and experiences acquired during the interventions. This study, given nature of intervention, also provides a higher level of scientific evidence, which will undoubtedly support the advancement and training of professionals in the discipline of Nursing, by basing knowledge and thinking to take actions and decisions that form part of the practice and assistance of nursing care in maternal and child health. Finally, the findings of this study will be a valuable resource for the management of nursing care, which will support the formulation, implementation, monitoring and evaluation of national policies aimed at the promotion, support, and protection of breastfeeding, by involving the educational component as an important strategy that guarantees respect and protection of the act of breastfeeding as a human right appropriate for women and their children. Declarations Ethics approval and consent to participate. The pilot protocol is approved by the Ethics Committee in Scientific Research of the Industrial University of Santander (Acta 014-August 17/2018). The parents of the participants must sign the informed consent, as well as a consent for those under 18 years of age because they are considered a population of minors. Consent for publication: Consent was not obtained to publish personal data because it is not expected to be used. Funding: This study was funded by Ministry of Science and Technology of Colombia (MINCIENCIAS), call for research 821/2018 for young research program (#8009). and the Universidad Industrial de Santander grant code 6287 (#2453), and funded all trial costs. The funding source had no role in the design, execution, analysis, interpretation of data, or the decision to present the results of this study. Trial Registration: ClinicalTrials.gov NCT04655846, Registered December 7, 2020. https://www.clinicaltrials.gov/ct2/show/record/NCT04655846 Authors' contributions: All authors contributed to the design of the study, and the preparation of the article. Competing/Conflict of Interest Statement: The authors declared not to have conflicts of interest. Availability of the data: The datasets generated and analyzed during the current study will be available from the corresponding author on reasonable request. References 1. Rodrigues GC, Dias V, Oliveira I de J. 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Forero Y, Rodríguez SM, Isaács MA, Hernández JA. La lactancia materna desde la perspectiva de madres adolescentes de Bogotá. Biomedica. 2013;33(4):554–63. 24. Pinilla EG, Domínguez-Nariño CC, García-Rueda A. Adolescent mothers a challenge facing the factors influencing exclusive breastfeeding/Madres adolescentes, un reto frente a los factores que influyen en la lactancia materna exclusiva. Enfermería Glob [Internet]. 2014;13(1):71–82. Available from: http://oxfordbrookes.idm.oclc.org/login?url=http://search.proquest.com/docview/1664837316?accountid=13041%5Cnhttp://linksource.ebsco.com/linking.aspx?sid=ProQ%3Abritishnursingindexft&fmt=journal&genre=article&issn=&volume=13&issue=1&date=2014-01-01&spage= 25. Zweigenthal V, Strebel A, Hunter-Adams J. Adolescent girls’ perceptions of breastfeeding in two low-income periurban communities in South Africa. Health Care Women Int [Internet]. 2019 Aug 20;40(7–9):995–1011. Available from: https://doi.org/10.1080/07399332.2018.1549043 26. Acosta Silva M, De la Rosa Ferrera JM. Causas que determinan la interrupción de la lactancia materna exclusiva en los barrios Santa Cruz y Propicia I en Esmeraldas, Ecuador. Arch Médico Camagüey. 2018;22(4):434–44. 27. Dennison BA, Nguyen TQ, Gregg DJ, Fan W, Xu C. The Impact of Hospital Resources and Availability of Professional Lactation Support on Maternity Care: Results of Breastfeeding Surveys 2009–2014. Breastfeed Med [Internet]. 2016 Sep 19;11(9):479–86. Available from: https://doi.org/10.1089/bfm.2016.0072 28. Lumbiganon P, Martis R, Laopaiboon M, Festin MR, Ho JJ, Hakimi M. Antenatal breastfeeding education for increasing breastfeeding duration. Cochrane Database Syst Rev. 2016;2016(12). Tables Table 1. Summary description of educational sessions for Lactation Counseling intervention. Session Content Methodologies Materials 1 Composition of breast milk Psychological and physiological benefits of breastfeeding Lecture method Audiovisual Presentation Group assignment PowerPoint presentations Breast milk production video Breastfeeding benefits video Breastfeeding kit with educational elements such as games and models (bottles with types of breast milk) Explanatory sheets with each of the components of breast milk. Sheets with text to identify the benefits of breast for the mother, baby, family and society. 2 Technique and positions for breastfeeding Audiovisual Presentation Demonstration Practical exercise Simulated models (baby dolls) Video on breastfeeding and nipple latch technique 3 Extraction, conservation, and administration of breast milk Lecture method Audiovisual Presentation Demonstration Practical exercise PowerPoint Presentations Video on storage, conservation, and administration of breast milk. Vest-type simulators for breast milk extraction 4 · Breast complications during breastfeeding Lactating mother needs (rest, hydration and a balanced diet) Lecture method Audiovisual Presentation Demonstration Practical exercise Group activity PowerPoint Presentaciones Breastfeeding kit with educational elements such as games and models (Breast models) Lottery game on care and complications during breastfeeding Memory game on nutrition and hydration during breastfeeding Video on care for the prevention of breast complications Table 2. Items and Indicators to Quantify the Nursing Knowledge Outcome: Breastfeeding (1800) INDICATOR 180003: Composition of breast milk, milk outlet process, and initial vs late milk 1. Occurs between 5 and 10 days after delivery 2. Contains less sugar, fats, and vitamins of B complex and vitamin C 3. Contains proteins, sugar, fats, minerals such as sodium, calcium, iron, selenium, zinc and B complex vitamins and vitamins such as C, A, E, K. 4. Its composition contains between 88% to 90% water 5. Occurs in the first 3 to 4 days after delivery 6. It is yellow, thick and of little amount 7. Contains more sugar, fats, calories and B Complex vitamins and vitamin C 8. It occurs progressively up to about 100 milliliters a day 9. Contains fewer proteins, antibodies and vitamins A, E, K 10. It occurs in an amount of 400 to 600 milliliters per day 11. Occurs from the tenth day after delivery 12. Contains more protein, minerals such as sodium, iron, selenium, zinc, and vitamins such as A, E, K 13. Its composition contains 87% water 14. It is produced in an amount of 700 to 800 milliliters per day INDICATOR 180001: Benefits of breastfeeding 15. Prevents breast, uterine and ovarian cancer 16. Prevents respiratory diseases such as bronchitis, pneumonia, and gastrointestinal diseases such as diarrhea and dehydration 17. Prevents the onset of diseases such as allergies, obesity, high blood sugar, high blood pressure and cancer 18. Prevents postpartum depression states (mood affecting women after giving birth, characterized by feelings of extreme sadness and anxiety) 19. Prevents constipation and cramping 20. Prevents child malnutrition 21. Facilitates the affective bond between mother and child 22. Strengthens self-appreciation, self-confidence and emotional satisfaction 23. Contributes to postpartum weight loss 24. Lowers the risk of osteoporosis (a disease that thins and weakens bones, causing them to break easily) 25. Promotes better growth and development of physical, language and social capacities 26. Reduces risk of postpartum hemorrhaging or bleeding 27. Lowers the risk of heart disease 28. Improves intelligence 29. Delays the return of ovulation and menstruation INDICATOR 180005: Proper technique for breastfeeding the baby 30. The mother should select the most comfortable position 31. The baby's body must be attached to the mother's body 32. The baby's head and body are in the same direction 33. The mother should grab the breast with her C-shaped hand (placing her thumb above the breast and the other four fingers below the nipple and behind the areola (ring of pigmented skin around the breast) 34. The mother should bring the child closer to the breast and not the breast to the child 35. The mother should stimulate the baby to have a search reflex, bringing the nipple closer to the baby's lip and when it opens its mouth to insert the nipple and the areola 36. The baby's lips should remain outside like the mouth of a fish 37. The baby's mouth should coat the entire areola (dark area of the breast) 38. The baby's chin must touch or almost be touching the mother's chest INDICATOR 180006: Adequate position of the infant during breastfeeding 39. Stretched or cradle position (classic or traditional) 40. Cross-cradle position 41. Parallel stretched position (side lying down) 42. Rugby ball or football position (inverted) 43. Sitting or horse position 44. Face-up position 45. Vertical or standing position INDICATOR 180014: Signs of mastitis, duct obstruction and nipple trauma 46. Breast skin is shiny, red, tense and warm 47. Formation of a mass or lump in the breast that is palpable and painful, often with redness of the skin in that area 48. Painful cracks or wounds on the nipple 49. Uncontrolled fever, chills, general discomfort, nausea, vomiting, headache 50. Formation of a mass or lump in the breast, severe pain, swollen and hardened sinus, obstruction at the milk outlet (milk does not flow), pus secretion 51. Inflammation or swelling in the breast with a feeling of warmth 52. Nipple pain 53. Cracks or nipple wounds that may bleed 54. Decreased milk flow 55. No fever or symptoms of general discomfort INDICATOR 180015: Appropriate techniques for the extraction and storage of breast milk 56. Massage into the breast before breast milk extraction 57. At room temperature: Breast milk is preserved for up to 4 hours, it is advisable to leave it in a dry place, protected from sunlight and heat. 58. In the freezer: Breast milk is kept frozen for up to 15 days, so it is recommended not to constantly open and close the freezer. If the refrigerator is two doors, breast milk can be stored for up to 3 months. 59. With your hand in the shape of a C, place it on breast (placing your thumb above the breast and the other four fingers below the nipple and behind the areola (dark area of the breast) 60. In a refrigerator or refrigerator: Breast milk is stored for up to 12 hours, it is advisable not to place it in the refrigerator door to avoid temperature changes every time the door is opened or closed. 61. Lean the body forward, squeeze the breast without swiping your fingers and gently push against the ribs 62. Then move your fingers forward and repeat the procedure as many times as necessary simultaneously and smoothly INDICATOR 180020: Need for fluid intake by the mother 63. It is advisable to increase the consumption of liquids, preferably water, as it is the largest component of breast milk 64. Water intake during lactation should be sufficient to compensate for the loss of water through milk 65. Vitamin C-rich juices are recommended 66. The most recommended liquids for women during breastfeeding are water, fruit juices, and milk 67. Avoid drinking alcoholic beverages, excessive coffee, and tea (more than 2 cups a day, during the term of breastfeeding) Cite Share Download PDF Status: Published Journal Publication published 01 Dec, 2021 Read the published version in Pilot and Feasibility Studies → Version 1 posted Editorial decision: Minor revision 22 Jul, 2021 Review # 1 received at journal 04 Jul, 2021 Review # 2 received at journal 30 Jun, 2021 Reviewer # 2 agreed at journal 20 Jun, 2021 Reviews received at journal 19 Jun, 2021 Reviewer # 1 agreed at journal 19 Jun, 2021 Reviewers invited by journal 18 Jun, 2021 Editor assigned by journal 02 Jun, 2021 Submission checks completed at journal 02 Jun, 2021 Editor invited by journal 02 Jun, 2021 First submitted to journal 30 May, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-578613","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Study Protocol","associatedPublications":[],"authors":[{"id":31413475,"identity":"b1b88e81-012e-4131-828f-c04255015f7e","order_by":0,"name":"Iliana Milena Ulloa Sabogal","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvElEQVRIiWNgGAWjYBACNgYGxgMPGBjkGJihXGK0MBxIYGAwJl4LA1RLYgPcBEKAT+yMwYGECrv0DcfZHzB8KDvMwN/eQMBh0jlALWeSczcc5jFgnHHuMIPEmQNEaElsYwZpYWDmbTvMYCCRQJSW+nSDw+wPmP+SoOVwggFQMTMjcVrSCoB+OW44E+iXgz3n0nkI+kV+dvLGBx8qquX5zh9/+OBHmbUcwRBDASDjeUhQPwpGwSgYBaMAFwAADmpBk4pUldgAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0003-1605-6837","institution":"Universidad Industrial de Santander","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Iliana","middleName":"Milena Ulloa","lastName":"Sabogal","suffix":""},{"id":31413476,"identity":"2b8af926-6bc0-4d75-8fcb-519c1a670951","order_by":1,"name":"Claudia Consuelo Domínguez-Nariño","email":"","orcid":"","institution":"Universidad Industrial de Santander","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Claudia","middleName":"Consuelo","lastName":"Domínguez-Nariño","suffix":""},{"id":31413477,"identity":"03dc8d2b-ddd5-4479-b67c-7f461bc59160","order_by":2,"name":"Mary Alejandra Mendoza-Monsalve","email":"","orcid":"","institution":"Joven Investigador -Minciencias.","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mary","middleName":"Alejandra","lastName":"Mendoza-Monsalve","suffix":""}],"badges":[],"createdAt":"2021-05-31 19:53:00","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-578613/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-578613/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40814-021-00950-9","type":"published","date":"2021-12-01T13:54:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":10297019,"identity":"da4eff19-5c7a-411b-b262-aec551a55815","added_by":"auto","created_at":"2021-06-12 16:34:53","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":66743,"visible":true,"origin":"","legend":"Flowchart of study protocol ","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-578613/v1/6bde4ab135c3b20b53411bf9.jpg"},{"id":16513906,"identity":"c89aba59-f2a7-4633-a791-b3bc1d483d87","added_by":"auto","created_at":"2021-12-16 13:54:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":265156,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-578613/v1/d4ae31f0-e957-4f7c-bbba-8dc8afa4b92a.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eLactation Counseling for Maintaining Exclusive Breastfeeding in Adolescent Mothers: A Trial Protocol\u003c/p\u003e","fulltext":[{"header":"Introduction ","content":"\u003cp\u003eBreast milk is the natural and optimal source of nutrition for the newborn; it is associated with multiple health benefits\u0026nbsp;(1,2), providing nutrients, hormonal immunoactives, and microbiomes necessary for growth and development\u0026nbsp;(3). Furthermore, in the mother, it reduces the probability of breast and ovarian cancers, improves birth spacing, prevents type-2 diabetes, obesity and hypertension, among other benefits\u0026nbsp;(4,5).\u003c/p\u003e\n\u003cp\u003eCountries have made efforts to protect, promote and support exclusive breastfeeding (EB). It is expected that by 2025 the prevalence of EB will be 50%\u0026nbsp;(6), although globally only about 38% of children benefit from it\u0026nbsp;(7). The outlook is worse in developing countries, such as Colombia with a prevalence of 36.1% in children under 6 months, and only 52.2% of children 6 to 12 months continued to receive breastfeeding\u0026nbsp;(8).\u003c/p\u003e\n\u003cp\u003eExclusive breastfeeding is one of the most important cost-effective strategies in the prevention of maternal and infant morbidity and mortality. An estimated 823,000 deaths of children under 5 years of age and 20,000 deaths of women from breast cancer could be prevented each year if breastfeeding were a universal practice\u0026nbsp;(2).\u003c/p\u003e\n\u003cp\u003eThe optimal practice of breastfeeding in adolescent mothers is determined by a range of personal and cultural factors such as attitudes about breastfeeding, perceived benefit, knowledge, previous experiences, self-efficacy, and affective or social support. All these factors significantly influence the duration of breastfeeding in adolescent mothers\u0026nbsp;(9).\u003c/p\u003e\n\u003cp\u003eThe development of educational strategies that intervene in the factors that influence breastfeeding in adolescent mothers is key. Therefore, nurses must acquire a commitment and responsibility in the implementation of educational interventions, motivating the mother to generate positive thoughts and commitments, as well as providing a support network and knowledge that contribute to the significant improvement of breastfeeding practices and indices of initiation, exclusivity and duration\u0026nbsp;(10\u0026ndash;14).\u003c/p\u003e\n\u003cp\u003eThe Global Breastfeeding Scorecard 2019 urges that primary care facilities offer individual advice on infant and child feeding, seeking the goal of 80% of countries whose health institutions provide this advice by 2030. It emphasizes in the importance of improving access to qualified breastfeeding counseling by providing specialized guidance that helps to make informed decisions and overcomes difficulties for breastfeeding, focusing on new mothers who have the greatest lack of knowledge and confidence\u0026nbsp;(15).\u003c/p\u003e\n\u003cp\u003eTo carry out educational interventions, the nurse must implement the nursing care plan, as it provides patient-centered care and improves the expected results. To implement this care plan, the use of the Nursing Intervention Classification (NIC)\u0026nbsp;(16)\u0026nbsp;is recommended, which includes the nursing intervention \u0026ldquo;Lactation Counseling\u0026rdquo;; however, available evidence on the use of the classification in clinical trials is scarce especially in the adolescent maternal population\u0026nbsp;(17).\u003c/p\u003e\n\u003cp\u003ePurpose: This article describes the methodology of intervention design based on the nursing intervention \u0026ldquo;Lactation Counseling\u0026rdquo; that aims to determine the effectiveness of this intervention in first-time adolescent mothers for maintaining exclusive breastfeeding in the first six months of child-life.\u0026nbsp;\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cp\u003eDesign: This is a pilot study protocol for a randomized controlled trial using a parallel-group design with a 1:1 allocation ratio, to evaluate the effect on exclusive breastfeeding rates of the intervention \u0026quot;Lactation Counseling\u0026quot; described in the Classification of Nursing Interventions (NIC)\u0026nbsp;(16)\u0026nbsp;(n=59), versus usual education and nursing interventions not related to breastfeeding (n=59) in first-time pregnant adolescents, attending the control prenatal, and followed-up with for up to 6 months after delivery.\u003c/p\u003e\n\u003cp\u003eParticipants: Eligible participants are first-time teenage mothers; between 14 and 19 years old, between 20 to 30 weeks gestation. Adolescents with psychiatric and/or communication disorders will be excluded and who have obtained a score less than or equal to 3.8 on the Knowledge outcome: Breastfeeding (1800), described in the Nursing Outcomes Classification (NOC)\u0026nbsp;(18).\u003c/p\u003e\n\u003cp\u003eSettings and locations: The study will be carried out in two public hospitals in the cities of Gir\u0026oacute;n and Piedecuesta in Santander, Colombia, which mainly provide care for low-income people. The recruitment of participants began in 2019 and is expected to end in 2021 due to delays caused by quarantines and restrictions to control the COVID-19 pandemic. The protocol is approved by the research ethics board of the Industrial University of Santander and is covered by the inter-institutional agreement between the participating hospitals; it has obtained approval and funding from the university\u0026rsquo;s Research and Extension Directorate (#2453) and additional funding from young research program form the\u0026nbsp;Ministry of Science, Technology and Innovation(#8009).\u003c/p\u003e\n\u003cp\u003ePregnant women attending prenatal controls will be invited to participate in the study. Pregnant women who meet the inclusion criteria will fill out a questionnaire designed based on the Knowledge outcome: Breastfeeding (1800). Adolescents who obtain a score on the knowledge test less than or equal to 3.8 points will be invited to participate in the intervention, with prior informed consent. Pregnant women scoring above 3.8 in breastfeeding knowledge will not be invited as they are considered to have extensive breastfeeding knowledge.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInterventions: Control group: This group will receive the usual education given in prenatal \u0026nbsp; control \u0026nbsp;and maternity preparation classes, using the interventions: Infant Care (6820) and Prenatal Care (6960), taken from the Nursing Interventions Classification\u0026nbsp;(16). This group will not receive specific interventions in breastfeeding and the information on this aspect will be that which is usually offered in prenatal control.\u003c/p\u003e\n\u003cp\u003eThis group will receive the interventions in four educational sessions with the following topics: physical-psychological changes and care during pregnancy, the process of labor, delivery and postpartum in its different stages, care of the newborn at home, and family planning. The sessions will be carried out in groups of a maximum of ten pregnant women, led by a nurse trained in maternal and perinatal care. The frequency of each session will be weekly, lasting between 45-60 minutes each. The sessions will be supported by audiovisual materials like slides, photography, videos, and educational games.\u003c/p\u003e\n\u003cp\u003eExperimental group: In addition to the usual education given in prenatal control and maternity preparation classes, this group will receive the intervention \u0026ldquo;Lactation counselling\u0026rdquo; (5244) defined as \u0026ldquo;assisting in the establishment and maintenance of successful breastfeeding\u0026rdquo;\u0026nbsp;(16).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe intervention will consist of four educational sessions with seven topics (See Table 1). The frequency of each session will be weekly, lasting 45-60 minutes each. \u0026nbsp;Each session contains three parts: 1) introduction to the topic where the objective of the session is explained and the pre-knowledge and usual practices in the community on the topic are explored, 2) development of the topic using PowerPoint presentations, audiovisual material such as photographs and videos, simulation material as well as strategies to encourage the participation of mothers such as games and challenges, and 3) end of the session reviewing the main lessons, addressing doubts and concerns and carrying out an evaluation with questions on the topic of the session.\u003c/p\u003e\n\u003cp\u003eParticipants will not receive educational material about interventions, neither will they be encouraged or prohibited from seeking information about breastfeeding by other means. All mothers will be called before each session to encourage their attendance and another phone call will be made near to childbirth to know the health status of mother-child binomial.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOutcomes: The primary outcome will be the exclusive breastfeeding rate in the first 6 months postpartum. We use the WHO definition of exclusive breastfeeding:\u0026nbsp;\u0026ldquo;exclusive breastfeeding for at least 6\u0026thinsp;months in all infants,\u0026rdquo; meaning that the infant receives only breast milk and no other liquids or solids, not even water, except for oral rehydration solution or drops/syrups of vitamins, minerals, or medicines(19).\u003c/p\u003e\n\u003cp\u003eThis result will be evaluated by phone call at 2, 4 and 6 months postnatal and a checklist will be applied to evaluate the following: offer exclusive breastfeeding, offer food or fluids other than breast milk, ensure breastfeeding even when separated from your child (express), describe correct breastfeeding technique, and recognize the importance of breastfeeding for the growth and development of the newborn.\u003c/p\u003e\n\u003cp\u003eAdditionally, mothers will be invited to continue breastfeeding and participating in the study.\u003c/p\u003e\n\u003cp\u003eSecondary outcomes: The secondary outcome will be the level of knowledge about the breastfeeding process using a questionnaire based on the nursing Knowledge outcome: Breastfeeding (1800)\u0026nbsp;defined as the \u0026ldquo;Extent of understanding conveyed about lactation and nourishment of an infant through breastfeeding\u0026rdquo;(18). For questionnaire design 7 indicators were selected for each topic taught in the 4 sessions, with a Likert-type scale with a score from 1 to 5 (1: no knowledge, 2: little knowledge, 3: moderate knowledge, 4: substantial knowledge and 5: extensive knowledge). Each of the indicators selected will be quantifiable constructing a questionnaire with a single answer, multiple choice question (Table 2). The internal consistency of the instrument was 0.8712 Cronbach\u0026apos;s Alpha coefficient.\u003c/p\u003e\n\u003cp\u003eAt the end of the intervention, the level of knowledge acquired will be verified and a phone call will be made at 2, 4 and 6 months after the birth of the babies. Instrument 1 will be used again in each of the visits to evaluate the level of knowledge over time and Instrument 4 will be used to verify the adherence and maintenance of mothers to breastfeeding.\u003c/p\u003e\n\u003cp\u003eSample size: We used STATA-12 to calculate the sample size with the following statistical parameters: a rate of exclusive breastfeeding of 70% in the experimental group and 60% in the control group, a power of 80%, an alpha error of 5%, and the rate of abandonment of exclusive breastfeeding being 2.5 times higher in the control group compared to the experimental group. Additionally, for the knowledge level outcome, we considered a delta or expected difference of 0.4 in the knowledge assessment result score between both groups, a power of 95%, an alpha of 5%, a standard deviation of the result scores of 0.5, an average of correlations between the first and second assessment of 0.5. Finally, the sample size estimated was n=118 primigravidae mothers including 20% of the possible losses; distributed by simple randomization with a ratio of experimental group/control group 1:1 (n=59 pregnant women in the experimental group and n=59 pregnant women control group).\u003c/p\u003e\n\u003cp\u003eRandomization and blinding: We will use simple randomization with an allocation ratio of 1:1. The generation of the allocation sequence will be carried out using a succession of true random numbers stored in tables of random digits. A person who does not know the participants will access this table to find out which group each participant belongs to, depending on whether the number was odd or even and will inform the nurses who will carry out the intervention. The nurse who will perform the intervention \u0026ldquo;Lactation Counselling\u0026rdquo; will only maintain contact with the experimental group, and the nurse who will carry out the initial and final measurements along with the person who will perform the data analysis will be blinded to the group assignment.\u0026nbsp;Study participants, nurses conducting the interview and statistical analysis of data will be masked in group assignments.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthical consideration: This research is based on\u0026nbsp;the World Medical Association Declaration of Helsinki and the research guidelines in Colombia (Resolution 008430/1993 and Law 911/2004) and has the approval of the Ethics Committee in Scientific Research of the Industrial University of Santander. The parents of the participants must sign the informed consent, as well as a consent for those under 18 years of age because they are considered a population of minors.\u003c/p\u003e\n\u003cp\u003eStatistical analysis: The information will be recorded in EPIDATA 3.1. An intention-to-treat analysis will be performed. The categorical and continuous variables will be compared according to the treatment group using chi-square tests or Fisher\u0026apos;s exact tests and Student\u0026apos;s T-test or Mann Whitney\u0026apos;s U test, respectively. The exclusive breastfeeding rate will be calculated at 2, 4 and 6 months of follow-up with their respective confidence intervals. To evaluate the effect of the intervention on the level of Knowledge: Breastfeeding, two approximations will be made by different statistical methods: mean differences through an independent samples Student\u0026apos;s t-test and repeated measures ANOVA. Additionally, the effect of the intervention on the abandonment of exclusive breastfeeding will be calculated in terms of relative risk by means of a binomial regression.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe detail the design of a nursing intervention to standardize breastfeeding counseling, as well as the evaluation of its effect on adolescent mothers. This intervention has the advantage of having been designed using standardized language from the Nursing Intervention Classification and using the same standardized language to evaluate its effect through the Nursing Outcome Classification, using standardized language facilitates the use of interventions and the measurement of their effect in different populations, as well as consolidating the use of a specific nursing language.\u003c/p\u003e\n\u003cp\u003eEducational interventions in first-time mothers has shown effectiveness in maintaining exclusive breastfeeding in the first six months of life\u0026nbsp;(13)\u0026nbsp;and an increase in the level of knowledge about breastfeeding\u0026nbsp;(20,21). However, these interventions were not carried out on adolescent mothers, despite the fact that pregnancy at this stage of the life cycle is considered a global public health problem given that nearly 16 million adolescents give birth every year in the world. which is equivalent to 11% of all births worldwide, a figure that increases in developing countries. Likewise, Latin America and the Caribbean have the second highest adolescent fertility rate in the world, estimating 67 births per 1000 girls between the ages of 15 and 19 between 2010-2015\u0026nbsp;(22). The above figures denote the urgency of providing counseling support to sustain breastfeeding in these young mothers, with appropriate methodologies for these ages.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdditionally, it should be considered that the adolescent mother is generally not prepared to carry out effective breastfeeding, and in developing countries it is working mothers who can put breastfeeding at risk. Different studies have established that adolescent mothers, compared to adult mothers, are less likely to initiate breastfeeding and those who initiate it are more likely to abandon it. Among the reasons for dropping out, causes such as hypogalactia, returning to school, medical indication, causes related to the nipple, maternal illness, maternal labor, and acid reflux in the newborn have been described\u0026nbsp;(23). In a study carried out in adolescent mothers, 39.4% lactated for 6 months and 9.8% lactated for more than 6 months; the reasons why they do not feed their child with only breast milk are: 9.5% produce little milk, 12% the child is left hungry, and 20.7% other causes\u0026nbsp;(24). \u0026nbsp;On the other hand, a study in South Africa found that adolescent mothers knew the benefits of breastfeeding but abandoned it easily due to its lack of practicality when faced with the need to go to school\u0026nbsp;(25)\u0026nbsp;as was found by Acosta Silva in Ecuadorian adolescents\u0026nbsp;(26), adding as a barrier the insufficient breastfeeding education during prenatal or in the early postpartum period\u0026nbsp;(26,27). The foregoing highlights the importance of designing interventions that promote exclusive breastfeeding and therefore evaluating its effect.\u003c/p\u003e\n\u003cp\u003eOn the other hand, a review by Lumbiganon et al. in 2016 found that the majority of intervention studies to promote exclusive breastfeeding had been done in high-income countries\u0026nbsp;(28). This is a pilot study that seeks to know the efficacy of a nursing intervention in low-income adolescent mothers in a developing country, considering that sustaining breastfeeding depends on social and cultural factors and in view of the need to explore an intervention that is low cost and easy to perform by nurses.\u003c/p\u003e\n\u003cp\u003eEven though this pilot uses a randomized design, with the aim of preventing potential biases, some measures will be taken to reduce their appearance: Offer the possibility of participation to all adolescents in maternity classes, Have strict measures for the random assignment of mothers to groups. Ensure blinding of nurses who will assess the results and those who analyze the data. It is worth highlighting the importance of the intervention activities being standardized and supervised with prior training of the nursing staff.\u003c/p\u003e\n\u003cp\u003eIt is important to note that mothers will be able to access information or training on breastfeeding in a complementary way through different means and could bring the levels of knowledge about breastfeeding closer to those of the intervention group. There can also be a potential contamination of the groups in the event that some mothers who are in different intervention / control groups have a close relationship given the proximity of their homes and the similarity in age and share the learning and experiences acquired during the interventions.\u003c/p\u003e\n\u003cp\u003eThis study, given nature of intervention, also provides a higher level of scientific evidence, which will undoubtedly support the advancement and training of professionals in the discipline of Nursing, by basing knowledge and thinking to take actions and decisions that form part of the practice and assistance of nursing care in maternal and child health.\u003c/p\u003e\n\u003cp\u003eFinally, the findings of this study will be a valuable resource for the management of nursing care, which will support the formulation, implementation, monitoring and evaluation of national policies aimed at the promotion, support, and protection of breastfeeding, by involving the educational component as an important strategy that guarantees respect and protection of the act of breastfeeding as a human right appropriate for women and their children.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate.\u0026nbsp;The pilot protocol is approved by the Ethics Committee in Scientific Research of the Industrial University of Santander (Acta 014-August 17/2018). The parents of the participants must sign the informed consent, as well as a consent for those under 18 years of age because they are considered a population of minors.\u003c/p\u003e\n\u003cp\u003eConsent for publication: Consent was not obtained to publish personal data because it is not expected to be used.\u003c/p\u003e\n\u003cp\u003eFunding: This study was funded by Ministry of Science and Technology of Colombia (MINCIENCIAS), call for research 821/2018 for young research program (#8009). and the Universidad Industrial de Santander grant code 6287 (#2453), and funded all trial costs. The funding source had no role in the design, execution, analysis, interpretation of data, or the decision to present the results of this study.\u003c/p\u003e\n\u003cp\u003eTrial Registration: ClinicalTrials.gov NCT04655846, Registered December 7, 2020. \u003ca href=\"https://www.clinicaltrials.gov/ct2/show/record/NCT04655846\"\u003ehttps://www.clinicaltrials.gov/ct2/show/record/NCT04655846\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions: All authors contributed to the design of the study, and the preparation of the article.\u003c/p\u003e\n\u003cp\u003eCompeting/Conflict of Interest Statement: The authors declared not to have conflicts of interest.\u003c/p\u003e\n\u003cp\u003eAvailability of the data: The datasets generated and analyzed during the current study will be available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003cp\u003e1. \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Rodrigues GC, Dias V, Oliveira I de J. Benefits of exclusive breastfeeding: An integrative review. Nurs Pract Today [Internet]. 2020;7(4):245\u0026ndash;54. Available from: https://doi.org/10.18502/npt.v7i4.4034\u003c/p\u003e\n\u003cp\u003e2. \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Victora CG, Bahl R, Barros AJD, Fran\u0026ccedil;a GVA, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. Lancet [Internet]. 2016;387(10017):475\u0026ndash;90. Available from: http://dx.doi.org/10.1016/S0140-6736(15)01024-7\u003c/p\u003e\n\u003cp\u003e3. \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Boix-Amor\u0026oacute;s A, Collado MC, Van\u0026rsquo;t Land B, Calvert A, Le Doare K, Garssen J, et al. Reviewing the evidence on breast milk composition and immunological outcomes. Nutr Rev [Internet]. 2019;77(8):541\u0026ndash;56. Available from: doi: 10.1093/nutrit/nuz019\u003c/p\u003e\n\u003cp\u003e4. \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Binns C, Lee M, Low WY. The Long-Term Public Health Benefits of Breastfeeding. Asia-Pacific J Public Heal [Internet]. 2016;28(1):7\u0026ndash;14. Available from: doi: 10.1177/1010539515624964\u003c/p\u003e\n\u003cp\u003e5. \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Hashemi-Nazari SS, Hasani J, Izadi N, Najafi F, Rahmani J, Naseri P, et al. The effect of pre-pregnancy body mass index on breastfeeding initiation, intention and duration: A systematic review and dose-response meta-analysis. Heliyon [Internet]. 2020;6(12):0\u0026ndash;7. Available from: doi: 10.1016/j.heliyon.2020.e05622\u003c/p\u003e\n\u003cp\u003e6. \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;WHO/UNICEF. Global nutrition targets 2025: breastfeeding policy brief (WHO/NMH/NHD/14.7). Geneva: World Health Organization; 2014. [Internet]. Geneva: World Health Organization; 2014. 8 p. Available from: https://apps.who.int/iris/rest/bitstreams/665591/retrieve#:~:text=Globally%2C only 38%25 of infants,under 5 years of age.\u003c/p\u003e\n\u003cp\u003e7. \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, De Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries.\u0026nbsp;Lancet. 2013;382(9890):427\u0026ndash;51.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e8. \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Instituto Colombiano de Bienestar Familiar. Encuesta Nacional de la Situaci\u0026oacute;n Nutricional (ENSIN). Resultados generales [Internet]. Bogot\u0026aacute;, Colombia; 2015. Available from: https://www.icbf.gov.co/bienestar/nutricion/encuesta-nacional-situacion-nutricional\u003c/p\u003e\n\u003cp\u003e9. \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Kanhadilok S, McGrath JM. An Integrative Review of Factors Influencing Breastfeeding in Adolescent Mothers. J Perinat Educ [Internet]. 2015;24(2):119\u0026ndash;27. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4744340/\u003c/p\u003e\n\u003cp\u003e10. \u0026nbsp; \u0026nbsp;\u0026nbsp;Oliveira IBB, Leal LP, Coriolano-Marinus MW de L, Santos AH da S, Horta BL, Pontes CM.\u0026nbsp;Meta-analysis of the effectiveness of educational interventions for breastfeeding promotion directed to the woman and her social network. J Adv Nurs. 2017 Feb;73(2):323\u0026ndash;35.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e11. \u0026nbsp; \u0026nbsp;\u0026nbsp;Franco-Antonio C, Calder\u0026oacute;n-Garc\u0026iacute;a JF, Santano-Mogena E, Rico-Mart\u0026iacute;n S, Cordovilla-Guardia S. Effectiveness of a brief motivational intervention to increase the breastfeeding duration in the first 6 months postpartum: Randomized controlled trial. J Adv Nurs. 2020;76(3):888\u0026ndash;902.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e12. \u0026nbsp; \u0026nbsp;\u0026nbsp;Piro SS, Ahmed HM. Impacts of antenatal nursing interventions on mothers\u0026rsquo; breastfeeding self-efficacy: An experimental study. BMC Pregnancy Childbirth [Internet]. 2020;20(1):1\u0026ndash;12. Available from: https://doi.org/10.1186/s12884-019-2701-0\u003c/p\u003e\n\u003cp\u003e13. \u0026nbsp; \u0026nbsp;\u0026nbsp;Tseng J-F, Chen S-R, Au H-K, Chipojola R, Lee GT, Lee P-H, et al.\u0026nbsp;Effectiveness of an integrated breastfeeding education program to improve self-efficacy and exclusive breastfeeding rate: A single-blind, randomised controlled study. Int J Nurs Stud [Internet]. 2020;111:103770. Available from: https://doi.org/10.1016/j.ijnurstu.2020.103770\u003c/p\u003e\n\u003cp\u003e14. \u0026nbsp; \u0026nbsp;\u0026nbsp;Gu Y, Zhu Y, Zhang Z, Wan H. Effectiveness of a theory-based breastfeeding promotion intervention on exclusive breastfeeding in China: A randomised controlled trial. Midwifery [Internet]. 2016;42:93\u0026ndash;9. Available from: https://www.sciencedirect.com/science/article/pii/S0266613816301668\u003c/p\u003e\n\u003cp\u003e15. \u0026nbsp; \u0026nbsp;\u0026nbsp;United Nations Children\u0026rsquo;s Fund (UNICEF), World Health Organization. Global Breastfeeding Scorecard, 2019. increasing commitment to breastfeeding through funding and improved policies and programmes [Internet]. World Health Organization. 2019. Available from: https://www.who.int/nutrition/publications/infantfeeding/global-bf-scorecard-2019/en/\u003c/p\u003e\n\u003cp\u003e16. \u0026nbsp; \u0026nbsp;\u0026nbsp;Butcher HK, Bulechek GM, McCloskey JD, Wagner CM. The Nursing Interventions Classification (NIC). 7th ed. ST. Louis, Missouri: Elsevier; 2018. 237 p.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e17. \u0026nbsp; \u0026nbsp;\u0026nbsp;Jantasin B. Modified Nurse-Family Partnership Home Visiting Program on Prenatal and Postnatal Health Outcomes in Thai Adolescent Mothers: A Cluster Randomized Controlled Trial [Internet]. Doctoral Thesis. Mahasarakham University; 2019. Available from: http://202.28.34.124/dspace/bitstream/123456789/122/1/56011460010.pdf\u003c/p\u003e\n\u003cp\u003e18. \u0026nbsp; \u0026nbsp;\u0026nbsp;Moorhead S, Johnson M, Maas ML, Swanson E. Nursing outcomes classification (NOC)-E-Book: Measurement of health outcomes. Six editio. Elsevier Health Sciences; 2018. 671 p.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e19. \u0026nbsp; \u0026nbsp;\u0026nbsp;World Health Organization. Infant and Young Child Feeding. Model chapter for textbooks for medical students and allied health professionals [Internet]. Geneva, Switzerland: World Health Organization; 2009. 1\u0026ndash;99 p. Available from: http://apps.who.int/iris/bitstream/10665/44117/1/9789241597494_eng.pdf?ua=1\u0026amp;ua=1\u003c/p\u003e\n\u003cp\u003e20. \u0026nbsp; \u0026nbsp;\u0026nbsp;Abuidhail J, Mrayyan L, Jaradat D. Evaluating effects of prenatal web-based breastfeeding education for pregnant mothers in their third trimester of pregnancy: Prospective randomized control trial. Midwifery [Internet]. 2019;69:143\u0026ndash;9. Available from: https://doi.org/10.1016/j.midw.2018.11.015\u003c/p\u003e\n\u003cp\u003e21. \u0026nbsp; \u0026nbsp;\u0026nbsp;Yılmaz M, Aykut M. The effect of breastfeeding training on exclusive breastfeeding: a randomized controlled trial. J Matern Neonatal Med [Internet]. 2021;34(6):925\u0026ndash;32. Available from: https://doi.org/10.1080/14767058.2019.1622672\u003c/p\u003e\n\u003cp\u003e22. \u0026nbsp; \u0026nbsp;\u0026nbsp;United Nations. The Millennium Development Goals Report. United Nations [Internet]. 2015;72. Available from: https://visit.un.org/millenniumgoals/2008highlevel/pdf/MDG_Report_2008_Addendum.pdf\u003c/p\u003e\n\u003cp\u003e23. \u0026nbsp; \u0026nbsp;\u0026nbsp;Forero Y, Rodr\u0026iacute;guez SM, Isa\u0026aacute;cs MA, Hern\u0026aacute;ndez JA. La lactancia materna desde la perspectiva de madres adolescentes de Bogot\u0026aacute;. Biomedica. 2013;33(4):554\u0026ndash;63.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e24. \u0026nbsp; \u0026nbsp;\u0026nbsp;Pinilla EG, Dom\u0026iacute;nguez-Nari\u0026ntilde;o CC, Garc\u0026iacute;a-Rueda A. Adolescent mothers a challenge facing the factors influencing exclusive breastfeeding/Madres adolescentes, un reto frente a los factores que influyen en la lactancia materna exclusiva.\u0026nbsp;Enfermer\u0026iacute;a Glob [Internet]. 2014;13(1):71\u0026ndash;82. Available from: http://oxfordbrookes.idm.oclc.org/login?url=http://search.proquest.com/docview/1664837316?accountid=13041%5Cnhttp://linksource.ebsco.com/linking.aspx?sid=ProQ%3Abritishnursingindexft\u0026amp;fmt=journal\u0026amp;genre=article\u0026amp;issn=\u0026amp;volume=13\u0026amp;issue=1\u0026amp;date=2014-01-01\u0026amp;spage=\u003c/p\u003e\n\u003cp\u003e25. \u0026nbsp; \u0026nbsp;\u0026nbsp;Zweigenthal V, Strebel A, Hunter-Adams J. Adolescent girls\u0026rsquo; perceptions of breastfeeding in two low-income periurban communities in South Africa. Health Care Women Int [Internet]. 2019 Aug 20;40(7\u0026ndash;9):995\u0026ndash;1011. Available from: https://doi.org/10.1080/07399332.2018.1549043\u003c/p\u003e\n\u003cp\u003e26. \u0026nbsp; \u0026nbsp;\u0026nbsp;Acosta Silva M, De la Rosa Ferrera JM. Causas que determinan la interrupci\u0026oacute;n de la lactancia materna exclusiva en los barrios Santa Cruz y Propicia I en Esmeraldas, Ecuador.\u0026nbsp;Arch M\u0026eacute;dico Camag\u0026uuml;ey. 2018;22(4):434\u0026ndash;44.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e27. \u0026nbsp; \u0026nbsp;\u0026nbsp;Dennison BA, Nguyen TQ, Gregg DJ, Fan W, Xu C. The Impact of Hospital Resources and Availability of Professional Lactation Support on Maternity Care: Results of Breastfeeding Surveys 2009\u0026ndash;2014. Breastfeed Med [Internet]. 2016 Sep 19;11(9):479\u0026ndash;86. Available from: https://doi.org/10.1089/bfm.2016.0072\u003c/p\u003e\n\u003cp\u003e28. \u0026nbsp; \u0026nbsp; Lumbiganon P, Martis R, Laopaiboon M, Festin MR, Ho JJ, Hakimi M. Antenatal breastfeeding education for increasing breastfeeding duration. Cochrane Database Syst Rev. 2016;2016(12).\u0026nbsp;\u003c/p\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Summary description of educational sessions for Lactation Counseling intervention.\u003c/p\u003e\n\u003cdiv align=\"center\" style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\n \u003ctable style=\"width:515.7pt;border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"border-top:solid windowtext 1.0pt;border-left:none;border-bottom: solid windowtext 1.0pt;border-right:none;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:center;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eSession\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:132.1pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:.25in;text-align:center;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eContent\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:149.4pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:center;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eMethodologies\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:184.25pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:center;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eMaterials\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:center;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:132.1pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cdiv style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;\"\u003e\n \u003cli style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eComposition of breast milk\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003ePsychological and physiological benefits of breastfeeding\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:149.4pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cdiv style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;\"\u003e\n \u003cli style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eLecture method\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eAudiovisual Presentation\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eGroup assignment\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:.25in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:184.25pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003ePowerPoint presentations\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eBreast milk production video\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eBreastfeeding benefits video\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eBreastfeeding kit with educational elements such as games and models (bottles with types of breast milk)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eExplanatory sheets with each of the components of breast milk.\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eSheets with text to identify the benefits of breast for the mother, baby, family and society.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:center;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:132.1pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cdiv style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;\"\u003e\n \u003cli style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eTechnique and positions for breastfeeding\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:149.4pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cdiv style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;\"\u003e\n \u003cli style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eAudiovisual \u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Presentation\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eDemonstration\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003ePractical exercise\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:184.25pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eSimulated models (baby dolls)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eVideo on breastfeeding and nipple latch technique\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:79.65pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:center;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:132.1pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:79.65pt;\"\u003e\n \u003cdiv style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;\"\u003e\n \u003cli style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eExtraction, conservation, and administration of breast milk\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:149.4pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:79.65pt;\"\u003e\n \u003cdiv style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;\"\u003e\n \u003cli style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eLecture method\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eAudiovisual Presentation\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eDemonstration\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003ePractical exercise\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:184.25pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:79.65pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003ePowerPoint Presentations\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eVideo on storage, conservation, and administration of breast milk.\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eVest-type simulators for breast milk extraction\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:center;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:132.1pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cdiv style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: undefined;\"\u003e\n \u003cli style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color:black;\"\u003e\u0026middot;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/span\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eBreast complications during breastfeeding\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:2.85pt;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;\"\u003e\n \u003cli style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eLactating mother needs (rest, hydration and a balanced diet)\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:149.4pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cdiv style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;\"\u003e\n \u003cli style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eLecture method\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eAudiovisual Presentation\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eDemonstration\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003ePractical exercise\u003c/span\u003e\u003c/li\u003e\n \u003cli style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eGroup activity\u0026nbsp;\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width:184.25pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003ePowerPoint Presentaciones\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eBreastfeeding kit with educational elements such as games and models (Breast models)\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eLottery game on care and complications during breastfeeding\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eMemory game on nutrition and hydration during breastfeeding\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003eVideo on care for the prevention of breast complications\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family:\"Arial\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eTable 2. Items and Indicators to Quantify the Nursing Knowledge Outcome: Breastfeeding (1800)\u003c/p\u003e\n\u003cdiv align=\"center\" style='margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;text-align:justify;line-height:105%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\n \u003ctable style=\"width:508.65pt;border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;border-top:solid windowtext 1.0pt;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:none;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eINDICATOR 180003: \u0026nbsp; \u0026nbsp; Composition of breast milk, milk outlet process, and initial vs late milk\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;border:none;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e1.\u003c/span\u003e\u003cspan style='font-size:9px;font-family: \"Times New Roman\",serif;color:black;'\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eOccurs between 5 and 10 days after delivery\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e2.\u003c/span\u003e\u003cspan style='font-size:9px;font-family: \"Times New Roman\",serif;color:black;'\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eContains less sugar, fats, and vitamins of B complex and vitamin C\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e3.\u003c/span\u003e\u003cspan style='font-size:9px;font-family: \"Times New Roman\",serif;color:black;'\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eContains proteins, sugar, fats, minerals such as sodium, calcium, iron, selenium, zinc and B complex vitamins and vitamins such as C, A, E, K.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e4.\u003c/span\u003e\u003cspan style='font-size:9px;font-family: \"Times New Roman\",serif;color:black;'\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eIts composition contains between 88% to 90% water\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e5.\u003c/span\u003e\u003cspan style='font-size:9px;font-family: \"Times New Roman\",serif;color:black;'\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eOccurs in the first 3 to 4 days after delivery\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e6.\u003c/span\u003e\u003cspan style='font-size:9px;font-family: \"Times New Roman\",serif;color:black;'\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eIt is yellow, thick and of little amount\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e7.\u003c/span\u003e\u003cspan style='font-size:9px;font-family: \"Times New Roman\",serif;color:black;'\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eContains more sugar, fats, calories and B Complex vitamins and vitamin C\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e8.\u003c/span\u003e\u003cspan style='font-size:9px;font-family: \"Times New Roman\",serif;color:black;'\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eIt occurs progressively up to about 100 milliliters a day\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e9.\u003c/span\u003e\u003cspan style='font-size:9px;font-family: \"Times New Roman\",serif;color:black;'\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eContains fewer proteins, antibodies and vitamins A, E, K\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e10.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eIt occurs in an amount of 400 to 600 milliliters per day\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e11.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eOccurs from the tenth day after delivery\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e12.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eContains more protein, minerals such as sodium, iron, selenium, zinc, and vitamins such as A, E, K\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e13.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eIts composition contains 87% water\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e14.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eIt is produced in an amount of 700 to 800 milliliters per day\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eINDICATOR 180001: Benefits of breastfeeding\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;border:none;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e15.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003ePrevents breast, uterine and ovarian cancer\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e16. Prevents respiratory diseases such as bronchitis, pneumonia, and gastrointestinal diseases such as diarrhea and dehydration\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e17.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003ePrevents the onset of diseases such as allergies, obesity, high blood sugar, high blood pressure and cancer\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e18.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003ePrevents postpartum depression states (mood affecting women after giving birth, characterized by feelings of extreme sadness and anxiety)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e19.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003ePrevents constipation and cramping\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e20.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003ePrevents child malnutrition\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e21.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eFacilitates the affective bond between mother and child\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e22.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eStrengthens self-appreciation, self-confidence and emotional satisfaction\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e23.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eContributes to postpartum weight loss \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e24.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eLowers the risk of osteoporosis (a disease that thins and weakens bones, causing them to break easily)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e25.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003ePromotes better growth and development of physical, language and social capacities\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e26.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eReduces risk of postpartum hemorrhaging or bleeding\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e27.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eLowers the risk of heart disease\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e28.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eImproves intelligence\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e29.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eDelays the return of ovulation and menstruation\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eINDICATOR 180005: Proper technique for breastfeeding the baby\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;border:none;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e30.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eThe mother should select the most comfortable position\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e31.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eThe baby\u0026apos;s body must be attached to the mother\u0026apos;s body\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e32.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eThe baby\u0026apos;s head and body are in the same direction\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e33.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eThe mother should grab the breast with her C-shaped hand (placing her thumb above the breast and the other four fingers below the nipple and behind the areola (ring of pigmented skin around the breast)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e34.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eThe mother should bring the child closer to the breast and not the breast to the child\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e35.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eThe mother should stimulate the baby to have a search reflex, bringing the nipple closer to the baby\u0026apos;s lip and when it opens its mouth to insert the nipple and the areola\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e36.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eThe baby\u0026apos;s lips should remain outside like the mouth of a fish\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e37.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eThe baby\u0026apos;s mouth should coat the entire areola (dark area of the breast)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e38.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eThe baby\u0026apos;s chin must touch or almost be touching the mother\u0026apos;s chest\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eINDICATOR 180006: Adequate position of the infant during breastfeeding\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;border:none;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e39.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eStretched or cradle position (classic or traditional)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e40.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eCross-cradle position\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e41.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eParallel stretched position (side lying down)\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e42.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eRugby ball or football position (inverted)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e43.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eSitting or horse position\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e44.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eFace-up position\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e45.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eVertical or standing position\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eINDICATOR 180014: Signs of mastitis, duct obstruction and nipple trauma\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;border:none;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e46.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eBreast skin is shiny, red, tense and warm\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e47.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eFormation of a mass or lump in the breast that is palpable and painful, often with redness of the skin in that area\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e48.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003ePainful cracks or wounds on the nipple\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e49.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eUncontrolled fever, chills, general discomfort, nausea, vomiting, headache\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e50.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eFormation of a mass or lump in the breast, severe pain, swollen and hardened sinus, obstruction at the milk outlet (milk does not flow), pus secretion\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e51.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eInflammation or swelling in the breast with a feeling of warmth\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e52.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eNipple pain\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e53.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eCracks or nipple wounds that may bleed \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e54.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eDecreased milk flow\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e55.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eNo fever or symptoms of general discomfort\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eINDICATOR 180015: \u0026nbsp; \u0026nbsp; Appropriate techniques for the extraction and storage of breast milk\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;border:none;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e56.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eMassage into the breast before breast milk extraction\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e57. At room temperature: Breast milk is preserved for up to 4 hours, it is advisable to leave it in a dry place, protected from sunlight and heat.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e58. In the freezer: Breast milk is kept frozen for up to 15 days, so it is recommended not to constantly open and close the freezer. If the refrigerator is two doors, breast milk can be stored for up to 3 months.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e59.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eWith your hand in the shape of a C, place it on breast (placing your thumb above the breast and the other four fingers below the nipple and behind the areola (dark area of the breast)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e60.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eIn a refrigerator or refrigerator: Breast milk is stored for up to 12 hours, it is advisable not to place it in the refrigerator door to avoid temperature changes every time the door is opened or closed.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e61.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eLean the body forward, squeeze the breast without swiping your fingers and gently push against the ribs\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e62.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eThen move your fingers forward and repeat the procedure as many times as necessary simultaneously and smoothly\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eINDICATOR 180020: \u0026nbsp; \u0026nbsp; Need for fluid intake by the mother\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;border:none;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e63.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eIt is advisable to increase the consumption of liquids, preferably water, as it is the largest component of breast milk\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e64.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eWater intake during lactation should be sufficient to compensate for the loss of water through milk\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e65.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eVitamin C-rich juices are recommended\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e66.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eThe most recommended liquids for women during breastfeeding are water, fruit juices, and milk\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:508.65pt;border:none;border-bottom:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:.0001pt;margin-left:0in;text-align:justify;line-height: normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003e67.\u003c/span\u003e\u003cspan style='font-size:9px;font-family:\"Times New Roman\",serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003cspan style='font-size:16px;font-family:\"Arial\",sans-serif;color:black;'\u003eAvoid drinking alcoholic beverages, excessive coffee, and tea (more than 2 cups a day, during the term of breastfeeding)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pilot-and-feasibility-studies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pafs","sideBox":"Learn more about [Pilot and Feasibility Studies](http://pilotfeasibilitystudies.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/PAFS/default.aspx","title":"Pilot and Feasibility Studies","twitterHandle":"@MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Breastfeeding, Nursing Education, Pregnancy in Adolescence, Nursing Care, Nursing Process (Source: DeCS-MeSH)","lastPublishedDoi":"10.21203/rs.3.rs-578613/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-578613/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAdolescent mothers have lower rates of initiation, continuation, and exclusivity of breastfeeding, and even more so in the first pregnancy. Current interventions target adult women, and little evidence is available for breastfeeding promotion among adolescents. This is a pilot study protocol with a parallel, single-blind, randomized, controlled trial design, to evaluate the effectiveness of the intervention \u0026ldquo;Lactation Counseling\u0026rdquo; in first-time adolescent mothers to maintain exclusive breastfeeding in the first six months of life. The control group will receive routine education in prenatal care and prenatal and childbirth classes and, the experimental group will receive additionally the intervention \u0026ldquo;Lactation Counseling\u0026rdquo;, for four weeks, both conducted by trained nurses. The primary outcome will be the exclusive breastfeeding rate; and the secondary, the breastfeeding knowledge. Measurements will be taken at baseline, post-intervention, and two, four and six months after childbirth. This study will allow the evaluation of the feasibility of an intervention in low-income, Latin American population adolescents.\u003c/p\u003e","manuscriptTitle":"Lactation Counseling for Maintaining Exclusive Breastfeeding in Adolescent Mothers: A Trial Protocol","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-06-12 16:34:51","doi":"10.21203/rs.3.rs-578613/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2021-07-23T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-07-05T00:00:00+00:00","index":1,"fulltext":"Recommendation: Minor Revision\nForm responses:\n---\n\nComments to Author:\n---\nThank you for the opportunity to review this protocol. The topic is exciting; just a few suggestions and clarification needed.\nPage 5, row 105 Authors can detail and specify details on the language of participants\nPage 7, row 156 authors can specify that this paragraph is referred to the participant retention strategy.\nPage 9 row 166 Since there will be phone calls, how would you deal with the trustworthiness of answers given by parents?\nPage 11, row 211 On page 6, lines 118-120, you stated that eligible participants would be invited to participate in the intervention with previous consent. Given this statement, it is not clear how they will be blinded to the intervention.\nIt will better state: They will be invited to participate in the study.\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Level of interest: **An article of importance in its field**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **I declare that I have no competing interests' below**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: **\nI agree to the open peer review policy of the journal**\n* Were you mentored through this peer review?: **No**\n"},{"type":"editorInvitedReview","content":"","date":"2021-07-01T00:00:00+00:00","index":2,"fulltext":"Recommendation: Minor Revision\nForm responses:\n---\n\nComments to Author:\n---\nThe article is well written and the study will be of significant relevance in the evaluation and improvement of Exclusive Breastfeeding, specifically among adolescent mothers.\nSome issues to be addressed are:\n1. Appropriate line break for the heading 'Introduction' so that it starts on page 3 and is in line 47.\n2. Second half of the sentence in line 103 and 104 should be rephrased as 'including' those who obtained a score less than or equal to 3.8.\n3. A clearer explanation is required for Instrument 1 and Instrument 4 in the sentence in line 186 to 188.\n4. What feasibility factors will the study take into consideration to evaluate this intervention that is specifically targeting adolescent mothers?\n5. The attrition rate is quite high as per the flow chart on page 19 and line 46? What are the reasons for high attrition rate in this specific study and will any of it be addressed?\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Level of interest: **An article of importance in its field**\n* Quality of written English: **Needs some language corrections before being published**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). 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