Exclusive breastfeeding for six months, in practice

Exclusive is a strict word and it is meant strictly. For the first six months the baby has breast milk and nothing else. No water. No thin porridge because the baby seems hungry. No cow's milk, no tea, no glucose water, no herbal mixtures given for colic or to make a baby strong.

The only exceptions are things a health worker gives or prescribes for the baby, which are not food and are given for a reason. If somebody advises you to give a baby anything else in those months, ask who advised it and why, before it goes in the cup.

Start early. The first feed in the first hour after birth matters, and the thick yellow milk that comes before the mature milk is not to be discarded. Older relatives sometimes call it dirty or spoiled. It is the first and most concentrated feed a baby will ever get.

In Napak in the dry season, or Kamuli in the middle of the afternoon, telling a grandmother that a baby needs no water is the single most argued instruction in this whole guide. It sounds like cruelty.

The reason it holds is that breast milk is mostly water already, and the baby regulates it themselves. A hot baby feeds more often and takes more of the thin milk that comes at the start of a feed. What water does is fill a very small stomach with something that has no food in it, so the baby takes less milk at the next feed and the mother's supply drops in response.

The other reason is the cup. Water given to a baby is water from wherever the household draws it, poured into a container washed in the same water. A baby under six months has very little defence against what comes with it, and diarrhoea at that age moves fast.

This is the practical wall most mothers hit at around six to eight weeks, when the household needs her working again. It is solvable, and it is solved by hand expression rather than by starting porridge early.

Wash hands, sit somewhere clean, and hand express into a clean cup with a cover. Leave it with whoever is minding the baby, along with a clean cup and spoon to feed from. Milk left in a covered cup keeps for a matter of hours in the shade, and less in the heat, so express in the morning for the morning and again for the afternoon rather than expressing once for the whole day.

Feed from a cup, not a bottle. A cup can be scrubbed and boiled properly and a bottle teat, in a house without reliable clean water, usually cannot. Feed the baby on the breast before leaving and again as soon as you return, and express once during the day if you are away for long, which keeps the supply from falling.

Almost every mother thinks this at some point, usually in a week when the baby feeds constantly and sleeps badly. Genuine low supply is uncommon. Low stimulation is common, and the two look identical from the outside.

The way to tell is not by feeling the breast, which tells you nothing useful after the early weeks. It is by what comes out of the baby: regular wet nappies through the day and night, stools that keep coming, a baby who settles for a while after most feeds, and weight going up at the health facility. Those four together mean the milk is enough.

If it is not enough, the fix is more feeding rather than less. Offer the breast more often, let the baby finish the first side before switching so they get the richer milk at the end, and check the attachment, because a baby latched onto the nipple alone will suck for an hour and get very little. A mother also needs to eat and drink properly herself, which in a lean month means the household deciding she eats first, not last.

Feeding should not be painful past the first few seconds of a latch. Persistent pain almost always means the baby has taken the nipple only, rather than a good mouthful of the areola underneath it. Break the suction gently with a clean finger and start again rather than enduring it, because a bad latch causes cracks and cracks cause the next problem.

A breast that becomes hard, hot and painful in one area, especially with fever and body aches, needs a health worker the same day. Do not wait it out at home and do not stop feeding from that side, because leaving the milk in makes it worse.

None of these are reasons to give up breastfeeding, and none of them are reasons to start porridge early. They are reasons to be seen and helped, and they are usually sorted out quickly.

A mother rarely decides this alone. The grandmother who raised six children a different way, the aunt who minds the baby while the mother digs, and the father who hears the baby crying at night all have a view, and one cup of porridge from any of them ends the exclusivity.

The conversation goes better when it is had once, early, with everyone present, rather than as a series of corrections after the fact. Say plainly what the plan is until six months, what happens after six months, and what you would like each person to do when the baby cries and you are not there.

It also helps to name the thing that is really being asked, which is help. A mother who is expected to dig, cook, fetch water and feed on demand will stop feeding on demand first. If somebody else carries the water for a few months, the feeding usually looks after itself.

A mother with an ordinary illness, malaria, a cold, a stomach upset, normally goes on feeding. Stopping does not protect the baby and it puts the supply at risk. Tell the health worker treating you that you are breastfeeding, so that is taken into account.

A mother living with HIV should follow the plan the health worker managing her care gives her, and should raise feeding specifically at that visit rather than acting on what a neighbour did.

Where a mother has died, is very ill or has had to travel for a long period, the household needs a proper conversation with a health worker rather than a bag of powdered milk from a shop. There are safer options in that situation and they depend on the child's age, and getting it wrong at that age is dangerous.

Six months of exclusive breastfeeding gives a child the strongest start available in a village with unreliable water, and it is free, which is not a small thing in a household counting shillings.

It does not immunise a child against everything that comes later. The most common pattern our field teams see is a child who was exclusively breastfed beautifully and then, at six months, was moved onto thin porridge alone for the next year. That child ends up in the yellow just the same.

The six-month mark is a beginning, not a finish. Breastfeeding continues alongside food from then on, well into the second year, and the food that joins it is what decides how the next year goes.