document_title: Breastfeeding

question_text: when does a woman's body produce milk

question_tokens: when does a woman 's body produce milk

root

text: Breastfeeding

text: Lactation[edit]

text: Changes early in pregnancy prepare the breast for lactation. Pre-birth hormone levels become altered after the birth and stimulate the production of milk. From around halfway through pregnancy, the breasts begin to produce colostrum.[17] Colostrum, a thick yellowish fluid rich in protein, continues to be produced for the first few days after delivery. Around 30 to 40 hours after delivery, the composition of milk changes to mature milk and milk volume becomes copious, an event known as the milk "coming in".[18] Sucking causes the pituitary to release oxytocin that causes to the contraction of the uterus.[19][20] Progesterone is the hormone that influences the growth of breast tissue before the birth. The postpartum changes that occur in the endocrine system after the birth shift from hormones that prevent lactation to hormones that trigger milk production.[citation needed] This can be felt by the mother in the breasts. The crying of the infant can induce the release of oxytocin from the pituitary gland.[21]

tag: p

text: Breast milk[edit]

text: Not all of breast milk's properties are understood, but its nutrient content is relatively consistent. Breast milk is made from nutrients in the mother's bloodstream and bodily stores. Breast milk has an optimal balance of fat, sugar, water, and protein that is needed for a baby's growth and development.[23] Breastfeeding triggers biochemical reactions which allows for the enzymes, hormones, growth factors and immunologic substances to effectively defend against infectious diseases for the infant. The breastmilk also has long-chain polyunsaturated fatty acids which help with normal retinal and neural development.[24]

text: The composition of breast milk changes depending on how long the baby nurses at each session, as well as on the child's age.[25] The first type, produced during the first days after childbirth, is called colostrum. Colostrum is easy to digest although it is more concentrated than mature milk. It has a laxative effect that helps the infant to pass early stools, aiding in the excretion of excess bilirubin, which helps to prevent jaundice. It also helps to seal the infants gastrointestional tract from foreign substances, which may sensitize the baby to foods that the mother has eaten. Although the baby has received some antibodies through the placenta, colostrum contains a substance which is new to the newborn, secretory immunoglobulin A (IgA). IgA works to attack germs in the mucous membranes of the throat, lungs, and intestines, which are most likely to come under attack from germs.[26]

text: Breasts begin producing mature milk around the third or fourth day after birth. Early in a nursing session, the breasts produce foremilk, a thinner milk containing many proteins and vitamins. If the baby keeps nursing, then hindmilk is produced. Hindmilk has a creamier color and texture because it contains more fat.[27]

text: Process[edit]

text: Commencement[edit]

text: Breastfeeding can begin immediately after birth. The baby is placed on the mother and feeding starts as soon as the baby shows interest.

text: According to some authorities, increasing evidence suggests that early skin-to-skin contact (also called kangaroo care) between mother and baby stimulates breastfeeding behavior in the baby.[28] Newborns who are immediately placed on their mother’s skin have a natural instinct to latch on to the breast and start nursing, typically within one hour of birth. Immediate skin-to-skin contact may provide a form of imprinting that makes subsequent feeding significantly easier. In addition to more successful breastfeeding and bonding, immediate skin-to-skin contact reduces crying and warms the baby.

text: According to studies cited by UNICEF, babies naturally follow a process which leads to a first breastfeed. Initially after birth the baby cries with its first breaths. Shortly after, it relaxes and makes small movements of the arms, shoulders and head. The baby crawls towards the breast and begins to feed. After feeding, it is normal for a baby to remain latched to the breast while resting. This is sometimes mistaken for lack of appetite. Absent interruptions, all babies follow this process. Rushing or interrupting the process, such as removing the baby to weigh him/her, may complicate subsequent feeding.[29] Activities such as weighing, measuring, bathing, needle-sticks, and eye prophylaxis wait until after the first feeding."[30]

text: Children who are born preterm have difficulty in initiating breast feeds immediately after birth. By convention, such children are often fed on expressed breast milk or other supplementary feeds through tubes or bottles until they develop satisfactory ability to suck breast milk. Tube feeding, though commonly used, is not supported by scientific evidence as of October 2016.[31] It has also been reported in the same systematic review that by avoiding bottles and using cups instead to provide supplementary feeds to preterm children, a greater extent of breast feeding for a longer duration can subsequently be achieved.[31]

text: Timing[edit]

text: Newborn babies typically express demand for feeding every one to three hours (8–12 times in 24 hours) for the first two to four weeks.[32] A newborn has a very small stomach capacity. At one-day old it is 5–7 ml, about the size of a marble; at day three it is 22–30 ml, about the size of a "shooter" marble; and at day seven it is 45–60 ml, or about the size of a ping-pong ball. The amount of breast milk that is produced is timed to meet the infant's needs in that the first milk, colostrum, is concentrated but produced in only very small amounts, gradually increasing in volume to meet the expanding size of the infant's stomach capacity.[26]

text: According to La Leche League International, "Experienced breastfeeding mothers learn that the sucking patterns and needs of babies vary. While some infants' sucking needs are met primarily during feedings, other babies may need additional sucking at the breast soon after a feeding even though they are not really hungry. Babies may also nurse when they are lonely, frightened or in pain....Comforting and meeting sucking needs at the breast is nature's original design. Pacifiers (dummies, soothers) are a substitute for the mother when she cannot be available. Other reasons to pacify a baby primarily at the breast include superior oral-facial development, prolonged lactational amenorrhea, avoidance of nipple confusion, and stimulation of an adequate milk supply to ensure higher rates of breastfeeding success."[33]

text: During the newborn period, most breastfeeding sessions take from 20 to 45 minutes.[32] After one breast is empty, the mother may offer the other breast.

text: Location[edit]

text: Most US states now have laws that allow a mother to breastfeed her baby anywhere. In hospitals, rooming-in care permits the baby to stay with the mother and simplifies the process. Some commercial establishments provide breastfeeding rooms, although laws generally specify that mothers may breastfeed anywhere, without requiring a special area. Breastfeeding in public remains controversial in many developed countries.

text: In 2014, newly elected Pope Francis drew worldwide commentary when he encouraged mothers to breastfeed babies in church. During a papal baptism, he said that mothers "should not stand on ceremony" if their children were hungry. "If they are hungry, mothers, feed them, without thinking twice," he said, smiling. "Because they are the most important people here."[34]

text: Position[edit]

text: Correct positioning and technique for latching on are necessary to prevent nipple soreness and allow the baby to obtain enough milk.[35]

text: Babies can successfully latch on to the breast from multiple positions. Each baby may prefer a particular position. The "football" hold places the baby's legs next to the mother's side with the baby facing the mother. Using the "cradle" or "cross-body" hold, the mother supports the baby's head in the crook of her arm. The "cross-over" hold is similar to the cradle hold, except that the mother supports the baby's head with the opposite hand. The mother may choose a reclining position on her back or side with the baby laying next to her.[36]

text:
Illustration depicting correct latch-on position during breastfeeding.

Breastfeeding – Cradle hold.

Breastfeeding – Cross cradle position.

Breastfeeding – Football hold.

Breastfeeding – Incorrect vs correct latch-on.

Breastfeeding – Semi-reclining position.

Breastfeeding – Side-lying position.

Breastfeeding – Supine position.

Breastfeeding – Tease lips or cheek.

Breastfeeding – Twins, cross cradle position I.

Breastfeeding – Twins, football or clutch hold.

Breastfeeding – Twins, parallel position II.

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text: Latching on[edit]

text: Latching on refers to how the baby fastens onto the breast while breastfeeding. A good latch means that the bottom of the areola (the area around the nipple) is in the baby's mouth and the nipple is back inside his or her mouth. A poor latch happens when the baby does not have enough of the breast in his/her mouth or is too close to the tip. This can cause cracked nipples and a reluctance to continue to breastfeed.[37][38]

text: Weaning[edit]

text: Weaning is the process of replacing breast milk with other foods; the infant is fully weaned after the replacement is complete. Psychological factors affect the weaning process for both mother and infant, as issues of closeness and separation are very prominent.[39] If the baby is less than a year old substitute bottles are necessary; an older baby may accept milk from a cup. Unless a medical emergency necessitates abruptly stopping breastfeeding, it is best to gradually cut back on feedings to allow the breasts to adjust to the decreased demands without becoming engorged. La Leche League advises: "The nighttime feeding is usually the last to go. Make a bedtime routine not centered around breastfeeding. A good book or two will eventually become more important than a long session at the breast."[40]

text: If breastfeeding is suddenly stopped a woman's breasts are likely to become engorged with milk. Pumping small amounts to relieve discomfort helps to gradually train the breasts to produce less milk. There is presently no safe medication to prevent engorgement, but cold compresses and ibuprofen may help to relieve pain and swelling. Pain should go away in one to five days. If symptoms continue and comfort measures are not helpful a woman should consider the possibility that a blocked milk duct or infection may be present and seek medical intervention.[41]

text: When weaning is complete the mother's breasts return to their previous size after several menstrual cycles. If the mother was experiencing lactational amenorrhea her periods will return along with the return of her fertility. When no longer breastfeeding she will need to adjust her diet to avoid weight gain.[42]

text: Drugs[edit]

text: Almost all medicines pass into breastmilk in small amounts. Some have no effect on the baby and can be used while breastfeeding.[43] Many medications are known to significantly suppress milk production, including pseudoephedrine, diuretics, and contraceptives that contain estrogen.[44]

text: The American Academy of Pediatrics (AAP) states that "tobacco smoking by mothers is not a contraindication to breastfeeding."[30] Breastfeeding is actually especially recommended for mothers who smoke, because of its protective effects against SIDS.[45]

text: With respect to alcohol, the AAP states that when breastfeeding, "moderation is definitely advised" and recommends waiting for 2 hours after drinking before nursing or pumping.[46] A 2014 review found that "even in a theoretical case of binge drinking, the children would not be subjected to clinically relevant amounts of alcohol [through breastmilk]", and would have no adverse effects on children as long as drinking is "occasional".[47]

text: Methods[edit]

text: Exclusive[edit]

text: Exclusive breastfeeding is defined as "an infant's consumption of human milk with no supplementation of any type (no water, no juice, no nonhuman milk and no foods) except for vitamins, minerals and medications."[30] Exclusive breastfeeding till six months of age helps to protect an infant from gastrointestinal infections in both developing and industrialized countries. The risk of death due to diarrhea and other infections increases when babies are either partially breastfed or not breastfed at all.[2]

text: Measuring how many calories a breastfed baby consumes is complex, although babies normally attempt to meet their own requirements.[48] Babies that fail to eat enough may exhibit symptoms of failure to thrive.[49]

text: La Leche League says that mothers' most often asked question is, "How can I tell if my baby is getting enough milk?" They advise that for the first few days, while the baby is receiving mostly colostrum, one or two wet diapers per day is normal. Once the mother starts producing milk, usually on the third or fourth day, the baby should have 6–8 wet cloth diapers (5–6 wet disposable diapers) per day. In addition, most young babies have at least 2–5 bowel movements every 24 hours for the first several months.[50]

text: La Leache League offers the following additional signs that indicate a baby is receiving enough milk:

text:
Averages at least 8–12 feedings per 24-hour period.
Determines the duration of feeding, which may be 10–20 minutes per breast or longer.
Swallowing sounds are audible.
Gains at least 4–7 ounces per week after the fourth day.
Is alert and active, appears healthy, has good color, firm skin and is growing in length and head circumference.[50]

text: If the baby is latching and swallowing well but is not drinking enough milk, low milk supply in the mother can be suspected. Most cases of low milk supply are caused by not nursing feeding frequently enough or the baby not effectively taking milk, but medical conditions cause or contribute to low milk supply in some cases.

text: Mixed feeding[edit]

text: Predominant or mixed breastfeeding means feeding breast milk along with infant formula, baby food and even water, depending on the child's age.[51]

text: Expressed milk[edit]

text: A mother can express (produce) her milk for storage and later use. Expression occurs with massage or a breast pump. It can be stored in freezer storage bags, containers made specifically for breastmilk, a supplemental nursing system, or a bottle ready for use. Using someone other than the mother/wet nurse to deliver the bottle maintains the baby's association of nursing with the mother/wet nurse and bottle feeding with other people.

text: Breast milk may be kept at room temperature for up to six hours, refrigerated for up to eight days or frozen for six to twelve months.[52] Research suggests that the antioxidant activity in expressed breast milk decreases over time, but remains at higher levels than in infant formula.[53]

text: Mothers express milk for multiple reasons. Expressing breast milk can maintain a mother's milk supply when she and her child are apart. A sick baby who is unable to nurse can take expressed milk through a nasogastric tube. Some babies are unable or unwilling to nurse. Expressed milk is the feeding method of choice for premature babies.[54] Viral disease transmission can be prevented by expressing breast milk and subjecting it to Holder pasteurisation.[55] Some women donate expressed breast milk (EBM) to others, either directly or through a milk bank. This allows mothers who cannot breastfeed to give their baby the benefits of breast milk.

text: Babies feed differently with artificial nipples than from a breast. With the breast, the infant's tongue massages the milk out rather than sucking, and the nipple does not go as far into the mouth. Drinking from a bottle takes less effort and the milk may come more rapidly, potentially causing the baby to lose desire for the breast. This is called nursing strike, nipple strike or nipple confusion. To avoid this, expressed milk can be given by means such as spoons or cups.[51]

text: "Exclusively expressing", "exclusively pumping", and "EPing" are terms for a mother who exclusively feeds her baby expressed milk. With good pumping habits, particularly in the first 12 weeks while establishing the milk supply, it is possible to express enough milk to feed the baby indefinitely. With the improvements in breast pumps, many women exclusively feed expressed milk, expressing milk at work. Women can leave their infants in the care of others while traveling, while maintaining a supply of breast milk.[56]

text: Shared nursing[edit]

text: Wet nursing was common throughout history. It remains popular in some developing nations, including those in Africa, for more than one woman to breastfeed a child. Shared breastfeeding is a risk factor for HIV infection in infants.[57] A woman who is engaged to breastfeed another's baby is known as a wet nurse. Shared nursing can sometimes provoke negative reactions in the English-speaking world.[58][59]

text: Tandem nursing[edit]

text: Feeding two children at the same time who are not twins or multiples is called tandem nursing. Appetite and feeding habits of each baby may differ, so they may feed at the same or different times, which may involve feeding them simultaneously, one on each breast.[citation needed]

text: Breastfeeding triplets or larger broods is a challenge given babies' varying appetites. Breasts can respond to the demand and produce larger milk quantities; mothers have breastfed triplets successfully.[60][61][62]

text: Tandem nursing occurs when a woman gives birth while breastfeeding an older child. During the late stages of pregnancy, the milk changes to colostrum. While some children continue to breastfeed even with this change, others may wean. Breastfeeding a child while pregnant with another may be considered a form of tandem feeding for the nursing mother, as she provides nutrition for two.[63]

text: Induced lactation[edit]

text: Induced lactation, also called adoptive lactation, is the process of starting breastfeeding in a woman who did not give birth.[64] This usually requires the adoptive mother to take hormones and other drugs to stimulate breast development and promote milk production. In some cultures, breastfeeding an adoptive child creates milk kinship that built community bonds across class and other hierarchal bonds.[64]

text: Re-lactation[edit]

text: Re-lactation is the process of restarting breastfeeding.[64] In developing countries, mothers may restart breastfeeding after a weaning as part of an oral rehydration treatment for diarrhea. In developed countries, re-lactation is common after early medical problems are resolved, or because a mother changes her mind about breastfeeding.

text: Re-lactation is most easily accomplished with a newborn or with a baby that was previously breastfeeding; if the baby was initially bottle-fed, the baby may refuse to suckle. If the mother has recently stopped breastfeeding, she is more likely to be able to re-establish her milk supply, and more likely to have an adequate supply. Although some women successfully re-lactate after months-long interruptions, success is higher for shorter interruptions.[64]

text: Techniques to promote lactation use frequent attempts to breastfeed, extensive skin-to-skin contact with the baby, and frequent, long pumping sessions.[64] Suckling may be encouraged with a tube filled with infant formula, so that the baby associates suckling at the breast with food. A dropper or syringe without the needle may be used to place milk onto the breast while the baby suckles. The mother should allow the infant to suckle at least ten times during 24 hours, and more times if he or she is interested. These times can include every two hours, whenever the baby seems interested, longer at each breast, and when the baby is sleepy when he or she might suckle more readily. In keeping with increasing contact between mother and child, including increasing skin-to-skin contact, grandmothers should pull back and help in other ways. Later on, grandmothers can again provide more direct care for the infant.[65]

text: These techniques require the mother's commitment over a period of weeks or months. However, even when lactation is established, the supply may not be large enough to breastfeed exclusively. A supportive social environment improves the likelihood of success.[64] As the mother's milk production increases, other feeding can decrease. Parents and other family members should watch the baby's weight gain and urine output to assess nutritional adequacy.[65]

text: A WHO manual for physicians and senior health workers citing a 1992 source states: "If a baby has been breastfeeding sometimes, the breastmilk supply increases in a few days. If a baby has stopped breastfeeding, it may take 1-2 weeks or more before much breastmilk comes."[65]

text: Extended[edit]

text: Extended breastfeeding means breastfeeding after the age of 12 or 24 months, depending on the source. In Western countries such as the United States, Canada, and Great Britain, extended breastfeeding is relatively uncommon and can provoke criticism.[66][67]

text: In the United States, 22.4% of babies are breastfed for 12 months, the minimum amount of time advised by the American Academy of Pediatrics. In India, mothers commonly breastfeed for 2 to 3 years.[68]

text: Health effects[edit]

text: Breastfeeding decreases the risk of a number of diseases in both mothers and babies.[69] The US Preventive Services Task Force recommends efforts to promote breastfeeding.[70]

text: Baby[edit]

text: Early breastfeeding is associated with fewer nighttime feeding problems.[71] Early skin-to-skin contact between mother and baby improves breastfeeding outcomes and increases cardio-respiratory stability.[72] Reviews from 2007 found numerous benefits. Breastfeeding aids general health, growth and development in the infant. Infants who are not breastfed are at mildly increased risk of developing acute and chronic diseases, including lower respiratory infection, ear infections, bacteremia, bacterial meningitis, botulism, urinary tract infection and necrotizing enterocolitis.[73][74] Breastfeeding may protect against sudden infant death syndrome,[75] insulin-dependent diabetes mellitus, Crohn's disease, ulcerative colitis, lymphoma, allergic diseases, digestive diseases,[30] obesity, develop diabetes, or childhood leukemia later in life.[76] and may enhance cognitive development.[30]

text: Growth[edit]

text: The average breastfed baby doubles its birth weight in 5–6 months. By one year, a typical breastfed baby weighs about 2-1/2 times its birth weight. At one year, breastfed babies tend to be leaner than formula-fed babies, which improves long-run health.[77]

text: The Davis Area Research on Lactation, Infant Nutrition and Growth (DARLING) study reported that breastfed and formula-fed groups had similar weight gain during the first 3 months, but the breastfed babies began to drop below the median beginning at 6 to 8 months and were significantly lower weight than the formula-fed group between 6 and 18 months. Length gain and head circumference values were similar between groups, suggesting that the breastfed babies were leaner.[78]

text: Infections[edit]

text: Breast milk contains several anti-infective factors such as bile salt stimulated lipase (protecting against amoebic infections) and lactoferrin (which binds to iron and inhibits the growth of intestinal bacteria).[79][80]

text: Infants who are exclusively breastfed for the first six months are less likely to die of gastrointestinal infections than infants who switched from exclusive to partial breastfeeding at three to four months.[81]

text: During breastfeeding, approximately 0.25–0.5 grams per day of secretory IgA antibodies pass to the baby via milk.[82][83] This is one of the important features of colostrum.[84] The main target for these antibodies are probably microorganisms in the baby's intestine. The rest of the body displays some uptake of IgA,[85] but this amount is relatively small.[86]

text: Maternal vaccinations while breastfeeding is safe for almost all vaccines. Additionally, the mother's immunity obtained by vaccination against tetanus, diphtheria, whooping cough and influenza can protect the baby from these diseases, and breastfeeding can reduce fever rate after infant immunization. However, smallpox and yellow fever vaccines increase the risk of infants developing vaccinia and encephalitis.[87][88]

text: Mortality[edit]

text: Babies who are not breastfed are almost six times more likely to die by the age of one month than those who receive at least some breastmilk.[89]

text: Childhood obesity[edit]

text: The protective effect of breastfeeding against obesity is consistent, though small, across many studies.[73][74][90] A 2013 longitudinal study reported less obesity at ages two and four years among infants who were breastfed for at least four months.[91]

text: Allergic diseases[edit]

text: In children who are at risk for developing allergic diseases (defined as at least one parent or sibling having atopy), atopic syndrome can be prevented or delayed through 4-month exclusive breastfeeding, though these benefits may not persist.[92]

text: Other health effects[edit]

text: Breastfeeding may reduce the risk of necrotizing enterocolitis (NEC).[74]

text: Breastfeeding or introduction of gluten while breastfeeding don't protect against celiac disease among at-risk children. Breast milk of healthy human mothers who eat gluten-containing foods presents high levels of non-degraded gliadin (the main gluten protein). Early introduction of traces of gluten in babies to potentially induce tolerance doesn't reduce the risk of developing celiac disease. Delaying the introduction of gluten does not prevent, but is associated with a delayed onset of the disease.[93][94]

text: About 19% of leukemia cases may be prevented by breastfeeding for six months or longer.[95]

text: Breastfeeding may decrease the risk of cardiovascular disease in later life, as indicated by lower cholesterol and C-reactive protein levels in breastfed adult women.[73] Breastfed infants have somewhat lower blood pressure later in life, but it is unclear how much practical benefit this provides.[73][74]

text: A 1998 study suggested that breastfed babies have a better chance of good dental health than formula-fed infants because of the developmental effects of breastfeeding on the oral cavity and airway. It was thought that with fewer malocclusions, breastfed children may have a reduced need for orthodontic intervention. The report suggested that children with a well rounded, "U-shaped" dental arch, which is found more commonly in breastfed children, may have fewer problems with snoring and sleep apnea in later life.[96] A 2016 review found that breastfeeding protected against malocclusions.[7]

text: Intelligence[edit]

text: It is unclear whether breastfeeding improves intelligence later in life. Several studies found no relationship after controlling for confounding factors like maternal intelligence (smarter mothers were more likely to breastfeed their babies).[74][97] However, other studies concluded that breastfeeding was associated with increased cognitive development in childhood, although the cause may be increased mother–child interaction rather than nutrition.[73]

text: Mother[edit]

text: Breastfeeding may improve a mothers physical and emotional health.

text: Maternal bond[edit]

text: Hormones released during breastfeeding help to strengthen the maternal bond.[23] Teaching partners how to manage common difficulties is associated with higher breastfeeding rates.[98] Support for a breastfeeding mother can strengthen familial bonds and help build a paternal bond.[23][99]

text: Fertility[edit]

text: Exclusive breastfeeding usually delays the return of fertility through lactational amenorrhea, although it does not provide reliable birth control. Breastfeeding may delay the return to fertility for some women by suppressing ovulation. Mothers may not ovulate, or have regular periods, during the entire lactation period. The non-ovulating period varies by individual. This has been used as natural contraception, with greater than 98% effectiveness during the first six months after birth if specific nursing behaviors are followed.[100]

text: Bleeding[edit]

text: While breastfeeding soon after birth is believed to increases uterus contraction and reducing bleeding high quality evidence to support this is lacking.[101]

text: Other[edit]

text: It is unclear whether breastfeeding causes mothers to lose weight after giving birth.[74][102][103] The National Institutes of Health states that it may help with weight loss.[104]

text: For breastfeeding women, long-term health benefits include reduced risk of breast cancer, ovarian cancer, and endometrial cancer.[30][74][105]

text: A 2011 review found unclear if breastfeeding affects the risk of postpartum depression.[106] Other reviews found tentative evidence of a lower risk among mothers who successfully breastfeed.[107][108]

text: Diabetes[edit]

text: Breastfeeding of babies is associated with a lower chance of developing diabetes mellitus type 1.[74] Breastfed babies also appear to have a lower likelihood of developing diabetes mellitus type 2 later in life.[73][74][109] Breastfeeding is also associated with a lower risk of type 2 diabetes among mothers who practice it.[110]

text: Social factors[edit]

text: The majority of mothers intend to breastfeed at birth. Many factors can disrupt this intent. Research done in the US shows that information about breastfeeding is rarely provided by a women's obstetricians during their prenatal visits and some health professionals incorrectly believe that commercially prepared formula is nutritionally equivalent to breast milk.[111] Many hospitals have instituted practices that encourage breastfeeding, however a 2012 survey in the US found that 24% of maternity services were still providing supplements of commercial infant formula as a general practice in the first 48 hours after birth.[3] The Surgeon General’s Call to Action to Support Breastfeeding attempts to educate practitioners.[112]

text: Social support[edit]

text: Positive social support in essential relationships of new mothers plays a central role in the promotion of breastfeeding outside of the confines of medical centers. Social support can come in many incarnations, including tangible, affectionate, social interaction, and emotional and informational support. An increase in these capacities of support has shown to greatly positively effect breastfeeding rates, especially among women with education below a high school level.[113] In the social circles surrounding the mother, support is most crucial from the male partner, the mother's mother, and her family and friends.[114] Research has shown that the closest relationships to the mother have the strongest impact on breastfeeding rates, while negative perspectives on breastfeeding from close relatives hinder its prevalence.[113]

text: Work is the most commonly cited reason for not breastfeeding.[115] In 2012 Save the Children examined maternity leave laws, ranking 36 industrialized countries according to their support for breastfeeding. Norway ranked first, while the United States came in last.[116] Maternity leave in the US varies widely, including by state, despite the Family Medical Leave Act (FMLA), which guarantees most mothers up to 12 weeks unpaid leave. The majority of US mothers resume work earlier.

text:
Mother – Adolescence is a risk factor for low breastfeeding rates, although classes, books and personal counseling (professional or lay) can help compensate.[117] Some women fear that breastfeeding will negatively impact the look of their breasts. However, a 2008 study found that breastfeeding had no effect on a woman's breasts, other factors did contribute to "drooping" of the breasts, such as advanced age, number of pregnancies and smoking behavior.[118]
Partner – Partners may lack knowledge of breastfeeding and their role in the practice.
Wet nursing – Social and cultural attitudes towards breastfeeding in the African-American community are also influenced by the legacy of forced wet-nursing during slavery.[119]

text: Healthcare[edit]

text: Infants that are otherwise healthy uniformly benefit from breastfeeding. "No known disadvantages" stem from breastfeeding.[120] However, extra precautions should be taken or breastfeeding be avoided in circumstances including certain infectious diseases, or use of certain medications.[120] In some cases it may not be feasible for the mother to continue breastfeeding.[120]

text: A number of hospital-employed procedures have been found to interfere with breastfeeding, including routine mother/baby separation, delayed initiation, vigorous routine suctioning, medications and mode of delivery.[121] There are also racial disparities in access to maternity care practices that support breastfeeding. Primarily African-American neighborhoods are more likely to have facilities (such as hospitals and female healthcare clinics) that do not support breastfeeding, contributing to the low rate of breastfeeding in the African-American community. Comparing facilities in primarily African American neighborhoods to ones in primarily White neighborhoods, the rates of practices that support or discourage breastfeeding were: limited use of supplements (13.1% compared with 25.8%) and rooming-in (27.7–39.4%)[122]

text: Pain caused from mis-positioning the baby on the breast or a tongue-tie in the infant can cause pain in the mother and discourage her. These problems are generally easy to correct (by re-positioning or clipping the tongue-tie).[123]

text: Breast surgery, including breast implants or breast reduction surgery, reduces the chances that a woman will have sufficient milk to breastfeed.[124] Women whose pregnancies are unintended are less likely to breast feed their babies.[125]

text: Maternal infections[edit]

text: A breastfeeding child can become infected with HIV. Factors such as the viral load in the mother’s milk complicate breastfeeding recommendations for HIV-positive mothers.[126][127]

text: In mothers who are treated with antiretroviral drugs the risk of HIV transmission with breastfeeding is 1–2%.[2] Therefore, of breastfeeding is still recommended in areas of the world with death from infectious diseases is common.[2] Infant formula should only be given if this can be safely done.[2]

text: WHO recommends that national authorities in each country decide which infant feeding practice should be promoted by their maternal and child health services to best avoid HIV transmission from mother to child.[128] Other maternal infection of concern include active untreated tuberculosis or human T-lymphotropic virus.

text: Medications[edit]

text: Breastfeeding mothers should inform their healthcare provider about all of the medications they are taking, including herbal products. Nursing mothers can safely take many over-the-counter drugs and prescription drugs and receive immunizations, but certain drugs, including painkillers and psychiatric drugs, may pose a risk.

text: The US National Library of Medicine publishes "LactMed", an up-to-date online database of information on drugs and lactation. Geared to both healthcare practitioners and nursing mothers, LactMed contains over 450 drug records with information such as potential drug effects and alternate drugs to consider.[88][129]

text: Some substances in the mother's food and drink are passed to the baby through breast milk, including mercury (found in some carnivorous fish),[130] caffeine,[131] and bisphenol A.[132][133]

text: Celiac disease[edit]

text: Undiagnosed maternal celiac disease may cause a short duration of the breastfeeding period. Treatment with the gluten-free diet can increase its duration and restore it to the average value of the healthy women.[134]

text: Socioeconomic status[edit]

text: Race, ethnicity and socioeconomic status affect choice and duration in the United States. A 2011 study found that on average, US women who breastfed had higher levels of education, were older and were more likely to be white.[135]

text: The rates of breastfeeding in the African-American community remain much lower than any other race, for a variety of reasons. These include the legacy of Wet nursing during slavery, as well as systemic racism in the American healthcare system that does not offer adequate support to African-American breastfeeding mothers. While for other races as socio-economic class raises rates of breastfeeding also go up, for the African-American community breastfeeding rates remain consistently low regardless of socio-economic class.[136] Within the African-American community, social stigma exists because of the association of breastfeeding with the legacy of wet-nursing during slavery. Because of breastfeeding’s well-documented benefits to both baby and mother, many blactavists – Black Lactation Activists, such as Kimberly Seals Allers[137] advocate and support breastfeeding in the African-American community. Resources such as the African-American Breastfeeding Project can provide cultural and social support to new African-American mothers, as well as Instagram pages such as Blactavist and Black Breastfeeding Week.[138][139]

text: Although return to work is associated with early discontinuation, a supportive work environment may encourage mothers to continue.

text: Low-income mothers are more likely to have unintended pregnancies.[135] Mothers whose pregnancies are unintended are less likely to breastfeed.[125]

text: Social acceptance[edit]

text: Some women feel discomfort when breastfeeding in public.[140] Public breastfeeding may be forbidden in some places, not addressed by law in others, and a legal right in others. Even given a legal right, some mothers are reluctant to breastfeed,[141][142] while others may object to the practice.[143]

text: The use of infant formula was thought to be a way for western culture to adapt to negative perceptions of breastfeeding.[144] The breast pump offered a way for mothers to supply breast milk with most of formula feeding's convenience and without enduring possible disapproval of nursing.[145] Some may object to breastfeeding because of the implicit association between infant feeding and sex.[146] These negative cultural connotations may reduce breastfeeding duration.[141][147][148][149] Maternal guilt and shame is often affected by how a mother feeds her infant. These emotions occur in both bottle- and breast- feeding mothers, although for different reasons. Bottle feeding mothers may feel that they should be breastfeeding.[150] Conversely, breastfeeding mothers may feel forced to feed in uncomfortable circumstances. Some may see breastfeeding as, “indecent, disgusting, animalistic, sexual, and even possibly a perverse act."[151] Advocates use "nurse-ins" to show support for breastfeeding in public.[140] Some advocates emphasize providing women with education on breastfeeding's benefits as well as problem-solving skills.[150]

text: Prevalence[edit]

text: Globally about 38% of babies are just breastfeed during their first six months of life.[2] In the United States as of 2012, 75% of women started breastfeeding, 43% breastfeed for six months though only 13% exclusively breastfed, and 23% breastfeed for twelve months.[3][153] In the United States African-American women have persistently low rates of breastfeeding compared to White and Hispanic American women. 58.1% of African-American women breastfeed in the early postpartum period, compared to 77.7% of White women and 80.6% of Hispanic women.[136]

text: Breastfeeding rates in different parts of China vary considerably.[154]

text: Breastfeeding rates in the United Kingdom were the lowest in the world in 2015 with only 0.5% of mothers still breastfeeding at a year, while in Germany 23% are doing so, 56% in Brazil and 99% in Senegal.[155]

text: In Australia for children born in 2004, more than 90% were initially breastfed.[156] In Canada for children born in 2005-06, more than 50% were only breastfed and more than 15% received both breastmilk and other liquids, by the age of 3 months.[157]

text: History[edit]

text: In the Egyptian, Greek and Roman empires, women usually fed only their own children.[citation needed] However, breastfeeding began to be seen as something too common to be done by royalty, and wet nurses were employed to breastfeed the children of the royal families. This extended over time, particularly in western Europe, where noble women often made use of wet nurses. Lower-class women breastfed their infants and used a wet nurse only if they were unable to feed their own infant. Attempts were made in 15th-century Europe to use cow or goat milk, but these attempts were not successful. In the 18th century, flour or cereal mixed with broth were introduced as substitutes for breastfeeding, but this was also unsuccessful.[citation needed]

text: The history of breastfeeding in Canada includes the description that societies considered it a low class and uncultured practice. This coincided with the appearance of improved infant formulas in the mid 19th century and its increased use, which accelerated after World War II. From the 1960s onwards, breastfeeding experienced a revival which continued into the 2000s, though negative attitudes towards the practice were still entrenched up to 1990s.[158]

text: Language[edit]

text: In languages around the world, the word for "mother" is something like "mama". The cross-linguistic similarities between these terms are thought to result from the nature of language acquisition.[159][160][161][162] These words are the first word-like sounds made by babbling babies, and parents tend to associate the first sound babies make with themselves and to employ them subsequently as part of their baby-talk lexicon.

text: The linguist Roman Jakobson hypothesized that the nasal sound in "mama" comes from the nasal murmur that babies produce when breastfeeding:

text: Often the sucking activities of a child are accompanied by a slight nasal murmur, the only phonation which can be produced when the lips are pressed to mother’s breast or to the feeding bottle and the mouth full. Later, this phonatory reaction to nursing is reproduced as an anticipatory signal at the mere sight of food and finally as a manifestation of a desire to eat, or more generally, as an expression of discontent and impatient longing for missing food or absent nurser, and any ungranted wish. When the mouth is free from nutrition, the nasal murmur may be supplied with an oral, particularly labial release; it may also obtain an optional vocalic support.

text: Society and culture[edit]

text: Milk kinship[edit]

text: In some cultures, people who have been breastfed by the same woman are milk-siblings who are equal in legal and social standing to a consanguineous sibling.[163] Islam has a complex system of rules regarding this, known as Rada (fiqh). Like the Christian practice of godparenting, milk kinship established a second family that could take responsibility for a child whose biological parents came to harm. "Milk kinship in Islam thus appears to be a culturally distinctive, but by no means unique, institutional form of adoptive kinship."[164]:308

text: Financial considerations[edit]

text: Breastfeeding is less costly than alternatives, but the mother generally must eat more food than she would otherwise. In the US, the extra money spent on food (about US$14 each week) is usually about half as much money as the cost of infant formula.[165]

text: Breastfeeding represents an opportunity cost. This is the cost of the mother having to spend hours each day breastfeeding instead of other activities, such as paid work or home production (such as growing food). In general, the higher the mother's earning power, the less likely she is to save money by breastfeeding.[166]

text: Breastfeeding reduces health care costs and the cost of caring for sick babies. Parents of breastfed babies are less likely to miss work and lose income because their babies are sick.[165] Looking at three of the most common infant illnesses, lower respiratory tract illnesses, otitis media, and gastrointestinal illness, one study compared infants that had been exclusively breastfed for at least three months to those who had not. It found that in the first year of life there were 2033 excess office visits, 212 excess days of hospitalization, and 609 excess prescriptions for these three illnesses per 1000 never-breastfed infants compared with 1000 infants exclusively breastfed for at least 3 months.[167]

text: Recommendations[edit]

text: Support for breastfeeding is universal among major health and children's organizations. WHO states, "Breast milk is the ideal food for the healthy growth and development of infants; breastfeeding is also an integral part of the reproductive process with important implications for the health of mothers.".[168] WHO's guidelines recommend "continue[d] frequent, on-demand breastfeeding until two years of age or beyond."[169][170]

text: The European Commission,[171][172] the US Centers for Disease Control and Prevention[173] (CDC), UNICEF, AAP,[3] Save The Children and the UK National Health Service[174] (NHS), Australian Department of Health,[175] Health Canada, Canadian Paediatric Society, Dietitians of Canada, and Breastfeeding Committee for Canada,[176] recommend exclusive breastfeeding for six months following birth and continued nursing for an additional eighteen months or more.[2][177] Save the Children states, "Six months of exclusive breastfeeding increases a child’s chance of survival at least six-fold."[178]

text: Advocacy[edit]

text: International board certified lactation consultants (IBCLCs) are health care professionals certified in lactation management. They work with mothers to solve breastfeeding problems and educate families and health professionals. Exclusive and partial breastfeeding are more common among mothers who gave birth in IBCLC-equipped hospitals.[180]

text: There are also controversies and ethical considerations surrounding the means used by public campaigns which attempt to increase breastfeeding rates, relating to pressure put on women, and potential feeling of guilt and shame of women who fail to breastfeed; and social condemnation of women who use formula.[181][182] [183][184] In addition to this, there is also the moral question as to what degree the state or medical community can interfere with the self-determination of a woman: for example in the United Arab Emirates the law requires a woman to breastfeed her baby for at least 2 years and allows her husband to sue her if she does not do so.[185][186]

text: Social marketing[edit]

text: Social marketing is a marketing approach intended to change people's behavior to benefit both individuals and society.[187] When applied to breastfeeding promotion, social marketing works to provide positive messages and images of breastfeeding to increase visibility. Social marketing in the context of breastfeeding has shown efficacy in media campaigns such as Loving Support, Mother-Friendly Worksite Program, Fathers Supporting Breastfeeding, and Best for Babes: Champions for Moms.[188] Some oppose the marketing of infant formula, especially in developing countries. They are concerned that mothers who use formula will stop breastfeeding and become dependent upon substitutes that are unaffordable or less safe.[189][190] Through efforts including the Nestlé boycott, they have advocated for bans on free samples of infant formula and for the adoption of pro-breastfeeding codes such as the International Code of Marketing of Breast-milk Substitutes by the World Health Assembly in 1981 and the Innocenti Declaration by WHO and UNICEF policy-makers in August 1990.[189] Additionally, formula companies have spent millions internationally on campaigns to promote the use of formula as an alternative to mother's milk.[191]

text: Baby Friendly Hospital Initiative[edit]

text: The Baby Friendly Hospital Initiative is a program launched by WHO in conjunction with UNICEF in order to promote infant feeding and maternal bonding through certified hospitals and birthing centers. BFHI was developed as a response to the influence held by formula companies in private and public maternal health care.[192] The initiative has two core tenets: the Ten Steps to Successful Breastfeeding and the International Code of Marketing of Breast-milk Substitutes.[192] These methods are intended to reduce practices detrimental to breastfeeding such as early mixed feeding, use of pacifiers, and separation of mother and child in the clinical setting.The BFHI has especially targeted hospitals and birthing centers in the developing world, as these facilities are most at risk to the detrimental effects of reduced breastfeeding rates. Currently, 468 hospitals in the United States hold the "Baby-Friendly" title in all 50 states. Globally, there are more than 20,000 "Baby-Friendly" hospitals worldwide in over 150 countries.[193]

text: Studies have also shown a positive correlation of breastfeeding with increased professional education of care providers.[188] 86% of Americans rely on professional healthcare providers like doctors, midwives, and nurses for medical advice and recommendations.[194] Classes are then offered in group and individual settings as "low-intensity intervention" directed by trained medical professionals.[195] Research conducted at large healthcare institutions in Massachusetts has demonstrated a statistically significant increase in breastfeeding rates for mothers who participate in breastfeeding and lactation training.[196]

text: Research[edit]

text: Breastfeeding research continues to assess prevalence, HIV transmission, pharmacology, costs, benefits, immunology, contraindications, and comparisons to synthetic breast milk substitutes.[197][198] Factors related to the mental health of the nursing mother in the perinatal period have been studied. While cognitive behavior therapy may be the treatment of choice, medications are sometimes used. The use of therapy rather than medication reduces the infant's exposure to medication that may be transmitted through the milk.[199] In coordination with institutional organisms, researchers are also studying the social impact of brestfeeding throughout history. Accordingly, strategies have been developed to foster the increase of the breastfeeding rates in the different countries.[200]


question_text: what are the main sections within iso 9001

text: ISO 9000

text: Background[edit]

text: ISO 9000 was first published in 1987 by ISO (International Organization for Standardization).[11] It was based on the BS 5750 series of standards from BSI that were proposed to ISO in 1979.[12] However, its history can be traced back some twenty years before that, to the publication of government procurement standards, such as the United States Department of Defense MIL-Q-9858 standard in 1959, and the U.K's Def Stan 05-21 and 05-24. Large organizations which supplied government procurement agencies often had to comply with a variety of quality assurance requirements for each contract awarded which led the defence industry to adopt mutual recognition of NATO AQAP, MIL-Q and Def Stan standards. Eventually, ISO 9000 was adopted as a suitable option, instead of forcing contractors to adopt multiple - and often similar - requirements.[13]

text: Reasons for use[edit]

text: The global adoption of ISO 9001 may be attributable to a number of factors. In the early days, the ISO 9001 (9002 and 9003) requirements were intended to be used by procuring organizations, as the basis of contractual arrangements with their suppliers. This helped reduce the need for "supplier development" by establishing basic requirements for a supplier to assure product quality. The ISO 9001 requirements could be tailored to meet specific contractual situations, depending on the complexity of product, business type (design responsibility, manufacture only, distribution, servicing etc.) and risk to the procurer. If a chosen supplier was weak on the controls of their measurement equipment (calibration), and hence QC/inspection results, that specific requirement would be invoked in the contract. The adoption of a single Quality Assurance requirement also lead to cost savings throughout the supply chain by reducing the administrative burden of  maintaining multiple sets of quality manuals and procedures.

text: A few years later, the U.K. Government took steps to improve national competitiveness following publication of cmd 8621, and Third Party Certification of Quality Management Systems was born, under the auspices of the National Accreditation Council of Certification Bodies (NACCB) which has become the United Kingdom Accreditation Service (UKAS) .

text: In addition to several stakeholders' benefits, a number of studies have identified significant financial benefits for organizations certified to ISO 9001, with a 2011 survey from the British Assessment Bureau showing 44% of their certified clients had won new business.[14] Corbett et al. showed that certified organizations achieved superior return on assets[15] compared to otherwise similar organizations without certification.[16] Heras et al.  found similarly superior performance[16] and demonstrated that this was statistically significant and not a function of organization size.[17] Naveha and Marcus claimed that implementing ISO 9001 led to superior operational performance in the U.S. automotive industry.[18] Sharma identified similar improvements in operating performance and linked this to superior financial performance.[19] Chow-Chua et al. showed better overall financial performance was achieved for companies in Denmark.[20] Rajan and Tamimi (2003) showed that ISO 9001 certification resulted in superior stock market performance and suggested that shareholders were richly rewarded for the investment in an ISO 9001 system.[21]

text: While the connection between superior financial performance and ISO 9001 may be seen from the examples cited, there remains no proof of direct causation, though longitudinal studies, such as those of Corbett et al. (2005)[16] may suggest it. Other writers, such as Heras et al. (2002),[17] have suggested that while there is some evidence of this, the improvement is partly driven by the fact that there is a tendency for better performing companies to seek ISO 9001 certification.

text: The mechanism for improving results has also been the subject of much research. Lo et al. (2007) identified operational improvements (e.g., cycle time reduction, inventory reductions) as following from certification.[22] Internal process improvements in organizations lead to externally observable improvements.[23][24] The benefit of increased international trade and domestic market share, in addition to the internal benefits such as customer satisfaction, interdepartmental communications, work processes, and customer/supplier partnerships derived, far exceeds any and all initial investment.[25]

text: Global adoption[edit]

text: The increase in ISO 9001 certification is shown in the tables below.

text:
Worldwide total of ISO 9001 certificates (end of each year)

2000[26]
2001[26]
2002[26]
2003[26]
2004[27]
2005[27]
2006[27]
2007[27]

409,421
510,616
561,747
567,985
660,132
773,867
896,929
951,486

2008[28]
2009[28]
2010[29]
2011[29]
2012[30]
2013[31]
2014[31]

982,832
1,064,785
1,118,510
1,111,698
1,096,987
1,126,460
1,138,155

tag: table

text:
Top 10 countries for ISO 9001 certificates (2014)[30]

Rank

Country

No. of certificates

1
China
342,800

2
Italy
168,960

3
Germany
55,363

4
Japan
45,785

5
India
41,016

6
United Kingdom
40,200

7
Spain
36,005

8
United States
33,008

9
France
29,122

10
Australia
19,731

text:
Top 10 countries for ISO 9001 certificates (2010)[32]

Rank

Country

No. of certificates

1
China
297,037

2
Italy
138,892

3
Russian Federation
62,265

4
Spain
59,854

5
Japan
59,287

6
Germany
50,583

7
United Kingdom
44,849

8
India
33,250

9
United States
25,101

10
Korea, Republic of
24,778

text:
Top 10 countries for ISO 9001 certificates (2009)[28]

Rank

Country

No. of certificates

1
China
257,076

2
Italy
130,066

3
Japan
68,484

4
Spain
59,576

5
Russian Federation
53,152

6
Germany
47,156

7
United Kingdom
41,193

8
India
37,493

9
United States
28,935

10
Korea, Republic of
23,400

text: ISO 9000 series Quality Management Principles[edit]

text: The ISO 9000 series are based on seven quality management principles (QMP)[33]

text: The seven quality management principles are:

text:
QMP 1 – Customer focus
QMP 2 – Leadership
QMP 3 – Engagement of people
QMP 4 – Process approach
QMP 5 – Improvement
QMP 6 – Evidence-based decision making
QMP 7 – Relationship management

text: Principle 1 – Customer focus

text: Principle 2 – Leadership

text: Principle 3 – Engagement of people

text: Principle 4 – Process approach

text: Principle 5 – Improvement

text: Principle 6 – Evidence-based decision making

text: Principle 7 – Relationship management

text: Contents of ISO 9001:2015[edit]

text: ISO 9001:2015 Quality management systems — Requirements is a document of approximately 30 pages which is available from the national standards organization in each country.  Only ISO 9001 is directly audited against for third party assessment purposes.

text: Contents of ISO 9001:2015 are as follows:

text:
Section 1: Scope
Section 2: Normative references
Section 3: Terms and definitions
Section 4: Context of the organization
Section 5: Leadership
Section 6: Planning
Section 7: Support
Section 8: Operation
Section 9: Performance evaluation
Section 10: Continual Improvement

text: Essentially the layout of the standard is similar to the previous ISO 9001:2008 standard in that it follows the Plan, Do, Check, Act cycle in a process-based approach, but is now further encouraging this to have risk-based thinking. (section 0.3.3 of the introduction) The purpose of the quality objectives is to determine the conformity of the requirements (customers and organizations), facilitate effective deployment and improve the quality management system.[34][35]

text: Before the certification body can issue or renew a certificate, the auditor must be satisfied that the company being assessed has implemented the requirements of sections 4 to 10.  Sections 1 to 3 are not directly audited against, but because they provide context and definitions for the rest of the standard, not that of the organization, their contents must be taken into account.

text: The standard no longer specifies that the organization shall issue and maintain documented procedures, however, ISO 9001:2015 requires the organization to document any other procedures required for its effective operation.  The standard also requires the organization to issue and communicate a documented quality policy, a quality management system scope, and quality objectives. The standard no longer requires compliant organizations to issue a formal Quality Manual. The standard does require retention of numerous records, as specified throughout the standard. New for the 2015 release is a requirement for an organization to assess risks and opportunities (section 6.1) and to determine internal and external issues relevant to its purpose and strategic direction (section 4.1). The organization must demonstrate how the standard’s requirements are being met, while the external auditor’s role is to determine the quality management system's effectiveness. More detailed interpretation and implementation examples are often sought by organizations seeking more information in what can be a very technical area.

text: Certification[edit]

text: International Organization for Standardization (ISO) does not certify organizations itself. Numerous certification bodies exist, which audit organizations and, upon success, issue ISO 9001 compliance certificates. Although commonly referred to as "ISO 9000" certification, the actual standard to which an organization's quality management system can be certified is ISO 9001:2015 (ISO 9001:2008 will expire by around September 2018). Many countries have formed accreditation bodies to authorize ("accredit") the certification bodies. Both the accreditation bodies and the certification bodies charge fees for their services. The various accreditation bodies have mutual agreements with each other to ensure that certificates issued by one of the accredited certification bodies (CB) are accepted worldwide. Certification bodies themselves operate under another quality standard, ISO/IEC 17021,[36] while accreditation bodies operate under ISO/IEC 17011.[37]

text: An organization applying for ISO 9001 certification is audited based on an extensive sample of its sites, functions, products, services and processes. The auditor presents a list of problems (defined as "nonconformities", "observations", or "opportunities for improvement") to management. If there are no major nonconformities, the certification body will issue a certificate.  Where major nonconformities are identified, the organization will present an improvement plan to the certification body (e.g., corrective action reports showing how the problems will be resolved); once the certification body is satisfied that the organization has carried out sufficient corrective action, it will issue a certificate.  The certificate is limited by a certain scope (e.g., production of golf balls) and will display the addresses to which the certificate refers.

text: An ISO 9001 certificate is not a once-and-for-all award but must be renewed at regular intervals recommended by the certification body, usually once every three years. There are no grades of competence within ISO 9001: either a company is certified (meaning that it is committed to the method and model of quality management described in the standard) or it is not. In this respect, ISO 9001 certification contrasts with measurement-based quality systems.

text: Evolution of ISO 9000 standards[edit]

text: The ISO 9000 standard is continually being revised by standing technical committees and advisory groups, who receive feedback from those professionals who are implementing the standard.

text: 1987 version[edit]

text: ISO 9000:1987 had the same structure as the UK Standard BS 5750, with three "models" for quality management systems, the selection of which was based on the scope of activities of the organization:

text:
ISO 9001:1987 Model for quality assurance in design, development, production, installation, and servicing was for companies and organizations whose activities included the creation of new products.
ISO 9002:1987 Model for quality assurance in production, installation, and servicing had basically the same material as ISO 9001 but without covering the creation of new products.
ISO 9003:1987 Model for quality assurance in final inspection and test covered only the final inspection of finished product, with no concern for how the product was produced.

text: ISO 9000:1987 was also influenced by existing U.S. and other Defense Standards ("MIL SPECS"), and so was well-suited to manufacturing. The emphasis tended to be placed on conformance with procedures rather than the overall process of management, which was likely the actual intent.[citation needed]

text: 1994 version[edit]

text: ISO 9000:1994 emphasized quality assurance via preventive actions, instead of just checking final product, and continued to require evidence of compliance with documented procedures. As with the first edition, the down-side was that companies tended to implement its requirements by creating shelf-loads of procedure manuals, and becoming burdened with an ISO bureaucracy. In some companies, adapting and improving processes could actually be impeded by the quality system.[citation needed]

text: 2000 version[edit]

text: ISO 9001:2000 replaced all three former standards of 1994 issue, ISO 9001, ISO 9002 and ISO 9003. Design and development procedures were required only if a company does, in fact, engage in the creation of new products. The 2000 version sought to make a radical change in thinking by actually placing front and centre the concept of process management (the monitoring and optimisation of a company's tasks and activities, instead of just inspection of the final product). The 2000 version also demanded involvement by upper executives in order to integrate quality into the business system and avoid delegation of quality functions to junior administrators. Another goal was to improve effectiveness via process performance metrics: numerical measurement of the effectiveness of tasks and activities. Expectations of continual process improvement and tracking customer satisfaction were made explicit.

text: ISO 9000 Requirements include:

text:
Approve documents before distribution;
Provide correct version of documents at points of use;
Use your records to prove that requirements have been met; and
Develop a procedure to control your records.

text: 2008 version[edit]

text: ISO 9001:2008 in essence re-narrates ISO 9001:2000. The 2008 version only introduced clarifications to the existing requirements of ISO 9001:2000 and some changes intended to improve consistency with ISO 14001:2004. There were no new requirements. For example, in ISO 9001:2008, a quality management system being upgraded just needs to be checked to see if it is following the clarifications introduced in the amended version.

text: ISO 9001 is supplemented directly by two other standards of the family:

text:
ISO 9000:2005 "Quality management systems. Fundamentals and vocabulary"
ISO 9004:2009 "Managing for the sustained success of an organization. A quality management approach"

text: Other standards, like ISO 19011 and the ISO 10000 series, may also be used for specific parts of the quality system.

text: 2015 version[edit]

text: In 2012, ISO TC 176 - responsible for ISO 9001 development - celebrated 25 years of implementing ISO 9001,[38] and concluded that it is necessary to create a new QMS model for the next 25 years. This is why they commenced the official work on creating a revision of ISO 9001, starting with the new QM principles. This moment was considered by important specialists in the field as "beginning of a new era in the development of quality management systems."[39] As a result of the intensive work from this technical committee, the revised standard ISO 9001:2015 was published by ISO on 23 September 2015. The scope of the standard has not changed; however, the structure and core terms were modified to allow the standard to integrate more easily with other international management systems standards.

text: The 2015 version is also less prescriptive than its predecessors and focuses on performance. This was achieved by combining the process approach with risk-based thinking, and employing the Plan-Do-Check-Act cycle at all levels in the organization.[40]

text: Some of the key changes include:

text:
High-Level Structure of 10 clauses is implemented. Now all new standard released by ISO will have this High-level structure.
Greater emphasis on building a management system suited to each organization's particular needs
A requirement that those at the top of an organization be involved and accountable, aligning quality with wider business strategy
Risk-based thinking throughout the standard makes the whole management system a preventive tool and encourages continuous improvement
Less prescriptive requirements for documentation: the organization can now decide what documented information it needs and what format it should be in
Alignment with other key management system standards through the use of a common structure and core text[41]
Inclusion of Knowledge Management principles
Quality Manual & Management representative is now not mandatory requirements.

text: Auditing[edit]

text: Two types of auditing are required to become registered to the standard: auditing by an external certification body (external audit) and audits by internal staff trained for this process (internal audits). The aim is a continual process of review and assessment to verify that the system is working as it is supposed to; to find out where it can improve, and to correct or prevent problems identified.  It is considered healthier for internal auditors to audit outside their usual management line, so as to bring a degree of independence to their judgments.

text: Under the 1994 standard, the auditing process could be adequately addressed by performing "conformance auditing":

text:
Tell me what you do (describe the business process)
Show me where it says that (reference the procedure manuals)
Prove that this is what happened (exhibit evidence in documented records)

text: The 2000 standard uses a different approach. Auditors are expected to go beyond mere auditing for rote conformance by focusing on risk, status, and importance. This means they are expected to make more judgments on what is effective, rather than merely adhering to what is formally prescribed.  The difference from the previous standard can be explained thus:

text: Industry-specific interpretations[edit]

text: The ISO 9001 standard is generic; its parts must be carefully interpreted to make sense within a particular organization. Developing software is not like making cheese or offering counseling services, yet the ISO 9001 guidelines, because they are business management guidelines, can be applied to each of these.  Diverse organizations—police departments (United States), professional soccer teams (Mexico), and city councils (UK)—have successfully implemented ISO 9001:2000 systems.

text: Over time, various industry sectors have wanted to standardize their interpretations of the guidelines within their own marketplace.  This is partly to ensure that their versions of ISO 9000 have their specific requirements, but also to try and ensure that more appropriately trained and experienced auditors are sent to assess them.

text:
The TickIT guidelines are an interpretation of ISO 9000 produced by the UK Board of Trade to suit the processes of the information technology industry, especially software development.
AS9000 is the Aerospace Basic Quality System Standard, an interpretation developed by major aerospace manufacturers. Those major manufacturers include AlliedSignal, Allison Engine, Boeing, General Electric Aircraft Engines, Lockheed-Martin, McDonnell Douglas, Northrop Grumman, Pratt & Whitney, Rockwell-Collins, Sikorsky Aircraft, and Sundstrand. The current version is AS9100D.
PS 9000 * QS 9000 is an interpretation agreed upon by major automotive manufacturers (GM, Ford, Chrysler). It includes techniques such as FMEA and APQP. QS 9000 is now replaced by ISO/TS 16949.
ISO/TS 16949:2009 is an interpretation agreed upon by major automotive manufacturers (American and European manufacturers); the latest version is based on ISO 9001:2008. The emphasis on a process approach is stronger than in ISO 9001:2008. ISO/TS 16949:2009 contains the full text of ISO 9001:2008 and automotive industry-specific requirements.
TL 9000 is the Telecom Quality Management and Measurement System Standard, an interpretation developed by the telecom consortium, QuEST Forum. In 1998 QuEST Forum developed the TL 9000 Quality Management System to meet the supply chain quality requirements of the worldwide telecommunications industry. The TL 9000 standard is made up of two handbooks: the QMS Requirements Handbook, and the QMS Measurement Handbook. The current versions of the Requirements and Measurements Handbooks are 5.0. Unlike ISO 9001 or other sector-specific standards, TL 9000 includes standardized product and process measurements that must be reported into a central repository, which allows organizations to benchmark their performance in key process areas against peer organizations. It is important to note that TL 9000 R5.0 contains the full text of ISO 9001:2008.
ISO 13485:2016 is the medical industry's equivalent of ISO 9001. ISO 13485:2016 is a stand-alone standard. Because ISO 13485 is relevant to medical devices manufacturers (unlike ISO 9001, which is applicable to any industry), and because of the differences between the two standards relating to continual improvement, compliance with ISO 13485 does not necessarily mean compliance with ISO 9001 (and vice versa).
ISO/IEC 90003:2014 provides guidelines for the application of ISO 9001 to computer software.
ISO/TS 29001 is quality management system requirements for the design, development, production, installation, and service of products for the petroleum, petrochemical, and natural gas industries.  It is equivalent to API Spec Q1 without the Monogram annex.
ISO 22000 Food Safety Management Systems.

text: Effectiveness[edit]

text: This section  possibly contains original research. Please improve it by verifying the claims made and adding inline citations. Statements consisting only of original research should be removed. (May 2013) (Learn how and when to remove this template message)

text: The debate on the effectiveness of ISO 9000 commonly centres on the following questions:

text:
Are the quality principles in ISO 9001 of value?
Does it help to implement an ISO 9001-compliant quality management system?
Does it help to obtain ISO 9001 certification?

tag: ol

text: The effectiveness of the ISO system being implemented depends on a number of factors, the most significant of which are:

text:
Commitment of senior management to monitor, control, and improve quality. Organizations that implement an ISO system without this desire and commitment often take the cheapest road to get a certificate on the wall and ignore problem areas uncovered in the audits.
How well the ISO system integrates into current business practices.  Many organizations that implement ISO try to make their system fit into a cookie-cutter quality manual instead of creating a manual that documents existing practices and only adds new processes to meet the ISO standard when necessary.
How well the ISO system focuses on improving the customer experience.  The broadest definition of quality is "Whatever the customer perceives good quality to be."  This means that a company doesn't necessarily have to make a product that never fails; some customers will have a higher tolerance for product failures if they always receive shipments on-time or have a positive experience in some other dimension of customer service.  An ISO system should take into account all areas of the customer experience and the industry expectations, and seek to improve them on a continual basis.  This means taking into account all processes that deal with the three stakeholders (customers, suppliers, and organization); only then will a company be able to sustain improvements in the customer's experience.
How well the auditor finds and communicates areas of improvement.  While ISO auditors may not provide consulting to the clients they audit, there is the potential for auditors to point out areas of improvement.  Many auditors simply rely on submitting reports that indicate compliance or non-compliance with the appropriate section of the standard; however, to most executives, this is like speaking a foreign language.  Auditors that can clearly identify and communicate areas for improvement in language and terms executive management understands facilitate action on improvement initiatives by the companies they audit.  When management doesn't understand why they were non-compliant and the business implications associated with non-compliance, they simply ignore the reports and focus on what they do understand.

text: Advantages[edit]

text: Proper quality management can improve business, often having a positive effect on investment, market share, sales growth, sales margins, competitive advantage, and avoidance of litigation.[42] The quality principles in ISO 9000:2000 are also sound, according to Wade [43] and Barnes, who says that "ISO 9000 guidelines provide a comprehensive model for quality management systems that can make any company competitive".[44] Sroufe and Curkovic, (2008) found benefits ranging from registration required to remain part of a supply base, better documentation, to cost benefits, and improved involvement and communication with management.[42] According to ISO[45] the 2015 version of the standard brings the following benefits:

text:
By assessing their context, organizations can define who is affected by their work and what they expect. This enables clearly stated business objectives and the identification of new business opportunities.
Organizations can identify and address the risks associated with their organization.
By putting customers first, organizations can make sure they consistently meet customer needs and enhance customer satisfaction. This can lead to more repeat customers, new clients and increased business for the organization.
Organizations work in a more efficient way as all their processes are aligned and understood by everyone. This increases productivity and efficiency, bringing internal costs down.
Organizations will meet necessary statutory and regulatory requirements.
Organizations can expand into new markets, as some sectors and clients require ISO 9001 before doing business.

text: Criticisms of ISO 9001 certification[edit]

text: A common criticism of ISO 9000 and 9001 is the amount of money, time, and paperwork required for a complete implementation, and later when needed; ISO 9001 certification.[7] Dalgleish cites the "inordinate and often unnecessary paperwork burden" of ISO, and says that "quality managers feel that ISO's overhead and paperwork are excessive and extremely inefficient".[46] The level of minimum documentation for a minimum scope organization has been greatly reduced going from ISO 9001:2000, through ISO 9001:2008 and lastly ISO 9001:2015.

text: According to Barnes, "Opponents claim that it is only for documentation. Proponents believe that if a company has documented its quality systems, then most of the paperwork has already been completed".[44] Wilson suggests that ISO standards "elevate inspection of the correct procedures over broader aspects of quality", and therefore, "the workplace becomes oppressive and quality is not improved".[8]

text: One study showing reasons for not adopting this standard include the risks and uncertainty of not knowing if there are direct relationships to improved quality, and what kind and how many resources will be needed.  Additional risks include how much certification will cost, increased bureaucratic processes and risk of poor company image if the certification process fails.[42] According to John Seddon, ISO 9001 promotes specification, control, and procedures rather than understanding and improvement.[9] Wade argues that ISO 9000 is effective as a guideline, but that promoting it as a standard "helps to mislead companies into thinking that certification means better quality, ... [undermining] the need for an organization to set its own quality standards".[43] In short, Wade argues that reliance on the specifications of ISO 9001 does not guarantee a successful quality system.

text: The standard is seen as especially prone to failure when a company is interested in certification before quality.[9] Certifications are in fact often based on customer contractual requirements rather than a desire to actually improve quality.[44][47] "If you just want the certificate on the wall, chances are you will create a paper system that doesn't have much to do with the way you actually run your business", said ISO's Roger Frost.[47] Certification by an independent auditor is often seen as the problem area, and according to Barnes, "has become a vehicle to increase consulting services".[44]

text: Dalgleish argues that while "quality has a positive effect on return on investment, market share, sales growth, better sales margins and competitive advantage," "taking a quality approach is unrelated to ISO 9000 registration."[48] In fact, ISO itself advises that ISO 9001 can be implemented without certification, simply for the quality benefits that can be achieved.[49]

text: Abrahamson argues that fashionable management discourse such as Quality Circles tends to follow a lifecycle in the form of a bell curve, possibly indicating a management fad.[50]

text: Pickrell argues[citation needed] that ISO systems merely gauge whether the processes are being followed. It does not gauge how good the processes are or whether the correct parameters are being measured and controlled to ensure quality. Furthermore, when unique technical solutions are involved in the creation of a new part, ISO does not validate the robustness of the technical solution which is a key part of advanced quality planning. It is not unheard of for an ISO-certified plant to display poor quality performance due to poor process selection and/or poor technical solutions.


document_title: List of National Football League career passing touchdowns leaders

question_text: who has the most touchdown passes in the nfl history

text: Players with at least 200 passing touchdowns[edit]

text:
Key

^
Inducted into the Pro Football Hall of Fame

*
Denotes player who is still active in the NFL

text: Through end of 2017 season.

text:
Rank
Player
Team(s) by season
Touchdowns

1
Manning, PeytonPeyton Manning
Indianapolis Colts (1998–2011)
Denver Broncos (2012–2015)
539

2
Favre, BrettBrett Favre^
Atlanta Falcons (1991)
Green Bay Packers (1992–2007)
New York Jets (2008)
Minnesota Vikings (2009–2010)
508

3
Brady, TomTom Brady*
New England Patriots (2000–present)
488

Brees, DrewDrew Brees*
San Diego Chargers (2001–2005)
New Orleans Saints (2006–present)

5
Dan Marino^
Miami Dolphins (1983–1999)
420

6
Rivers, PhilipPhilip Rivers*
San Diego/Los Angeles Chargers (2004–present)
342

Fran Tarkenton^
Minnesota Vikings (1961–1966), (1972–1978)
New York Giants (1967–1971)

8
Manning, EliEli Manning*
New York Giants (2004–present)
339

9
Roethlisberger, BenBen Roethlisberger*
Pittsburgh Steelers (2004–present)
329

10
Rodgers, AaronAaron Rodgers*
Green Bay Packers (2005–present)
313

11
Elway, JohnJohn Elway^
Denver Broncos (1983–1998)
300

12
Carson Palmer
Cincinnati Bengals (2003–2010)
Oakland Raiders (2011–2012)
Arizona Cardinals (2013–2017)
294

13
Warren Moon^
Houston Oilers (1984–1993)
Minnesota Vikings (1994–1996)
Seattle Seahawks (1997–1998)
Kansas City Chiefs (1999–2000)
291

14
Johnny Unitas^
Baltimore Colts (1956–1972)
San Diego Chargers (1973)
290

15
Vinny Testaverde
Tampa Bay Buccaneers (1987–1992)
Cleveland Browns (1993–1995)
Baltimore Ravens (1996–1997)
New York Jets (1998–2003, 2005)
Dallas Cowboys (2004)
New England Patriots (2006)
Carolina Panthers (2007)
275

16
Montana, JoeJoe Montana^
San Francisco 49ers (1979–1992)
Kansas City Chiefs (1993–1994)
273

17
Dave Krieg
Seattle Seahawks (1980–1991)
Kansas City Chiefs (1992–1993)
Detroit Lions (1994)
Arizona Cardinals (1995)
Chicago Bears (1996)
Tennessee Oilers (1997–1998)
261

18
Ryan, MattMatt Ryan*
Atlanta Falcons (2008–present)
260

19
Jurgensen, SonnySonny Jurgensen^
Philadelphia Eagles (1957–1963)
Washington Redskins (1964–1974)
255

20
Dan Fouts^
San Diego Chargers (1973–1987)
254

21
Bledsoe, DrewDrew Bledsoe
New England Patriots (1993–2001)
Buffalo Bills (2002–2004)
Dallas Cowboys (2005–2006)
251

22
Romo, TonyTony Romo
Dallas Cowboys (2003–2016)
248

23
Boomer Esiason
Cincinnati Bengals (1984–1992, 1997)
New York Jets (1993–1995)
Arizona Cardinals (1996)
247

24
John Hadl
San Diego Chargers (1962–1972)
Los Angeles Rams (1973–1974[a])
Green Bay Packers (1974–1975)
Houston Oilers (1976–1977)
244

25
Len Dawson^
Pittsburgh Steelers (1957–1959)
Cleveland Browns (1960–1961)
Dallas Texans (1962)
Kansas City Chiefs (1963–1975)
239

26
Jim Kelly^
Buffalo Bills (1986–1996)
237

27
George Blanda^
Chicago Bears (1949, 1950[b]–1958)
Baltimore Colts (1950)
Houston Oilers (1960–1966)
Oakland Raiders (1967–1975)
236

28
Donovan McNabb
Philadelphia Eagles (1999–2009)
Washington Redskins (2010)
Minnesota Vikings (2011)
234

29
Steve Young^
Tampa Bay Buccaneers (1985–1986)
San Francisco 49ers (1987–1999)
232

30
Cutler, JayJay Cutler*
Denver Broncos (2006–2008)
Chicago Bears (2009–2016)
Miami Dolphins (2017–present)
227

31
Stafford, MatthewMatthew Stafford*
Detroit Lions (2009–present)
216

32
Brodie, JohnJohn Brodie
San Francisco 49ers (1957–1973)
214

33
Terry Bradshaw^
Pittsburgh Steelers (1970–1983)
212

Hasselbeck, MattMatt Hasselbeck
Green Bay Packers (1998–2000)
Seattle Seahawks (2001–2010)
Tennessee Titans (2011–2012)
Indianapolis Colts (2013–2015)

Tittle, Y. A.Y. A. Tittle^[c]
Baltimore Colts (1950)
San Francisco 49ers (1951–1960)
New York Giants (1961–1964)

36
Hart, JimJim Hart
St. Louis Cardinals (1966–1983)
Washington Redskins (1984)
209

36
Collins, KerryKerry Collins
Carolina Panthers (1995–1998)
New Orleans Saints (1998)
New York Giants (1999–2003)
Oakland Raiders (2004–2005)
Tennessee Titans (2006–2010)
Indianapolis Colts (2011)
208

Warner, KurtKurt Warner^
St. Louis Rams (1998–2003)
New York Giants (2004)
Arizona Cardinals (2005–2009)

39
Cunningham, RandallRandall Cunningham
Philadelphia Eagles (1985–1995)
Minnesota Vikings (1997–1999)
Dallas Cowboys (2000)
Baltimore Ravens (2001)
207

40
Everett, JimJim Everett
Los Angeles Rams (1986–1993)
New Orleans Saints (1994–1996)
San Diego Chargers (1997)
203

41
Gabriel, RomanRoman Gabriel
Los Angeles Rams (1962–1972)
Philadelphia Eagles (1973–1977)
201

42
Flacco, JoeJoe Flacco*
Baltimore Ravens (2008–present)
200

text: Active players with 150–199 touchdowns[edit]

text: Through end of 2017 season.

text:
Alex Smith, 183
Ryan Fitzpatrick, 173
Andy Dalton, 167
Russell Wilson, 161
Cam Newton, 158