Purpose

The purpose of this protocol is to promote a philosophy of maternal infant care that advocates breastfeeding and supports the normal physiologic functions involved in the establishment of this maternal-infant process and to assist families choosing to breastfeed with initiating and developing a successful and satisfying experience.

This policy is based on recommendations from the most recent breastfeeding policy statements published by the Office on Women’s Health of the U.S. Department of Health and Human Services, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, the World Health Organization, the American Dietetic Association, the Academy of Breastfeeding Medicine, and the UNICEF/WHO evidence-based Ten Steps to Successful Breastfeeding .

Policy Statements

• 1.
  

  The “ name of institution ” staff will actively support breastfeeding as the preferred method of providing nutrition to infants. A multidisciplinary, culturally appropriate team comprising hospital administrators, physician and nursing staff, lactation consultants and specialists, nutrition staff, parents, and other appropriate staff shall be established and maintained to identify and eliminate institutional barriers to breastfeeding. On a yearly basis, this group will compile and evaluate data relevant to breastfeeding support services and formulate a plan of action to implement needed changes.

  
  
• 2.
  

  A written breastfeeding policy will be developed and communicated to all health care staff. The “ name of institution ” breastfeeding policy will be reviewed and updated routinely (biannually) using current research as an evidence-based guide.

  
  
• 3.
  

  All pregnant women and their support people as appropriate will be provided with information on breastfeeding and counseled on the benefits of breastfeeding, contraindications to breastfeeding, and risk of formula feeding.

  
  
• 4.
  

  The woman’s desire to breastfeed will be documented in her medical record.

  
  
• 5.
  

  Mothers will be encouraged to exclusively breastfeed unless medically contraindicated. The method of feeding will be documented in the medical record of every infant.

  
  
  
  
  • •
    

    Exclusive breastfeeding is defined as providing breast milk as the sole source of nutrition. Exclusively breastfed babies receive no other liquids or solids.

  
  
  
  
• 6.
  

  At birth or soon thereafter all newborns, if baby and mother are stable, will be placed skin-to-skin with the mother. Skin-to-skin contact involves placing the naked baby prone on the mother’s bare chest. Mother-infant couples will be given the opportunity to initiate breastfeeding within 1 hour of birth. Post-cesarean-birth babies will be encouraged to breastfeed as soon as possible. The administration of vitamin K and prophylactic antibiotics to prevent ophthalmia neonatorum should be delayed for the first hour after birth to allow uninterrupted mother-infant contact and breastfeeding.

  
  
• 7.
  

  Breastfeeding mother-infant couples will be encouraged to remain together throughout their hospital stay, including at night (rooming-in). Skin-to-skin contact will be encouraged as much as possible.

  
  
• 8.
  

  Breastfeeding assessment, teaching, and documentation will be done on each shift and whenever possible with each staff contact with the mother. After each feeding, staff will document information about the feeding in the infant’s medical record. This documentation may include the latch, position, and any problems encountered. For feedings not directly observed, a maternal report may be used. Every shift, a direct observation of the baby’s position and latch-on during feeding will be performed and documented.

  
  
• 9.
  

  Mothers will be encouraged to utilize available breastfeeding resources, including classes, written materials, and video presentations, as appropriate. If clinically indicated, the clinician or nurse will make a referral to a lactation consultant or specialist.

  
  
• 10.
  

  Breastfeeding mothers will be instructed about

  
  
  
  
  • a.
    

    proper positioning and latch-on;

    
    
  • b.
    

    nutritive suckling and swallowing;

    
    
  • c.
    

    milk production and release;

    
    
  • d.
    

    frequency of feeding/feeding cues;

    
    
  • e.
    

    expression of breastmilk and use of a pump if indicated;

    
    
  • f.
    

    how to assess if infant is adequately nourished; and

    
    
  • g.
    

    reasons for contacting the clinician.

    
    

    These skills will be taught to primiparous and multiparous women and reviewed before the mother goes home.

  
  
  
  
• 11.
  

  Parents will be taught that breastfeeding infants, including cesarean-birth babies, should be put to breast at least 8 to 12 times each 24 hours. Infant feeding cues (e.g., increased alertness or activity, mouthing, or rooting) will be used as indicators of the baby’s readiness for feeding. Breastfeeding babies will be breastfed at night.

  
  
• 12.
  

  Time limits for breastfeeding on each side will be avoided. Infants can be offered both breasts at each feeding but may be interested in feeding only on one side at a feeding during the early days.

  
  
• 13.
  

  No supplemental water, glucose water, or formula will be given unless specifically ordered by a physician or nurse practitioner or by the mother’s documented and informed request. Prior to nonmedically indicated supplementation, mothers will be informed of the risks of supplementing. The supplement should be fed to the baby by cup if possible and will be no more than 10 to 15 mL in a term baby. Alternative feeding methods such as syringe or spoon-feeding may also be used; however, these methods have not be shown to be effective in preserving breastfeeding. Bottles will not be placed in a breastfeeding infant’s bassinet.

  
  
• 14.
  

  This institution does not give group instruction in the use of formula. Those parents who, after appropriate counseling, choose to formula feed their infants will be provided individual instruction.

  
  
• 15.
  

  Pacifiers will not be given to normal full-term breastfeeding infants. The pacifier guidelines at “ name of institution ” state that preterm infants in the Neonatal Intensive Care or Special Care Unit or infants with specific medical conditions may be given pacifiers for nonnutritive sucking. Newborns undergoing painful procedures (e.g., circumcision) may be given a pacifier as a method of pain management during the procedure. The infant will not return to the mother with the pacifier. “ Name of institution ” encourages “pain-free newborn care,” which may include breastfeeding during the heel stick procedure for the newborn metabolic screening tests.

  
  
• 16.
  

  Routine blood glucose monitoring of full-term, healthy, appropriate for gestational age (AGA) infants is not indicated. Assessment for clinical signs of hypoglycemia and dehydration will be ongoing.

  
  
• 17.
  

  Antilactation drugs will not be given to any postpartum mother.

  
  
• 18.
  

  Routine use of nipple creams, ointments, or other topical preparations will be avoided unless such therapy has been indicated for a dermatologic problem. Mothers with sore nipples will be observed for latch-on techniques and will be instructed to apply expressed colostrum or breast milk to the areola after each feeding.

  
  
• 19.
  

  Nipple shields or bottle nipples will not be routinely used to cover a mother’s nipple to treat latch-on problems or prevent or manage sore or cracked nipples or when a mother has flat or inverted nipples. Nipple shields will be used only in conjunction with a lactation consultation.

  
  
• 20.
  

  After 24 hours of life, if the infant has not latched on or fed effectively, the mother will be instructed to begin breast massage and hand expression of colostrum into the baby’s mouth during feeding attempts. Skin-to-skin contact will be encouraged. (Parents will be instructed to watch closely for feeding cues and whenever these are observed to awaken and feed the infant.) If the baby continues to feed poorly, pumping with skilled hand expression or a double set-up electric breast pump will be initiated and maintained approximately every 3 hours or a minimum of eight times per day. Any expressed colostrum or mother’s milk will be fed to the baby by an alternative method. The mother will be reminded that she may not obtain much milk or even any milk the first few times she pumps her breasts. Until the mother’s milk is available, a collaborative decision should be made among the mother, nurse, and clinician regarding the need to supplement the baby. Each day clinicians will be consulted regarding the volume and type of the supplement. Pacifiers will be avoided. In cases of problem feeding, the lactation consultant or specialist will be consulted.

  
  
• 21.
  

  If the baby is still not latching on well or feeding well when going home, the feeding/pumping/supplementing plan will be reviewed in addition to routine breastfeeding instructions. A follow-up visit or contact will be scheduled within 24 hours. Depending on the clinical situation it may be appropriate to delay discharge of the couplet to provide further breastfeeding intervention, support, and education.

  
  
• 22.
  

  All babies should be seen for follow-up within the first few days postpartum. This visit should be with a pediatrician or other qualified health care practitioner for a formal evaluation of breastfeeding performance, a weight check, assessment of jaundice, and age-appropriate elimination:

  
  
  
  
  • •
    

    For infants discharged at less than 2 days of age (< 48 hours): Follow-up at 2 to 4 days of age.

    
    
  • •
    

    For infants discharged at more than 2 days of age (> 48 hours): Follow-up at 4 to 5 days of age.

    
    
  • •
    

    All newborns should be seen by 1 month of age.

  
  
  
  
• 23.
  

  Mothers who are separated from their sick or premature infants will be

  
  
  
  
  • a.
    

    instructed on how to use skilled hand expression or the double set-up electric breast pump—instructions will include expression at least eight times per day or approximately every 3 hours for 15 minutes (or until milk flow stops, whichever is greater) around the clock and the importance of not missing a pumping session during the night;

    
    
  • b.
    

    encouraged to breastfeed on demand as soon as the infant’s condition permits;

    
    
  • c.
    

    taught proper storage and labeling of human milk; and

    
    
  • d.
    

    assisted in learning skilled hand expression or obtaining a double set-up electric breast pump prior to going home.

  
  
  
  
• 24.
  

  Before leaving the hospital, breastfeeding mothers should be able to

  
  
  
  
  • a.
    

    position the baby correctly at the breast with no pain during the feeding;

    
    
  • b.
    

    latch the baby to breast properly;

    
    
  • c.
    

    state when the baby is swallowing milk;

    
    
  • d.
    

    state that the baby should be nursed approximately 8 to 12 times every 24 hours until satiety;

    
    
  • e.
    

    state age-appropriate elimination patterns (at least six urinations per day and three to four stools per day by the fourth day of life);

    
    
  • f.
    

    list indications for calling a clinician; and

    
    
  • g.
    

    manually express milk from their breasts.

  
  
  
  
  • 
    

    The Ten Steps to Successful Breastfeeding

    
    
  • 1.
    

    Have a written breastfeeding policy that is routinely communicated to all health care staff.

    
    
  • 2.
    

    Train all health care staff in skills necessary to implement this policy.

    
    
  • 3.
    

    Inform all pregnant women about the benefits and management of breastfeeding.

    
    
  • 4.
    

    Help mothers initiate breastfeeding within 1 hour of birth.

    
    
  • 5.
    

    Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.

    
    
  • 6.
    

    Give newborn infants no food or drink other than breast milk, unless medically indicated. ¹

    
    

    1 A hospital must pay fair market price for all formula and infant feeding supplies that it uses and cannot accept free or heavily discounted formula and supplies.

    
    
    
    
  • 7.
    

    Practice rooming-in—allow mothers and infants to remain together—24 hours a day.

    
    
  • 8.
    

    Encourage breastfeeding on demand.

    
    
  • 9.
    

    Give no artificial teats or pacifiers to breastfeeding infants.

    
    
  • 10.
    

    Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

  
  
  
  
• 25.
  

  Prior to going home, mothers will be given the names and telephone numbers of community resources to contact for help with breastfeeding, including (the support group or resource recommended by “ name of institution ”).

  
  
• 26.
  

  “ Name of institution ” does not accept free formula or free breastmilk substitutes. Nursery or NICU discharge bags offered to all mothers will not contain infant formula, coupons for formula, logos of formula companies, or literature with formula company logos.

  
  
• 27.
  

  “ Name of institution ” health professionals will attend educational sessions on lactation management and breastfeeding promotion to ensure that correct, current, and consistent information is provided to all mothers wishing to breastfeed.