Newborn Infant Feeding Policy and Guidelines
Document Control
Title
Newborn Infant Feeding Policy and Guidelines
Author
Author’s job title
Lead Midwife for Public Health, Community and Lead Midwife for Public Health, Community and
Antenatal Services
Antenatal Services
Directorate
Department
Surgical
Maternity
Date
Version
Status
Comment / Changes / Approval
Issued
0.1
Jan
Draft
Initial version for consultation. This is intended to replace the
2013
Breast Feeding Policy and the Artificial feeding Policy.
0.2
Feb
Draft
Amended in line with comments received.
2013
0.3
Apr 2013
Draft
Amended in line with final comments received.
1.0
Apr 2013
Final
Approved by Maternity Services Guidelines Group on 10th April.
1.1
Jul 2013
Revision Amendments by Corporate Governance to document control
report, formatting for appendices, document navigation and
semi-automatic table of contents.
No references to Appendices A- E in content of policy.
EIA started and completed.
1.2
Nov 13
Revision Comments received by the Infant Feeding Co-ordinator
April 15
Revision Amended in line with Baby Friendly Initiative standards
1.3
January
Revision Amended in line with current Baby Friendly Initiative
2016
information and sent to midwives & Consultant for comments
1.4
Feb 2016
Draft
Approved by Maternity Services Guidelines Group on 3rd
February 2016, subject to agreed amendments.
2.0
Feb 2016
Final
Amended in line with Maternity Services Guideline group
recommendations.
Main Contact
Lead Midwife for Public Health,
Community and Antenatal Services
Ladywell Unit
North Devon District Hospital
Raleigh Park
Barnstaple, EX31 4JB
Lead Director
Director of Nursing
Superseded Documents
Artificial feeding Policy
Breast Feeding Policy
Issue Date
Review Date
Review Cycle
February 2016
February 2019
Three years
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Newborn Infant Feeding Policy and Guidelines
Consulted with the following stakeholders: (list all)
 All users of this document
 Governance Department
 Compliance Manager
 Stakeholders and partner agencies including BFI advisor, Children’s Centres leads.
Approval and Review Process
 Maternity Services Guidelines Group
Local Archive Reference
G:\Maternity Services Team/
Local Path
Maternity Services/Policies and Guidelines/
Filename
Newborn Infant Feeding Policy V1.2 02Jan14
Policy categories for Trust’s internal website
(Bob)
Maternity Services
Maternity
Newborn Infant Feeding Policy and Guidelines V2.0 03FEB16
Tags for Trust’s internal website (Bob)
Infant Nutrition, Infant Feeding, Breast Feeding,
Bottle feeding, Artificial Feeding
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Newborn Infant Feeding Policy and Guidelines
CONTENTS
Document Control........................................................................................................................ 1
1. Introduction ......................................................................................................................... 3
2. Purpose ................................................................................................................................ 5
3. Definitions............................................................................................................................ 5
4. Responsibilities .................................................................................................................... 6
5. Informing Pregnant Women of the Benefits and Management of Breastfeeding..................... 7
6. Expression & storage of Breast milk .................................................................................... 15
7. Problems associated with Breastfeeding ............................................................................. 22
8. Care for Mothers Who Have Chosen to Feed their Newborn with Infant Formula ................. 26
9. Weighing in the neonatal period ......................................................................................... 30
10. Feeding babies with special needs....................................................................................... 31
11. Effects of diet, drugs, alcohol and smoking .......................................................................... 34
12. Training Health Care Staff ................................................................................................... 37
13. The Development of the Policy ........................................................................................... 37
14. Consultation, Approval and Ratification Process .................................................................. 38
15. Review and Revision Arrangements including Document Control ......................................... 39
16. Dissemination and Implementation .................................................................................... 40
17. Document Control including Archiving Arrangements .......................................................... 40
18. Monitoring Compliance with and the Effectiveness of the Policy .......................................... 41
19. Associated Documentation ................................................................................................. 42
20. References ......................................................................................................................... 42
Appendix A: The Baby Friendly Initiative..................................................................................... 48
Appendix B: Ten Steps and Seven Point plan to Successful Breastfeeding .................................... 49
Appendix C: Benefits of Breastfeeding ........................................................................................ 50
Appendix D: Composition of breast milk ..................................................................................... 52
Appendix E: Physiology of Lactation ........................................................................................... 53
Appendix F: Guidelines for the Management of Reluctant or Sleepy Babies who are going to
Breastfeed ................................................................................................................................. 56
Appendix G: Equality Impact Assessment Screening Form ........................................................... 58
1.
Introduction
Promoting and supporting sustainable breastfeeding is an essential part of an
integrated programme of child health promotion and parenting support as set out in
the Child Health Promotion Programme and Every Child Matters. A healthy
pregnancy, a healthy birth and a strong bond between a baby and its parents are a
vital start in life.
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There is clear evidence that breastfeeding has positive health benefits for both
mother and baby in the short- and longer-term (beyond the period of
breastfeeding). Breastmilk is the best form of nutrition for infants and exclusive
breastfeeding is recommended for the first six months (26 weeks) of an infant's life.
Thereafter breastfeeding should continue for as long as the mother and baby wish,
while gradually introducing a more varied diet (DH 2003).
The Government wants to encourage and support mothers to increase the duration
of breastfeeding and introduced prevalence of breastfeeding at 6-8 weeks as a key
indicator within the Child health and Wellbeing PSA and the Vital Signs performance
framework - with parents getting help and support with breastfeeding in hospitals
and in the community from health visiting and midwifery teams, General Practices,
Child Health Services and Children’s Centres.
Breastfeeding rates are affected by the mothers’ awareness of the health benefits,
antenatal care and postnatal support received, problems experienced, peer
influence and also when the mother returns to work.
It is recognised that inequalities in infant feeding that still exist. Socio-demographic
characteristics of the mother identified consistent patterns of practice, for example,
young mothers from lower socio-economic groups appear to be least likely to adopt
infant feeding practices recommended by Health Departments.
The World Health Organisation (WHO) suggests that at least 97% of all women are
physiologically capable of breastfeeding their babies. However, one of the most
common complaints from mothers about infant feeding is the conflicting advice they
receive. Many members of staff may help a mother and she is less likely to receive
conflicting advice if each professional is working within the parameters of the
Maternity Unit’s policy and guidelines in conjunction with the WHO United Nations
Children’s Fund (UNICEF) Baby Friendly recommendations. These guidelines have
been developed by a multi-professional working party within the Trust.
North Devon Healthcare NHS Trust believes that all mothers have the right to
receive clear, impartial and timely information, to enable them to make fully
informed decisions about feeding and caring for their babies. This document
therefore is aimed at enabling health professionals to fully support mothers when
offering them assistance in feeding their babies. It offers practical information to
help mothers succeed and ensures that support is given in an atmosphere of trust
and confidence. By creating a breastfeeding culture, the aim is to give the support
and assistance required for more women to choose to breastfeed. Please note that
unless stated otherwise these guidelines apply to healthy term babies, although
much of the information contained will be useful for those caring for pre-term
babies.
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All mothers have the right to receive clear and impartial information to enable them
to make a fully informed choice as to how they feed and care for their babies. All
staff that care for pregnant women will not discriminate against any woman in her
chosen method of infant feeding and will fully support her when she has made that
choice.
2.
Purpose
The purpose of this document is to ensure that all NDHT staff understand their role
and responsibilities in supporting expectant and new mothers and their partners to
feed and care for their baby in ways which support optimal health and well-being. .
All staff are expected to comply with this policy.
This document has been developed in conjunction with the UNICEF UK Baby Friendly
Initiative (BFI) and The Clinical Negligence Scheme for Trusts (CNST) Maternity
Clinical Risk Management Standards.
2.1.
In Support of this Policy
Any deviation from the Policy must be justified and recorded in the mother’s
and baby’s notes. It is the individual healthcare professional’s responsibility
to liaise with the baby's medical attendants (paediatrician, general
practitioner) should concerns arise about the baby's health.
No advertising of breast milk substitutes, feeding bottles, teats or dummies is
permissible in any part of this organisation. The display of manufacturers'
logos on items such as calendars and stationery is also prohibited.
No literature provided by infant formula manufacturers is permitted.
Educational material for distribution to women and their families must be
approved by the Lead Midwife for Public Health and Infant Feeding
Coordinator.
Parents who have made a fully informed choice to artificially feed their babies
should be shown how to prepare formula feeds correctly, how to sterilise
equipment, the type of milk to use (first/newborn milk which is suitable until
the baby is a year old), and how to hold the baby for feeding, either
individually or in small groups, in the postnatal period. No routine group
instruction on the preparation of artificial feeds will be given in the antenatal
period as evidence suggests that information given at this time is less well
retained and may serve to undermine confidence in breastfeeding.
3.
Definitions
BFI
Baby Friendly Initiative (UNICEF UK)
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4.
Responsibilities
4.1.
Role of the Chief Executive
The Chief Executive holds overall responsibility for the safety of all the staff
and patients cared for within the Trust
4.2.
Role of the Director of Nursing/ Medical Director
The responsibility at Executive Director level for Midwifery and Obstetric
Services is shared between the Director of Nursing and the Medical Director.
They are responsible for ensuring that comprehensive service for supporting
infant feeding and nutrition is adequately resourced and managed.
4.3.
Role of the Head of Midwifery
The Head of Midwifery is the Lead Professional for Maternity Services and is
responsible to ensure that there is sufficient, appropriately qualified staff to
undertake the support of newborn infant feeding both in the hospital and the
community.
4.4.
Role of the Paediatrician
Within the maternity unit a Paediatrician is responsible for the management
of the ‘at risk’ or sick neonate.
4.5.
Role of Maternity Services Staff, including midwives, maternity support
workers and doctors
Maternity services staff will:



4.6.
Give women fully informed choice on methods of feeding.
Support new mothers with their breastfeeding choice.
Receive training, including annual updates.
Responsibility of all Trust Staff
All staff should be aware of the Newborn infant feeding policy and provide
support where required
The policy will be effectively communicated to all pregnant women with the
aim of ensuring that they understand the standard of information and care
expected from this Trust. Where a mothers’ guide is used in place of the full
policy, the full version should be available in each ward area on request. A
statement to this effect will be included on the mothers’ guide. Translation of
the policy in other languages can be available on request.
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5.
Informing Pregnant Women of the Benefits and Management
of Breastfeeding
Staff involved with the provision of antenatal care should ensure that all pregnant
women are informed of the benefits of breastfeeding and the potential health risks
of formula feeding. Staff will inform mothers about/refer mothers to targeted
community interventions to promote breastfeeding as appropriate.
All pregnant women should be given an opportunity to discuss infant feeding on a
one to one basis with a heath professional. Such discussion should not solely be
attempted during a group class. This should be achieved by 34 completed weeks of
pregnancy.
The physiological basis of breastfeeding should be clearly and simply explained to all
pregnant women, together with good management practices which have been
proven to protect breastfeeding and reduce common problems. The aim should be
to give women confidence in their ability to breastfeed. Parent Education classes,
should reinforce the above.
Staff should be aware of the principles of effective communication – when talking to
a pregnant woman:





5.1.
Explore her feelings (open-ended questions)
Listen
Accept
Provide information as needed
Be non-judgemental
Antenatal Preparation
It is essential that prospective parents are able to make a fully informed
decision about feeding their babies. Every opportunity should be taken
during antenatal visits and parent information sessions to provide
information. The greatest effect on the decision of how to feed will be the
mother’s socially acquired attitudes and the support that she feels she will
get from her family and friends (Switzky1979, Littman 1994). If a woman
decides to formula feed at this stage, it may be difficult for her to change her
mind at a later date.
Keeping conversations woman-centred






Ask open questions
Listen actively
Reflect back
Find out and build on information she knows
Show empathy
Remain neutral
Encouraging parents to connect with their baby
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


5.2.
Sharing the value of skin contact
Responding to baby’s needs
Feeding
See link below - ‘Having meaningful conversations with mothers’
http://www.unicef.org.uk/Documents/Baby_Friendly/Leaflets/meaningful_co
nversations.pdf At the Booking Visit
Assess the woman's level of knowledge on the subject rather than demand a
decision from her, so that appropriate information can be given and a
positive attitude encouraged.
Inform the woman about NHS Choices “You and your baby” guide which has
information on the risks and benefits of methods of infant feeding – available
at
http://www.nhs.uk/Conditions/pregnancy-and-baby/pages/pregnancy-andbaby-care.aspx#close
Give the woman the information booklet “Off to the best start; important
information about feeding your baby”. This will usefully provide a good
foundation for on-going discussion about infant feeding options. Discuss and
complete the antenatal infant feeding checklist by 34 weeks of pregnancy,
this should include:









The value of breastfeeding to mother and baby
Exclusive breastfeeding leads to the best health outcomes for mother
and baby, and is especially important during the first few weeks when
breastfeeding is becoming established.
Importance of skin-to-skin contact regardless of chosen feeding method
Importance of good positioning and attachment (To ensure good breast
milk supply, effective milk transfer and to prevent sore/cracked nipples
and excessive weight loss)
Importance of rooming-in
Responsive feeding describes a feeding relationship which is sensitive,
reciprocal, and about more than nutrition. Staff should ensure that
mothers have the opportunity to discuss this aspect of feeding and
reassure mothers that: breastfeeding can be used to feed, comfort and
calm babies; breastfeeds can be long or short, breastfed babies cannot
be overfed or ‘spoiled’ and that it is always appropriate to offer the
breast.
Connecting with her baby helps the mother to be more responsive once
he is born and is good for his development
Problems using teats, dummies, nipple shields
Routine demonstration of bottle-feeding to pregnant women attending
antenatal classes should NOT be carried out
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A well-nourished mother is more likely to succeed with breastfeeding. Advice
on attaining a balanced diet must be tailored to a woman's individual
financial, social and cultural circumstances. Midwives should ensure dietary
advice is given antenatally; a dietician’s help may be needed.
Pregnancy naturally prepares the breast for feeding. The milk producing
glands grow; Montgomery's tubercles provide extra skin lubrication and
nipples become more protractile. Most women with poorly protractile
nipples can breastfeed successfully.
There is no evidence that any topical application to nipples is of benefit.
Antenatal expression of colostrum is not necessary, unless a mother wishes
to harvest colostrum antenatally for a specific reason, i.e. because she has
diabetes. A well fitting bra can help a woman's comfort in pregnancy and
during breastfeeding. Midwives should be prepared to discuss the wearing
and fitting of bras including where bras may be obtained. If in doubt consult
the Infant Feeding Coordinator.
5.3.
Postnatal conversations
A mother-centred approach - make the time you do have with mothers
count. Mother and baby have individual needs, which vary according to the
mother’s condition, confidence and previous experience. It is therefore
important to find out what those needs are and to avoid making assumptions.
After birth - All mothers should offer the first feed in skin contact when their
baby shows signs of readiness. Babies should not be rushed to feed before
they are ready.
Care for all mothers - Young babies need to be close to their mother as this is
the biological norm. Encouraging mothers to keep their baby close to them
and continuing support for skin-to-skin contact throughout the postnatal
period and beyond will help with this. Supporting parents to understand their
baby’s needs for frequent touch and sensitive visual and verbal
communication (including that this is good for their baby’s brain
development) will help them get to know their baby and build up strong and
loving bonds. Explaining to parents that giving love and comfort will not make
their baby demanding or ‘spoilt’, but rather ensure the best possible
development for him, can be very reassuring.
Breastfeeding mothers - All breastfeeding mothers will benefit from some
one-to-one time to ensure they are supported with the basic principles of
positioning and attachment, including how continued skin contact can help
facilitate feeding. This is also a good time to check if they are able to hand
express breast milk as this skill may be needed to tempt their baby to feed,
soften a full breast as the milk comes in or deal with issues such a blocked
ducts.
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Building on conversations started after birth around closeness, the meaning
of responsive feeding and how to make it work for them can be part of
ongoing discussions. Ensuring that mothers understand that they cannot
overfeed their baby and that breastfeeding can be used for comfort and rest,
as well as food, can be helpful. Before mothers leave hospital, making sure
that they know the signs to look out for to reassure them their baby is getting
enough breastmilk is an important safety issue. Leaflets will help re-enforce
information around recognising effective feeding, including the importance
of urine output and stooling. Parents also need to know how to access
appropriate help if they have concerns when at home.
Formula feeding mothers - Supporting mothers to recognise their baby’s
feeding cues, inviting the baby to draw in the teat (rather than forcing the
teat into the mouth), pacing the feed so that the baby is not forced to take
more milk than they need and recognising the signs that their baby has had
enough, will all help make bottle feeding a pleasant experience for the baby.
Encouraging mothers to hold their baby close and to look into their eyes
during feeds will also help build a close and loving relationship.
Mothers need to know how to sterilise equipment and make up feeds as
safely as possible. It is also important to stress that ‘first milks’ are most
appropriate for all babies throughout the first year. This is also the time to
discuss how much better it is for babies to have a limited number of people
involved with feeding them, so that babies feel secure and don’t have
different people feeding them using different techniques.
Breastfeeding assessments - All breastfeeding mothers should have a full
feeding assessment carried out at least twice during the first ten, and then
again at the Health Visitor new birth visit, to identify and address any
problems that might have developed. The UNICEF UK breastfeeding
assessment form (unicef.org.uk/babyfriendly/bfassessment) is designed to
help with this. It is best to do the assessment in partnership with the mother
and involve her in the plan of care. A new mother can often feel
overwhelmed when her milk comes in and her baby becomes more alert,
wanting frequent feeds. This is the time to talk about what is normal in terms
of feeding frequency and that babies need to do this to set6 up future supply.
Help her accept that this can be a challenging time and offer the following
suggestions to help her cope:
See ‘Having meaningful conversations with mothers’
5.4.
Skin-to-Skin Contact
Skin-to-skin contact is important, regardless of feeding intention, both in the
the first hour after birth and later on the postnatal ward, neonatal unit and
at home. Early skin-to-skin contact is thought to increase breastfeeding rates
(Widstrom et al 1987, Righard & Alde 1990) recent references.
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Other benefits include: (Christensson et al 1998, 1992, 1995):
An effective method of maintaining temperature and correcting hypothermia
in neonates, Significantly higher axillary and skin temperatures
Higher blood glucose levels at 90 minutes
A more rapid return towards zero of the negative base-excess (improves the
initial circulation to the skin)
Babies cry less than those kept in a cot next to their mother
For babies who are persistently unsettled, we recommend skin-to-skin
contact.
All mothers should be encouraged to hold their babies in skin-to-skin contact
as soon as possible after delivery in an unhurried environment, regardless of
their feeding method. Skin-to-skin contact should last for at least one hour or
until after the first breastfeed (whichever is sooner).
Skin-to-skin contact should never be interrupted at staff's instigation to carry
out routine procedures.
If skin-to-skin contact is interrupted for clinical indication or maternal choice
it should be re-instigated as soon as mother and baby are able.
Documentation of skin-to-skin contact will be recorded in the records and be
audited annually by the Infant Feeding Coordinator.
If skin-to-skin contact immediately after birth is not possible, then all mothers
and babies will be offered skin-to-skin contact and help with the first
breastfeed as soon as they are able. Fathers can hold their baby skin-to-skin if
the mother is not able to do so immediately. Skin-to-skin contact for babies
admitted to the neonatal unit should be offered as soon and as often as the
baby’s condition allows.
Staff will encourage close and loving relationships between parents and their
baby. High oxytocin and low stress hormone levels encourages the baby’s
brain development. On-going skin contact, responding to the baby’s cues,
soothing and comforting and not leaving him to cry for long periods all
encourage this relationship. Staff should explain that it is not possible to
‘spoil’ the baby.
5.5.
Initiation of breastfeeding
Key considerations related to early breastfeeding in the birth setting include
the timing of the first breastfeed, the mother’s overall comfort, access to
support, avoiding separation of mother and baby (in the absence of lifethreatening situations) and the process and routines of care.
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All mothers should be encouraged to offer the first breastfeed when mother
and baby are ready. Help and support must be available from a midwife or
maternity care assistant if needed.
There has been considerable debate about the “correct” timing of a first
breastfeed. Previously some authorities advocated initiation of breastfeeding
within certain times following birth, but, although feeding within an hour or
so of birth seems optimal (Colson 2007), there is no evidence of a “critical
period”, thus a less prescriptive approach that does not force the pace or
timing of the first feed appears more appropriate (Britton et al 2007,Enkin et
al:2000).The NICE guidelines on postnatal care state that most healthy full
term babies will demonstrate pre-feeding behaviours within the first hour of
life (Demott et al 2006).
Women should have access to professional support for their baby’s first
breastfeed (Dyson et al 2006, Renfrew et al. 2000). In the UK, midwives will
most commonly support early breastfeeding. Support should include helping
the mother to achieve a comfortable position for breastfeeding, pain relief if
required and use of an enabling rather than controlling approach (RCM
2002). The aim should be that early breastfeeding should be pain-free for the
mother and effective for her baby (Mulder 2006). It appears appropriate to
ensure privacy and to encourage the first breastfeed to take place whilst the
mother’s preferred support person is still present
5.6.
Showing women how to breastfeed and how to initiate lactation
All breastfeeding mothers should be offered further help with breastfeeding
within 6 hours of delivery. A midwife /maternity assistant /breastfeeding
supporter should be available to assist a mother at all breastfeeds during her
hospital stay.
Midwives should ensure that mothers are offered the support necessary to
acquire the skills of positioning and attachment. They should be able to
explain the necessary techniques to a mother, thereby helping her to acquire
this skill herself.
All breastfeeding mothers should be shown how to hand express their milk
within 24hours of birth, or within 6 hours if the baby is unable to breastfeed
for whatever reason. The ‘Off to the best start’ leaflet should be provided for
women to use for reference.
Mothers who are separated from their babies should be encouraged to begin
expressing as soon as possible after delivery as early initiation has long-term
benefits for milk production.
Mothers who are separated from their babies should be encouraged to
express milk at least 8 times in each 24 hours period, day and night. They
should be shown how to express breast milk by hand initially and by pump
once their milk supply ‘comes in’, or if the mother chooses to do so.
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5.7.
Rooming In (keeping babies close)
Mothers will normally assume primary responsibility for the care of their
babies.
Separation of mother and baby will normally only occur where the health of
either mother or baby prevents care being offered in the postnatal areas.
There is no designated nursery space in the postnatal areas.
Babies should not be routinely separated from their mothers at night. This
applies to babies who are being bottle-fed as well as those being breastfed.
Mothers recovering from caesarean section should be given appropriate care,
but the policy of keeping mothers and babies together should normally apply.
5.8.
Showing Women How to Maintain Lactation
Prior to transfer home, all breastfeeding mothers will receive information,
both verbal and in writing about how to recognise effective feeding to
include:
The signs which indicate that their baby is receiving sufficient milk (passing of
adequate quantities of urine and stool, effective suckling pattern with
swallows, weight loss within normal limits and later, weight gain) and what to
do if they suspect this is not the case;
How to recognise signs that breastfeeding is not progressing normally (e.g.
sore nipples, breast inflammation).
An assessment of breastfeeding will be carried out at around day 2/3 and day
5 to determine whether effective milk transfer is taking place and whether
further support with breastfeeding is required and this will be recorded in the
mother’s and baby’s records.
When a mother and her baby are separated for medical reasons, it is the
responsibility of all health professionals caring for both mother and baby to
ensure that the mother is given help and encouragement to express her milk
and maintain her lactation during periods of separation.
5.9.
Supporting Exclusive Breastfeeding
No water or infant formula should be given to a breastfed baby except in
cases of clinical indication or fully informed parental choice. The decision to
offer supplementary feeds for clinical reasons should be made by an
appropriately trained midwife or paediatrician. Reasons for supplementation
should be fully discussed with parents and recorded in the baby's notes.
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Prior to introducing infant formula to breastfed babies, every effort should be
made to encourage the mother to express breast milk to be given to the baby
via cup. This pro-active approach will reduce the need to offer artificial feeds.
Parents who request supplementation should be made aware of the possible
health implications and the harmful impact such action may have on
breastfeeding to enable them to make a fully informed choice.
A full record of this discussion should be made in the baby's notes.
For the first six months, no food or drink other than breast milk is to be
recommended for a breastfed baby except by an appropriately trained health
or medical professional.
5.10.
Responsive Feeding
Responsive feeding (i.e. feeding when the baby shows signs of wanting to
feed) should be explained and encouraged for all babies unless clinically
indicated.
Hospital/Community procedures should not interfere with this principle. Staff
will ensure that mothers understand the nature of feeding cues and the
importance of responding to them and that they have an awareness of
normal feeding patterns, including cluster feeding and ‘growth spurts’.
Mothers should be informed that it is acceptable to wake their baby for
feeding if their breasts become overfull. The importance of night-time
feeding for milk production should be explained.
5.11.
Cup feeding
Cup feeding can be used for babies whose parents wish their baby primarily
to breast feed, but who on occasion need an alternative method. Cup feeding
may be considered from 32 weeks gestation onwards for the preterm baby
who shows signs of wanting to suck and is not yet able to manage a full
breast feed.
Step 9 of the UNICEF UK Baby Friendly Initiative requires that when a mother
is unable to breastfeed use of a teat should be avoided in order to protect
breastfeeding and this in part has led to an increase in the use of cup feeding
as an alternative. Cup feeding should never be used to replace breastfeeding
Cup Feeding provides a positive oral experience for the baby and an
alternative method of feeding when a mother is temporarily unavailable to
breastfeed her baby. Cup feeding can be used if the baby needs a top up
following a breast feed, to avoid ‘nipple/teat’ confusion, which can arise from
the early and inappropriate introduction of bottles/pacifiers. A cup feed may
be used to give oral drugs to a breastfed baby. (See the Trust’s Cup feeding
neonatal Guidelines, March 2013),
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5.12.
Use of Artificial Teats, Dummies and Nipple Shields
Staff should not recommend the use of artificial teats and dummies during
the establishment of breastfeeding. Parents wishing to use them should be
advised of the possible detrimental effects such use may have on
breastfeeding to enable them to make a fully informed choice. A record of
the discussion and parents' decision should be recorded in the baby's records.
Nipple shields are of limited value in solving breastfeeding problems and will
not be recommended except in specific circumstances. Any mother
considering the use of a nipple shield must have the disadvantages fully
explained to her prior to commencing use. She should remain under the care
of a skilled practitioner whilst using the shield and should be helped to
discontinue its use as soon as possible.
The appropriate use of dummies for breastfeeding babies later in the
postnatal period should be discussed with mothers.
6.
Expression & storage of Breast milk
There are a number of reasons a breastfeeding mother may find expressing breast
milk helpful:
6.1.
Separation for clinical reason


6.2.
Separation for social reasons


6.3.
Prematurity: (UKAMB 2001) To establish lactation successfully mothers
should start to express as soon as possible after delivery, preferably
within the first 6 hours and certainly within 24 hours. They should
continue to express frequently 8 to 10 times a day including once at
night is recommended. It should be emphasised to the mother that she
should express as often as the baby would normally be put to the
breast.
Illness: If the baby is separated from his/her mother after the pattern is
established, encourage expression at the times the baby would
normally have fed.
Returning to work Expressing can wait until breastfeeding and lactation
are established, usually 6-8 weeks after baby's birth. Some mothers
begin to express earlier than their planned return to work to build up a
supply of expressed milk. When at work she could express during
breaks and meal times (see link below).
http://www.unicef.org.uk/BabyFriendly/Resources/Resources-forparents/Breastfeeding-and-work/
To relieve engorgement
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
6.4.
If the mother is having difficulty in latching the baby to the breast she
can gently express some milk to soften the areola prior to a feed.
Breast milk can be expressed directly into the baby’s mouth to
encourage attachment, or saved in a sterile container for later use.
Environment for breast milk expression
The right environment is very important as anxiety and stress can inhibit
lactation by delaying the let-down reflex. A place where the mother feels
comfortable and relaxed and away from disruptions is encouraged. She may
find that the let-down reflex is stimulated more effectively if she thinks about
her baby, smells clothing (s)he has worn, or looks at a photograph of him/her.
In hospital: this may be the mother’s/breastfeeding room or the expressing
room in the NNU to provide a quiet relaxed environment away from the
bustle of the ward.
At work: this may be an office or room - not the toilet!
At home: It may be helpful to take the phone off the hook or switch the
answerphone on to avoid disruption. She may want to feed her baby on one
side and express on the other.
Breastfeeding and expressing is thirsty work so suggest having a drink at
hand.
6.5.
Methods to express milk


6.6.
Hand expression
Mechanical expression
 Manual
 Battery operated
 Mini Electric
Hand Expressing
Hand expression is the preferred method and is particularly recommended
for the collection of colostrums during the first three days. This method costs
nothing and can be used anywhere. Many mothers also find this method is
comfortable and feels natural.
Methods of encouraging milk flow:



Mother should be comfortable and relaxed. Sitting in a quiet room with
a drink may help.
Have the baby close to the mother if possible or have something that
smells of her baby, or a photo of the baby to look at.
Have a warm bath or shower prior to expressing or apply a warm
flannel to the breast.
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

Gently massage the breast, using featherlight strokes to stimulate
hormone (prolactin) release, mimicking the movements of the baby’s
hands on the breast.
After massaging the breast gently roll the nipple between the first
finger and thumb (which encourages the release of oxytocin).
There is no need to wash the breasts prior to each expression of milk, a daily
wash is sufficient. However, it is important that hands and nails are
scrupulously clean. The container for collecting milk should also have been
sterilised.
Technique for hand expressing:









‘Walk’ the thumb down the breast, or backwards from the nipple, and
stop when a change in texture is detected (the milk making tissue under
the skin) about 2.5cm from the nipple.
Place first finger under the breast, and the thumb on top of the breast
opposite each other, forming a ‘C’ shape.
The other fingers can support the breast underneath.
Gently compress and release (this should not hurt).
Repeat, keeping a rhythm of press and release – milk drops may
become spurts and then subside.
Avoid sliding the fingers on the skin to avoid damaging the breast
tissue.
The milk may take a few minutes to flow (if the milk does not flow,
move the fingers slightly towards the nipple or further away).
Rotate the fingers and thumb around the breast to reach all the milk
ducts, and repeat press and release.
Swap to the other breast when the flow slows. Keep changing breasts
until the milk is dripping very slowly or stops altogether.
As with any method, there is no set time limit. The mother may not express
much milk on the first few attempts but as she becomes more comfortable
with the technique the amounts will improve.
6.7.
Mechanical expression
6.7.1
Breast Pumps
There are a large variety of pumps on the market. All breast pumps
come with sterilising instructions and most have adapters to make the
funnel a better fit when in use.
6.7.2
Hand Pumps
These are the cheapest pumps available and come in a variety of
shapes and forms.
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The "bicycle horn" pump should not be used as this cannot be
properly sterilised and the suction is not regulated. It can therefore
lead to tissue damage.
Cylinder pumps are cheap and efficient but you may find that it
requires two hands to use it effectively.
Some breast pumps work using a "trigger" action and so they can be
used with one hand. This is very useful if the mother wants to express
one breast while the baby is feeding on the other.
6.7.3
Battery Operated Pumps
These are slightly more expensive and can be quite noisy so it's worth
listening to one in action before purchase. These work on the
principle of alternate suction and release or suction to mimic a baby's
feeding pattern. Battery operated pumps can be quick, effective and
less tiring on the hand. Some are quieter than others but all appear
to go through batteries quickly. It may be worth the mother thinking
about investing in some rechargeable batteries if this is the pump of
her choice.
All the above pumps are extremely portable as they are small and
often come with their own bag or cover. They fit easily into a medium
sized handbag.
6.7.4
Mini Electric Pump
These pumps are effective and reasonable to purchase. They are also
portable. These can be purchased in a variety of supermarkets and
chemists.
6.7.5
Electric Pumps
Usually used in hospitals and are very expensive to buy. They are very
efficient but require a mains supply and are sometimes quite bulky.
If the baby is being nursed in hospital over a long period of time, e.g.
prematurity, then it may be worthwhile considering hiring an electric
breast pump. There are a number of organisations which rent out
breast pumps. Some electric pumps are available for hire from the
manufacturers. It is usually necessary to buy the "collection
equipment" and then hire is charged at a daily or weekly rate.
6.8.
One Breast or Two?
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The mother should express from one breast until the milk flow slows, and
then swap to the other breast (every few minutes). She may swap several
times. Some women find it more effective to pump one breast completely
first and then the other. She should express after her baby's feed, rather than
before, as this may leave him frustrated at the breast. Cuddling her baby at
the breast stimulates prolactin (the hormone responsible for milk production)
and oxytocin (the hormone which stimulates the milk ejection reflex, or ‘letdown’).
6.9.
Storing Milk
Once expressed it is important that the milk is stored in a fridge or freezer. If
the mother is at work and has no access to a fridge then she may use a cool
bag containing ice packs to store and transport her milk.





6.10.
The pump body of rechargeable breast pumps must not be immersed in
water. Should this be here or better with the pump section
Expressed breast milk can be stored in a sterilised container in a
refrigerator for up to 5 days, if it is to be used for a healthy term baby at
home, or up to 2 days if the baby is still in hospital after the birth (see
Expressed Breast Milk handling, labelling and storage Standard
Operating Procedure)
Expressed breast milk can be frozen for up to 6 months, for a healthy
term baby.
Unfinished feeds must be thrown away. Bacteria multiply rapidly.
A microwave must not be used to heat feeds – it can cause hot spots
which can burn the baby’s mouth.
Storage Times
Breast milk has bactericidal properties and so may keep for longer periods
than formula milk.
In the Fridge (2 – 4 degrees centigrade – usually at the back, never in the
door)
Freshly expressed breast milk
Thawed milk in fridge
5 days (2 days in hospital)
-
use straight away
In the Freezer
Freezer compartment in a fridge
Freezer
-
-
2 weeks
6 months
Thawed breast milk should never be refrozen.
6.11.
Containers
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Plastic containers are best for storing breast milk as they help to preserve the
bactericidal properties.
Specialist sterile freezer bags are available from chemists and supermarkets.
Plastic feeding bottles can also be used but should be sterilised first.
Remember that if the mother is freezing her milk she needs to allow a gap at
the top of her container for expansion.
6.12.
Defrosting and Warming Breast Milk
Ideally breast milk should be thawed slowly in a fridge or at room
temperature. If needed immediately, breast milk should be thawed by
holding the container under cool running water and gradually adjusting the
temperature of the water until the milk is thawed, avoiding the cap area. A
bowl of lukewarm water can be used to speed up the process but the
container must not be allowed to tip over and the cap becomes submerged.
It is very important not to boil breast milk as this destroys the bactericidal
properties and some of its nutritional value. This also happens in the case of
microwaves.
6.13.
Breastfeeding Support Groups
This Trust supports co-operation between health care professionals and
voluntary support groups whilst recognising that health care facilities have
their own responsibility to promote breastfeeding.
Contact details for approved breastfeeding peer supports, walk-in
breastfeeding clinics, community midwives, health visitors and voluntary
breastfeeding support groups should be given to all mothers in the postnatal
period and be routinely displayed in all relevant areas throughout the unit.
Contact details will be regularly checked and updated to ensure correct
information is distributed.
Sources of national and local support should be identified and mothers given
verbal and written information about these prior to transfer home from
hospital, to include:


Telephone numbers of midwives, infant feeding advisors and other
professional support;
Contact details for voluntary breastfeeding counsellors and support
groups and national breastfeeding helpline numbers.
Breastfeeding support groups will be invited to contribute to further
development of the Policy as it relates to breastfeeding through involvement
in appropriate meetings.
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When a mother has experienced difficulty with breastfeeding in hospital,
details of the problems and advice given, conveyed to the community
midwife, will enable her to continue appropriate care.
When a midwife's care ceases, mothers often lack support to enable
breastfeeding to continue happily. Everything a mother needs to know about
feeding may not be learned in such a short time and problems may still occur.
Mothers should be given information about where help can be obtained
before discharge from hospital.
6.14.
Sources of support:





Midwives can continue to care for up to 28 days after the birth and
health visitors are available after 10 days.
Local Breastfeeding support groups and peer support networks
http://www.virgincare.co.uk/wpcontent/uploads/sites/11/2014/08/Breastfeeding-support-registerMarch-2015.pdf
http://www.virgincare.co.uk/wpcontent/uploads/sites/11/2015/08/Devon_breastfeeding_support_regi
ster_2015.pdf
Children Centres
Lay organisations can provide support;
National Breastfeeding Helpline
0300 100 0212
www.nationalbreastfeeedinghelpline.org.uk
Staffed with volunteers from:

Association of Breastfeeding Mothers
http://abm.me.uk/

The Breastfeeding Network
www.breastfeedingnetwork.org.uk
The Breastfeeding Network Supporter line In Bengali/Sylheti:
0300 456 2421
National Childbirth Trust
NCT Breastfeeding Line 0300 330 07771
www.nct.org.uk
La Leche League
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0845 120 2918
www.laleche.org.uk Start4Life
0300 123 1021
UNICEF UK baby Friendly Initiative
www.babyfriendly.org.uk
7.
Problems associated with Breastfeeding
7.1.
Lactation and breastfeeding problem solving
Poor attachment, sore nipples, discomfort, poor co-ordination of swallowing
and breathing, engorgement and mastitis can all cause breast feeding
problems and should be appropriately assessed and supported.
Strategies may include correcting positioning and attachment, treating
thrush, changing expressing pump funnel size, the use of nipple shields,
pacing and maternal analgesia and/or antibiotic treatment.
A positive attitude from a midwife can help the mother believe she can
overcome a problem.
7.2.
Sore Nipples
Prevention is better than cure. Possible ways of prevention;


Make sure baby is correctly attached
Moist wound healing can be used to prevent scab formation on cracked
or sore nipples – Lansinoh or similar – any excess should be gently
removed with a tissue before putting the baby to the breast,
Nipples will heal quickly when given the conditions to do so:





Check how baby is attached on the breast and if necessary correct this.
Use a different position to allow the baby to attach and suckle without
making feeding more painful.
If feeding is now pain free or less painful - continue feeding even if
nipples are bleeding. Keeping the nipple moist by the applying Lansinoh
or Vaseline.
If feeding is still painful, rest the nipple and express the breast. 24 hours
is suggested. Express by hand to avoid further damage to the breast
tissue which could be caused by a breast pump. Ensure mother
understands correct hygiene procedures and changes breast pads
frequently if used.
The use of nipple shields is discouraged and must only be used as a very
last resort.
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
7.3.
Limiting the time a baby feeds at the breast is not helpful; it prevents
the baby obtaining an adequate feed and inhibits lactation by restricting
stimulation.
Engorgement
The fullness felt by mothers when the breast fills is normal and is due to the
effect of prolactin. Engorgement is the result of milk not being removed
effectively. This can be due to restricting the baby feeding at the breast or
incorrect positioning and attachment. It is less likely to occur if;




Breastfeeding is started soon after birth
Babies feed effectively and frequently in the first days
Babies are positioned and attached correctly
Unrestricted frequent feeding is encouraged
Discomfort may be relieved by a shower or warm compresses and massage
prior to a feed. If the areola is too hard to enable baby to attach correctly
expressing a small amount of milk may be helpful. A cold compress between
feeds may be soothing and reduce oedema. The wearing of a supportive bra
should be encouraged. Mothers should be reassured the problem is
temporary.
Expressing the breasts may be appropriate if the discomfort continues and is
not relieved by the baby feeding. Allowing a build-up of milk to continue will
reduce the milk supply (due to the action of feedback inhibitor of lactation –
FIL) and should be avoided.
Initial prevention of breast engorgement was felt to be the main priority and
Moon & Humenick (1989) identifies five variables which were significantly
correlated with breast engorgement:





Delayed initiation of breastfeeding
Infrequent feeds
Time-limited feeds
Late maturation of milk (i.e. the change from colostrum to milk)
Supplementary feeds#
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7.4.
Mastitis
Non-infective mastitis:

If a mother presents with symptoms of localised breast tenderness,
with or without a lump and inflammation and possibly 'flu-like"
symptoms the most likely cause is non-infective mastitis. It is essential
in these circumstances to ensure there is efficient drainage of milk from
the breast. The baby feeding first on the affected breast, positioned so
that his chin points towards the area of mastitis, will normally achieve
this, Gentle massage of the affected part towards the nipple and
expression by hand after the feed may be of assistance. If the mother is
able to take an anti-inflammatory preparation, such as ibrupofen, this
can also help to relieve her symptoms.
Infective mastitis:

7.5.
If symptoms of mastitis persist beyond 12 hours from onset, or worsen,
in spite of frequent drainage, infection is likely and a doctor may
prescribe antibiotics. If a mother with infective mastitis stops feeding
or expressing she is more likely to develop a breast abscess.
Inverted nipples
Inverted nipples are uncommon. There is now evidence that no interventions
are beneficial in treating inverted nipples (Main 1994). Antenatally it is
difficult to predict if breastfeeding will be successful on the basis of an
antenatal inspection of a woman’s nipples. Changes in shape often improve
around the time of delivery.
If a woman is unable to attach the baby to the breast effectively suggesting
she holds the baby in a different position may be helpful. Rolling the nipple
between the finger and thumb and assisting the baby to take a large
mouthful of breast tissue into his/her mouth can lessen the problem. Use of
Biological Nurturing (‘laid-back’) breastfeeding positions can help. The use of
a syringe or pump to draw the nipple out before feeds may also be suggested.
If the baby cannot suckle effectively in the first week or two, lactation can be
established by expressing breast milk by hand or breast pump and the baby
fed expressed breast milk by cup until further attempts can be made.
7.6.
Weight Loss
Babies will normally be weighed on the fifth day after birth. If a baby has a
weight loss greater than 10% of the birth weight or has not regained his/her
birth weight by three weeks old, the position and attached of the baby to the
breast should be checked and corrected if necessary. Supplementary feeding
may be considered. If weight loss persists then referral to the neonatologist
should be made.
7.7.
Inadequate Lactation
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The mother should receive information about the physiology of lactation, so
that she understands how the breasts work. She should also be advised
about the importance of baby-led feeding. Diet, rest and relaxation should
also be discussed. All appropriate steps should be taken while she is in
hospital to ensure optimum conditions are met.
A healthy term baby who is attaching correctly will normally provide
adequate stimulation for the breasts. If a baby is not sucking well, extra
stimulation can be provided by manual expression. Any expressed milk
should be given to the baby.
Two reliable indicators that the baby is not getting enough breast milk


Poor weight gain.
Passing small amounts of concentrated urine
Possible indicators that the baby is not feeding effectively and therefore not
getting enough breast milk







7.8.
A baby not satisfied after a feed
A baby who cries often
A baby requiring frequent breastfeeds
A baby requiring very long breastfeeds
A baby refusing to breastfeed
A baby who has hard and dry stools
No milk comes through when mother expresses.
Jaundice
It is important to ensure that babies with physiological jaundice receive
adequate feeds to maximise the natural metabolism of bilirubin. Adequate
hydration is important and can normally be achieved when the baby is
breastfeeding satisfactorily. Extra fluids are of no benefit and may interfere
with the establishment of lactation by reducing the number of feeds a baby
demands (De Carvalho 1981).
Babies under phototherapy have increased fluid loss. This is the result of
increased evaporation from the skin and, also, in some cases looseness of the
stools. In the case of breast fed babies, whose mothers are still establishing
lactation, it is reasonable to offer expressed breast milk after each breastfeed
to see if the baby is still thirsty. Observe the baby’s urine output to confirm
adequate hydration. Babies under phototherapy should be weighed every
day and attention given to weight loss greater than 10% of birth weight.
7.9.
HIV
Studies in animals suggest that transmission of HIV via breast milk occurs
when the virus crosses the mucosal tissue of the mouth and gut. Certain
other factors, such as the duration of breastfeeding and/or having cracked
nipples are considered to increase the rate of transmission.
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Evidence from HIV positive mothers in the West suggest that the risk of
transmitting the virus to their babies increases to approximately 1 in 3 if the
mother breastfeeds (Dunn 1998)



8.
Women should be advised of the significant risk of HIV transmission
through breastfeeding and advised to formula feed their babies from
the outset (BHIVA, 2005)
The Trust follows the recommendations of the Department of Health
and WHO that HIV infected women should avoid breastfeeding
British HIV Association (BHIVA) (2005) Guideline for the management of
HIV infection in pregnant women and the prevention of mother to child
transmission
Care for Mothers Who Have Chosen to Feed their Newborn
with Infant Formula
All mothers who choose not to breastfeed will be offered the opportunity to bottle
feed in skin-to-skin contact with their baby and be taught how to bottle feed while
holding their baby close and looking into their eyes.
Staff should ensure that all mothers who have chosen to feed their newborn with
infant formula are able to correctly sterilise equipment and make up a bottle of
infant formula during the early postnatal period and before discharge from hospital.
Staff should ensure that mothers are aware of effective techniques for formula
feeding their baby, waiting for feeding cues and not force feeding babies, and that
babies should be fed first/newborn milk which is suitable until the baby is a year old.
Mothers should be encouraged to limit the number of people who feed the baby and
feed their baby themselves. Community midwives should check and reinforce
learning following the mother’s transfer home.
All information given should follow guidance from the Department of Health.
Information should be reinforced by offering the Department of Health ‘Guide to
Bottle Feeding’ leaflet.
Mothers should be given contact details of health professional support available for
feeding issues once they have left hospital.
8.1.
Guidance on safe preparation, storage and handling of powdered infant
formula
When mothers choose to feed their babies infant formula, they will be given
individual instruction on the safe preparation, storage and handling of infant
formula and associated equipment.
8.2.
Demonstrations of Making Feeds and Sterilising Equipment
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Every formula-feeding mother should receive a demonstration of making up
feeds and sterilising equipment on a one-to-one basis. If a midwife has
doubts about a mother's understanding or ability to carry out these
procedures safely she should ask the mother to make up a feed and resterilise a bottle under supervision.
All midwives and maternity support workers receive training in the safe
preparation, storage and handling of infant formula and associated
equipment.
This training is delivered and monitored in line with the maternity service
education strategy and training needs analysis.
8.3.
Cleaning and sterilising feeding equipment
Wash hands thoroughly before cleaning and sterilising feeding equipment
Wash feeding and preparation equipment thoroughly in hot soapy water
Bottle and teat brushes should be used to scrub inside and outside of bottles
and teats to ensure the remaining feed is removed
After washing feeding equipment rinse it thoroughly under the tap
If using a commercial steriliser, follow the manufacturer’s instructions
If your bottles are suitable for sterilising by boiling, fill a large pan with water
and completely submerge all feeding equipment, ensuring there are no air
bubbles trapped; cover the pan and boil for at least 10 minutes, making sure
the pan does not boil dry. Keep the pan covered until equipment is needed.
Remember that teats tend to get damaged faster with this method.
Wash hands thoroughly and clean the surface around the steriliser before
removing equipment
It is best to remove the bottles just before they are used
If the bottles are not being used immediately, they should be fully assembled
with the teat and lid in place to prevent the inside of the sterilised bottle and
the inside and outside of the teat from being contaminated.
8.4.
Guidance for Preparing Feeds in the Home
Normally each bottle should be made up fresh for each feed. Storing madeup milk may increase the chance of a baby becoming ill and should be
avoided.
Clean the surface thoroughly on which to prepare the feed.
Wash hands with soap and water and dry.
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Boil fresh tap water in a kettle. Alternatively bottled water that is suitable for
infants can be used for making up feeds and should be boiled in the same
way as tap water.
practice using water that has been left covered, for less than 30 minutes after
boiling.
Pour the amount of boiled water required into a sterilised bottle.
Add the exact amount of formula as instructed on the label always using the
scoop provided by the manufacturer. Add more of less powder than
instructed could make the baby ill.
Re-assemble the bottle following the manufacturer’s instructions.
Shake the bottle well to mix the contents.
Cool quickly to feeding temperature by holding under a running tap, or
placing in a container of cold water.
Check the temperature by shaking a few drops onto the inside of your wrist –
it should feel lukewarm, not hot.
Discard any feed that has not been used within two hours.
8.5.
Guidance for the use of powdered infant formula feeds in care settings
Ready to use liquid feeds are sterile and are the safest option. However, they
are a more expensive option and therefore may not suit all parents.
8.6.
Preparing powdered feeds for later use
It is the length of time for which the reconstituted formula is stored that
increases the risk of bacterial growth. Reducing the storage time will
therefore reduce the risk. For example, when taking an infant to the nursery
it is best to make up the feeds on the morning before leaving home.
Follow the steps outlined above in ‘preparing a feed using powdered infant
formula’
Store the feed in the fridge at below 5 c. A prepared bottle is best kept in the
back of the fridge and not in the door
The temperature of the fridge should be checked regularly using a fridge
thermometer. A fridge that is opened frequently may need to be set at a
lower temperature to ensure that the temperature does not rise above 5 c
during times of frequent access. The thermostat in older fridges without
temperature settings may need to be adjusted to ensure that the
temperature is below 5 c
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The risk of infection to a baby will be lower if the feed is only stored for a
short time. Feeds should never be stored for longer than 24 hours and this
length of time is no longer considered ideal, especially for younger babies
Alternatively, boiling water may be placed in a sealed vacuum flask and used
to make up formula milk when needed.
8.7.
To re-warm stored feeds
Only remove stored feed from the fridge just before it is needed.
Re-warm using a bottle warmer, or by placing in a container of warm water.
Microwaves should never be used for re-warming a feed.
Never leave a feed warming for more than 15 minutes.
Shake the bottle to ensure that the feed has heated evenly.
Check the feeding temperature by shaking a few drops onto the inside of the
wrist – it should be lukewarm, not hot.
8.8.
Transporting feeds
Feeds should f
Prepare feeds and place in the fridge as outlined above in ‘preparing feeds for
use later’.
Ensure the feed has been in the fridge for at least one hour before
transporting.
Only remove feed from the fridge immediately before transporting.
Transport feeds in a cool bag containing a frozen ice brick.
Re-warm at the destination as above in ‘Re-warming stored feeds’.
Alternatively, if you reach the destination within 4 hours, feeds transported in
a cool bag can be placed in a fridge and kept up to a maximum of 24 hours
from the time of preparation – this is not ideal as the risk of illness increases
the longer it is store.
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9.
Weighing in the neonatal period
Recent research has shown that early weighing does not discourage breast-feeders
and may help identify problems in a timely manner, so current NICE
recommendations are that all babies should be weighed at birth, 5 days and 10 days
as part of the assessment of feeding and thereafter as needed. Many babies lose
weight in the early days and then begin to regain at between 3-5 days of age and
80% have regained birthweight by the age of 2 weeks. Recovery of birthweight
therefore helps to provide assurance that feeding is effective and that the child is
well. (Royal College of Paediatrics and Child Health, 2009)
Neonatal weight is measured using class 3 neonatal scales.
Calculating Percentage Weight loss Percentage weight loss is the difference
between the current weight and the weight at birth expressed as a percentage of
birthweight. Weight loss = current weight - birthweight [e.g. (2.700kg - 2.900kg) = 200g = a fall of 200g]
Percentage weight loss = weight loss birthweight [e.g. (-200g x 100) ÷ 2,900g = 6.9%]
It is not how many grams a baby loses within first two weeks to be concerned with –
it’s the percentage of weight loss that indicates a possible feeding problem or illness.
9.1.
Interpreting Percentage Weight Loss
One in five babies are still below their birthweight at 2 weeks, but only one in
50 will be 10% or more below at this age, so this is relatively unusual. Most
babies with weight loss greater than 10% will be medically well but many will
be having feeding problems of some kind and the severity of their weight loss
may be an indicator that more assessment and help is needed. Severe weight
loss may also be the only obvious sign that a baby has an underlying medical
problem such as a cardiac defect or an inherited metabolic disorder. This
means that if a baby is 10% or more below his or her birthweight at or
beyond 2 weeks, s/he must be carefully assessed and paediatric opinion
sought.
9.2.
System for reporting babies readmitted to hospital with feeding problems
during the first 28 days of life.
Babies with feeding problems in the first 28 days of life are re-admitted to
North Devon District Hospital, either to the SCBU or Caroline Thorpe Ward:
For babies re-admitted with a feeding related problem a Datix report is
logged by the ward staff for investigation by the Infant Feeding Coordinator.
Reports of babies re-admitted with feeding problems in the first 28 days will
be reviewed by the local Maternity Risk Management meetings.
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At six monthly intervals numbers will be discussed at the Maternity and
Quality meetings.
10.
Feeding babies with special needs
10.1.
Pre-Term and Small for Gestation Age Babies
Pre-term babies or those whose weight falls outside normal parameters may
need supplementary feeds via nasogastric feeding, because their neurological
development may be incomplete which may affect their ability to co-ordinate
sucking with swallowing and breathing. However when due regard is taken of
the weight, gestational age, blood sugar levels, the baby's feeding ability and
the advice of the paediatrician it may be possible to adequately feed the baby
by breast alone.
The primary aims of feeding are threefold:
1) To ensure adequate total intake.
2) Not to tire the baby.
3) To establish good lactation.
These babies will normally be weighed on the third day and then twice a
week.
10.2.
Babies on the Special Care Baby Unit
Mothers of babies who are to be nursed on the Special Care Baby Unit and
who wish to breastfeed must be encouraged to start expressing their breast
milk as soon as possible after birth. They can be reassured that breastfeeding
is still possible in these circumstances. Please refer to the EBM handling,
storage and administration Policy for full details. The key principles are as
follows:



Within 2 hours of delivery midwifery staff should support the mother to
use breast massage and hand expression to stimulate and remove
colostrum.
Early frequent expression (8-10 times in 24hrs including once at night)
enables the breast to move to copious milk production at around 36-48
hours post partum (lactogenesis II)and establish maximal supply in the
first few weeks after delivery.
Once a mother’s milk has come in and she is obtaining larger volumes
(>10mls) she should be shown how to use a electric and/or manual
pump and supported in her choices with advice and equipment for
future expressing.
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




10.3.
Each mother should be asked about medications she is taking and
advised on these and the potential detrimental effects of alcohol and
smoking on lactation.
Provision of manual or portable electric breast pumps and screens can
encourage expressing at the cot side.
Skin to skin contact should be routine practice in all but the most
unstable babies due to its numerous benefits including lactation and
breastfeeding.
Mouth cares using a cotton bud or piece of gauze wrapped around a
finger dipped into EBM can help give the baby early tastes of breast
milk.
For sufficient milk production for successful breastfeeding at discharge
a minimum of 600-800mls of milk in 24hrs by day 10-14 post delivery
has been suggested as optimal. Therefore on day 10 we check 24 hrs
production is above 600mls and give appropriate support as required
Multiple Births
Women expecting twins or triplets will undoubtedly give a lot of thought as
to how they are going to feed their babies. It should be stressed throughout
the pregnancy that it is very possible to breastfeed both twins and in a lot of
cases triplets, and as these babies are often born early and or small for
gestational age, breast milk is the best food for them. (see section on preterm & small for gestational age)
Expectant mothers of multiples should have a 1-2-1 about infant feeding with
a midwife earlier then a mother expecting one baby, and if possible meet a
mother who is successfully breastfeeding twins before she delivers.
Whilst she is in hospital she will need extra advice and support at feed times
to enable her to establish good feeding routines. The babies can either be
feed together or separately though it is advisable in the first few days to feed
each baby individually, this gives the mother time to get to know each baby
as an individual and feel confident in positioning and attaching her babies to
the breast correctly.
If the mother wants to feed both babies together she will need extra pillows
not only to support her back, but also to take the weight of the babies so her
hands are free to give extra attention should either baby need it. (see
diagrams in MBF booklet) She will also need plenty of help at each feed to
have the babies passed to her and help with positioning and too give
encouragement.
One of the most common worries is whether she can produce enough milk to
satisfy both babies. The answer is YES she most certainly can, but it can take 4
- 6 weeks to get breastfeeding established with multiples. The more
stimulation her breasts are given the more milk she will produce. Each baby
should have one complete breast per feed.
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10.4.
Cleft Lip and Palate
The benefits of breast milk for the baby with a cleft lip or palate are the same
as for any other infant. In addition it may be less irritating to exposed delicate
tissues of the nose in babies with cleft palate and may give additional
protection against infection at the time of surgery. Babies with a cleft lip only
are usually able to breastfeed well as the breast moulds into the cleft in the
lip and helps to create the seal necessary for good attachment.
A cleft in the palate, even if it is small, makes it hard to create a seal in the
mouth. This is needed to help form a vacuum to draw the mother’s breast
tissue into the mouth, a good attachment and to draw sufficient milk from
the mother’s breast. These problems may be overcome by stimulating the
milk flow with breast compression during the feed. (See leaflet by V Martin
and M Abbett ‘Feeding your baby with a cleft lip or palate – Your options’,
published by Medela UK). Other options are to express and top up using
specialised bottles, usually provided by the SCBU or the Exeter cleft palate
team, who will visit the baby on the ward shortly after birth - it is important
to contact them as soon as a baby, with cleft lip or palate, is born.
10.5.
Tongue tie
Tongue tie, also known as ankyloglossia is a short and tight membrane that
extends from the underside of the tongue to the floor of the mouth, or as a
thick fibrous tissue extending across the underside of the tongue, making
extension of the tongue difficult. The tongue may appear blunt or forked, or
have a heart-shaped appearance. It varies from mild to severe.
Approximately 10% of babies are born with some degree of tongue tie. It's
commoner in boys and there may be other members of the family who have
also had a tongue tie.
Many tongue-ties are asymptomatic and do not require treatment. A tongue
tie that is interfering with breast feeding may require assessment with a view
to possible tongue tie division (frenulotomy).
Bottle fed babies with tongue tie can also experience problems with their
feeding, such as gagging, excessive dribbling, wind and a general
dissatisfaction after a feed.
10.6.
Problems that may be associated with tongue tie




Sometimes mothers will experience painful feeding, grazing or damage
to the areola or nipple, or even mastitis
Inability to create a seal around the breast to form a vacuum and babies
constantly slipping off the breast
Babies may make a clicking noise when feeding
Feeding may be prolonged, frequent and babies never seem to be
contented
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

Some babies have problems with excessive wind and may be in pain,
passing green stools or suffer from vomiting as a result of swallowing
wind
Failure to gain weight
In 2005, The National Institute for Health and Clinical Excellence (NICE) has
issued full guidance to the NHS in England, Wales, Scotland and Northern
Ireland on division of ankyloglossia (tongue tie) for breastfeeding. Current
evidence suggests that there are no major safety concerns about division of
ankyloglossia. There is a growing tendency among breastfeeding specialists
to favour releasing the tongue of the infant to facilitate breastfeeding and to
protect the breastfeeding experience. However, there are conflicting
opinions among healthcare professionals, because of limited evidence of
randomized trials exist to demonstrate frenulotomy for ankyloglossia is
effective in treating infant or maternal breastfeeding problems.
The NICE guidance stated that if division of ankyloglossia is to be carried out,
it should be performed by registered healthcare professionals who are
properly trained.
10.7.
Referrals for division of ankyloglossia
A referral letter should be sent to the Exeter maxillo-facial team, using the
Tongue tie Referral pathway, giving the baby’s name, address, date of birth,
North Devon hospital number and a description of the appearance of the
tongue tie, with symptoms.
Further information
Parent Information sheet – NICE
Guidance on division of tongue tie - NICE
UKBFI – Helping baby with tongue tie
Lactation Consultant Great Britain website
11.
Effects of diet, drugs, alcohol and smoking
11.1.
Mother's Diet
Women are often hungry and thirsty when they are breastfeeding and should
be encouraged to eat and drink to satisfy their appetites. This should be
nutritionally balanced where possible with advice to avoid the temptation to
fill up on “empty calories” such as biscuits, cakes, sweets and chocolates,
although these foods are OK after a meal. Well-balanced snacks, e.g.
sandwiches, can be as nutritious as cooked meat.
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Milk supply tends only to be adversely affected in chronically malnourished or
starved women who have depleted body stores themselves. In the vast
majority adequate lactation can be maintained even during a moderate
weight reducing diet, although active weight reduction should not be
encouraged unless medically advised. However a lactating woman’s daily
intake of water soluble vitamins will affect the levels in her milk so all women
should be encouraged to eat a variety of fresh fruit and vegetables daily. The
type but not the amount of fat in breast milk is also dictated by the type of fat
in the woman’s diet. In general, most women will have sufficient essential
fatty acids in their diet to satisfy both their own and their baby’s needs as
long as they are eating a balanced diet.
Vegans should be referred to a dietician, as they may need a supplement of
vitamin B12.
Large doses of vitamins/minerals above the daily recommended amounts are
not necessary. The use of other nutritional supplements should be checked as
they are unlikely to be necessary. If there are any queries please refer to a
dietician
There are no foods which are banned for breastfeeding mothers. Women
have often heard "old wives tales" about foods which should be avoided and
unnecessarily restrict their diet. When giving advice on diet midwives should
respect a mother's cultural traditions. Individual nursing couples may
discover some foods that produce a reaction in the baby; these can then be
avoided. The loose, frequent, bright yellow stools which the baby begins to
produce when the milk comes in are often blamed on "something I ate", this
should be refuted and the mother reassured that this is normal in a breast fed
baby. Caffeine may cause a baby to be irritable and wakeful.
11.2.
Medication
Some medications are contraindicated in breastfeeding. The specific risk of a
mother’s medication causing side-effects in a baby needs to be balanced
carefully against the proven benefits of providing breast milk. It is important
to evaluate the infant’s ability to handle small amounts of medications on an
individual basis. Occasionally, premature or unstable infants may not be
suitable candidates for certain medications.
Consult the Paediatrician or Pharmacist if you have a drug query. They have
access to specialist sources from which the information may be interpreted
appropriately and with consideration to the individual circumstances. Specific
drugs which are usually contraindicated in breastfeeding include:



Any cytotoxic drugs – these usually require withholding breastfeeding
for a specific length of time.
Some antibiotics, for example, chloramphenicol
Phenindione
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
11.3.
Drugs of abuse, for example, cocaine, heroin, amphetamines, cannabis
Maternal Drug Abuse
Breastfeeding and drug and alcohol misuse (NHS Evidence)





Most women who use heroin or other opiod drugs or substitution
therapy (methadone) should be encouraged to breastfeed, but not if
they use cocaine/crack or high-dose benzodiazepines.
Mothers should breastfeed immediately before an opioid dose is taken
(to avoid peak concentrations of the drug in breast milk).
Some methadone passes into breast milk, and where a mother
continues to use methadone after birth, her fully breastfed baby is
likely to develop fewer withdrawal symptoms.
Seek specialist advice if the woman is HIV positive or hepatitis C positive
Alcohol passes into breast milk at approximately maternal
concentrations, and a baby’s growth and development may be affected
where the breastfeeding mother regularly drinks more than two units a
day (Jones)
NHS Evidence: clinical knowledge summaries. Opioid dependence –
management. Scenario: pregnant and breastfeeding
http://www.cks.nhs.uk/opioid_dependence#-482510
NICE guidance 2011 Pregnancy and complex social factors (CG110) A model
for service provision for pregnant women with complex social factors
http://guidance.nice.org.uk/CG110
11.4.
Alcohol
Alcohol will pass through to the breastmilk and will reach approximately the
same level as in the mother's blood. Small amounts are probably not harmful
but it is advisable to limit alcohol intake to the occasional single measure
during breastfeeding. Large amounts put an added burden on the baby's
immature liver and may also diminish milk supply.
11.5.
Smoking
Nicotine from inhaled tobacco smoke passes through to the milk. Nicotine
can also affect oxytocin levels, and the ‘let-down’ reflex, resulting in less
breast milk being available to her baby if the mother smokes immediately
before a breastfeed.
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Smoking mothers can be advised to leave the longest time possible between
the last cigarette smoked and a breast feed. This allows the level of nicotine
in the milk to fall. The half-life of nicotine in milk is 1 1/2 hours. Mothers who
smoke heavily seem less likely to lactate well and also risk respiratory illness
in their children. However this should be balanced against the protective
effect of breastfeeding. Mothers should be encouraged to smoke less and not
to stop breastfeeding.
12.
Training Health Care Staff
Midwives, neonatal staff, children’s staff working directly with them have the
primary responsibility for supporting breastfeeding women and for helping them to
overcome related problems.
All professional and support staff who have contact with pregnant women and
mothers will receive training in breastfeeding management at a level appropriate to
their professional group.
Professional and support staff will receive training in the skills needed to assist
mothers who have chosen to formula feed, including in the reconstitution of infant
formula and sterilisation techniques, at a level appropriate to their role and
responsibilities within the maternity service.
All clerical and ancillary staff will be orientated to the Policy and receive training to
enable them to refer breastfeeding queries appropriately.
New staff will receive training within six months of taking up their posts.
The responsibility for providing training lies with the Infant Feeding Coordinator,
who will ensure that all staff receive appropriate training.
A mechanism will be in place to ensure that all relevant staff are allocated to attend,
records of attendance are maintained and an effective system is in place for ensuring
non-attendees are followed up and their training needs are met (please refer to the
Maternity Services Training Policy and Training Needs Analysis). The Infant Feeding
coordinator will also audit uptake and efficacy of the training and publish results on
an annual basis. The ‘Practical Skills Reviews’ is utilised to audit training as suggested
in the BFI ‘Train the Trainer’ course.
13.
The Development of the Policy
This Policy has been based on a Sample Policy from The UNICEF UK Breastfeeding
Initiative (BFI) and the NHS Maternity Services Template Document for Newborn
Feeding (2010)
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An initial Infant Feeding Policy went out to all members of the Maternity Guideline
group, Infant Feeding Coordinator and paediatricians for consultation. Comments
and changes were collated and amendments made. This Infant Feeding Policy has
evolved from the Breastfeeding Policy, and Artificial Feeding Policy, based on the BFI
framework and the Clinical Negligence Scheme for Trusts (CNST) Maternity Clinical
Risk Management Standards. This document aims to meet the requirements of both
organisations.
13.1.
Document Development Process
As the author, the Lead Midwife for Public Health, Community and Antenatal
Services is responsible for developing the policy and for ensuring
stakeholders were consulted with. The advice of the Equality and Diversity
lead must be sought. For NHS Litigation Authority (NHSLA) policies, the
author must seek the advice of the Compliance Manager.
Draft copies were circulated for comment before approval was sought from
the relevant committees.
13.2.
Equality Impact Assessment
The Trust aims to design and implement services, policies and measures that
meet the diverse needs of our service, population and workforce, ensuring
that none are placed at a disadvantage over others. An Equality Impact
Assessment Screening has been undertaken and there are no adverse
impacts. There is a positive impact for Pregnancy, maternity and
breastfeeding (Appendix F).
14.
Consultation, Approval and Ratification Process
14.1.
Consultation Process
The author consulted widely with stakeholders, including:




All users of this document.
Governance Department.
Compliance Manager.
Stakeholders and partner agencies including BFI advisor, Children’s
Centres leads.
Consultation took the form of a request for comments and feedback via
email. Hard copies were available on request.
14.2.
Policy Approval Process
Approval of the policy will be sought from the Maternity Services Patient
Safety Forum.
The policy does not require ratification by the Trust Board in future.
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15.
Review and Revision Arrangements including Document
Control
15.1.
Process for Reviewing the Policy
The policy will be reviewed every three years. The author will be sent a
reminder by the Corporate Governance Manager four months before the due
review date. The author will be responsible for ensuring the policy is
reviewed in a timely manner.
The reviewed policy will be approved by the Maternity Patient Services
Forum.
If this policy has been identified as required by the NHS Litigation Service
(NHSLA), the author will ensure the Compliance Manager is sent an electronic
copy.
The author must update the Document Control Report each time the policy is
reviewed. Details of what has changed between versions should be recorded
in the Document Control Report.
15.2.
Process for Revising the Policy
In order to ensure the policy is up-to-date, the author may be required to
make a number of revisions, e.g. committee changes or amendments to
individuals’ responsibilities. Where the revisions are minor and do not change
the overall policy, the author will make the amendments, record these in the
document control report and send to the Corporate Governance Manager for
publishing.
Significant revisions will require approval by the Maternity Services Patient
Safety Forum.
For NHS Litigation Authority (NHSLA) policies, the author will notify the
Compliance Manager when a revision is being made or when the document is
reviewed. The Compliance Manager will ensure that the revised document
meets the NHSLA/CNST standards.
The author must update the Document Control Report each time the policy is
revised.
15.3.
Document Control
The author will comply with the Trust’s agreed version control process, as
described in the organisation-wide Guidance for Document Control.
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16.
Dissemination and Implementation
16.1.
Dissemination of the Policy
After approval, the author will provide a copy of the policy to the Corporate
Governance Manager to have it placed on the Trust’s intranet. The policy will
be referenced on the home page as a latest news release and staff will be
informed that this policy replaces any previous versions.
This Policy is to be communicated to all healthcare staff who have any
contact with pregnant women and mothers. All staff will have access to a
copy of this Policy.
All new staff will be orientated to the policy as soon as their employment
begins.
The policy will be effectively communicated to all pregnant women and
mothers with the aim of ensuring that they understand the standard of
information and care expected from this facility. Where a mothers’ guide is
used in place of the full Policy, the full version should be available on request
in all areas which serve mothers and babies. A statement to this effect will be
included on the mothers’ guide.
Information will also be included in the weekly Chief Executive’s Bulletin
which is circulated electronically to all staff.
16.2.
Implementation of the Policy
Line managers are responsible for ensuring this policy is implemented across
their area of work.
Current staff will be informed of this Policy through the Infant Feeding
Coordinator.
17.
Document Control including Archiving Arrangements
17.1.
Library of Procedural Documents
The author is responsible for recording, storing and controlling this policy.
Once approved, the author will provide a copy of the current policy to the
Corporate Governance Manager so that it can be placed on the Trust’s
Intranet site. Any future revised copies will be provided to ensure the most
up-to-date version is available on the Trust’s Intranet site.
17.2.
Archiving Arrangements
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All versions of this policy will be archived in electronic format within the
Maternity Services policy archive. Archiving will take place by the author
once the final version of the policy has been issued.
Revisions to the final document will be recorded on the Document Control
Report. Revised versions will be added to the policy archive held by Maternity
Services.
17.3.
Process for Retrieving Archived Policy
To obtain a copy of the archived policy, contact should be made with the
author.
18.
Monitoring Compliance with and the Effectiveness of the
Policy
18.1.
Standards/ Key Performance Indicators
Key performance indicators comprise:



18.2.
All mothers are supported in feeding their babies whatever their chosen
method in all care settings 100%.
Initiation and continuance rates increase year on year by 2%.
Improve the disparity between geographical areas within North Devon
for initiation and continuation rates by 2% each year.
Process for Monitoring Compliance and Effectiveness
Compliance with this Policy is mandatory.
Audit of the compliance will be undertaken by the Infant Feeding
Coordinator. This will be on an annual basis using the BFI Audit Tool.
This will be enhanced by monitoring: patient complaints, individual patient
reviews, risk management, clinical annual audit using BFI criteria, staff
meetings, clinical supervision and practical skills reviews.
Non-compliance with the Policy will be reported through the line
management channels for each Trust.
Any deficiencies should be identified and an action plan developed by the
Lead Midwife for Public Health, and Infant feeding Coordinator to enable
care to be improved and brought in line with requirements.
These action plans will be monitored by the risk management team of the
maternity unit as well as the original deficiency identified.
Head of Midwifery will be informed of audit results and subsequent action
plans.
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Evaluation, including further audit, will be carried out to ensure that the
actions implemented have met the requirements.
Specific audit of supplementation rate and re-admission rates in babies up to
28 days with feeding problems and the indications for these to be carried out
19.
Associated Documentation
Care of the Newborn Immediately After Birth Guideline
Post Natal Care Planning & Post Natal Information Guidelines
Cup Feeding Neonatal Guideline
Expressed Breast Milk handling, labelling and storage Standard Operating Procedure
20.
References
Anderson JW et al (1999) Breastfeeding and cognitive development: a meta-analysis.
Am J Clin Nutr 70; 525-35
Aniansson G, Alm B, Anderssonn et al (1994) A prospective cohort study on breastfeeding and otitis media in Swedish infants. Pediatric Infect Dis J 13;183-188
Barros CF, et al (1995) Use of pacifiers is associated with decreased breastfeeding
duration. Pediatrics 95:497-499.
Bartington S, Griffiths L, Tate A, Dezateux C and the Millennium Cohort Study Child
http://www.bestbeginnings.org.uk/drugs
Breastfeeding and Drug Misuse An Infomation Guide for Mothers
http://www.addictioneducation.co.uk/BF%20drug%20use.pdf
Health Group. (2006). ‘Are breastfeeding rates higher among mothers delivering in
Baby Friendly accredited maternity units in the UK?’ International Journal of
Epidemiology. Available at: http://ije.oxfordjournals.org
British HIV Association (BHIVA) 2005 Guidelines for the management of HIV infection
in pregnant women and the prevention of mother to child transmission. London:
BHIVA
Broadfoot M, Britten J, Tappin DM and Mackenzie JM. (2005). ‘The Baby Friendly
Initiative and breastfeeding rates in Scotland’. Archives of Disease in Childhood Fetal
Neonatal Edition, 90:F114-F116. Available at: http://fn.bmjjournals.com
Maternity
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Page 42 of 60
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Colson SD, Meek J, Hawdon JM (2008) Optimal positions for the release of primitive
neonatal reflexes stimulating breastfeeding. Early Human Development.
Doi10.1016/j.earlhumdev.2007.12.003
Christensson K, et al, (1992) Temperature, metabolic adaptation and crying in
healthy full term newborns cared for skin-to-skin or in a cot. Acta Paediatrica, 81:
488-493
Christensson K, et al, (1995) Separation distress call in the human neonate in the
absence of maternal body contact. Acta Paediatrica, 84:468-473.
Christensson K, et al, (1998) Randomised study of skin-to-skin versus incubator care
for warming low-risk hypothermic neonates. Lancet, 352(9134), 1115.
DH (1999) HIV and Infant Feeding: Guidance from the UK Chief Medical Officer’s
Expert Advisory Group on AIDS.
DH (2004) Infant Feeding Recommendations. London :DH
DH (2001) Optimal Duration of Exclusive Breastfeeding and Introduction of weaning
CACN/)!/)& www.doh.gov.uk/scan/scan0107.pdf
Dunn DT. et al (1998) Mother to child transmission of HIV: implications of variation in
maternal infectivity. AIDS 12(16): 2211-2216.
Dyson L, Renfrew M, McFadden A, McCormack F, Herbert G, Thomas J. (2006).
Promotion of breastfeeding initiation and duration: Evidence into practice briefing.
NICE. Available at: www.nice.org Enkin M, Keirse MJNC, Neilson J, et al. (2000) A
guide to effective care in pregnancy and childbirth. 3rd edition. Oxford University
Press: Oxford
Ford RP et al (1993) Breastfeeding and the risk of sudden infant death syndrome. Int
Journal Epidemiology 22; 885-90.
Galton Bachrach VR et al (2003) Breastfeeding and the risk of hospitalisation for
respiratory disease in infancy. A meta-analysis. Arch Pediatr Adolesc Med. 157; 237243
GrantJ, Fletcher M, Warwiwick C. (2000) The South Thames Evidence Based Practice
(STEP) project: Supporting Breastfeding Women Report. South Bank University &
Kings Health Care, London.
Hale T. (2004) Medication and Mothers’ Milk. Pharmasoft Medical Publishing.
Hawdon JM, Ward Platt MP, Aynsley Green A. (1992) Patterns of metabolic
adaptation for term and premature infants in the first neonatal week. Archives of
Disease in Childhood; 67: 357-365.
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Howie PW, Forsyth S, Orgston SA, Clark A, Florey C du V. (1990) Protective effect of
breastfeeding against infection. British Medical Journal 300; 11-16
Innocenti Declaration (2005) www.innocenti15.net
Karjalain J et al. (1992) A bovine albumen peptide as a possible trigger of insulindependent diabetes mellitus. New England J Med 327
Kramer M, Chalmers B, Hodnett E, Sevkovskaya E, Dzihovich I, Shapiro S, et al.
(2001). ‘The Promotion of Breastfeeding Intervention Trial (PROBIT): a
randomizedtrial in the republic of Belarus’. The Journal of the American Medical
Association 285:413-20. Available at: http://jama.ama-assn.org
Lang S, Lawrence CJ, Orme R. (1994) Cup feeding: an alternative method of infant
feeding. Archives of Disease in Childhood 71:365-569
Littman H.Medendorp SV, Goldfarb J. 1994. The decision to breastfeed: the
importance of fathers' approval. Clinical Pediatrics 33 (4); 214 – 219
Lucas A, Cole TJ. (1990) Breastmilk and neonatal necrotising enterocolitis. Lancet
336; 1519-1523.
Medforth, J., Battersby, S., Evans, M., Marsh, B., and Walker, A. (Editors). 2011 ,
Breastfeeding in Special Situations . Oxford Handbook of Midwifery. 2 nd edition.
MAIN Trial Collaborative Group (1994) Preparing for Breast feeding : treatment of
inverted nipples and non-protractile nipples in pregnancy. Midwifery; 10: 200 – 214.
Mohrbacher N Stock J. (1991) The breastfeeding answer book. La Leche League
International, Franklin, Illinois
Moore, E.R., Anderson, G.C., Bergman, N. (2007) Early skin to skin contact for
mothers and their healthy newborn infants. Cochrane Database of Systematic
Reviews. 2007. Issue 3. Art. No. CD003519. DOI: 10.1002/14651858:
CD003519.pub2.
Mulder P (2006) A concept analysis of effective breastfeeding. JOGNN 35(3):332-9.
Musoke RN. (1990) Breastfeeding promotion: feeding the low birth weight infant.
International Journal of Gynaecology and Obstetrics 31:57-59
National Childbirth Trust et al (1997) Hypoglycaemia of the Newborn. Guidelines for
appropriate blood glucose screening & treatment of breastfeeding and bottle fed
babies in the UK. NCT
National Institute for Health and Clinical Excellence (NICE). (2006). NICE clinical
guideline 37 Routine postnatal care of women and their babies. London:
NICE.Available at: www.nice.org.uk
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National Institute for Health and Clinical Excellence (NICE). (2008) NICE Public health
guidance 11. Improving the nutrition of pregnant and breastfeeding mothersand
children in low-income households. London: NICE. Available at:www.nice.org.uk
National Institute for Health and Clinical Excellence (NICE). (2010 [2008]) NICE
Clinical guideline 62. Antenatal care: routine care for the healthy pregnant
woman.London: NICE. Available at: www.nice.org.uk
Neifert M, Lawrence R, Seacat J. (1995) Nipple confusion – towards a formal
definition. Journal of Pediatrics 126: S125-S129
Newcomb PA et al (1994) Lactation and a reduced risk of premenopausal breast
cancer. New England J Med 330; 81-87.
Nowak AJ, Smith WL, Erenburg A. (1994) Imaging evaluation of artificial nipples
during bottle feeding. Archives of Paediatric and Adolescent Medicine 148:40-42.
Oddy WH et al (1999) Association between breastfeeding and asthma in 6 year old
children: findings of a prospective birth cohort study. British Medical Journal 319;
815-819
Oddy WH et al (2002) Maternal asthma, infant feeding, and the risk of asthma in
childhood. J Allergy Clin Immunol 110; 65-7
Oddy WH et al (2003) Breast feeding and respiratory morbidity in infancy: a birth
cohort study. Archives of Disease in Childhood. 88; 224-228
Paton LM et al (2003) Pregnancy and lactation have no long-term deleterious effect
on measures of bone mineral in healthy women: a twin study Am J Clin Nut 77; 70714
Perez-Escamilla R et al (1994) Infant feeding policies in maternity wards and their
effect on breastfeeding success: an analytical overview. American Journal of Public
Health 84(1):89-97.
Pisacane A, Graziano L, Mazzarella G et al (1992) Breastfeeding and urinary tract
infection. J Pediat 120(1); 331-332.
Quigley M.A., Kelly Y.J., Sacker A.S. (2007) ‘Breastfeeding and Hospitalization for
Diarrheal and Respiratory Infection in the United Kingdom Millennium Cohort Study’.
Pediatrics, 119: e837- e842. Available at: http://pediatrics.aappublications.org
Tufts-New England Medical Center Evidence-Based Practice Center, Boston,
Massachusetts. (2007). Breastfeeding and Maternal Health Outcomes in Developed
Countries. AHRQ Publication No. 07-E007. Rockville, MD: Agency for Healthcare
Research and Quality. U.S. Department of Health and Human Services. Available at:
www.ahrq.gov
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Righard L, Alade MO. (1990) Effect of delivery room routines on success of first
breastfeed. Lancet, 336(8723):1105-1107.
Renfrew MJ, Woolridge MW, Ross-McGill H. (2000) Enabling women to breastfeed: a
review of practices which support or hinder breastfeeding, with evidence-based
guidance for practice. The Stationary Office, London.
Rosenblatt KA (1993) Lactation and the risk of epithelial ovarian cancer – The WHO
Collaborative Study of Neoplasia and Steroid Contraceptives. Int J Epidemiology 22:
499-503
Royal College of Midwives (2002) Successful Breastfeeding. RCM, London:Churchill
Livingstone
Saarinen UM & Kajosaari M (1995) Breastfeeding as prophylaxis against atopic
disease: prospective follow-up study until 17 years old. Lancet 346; 1065-1069
Scientific Advisory Committee on nutrition (2008) Infant Feeding Survey 2005: A
commentary on infant feeding practices in the UK. London: The Stationery Office.
Snowden HM, Renfrew MJ, Woolridge MW. Treatments for breast engorgement
during lactation (Cochrane review). In: The Cochrane Library, 2001. Oxford: Update
Software.
Steldinger, R. and Luck W. (1988) Half lives of nicotine in milk of smoking mothers:
implications for nursing. J. Perinat. Med 16: 261-262.
Switzky LT, Vietze P, Switzky HN 1979 Attitudinal and Demographic Predictors of
Breastfeeding and Bottlefeeding Behaviour by Mothers of Six-Week-Old Infants.
Psychological Reports 45: 3–14
UNICEF UK Baby Friendly Initiative. (2008) Implementation Guidance. London:
UNICEF UK Baby Friendly Initiative. Available at: www.babyfriendly.org.uk
United Kingdom Association for Milk Banking Guidelines for the collection, storage
and handling of breastmilk for a mother’s own baby in hospital. UKAMB The Milk
Bank QCCH.
United Kingdom Association for Milk Banking (2001) Every drop counts: Guidelines
for the collection, storage and handling of breastmilk for a mother’s own baby in
hospital. The Milk Bank QCCH
Updated Baby Friendly standards: www.unicef.org.uk/babyfriendly/standards
Victoria CG et al (1993) Use of pacifiers and breastfeeding duration. Lancet 341:404406
Victoria CG et al (1997) Pacifier use and short breastfeeding duration: cause,
consequence or coincidence? Pediatrics 99:445-453
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World Health Organisation (WHO). (2007). Evidence on the long-term effects of
breastfeeding. Geneva, Switzerland: WHO. Available at: http://whqlibdoc.who.int
World Health Organisation (WHO). (1981) International Code of Marketing of
Breastmilk Substitutes. Geneva, Switzerland: WHO. Available at:
www.babymilkaction.org
WHO, Department of Child and Adolescent Health and Development. (2000) Mastitis
causes and management. Geneva, WHO (45 pages)
Wilson AC et al (1998) Relation of infant diet to childhood health: seven year follow
up cohort of children in Dundee infant feeding study. British Medical Journal 316; 2125
World Health Organisation (WHO), UNICEF. (1989). Protecting, promoting and
Supporting Breastfeeding. The Special Role of the Maternity Services. A joint
WHO/UNICEF Statement. Geneva, Switzerland: WHO. Available at: www.who.int
Walker M: Influence of the maternal anatomy and physiology on lactation. In
Breastfeeding Management for the Clinician: Using the Evidence. Sudbury,
Massachusetts: Jones and Bartlett Publishers; 2006::51-82.
www.babyfriendly.org.uk for information relating to the “10 steps to successful
breastfeeding” and the “7 point plan” and details of all Baby Friendly standards
WHO(2004) www.who.int/foodsafety/publications/micro/en/es contents. pdf
World Health Organisation (1998) Evidence for the ten steps to successful
breastfeeding. Division of Child Health and Development: Geneva
Woolridge MW, Baum D, Drewett RF (1980) Effect of a Traditional and of a New
Nipple Shield on Sucking Patterns and Milk Flow. Early Human Development 4(4):
357–364
Woolridge MW (1986) The anatomy of infant sucking. Midwifery4:164-171.
The Policy should be read in conjunction with:
UNICEF Baby Friendly Initiative (2016).
The international Code: http://www.unicef.org.uk/BabyFriendly/HealthProfessionals/Going-Baby-Friendly/Maternity/The-International-Code-of-Marketingof-Breastmilk-Substitutes-/
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Appendix A: The Baby Friendly Initiative
The Baby Friendly Initiative is a worldwide programme of the World Health Organization
and UNICEF. It was established in 1992 to encourage maternity hospitals to implement the
Ten Steps to Successful Breastfeeding and to practise in accordance with the International
Code of Marketing of Breast milk Substitutes.
The UNICEF UK Baby Friendly Initiative was launched in the UK in 1994 and, in 1998, its
principles were extended to cover the work of community healthcare services in the Seven
Point Plan for Sustaining Breastfeeding in the Community.
The Baby Friendly Initiative works with the healthcare system to ensure a high standard of
care for pregnant women and breastfeeding mothers and babies. We provide support for
healthcare facilities that are seeking to implement best practice, and we offer an
assessment and accreditation process that recognises those that have achieved the required
standard.
V.6 January 2011 Page 17 of 17.
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Appendix B: Ten Steps and Seven Point plan to Successful Breastfeeding
10 steps to successful breastfeeding
Step 1 – Have a written breastfeeding policy that is routinely communicated to all
healthcare staff.
Step 2 – Train all staff in the skills necessary to implement the breastfeeding policy.
Step 3 – Inform all pregnant women about the benefits and management of
breastfeeding.
Step 4 – Help mothers initiate breastfeeding soon after birth.
Step 5 – Show mothers how to breastfeed and how to maintain lactation, even if they
should be separated from their infants.
Step 6 – Give no food or drink other than breast milk to breastfeeding babies.
Step 7 – All mothers and babies to room-in together while in hospital.
Step 8 – Encourage breastfeeding on demand.
Step 9 – No teats or dummies to be given to breastfed babies during the
establishment of breastfeeding.
Step 10 – Identify sources of national and local support for breastfeeding and ensure
that mothers know how to access these prior to discharge from hospital.
7 Point Plan for sustaining breastfeeding tin the community.
1. Have a written policy that is routinely communicated to all healthcare staff.
2. Train all staff involved in the care of mothers and babies in the skills necessary to
implement the policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Support mothers to initiate and maintain breastfeeding.
5. Encourage exclusive and continued breastfeeding, with appropriately-timed
introduction of complementary foods.
6. Provide a welcoming atmosphere for breastfeeding families.
7. Promote co-operation between healthcare staff, breastfeeding support and the local
community.
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Appendix C: Benefits of Breastfeeding
Breastfeeding provides benefits that start from the first feed and continue into adulthood.
Recent Evidence is available for the following benefits:
Level of Evidence
Infants and Children
Convincing
Gastrointestinal Illness
(Heinig 1996, Hainig 2001,
Oddy, 2001 and Leon-Cava
2002)
Chronic disease in
childhood and / or
later life
Mothers
Slow maternal
recovery from
childbirth (Rea 2004,
Lobbock, 2001)
Neonatal necrotising
enterocolitis (Rodriguez ,
2005)
Reduced Period of
postpartum
infertility (Rea 2004)
Respiratory Tract
Infections (Bachrach
2003)
Premenopausal
Breast cancer (Beral
2002)
Otitis Media (Aniansson
1994)
Urinary Tract Infections
(Marild, 2004, Hanson
2004)
Probable
Asthma and Allergy
(Eigenmann 2004 and Kull,
2004)
Cognitive Ability and
Intelligence (Morley 2004,
Jain 2002 and Rey 2003)
Some childhood
leukaemias (Kwan 2004)
Urinary Tract Infection
(Marild and Hanson, both
2002)
Obesity (Arenz
2004, Dewey 2003,
Gill 2003, Owen
2005, SchackNielson 2004)
Postmenopausal
breast cancer (Beral
2002)
Ovarian Cancer
(Tung 2003 Riman
2002)
Rheumatoid
Arthritis (Rea 2004
Labbock 2001)
Inflammatory Bowel
Disease (Klement 2004)
Coeliac disease (Nash
2003)
SIDS (McVea 2000)
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Possible
Insulin Dependant
Diabetes Mellitis (Diniz
2004)
Ischaemic Heart
Disease (RichEdwards (2004)
Bacteraemia (Oken 2001)
Atherosclerosis
(Martin 2005)
Meningitis (Oken 2001)
Dental Occlusion
(Charchut 2003)
Maternal depression
(Mezzacappa 2004)
Reduced maternalinfant bonding (Hart
2003)
Endometrial Cancer
(Rea 2004 Labbock
2001)
Osteoporosis and
bone fracture (Rea
2004, Labbock 2001)
No or slow return to
pre-pregnancy
weight (Rea 2004)
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Appendix D: Composition of breast milk
The composition of breast milk is extremely variable and meets the needs of the growing
baby. Composition varies; as each feed progresses, with the time of day, length of lactation
and nutritional status of the mother.
Colostrum
This is the first milk produced. It is generally a thick yellow fluid, which is high in proteins,
mainly in the form of antibodies which help guard the body against infection. Colostrum
also has a laxative effect which encourages the passage of meconium.
Transition and mature milk
 Protein
Human babies grow slowly compared to other mammals and therefore require lower
protein levels. The protein in breast milk is easily digested, it differs from cow’s milk protein
which forms a solid, slow to digest curd in the stomach.
 Fat
The fat composition of breast milk reflects maternal dietary fat. It is low at the start of the
feed, increasing by 34 fold by the end. Breast milk contains a high proportion of
unsaturated fatty acids and more cholesterol, which may protect against high blood
cholesterol in later life. Breast milk also contains an enzyme called lipase, which aids
absorption of fat, preventing a large loss in the stools.
 Carbohydrate
Breast milk is high in the sugar lactose. This is important for calcium absorption and for
encouraging the growth of lactobacilli, which increases gut acidity to inhibit the growth of
harmful bacteria. Breast milk also contains a group of carbohydrates called oligosaccharides,
which are important, both to reduce microbiological infection and support the growth of
beneficial bacteria in the gut.
 Vitamins
These are present in plentiful amounts, especially if a mother has a good nutritional status.
 Iron
Babies born at term have iron stores in their livers, which are supplemented with recycled
iron from the breakdown of excess haemoglobin not required after birth. Breast milk
contains a small amount of iron; 80% of which is absorbed. Fully breastfed, appropriately
grown term, babies do not usually need an exogenous source of iron until around six
months
 Minerals
Sodium, potassium, phosphorous and calcium are present in ideal amounts required for full
term babies.
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Appendix E: Physiology of Lactation
Colostrum is present at birth and before. Between 48-96 hours after delivery of the
placenta oestrogen and progesterone levels fall and allow prolactin from the anterior
pituitary to stimulate milk production. The action of suckling stimulates the release of
oxytocin from the posterior pituitary which controls the milk ejection reflex. Milk
production continues both under the influence of prolactin and the mechanical removal of
milk from the breast. It is important to remember that the milk ejection reflex may not
occur until the baby has been suckling for a minute or two.
The Hormones involved:
Prolactin
When a baby suckles at the breast sensory impulses pass from the nipple to the brain. In
response, the anterior pituitary gland at the base of the brain secretes prolactin. Prolactin is
transported in the blood to the breast, where it directs milk secreting cells to produce milk.
Prolactin levels in the blood remain high for up to 90 minutes after the feed and make the
breast produce milk for the next feed. Therefore if a baby suckles more, the mother’s
breast will make more milk. Prolactin levels are higher at night, and a breastfeed at night
causes greater prolactin surge than one given during the day, therefore night feeding is
important for keeping up the milk supply.
Oxytocin ‘oxytocin reflex’ or ‘let-down reflex’
When a baby suckles sensory impulses go from the nipple to the brain. In response the
posterior part of the pituitary gland at the base of the brain secretes the hormone oxytocin.
The oxytocin is carried to the breast in the blood and makes the myo-epithelial cells around
the alveoli contract. And the milk is then available when the baby suckles.
Although it is important for a mother to eat and drink sufficiently this will not help her
produce more milk if her baby does not suckle. The baby must suckle often and effectively.
Feedback Inhibitor of lactation (FIL) is an active whey protein that inhibits milk secretion as
alveoli become distended and milk is not removed. Its concentration increases with longer
periods of milk accumulation, down regulating milk production in a chemical feedback loop.
The inhibition of milk secretion is reversible and dependent on concentration; it does not
affect the composition of the milk because it affects the secretion of all milk components
simultaneously
Correct Position
This is crucial for pain free feeding and efficient milking of the breast. Many early
breastfeeding problems may be due to incorrect positioning and attachment of the baby at
the breast. The NHS leaflet ‘Off to the best start’ outlines the following key points to
successful breastfeeding:




Ensure that the baby’s head and body are in a straight line
Ensure that the baby is held close to the mother, the baby should be able to tilt their
head back easily and should not have to reach out to feed
Ensure that the baby’s nose is opposite the nipple
The mother should wait until the baby opens their mouth wide with the tongue down.
This can be encouraged by gently stroking the top lip
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
The baby should quickly be brought even closer to the breast, where they will tilt the
head back and come to the breast chin first. The baby should take a large mouthful of
breast and the mother’s nipples should go towards roof of the mouth.
NICE recommend the following as signs of successful breastfeeding in their postnatal care
guidance:
Indicators of good attachment and positioning:
 Mouth wide open
 Less areola visible underneath the chin than above the nipple
 Chin touching the breast, lower lip rolled down, and nose free
 No pain
Indicators of successful feeding in babies
 Audible and visible swallowing
 Sustained rhythmic suck
 Relaxed arms and hands
 Moist mouth
 Regular soaked nappies
Indicators of successful breastfeeding in women
 Breast softening
 No compression of the nipple at the end of the feed
 Woman feels relaxed and sleepy
Unrestricted feeding. Why?
 The rate of flow of milk from the breast is variable
 The rate babies take milk from the breast varies
 Less engorgement
 More conducive to establishment of adequate lactation
Therefore, let the baby decide when and how long they wish to feed. Babies generally stop
feeding when they are satisfied, which may follow a feed from only one breast.

Healthy term babies of normal weight, with a good APGAR score and who are warm, will
show signs of hunger, however the interval between feeds may vary considerably (NCT
1997)
 During the first 24hours, it has been suggested that many healthy babies will feed less
than 4 times (Hawden et al 1992)
 Feed frequency increases rapidly between the 3rd and 7th day and then decreases again
(RCM 2002)
If a baby is unwilling to feed or wake up s/he may be ill and the midwife must use her
professional judgement and if necessary consult the Infant Feeding Specialist/Breastfeeding
Specialist or a paediatrician. (See Hypoglycaemia guidelines)
Healthy, term babies of a good weight, whose Apgar score was good and whose
temperature is normal can obtain adequate nourishment from breastfeeding alone, if
attached correctly and allowed frequent, effective sucking.
Breastfeeding mothers who request formula milk should be discouraged and the benefits of
breastfeeding along with the harmful impact supplementation may have on breastfeeding
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should be discussed with the mother and documented in the health records. Consult the
senior midwife on duty or the Infant Feeding Co-ordinator.
Supplementary feeds may be required when medically indicated. In these circumstances
expressed breast milk should be used whenever possible.
Suckling on a teat may confuse a baby who is still learning to suck on the breast. Mothers
should be educated and supported to enable them to cope with the frequent demand for
feeds which often occurs when lactation is establishing. Many need constant reassurance
they are capable of nurturing their babies adequately.
When at home, if a health professional is concerned about a baby they can refer the baby to
the: Paediatric medical doctor on duty, based on Caroline Thorpe ward, NDDH Telephone
no. 01271 322704, or via the hospital bleep system
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Appendix F: Guidelines for the Management of Reluctant or Sleepy Babies who are going
to Breastfeed
These guidelines should be used within the context of best management of breastfeeding in healthy
full term infants. The baby should be gently encouraged to feed soon after birth, helped by skin to
skin contact. If he has not has his first feed by the time he is 6 hours old or his second feed six hours
later. Follow the guidelines below:-
1. Is the baby / room temperature too hot?
Is the baby well?
2. Undress the baby and put skin to skin
Look at the history – Pethidine? Cold? Low Apgars?
Infection?
Be pro-active: this baby may not demand a feed.
Encourage his mother to lead the feeding until he has
woken up & asked for a couple of breast feeds and fed
well. Explain his feeding cues to the mother
Encourage the mother to chat to her baby, massage his
hands & feet
Assess baby’s level of consciousness. Does he rouse
easily? Is he excessively sleepy?
3. If the baby does not feed, teach mother to
hand express colostrum onto the nipple to
tempt the baby
4. Hand express and give the colostrum
5. Keep the mother and baby skin to skin as
much as possible
6. REPEAT IN TWO TO THREE HOURS
7. Continue with Mum hand expressing and
giving her colostrum hourly until baby is
breastfeeding well
8. Keep the baby near the breast so that he
gets lots of practice at breastfeeding
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If any colostrum is expressed, give it either
from the mother’s finger or by syringe or cup.
If no colostrum is obtained and baby is
otherwise well continue as below, a top up is
not necessary
REASSESS THE BABY – his mother is the
best person to keep an eye on her baby
e.g. his temp, respiration rate & tone.
Assess the baby’s level of
consciousness? Does he rouse easily? Is
he excessively sleepy?
Keep pace with the baby’s food
requirements. When he is 2 days
old, this will increase, see below
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These guidelines are for babies who are not waking for feeds at all. Once the baby breastfeeds well, he may
then have a long ‘feed-in’ to make up for lost time. Help the Mum to ensure that he is attached correctly
and taking breastfeeds well.
Some babies may however, may be unwell. Check the level of consciousness at every opportunity. Babies
who are not easily awoken, need to assessed by the paediatric team.
What are baby’s feeding cues? – Rapid eye movement under the eyelids, mouth and tongue
movements, body movements and sounds, sucking on a fist. These cues indicate a state of light
sleep and the beginning of feeding readiness when babies are more likely to latch on and suck.
Crying is a way of indicating to the mother that the feeding cues have been ignored.
Syringe Feeding – is a useful to give a baby small amounts of precious colostrum that would
otherwise get lost in a cup. To give a syringe feed safely, the baby should be held in his Mother’s
arms slightly upright i.e. not flat. The syringe is gently placed between his gum and cheek and a little
colostrum is gently dribbled in (no more than 0.2ml at a time). Allow the baby time to suck and enjoy
his food. Then dribble a little more in. Stop if he starts sucking, let him swallow then give some
more. Move onto cup feeding once you have more than 5mls to give.
What if the mother doesn’t want to hand express? – The length of her labour and the type of birth
may influence the mother’s feelings about hand expressing and giving her colostrum intensively for
the first few hours. She may ask you to give formula instead (see below). However, remember that if
her baby is not breastfeeding, she needs to initiate her milk supply within 6 hours of her baby’s birth
& continue until feeding established.
If a mother cannot, or chooses not to, express colostrum and requests her baby to receive a
supplementary feed, it is the responsibility of the accountable midwife to discuss with her the
alternatives available and the disadvantages of giving formula. If it is the mother’s informed choice
to proceed with the supplementary feed, then the amount for each feed must be considered
accordingly to the baby’s age and should be given by syringe or cup and not by teat. i.e.:First day
5 -10mls per feed
Second 24 hours
10 – 15mls per feed
Third 24 hours
15 – 20 mls per feed
This should never exceed 20 mls per feed, and no formula should be given after lactation
commences
If a baby becomes symptomatic, showing signs of the following, follow initial management of
hypoglycaemia guidelines
Jitteriness - “Excessive repetitive movements of one or more limbs, which are unprovoked and
usually relatively fast. It is important to be sure that this movement is not simply a response to
stimuli.”
Poor tone – check for floppiness when handling the baby.
Drowsiness – check for level of consciousness in the baby. Does it wake easily? It is excessively
sleepy?
Apnoea – Is the respiratory pattern of the baby irregular?
Irritable, abnormal cry – Does the baby have a high pitched cry?
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Appendix G: Equality Impact Assessment Screening Form
Equality Impact Assessment Screening Form
Title
Newborn Infant Feeding Policy and Guidelines
Author
Therese Chapman
Directorate
Surgical
Team/ Dept.
Maternity
Document Class
Document Status
Issue Date
Review Date
Policy
Review
April 2013
April 2016
1
What are the aims of the document?
Promoting and supporting sustainable breastfeeding is an essential part of an integrated
programme of child health promotion and parenting support as set out in the Child Health
Promotion Programme and Every Child Matters. A healthy pregnancy, a healthy birth and a
strong bond between a baby and its parents are a vital start in life.
2
What are the objectives of the document?
The purpose of this document is to ensure that the health benefits of breastfeeding and the
potential health risks of formula feeding are discussed with all women so that they can make
an informed choice about how they will feed their baby.
3
How will the document be implemented?
Published on the Trust Intranet, included in Policy Update News, during/with training, at
maternity services team meetings
4
How will the effectiveness of the document be monitored?
Audit of the compliance will be undertaken by the Infant Feeding Coordinator. This will be on
an annual basis using the BFI Audit Tool.
This will be enhanced by monitoring: patient complaints, individual patient reviews, risk
management, clinical annual audit using BFI criteria, staff meetings, clinical supervision and
practical skills reviews.
Non-compliance with the Policy will be reported through the line management channels for
each Trust.
Any deficiencies should be identified and an action plan developed by the Lead Midwife for
Public Health, and Infant feeding Coordinator to enable care to be improved and brought in
line with requirements.
These action plans will be monitored by the risk management team of the maternity unit as
well as the original deficiency identified.
Head of Midwifery will be informed of audit results and subsequent action plans.
Evaluation, including further audit, will be carried out to ensure that the actions
implemented have met the requirements.
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Specific audit of supplementation rate and re-admission rates in babies up to 28 days with
feeding problems and the indications for these to be carried out.
5
Who is the target audience of the document?
All staff that have any contact with parents-to-be and parents of newborn infants.
6
Is consultation required with stakeholders, e.g. Trust committees and equality groups?
Yes
7
Which stakeholders have been consulted with?





8
All users of this document
Governance Department
Compliance Manager
Stakeholders and partner agencies including BFI advisor, Children’s Centres leads.
Equality Impact Assessment
Please complete the following table using a cross, i.e. X. Please refer to the document “A
Practical Guide to Equality Impact Assessment”, Appendix 3, on the Trust’s Intranet site (Bob)
for areas of possible impact.
 Where you think that the policy could have a positive impact on any of the equality
group(s) like promoting equality and equal opportunities or improving relations within
equality groups, cross the ‘Positive impact’ box.
 Where you think that the policy could have a negative impact on any of the equality
group(s) i.e. it could disadvantage them, cross the ‘Negative impact’ box.
 Where you think that the policy has no impact on any of the equality group(s) listed below
i.e. it has no effect currently on equality groups, cross the ‘No impact’ box.
Equality Group
Positive
Impact
Negative
Impact
No
Impact
Age
X
Disability
X
Gender
X
Gender
reassignment
X
Human Rights
(rights to privacy,
dignity, liberty
and nondegrading
treatment)
X
Marriage and
civil partnership
X
Pregnancy,
maternity and
breastfeeding
Comments
X
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Race /
X
Ethnic Origins
Religion
X
or Belief
Sexual
Orientation
X
If you have identified a negative discriminatory impact of this procedural document, ensure
you detail the action taken to avoid/reduce this impact in the Comments column. If you have
identified a high negative impact, you will need to do a Full Equality Impact Assessment,
please refer to the document “A Practical Guide to Equality Impact Assessments”, Appendix
3, on the Trust’s Intranet site (Bob).
For advice in respect of answering the above questions, please contact the Equality and
Diversity Lead.
9
If there is no evidence that the document promotes equality, equal opportunities or
improved relations, could it be adapted so that it does? If so, how?
Completed by:
Name
Designation
Trust
Date
Therese Chapman
Lead Midwife for Public Health, Community and Antenatal Services
Northern Devon Healthcare NHS Trust
April 2013
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