Scope

RN, IBCLC, CLC

Purpose

To promote a philosophy of maternal infant care that advocates breastfeeding and supports the normal physiological functions involved in the establishment of this maternal/infant process. To assist families choosing to breastfeed with initiating breastfeeding and developing a successful and satisfying experience .

Policy Statement

Perinatal staff will actively support breastfeeding as the preferred method of providing nutrition to infants. This breastfeeding policy will be communicated to all healthcare staff. All pregnant women in our facility will be provided with evidence-based information on breastfeeding. Mothers who chose to breastfeed will be encouraged to exclusively breastfeed unless medically contraindicated.

Definitions

Exclusive breastfeeding is defined as providing breast milk as the sole source of nutrition. Exclusively breastfed babies receive no other liquids or solids, with the exception of medications and vitamins.

Procedure

  1. At birth or soon thereafter all newborns, if baby and mother are stable, will be placed skin-to- kin with the mother. Breastfeeding mother/infant couples will be given the opportunity to initiate breastfeeding within one hour of birth.
  2. To facilitate uninterrupted mother/infant contact and breastfeeding during the first hour, it is recommended to administer Vitamin K and prophylactic antibiotics during the second hour after birth.
  3. Breastfeeding mother-infant couples will be encouraged to remain together throughout their stay, including night (rooming-in). Skin-to-skin contact will be encouraged as much as possible.
  4. Breastfeeding mothers will be offered instruction including, but not limited to the following topics:
    • Proper positioning and latch on
    • Recognizing effective latch, sucking and swallowing
    • Milk production and milk ejection reflex
    • Frequency of feeding/feeding cues
    • Expression of breast milk and use of pump if indicated
    • How to assess if infant is adequately nourished
  5. Education will be given to parents of breastfeeding infants that the baby should be put to breast at least 8 to 12 times each 24 hours. Infant feeding cues (such as increased alertness or activity, mouthing or rooting) will be used as indicators as the babies readiness for feeding.
  6. Time limits for breastfeeding will be avoided. Infants can be offered both breasts at each feeding; at times they may only be interested in feeding on one side.
  7. No supplemental formula will be given unless specifically ordered by physician or by the mothers documented and informed request.
  8. Prior to non-medically indicated supplementations mothers will be informed of the risk of supplementing. The supplement may be fed to the baby by alternative feeding methods if possible.
  9. Pacifier introduction will be delayed until breastfeeding has been firmly established, usually by 3 to 4 weeks of age, unless parents request. (This recommendation does not contraindicate pacifier use for premature infants and other special needs infants.)
  10. Mothers with sore nipples will be assessed for nipple trauma and instructed on correct latching technique.
  11. If nipple shields are used, continue to evaluate latch and consider introduction of pumping. After 12 hours of life, if the infant has not latched on or fed effectively, continue encouraging skin-to-skin contact.
  12. Parents will be instructed to watch closely for feeding cues and whenever these are observed to awaken and feed the infant.
  13. The mother will be instructed on breast massage and hand expression of colostrum.
  14. After 24 hours of life, if the baby continues to feed poorly, breast stimulation with skilled hand expression or a double set-up electric breast pump will be initiated and maintained approximately every three hours or a minimum of 8 times per day. Any expressed colostrum or mother’s milk will be fed to the baby by an alternative method.
  15. Until the mother’s milk is available, a collaborative decision should be made between the mother, nurse, and physician/clinician regarding the need to supplement the baby. Each day, the feeding plan will be reviewed. In cases of problem feeding, the lactation consultant or specialist will be consulted.
    17. If the baby is still not latching-on well or feeding well when going home, the feeding plan will be reviewed in addition to routine breastfeeding instructions.
  16. A follow-up visit or contact within 24 hours is recommended. If an infant is not feeding well, the physician/clinician must be consulted prior to discharge.
  17. Mothers who are separated from their sick or premature infants should be:
    • Instructed on the double set up electric breast pump and informed that she may obtain more milk initially with hand expression
    • Taught proper storage and labeling of human milk
    • Assisted in obtaining a double set up electric breast pump prior to going home
    • Encouraged to begin kangaroo care as soon as infant’s condition permits
    • Encouraged to breastfeed as soon as the infant’s condition permits
  18. Before leaving the hospital, breastfeeding mothers will be assessed for the ability to:
    • Position the baby correctly at the breast
    • Latch the baby to breast properly
    • State when the baby is swallowing milk
    • State that the baby should be nursed approximately 8 to 12 times every 24 hours until satiety
    • State age-appropriate elimination patterns
    • List indications for calling a physician/clinician
    • Manually express milk from their breasts
    • Understanding of the importance of exclusive breastfeeding until the infant is 6 months of age.
  19. Prior to going home, mothers will be given the names and telephone numbers of community resources to contact for help with breastfeeding.
  20. Prior to discharge breastfeeding should be evaluated by trained personnel
  21. Health professionals will receive education on lactation management and breastfeeding promotion annually, to ensure that correct, current, and consistent information is provided to all mothers wishing to breastfeed.

Equipment

Hospital grade double pump system available to every patient in Women’s and
Children’s Services.

Documentation

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

The method of feeding will be documented in the medical record of every infant.

Breastfeeding assessment, teaching and documentation will be done at least once on each shift.

Documentation will include latch, position and any problems encountered.

For feedings not directly observed, maternal report may be used.

Prior to discharge evaluation of breastfeeding will be documented on the patient record

An RN, Lactation Consultant, or Lactation Counselor assess the infants’ breastfeeding at the bedside or asks the mother appropriate questions for each portion of the score.

L = Latch on ability

For mother-reported scoring, ask, “How easily did your infant grasp the breast? Did it take several attempts?”

  • Score 2 if the infant’s gum line is placed well over the lactiferous sinuses, tongue is positioned under the areola, and both lips are flanged outward. Jaw movement should be observed at the temple area. Cheeks should be full without dimpling. Infant should stay latched on with rhythmic sucking bursts of 6 to 7 compressions every 10 seconds.
  • Score 1 if these criteria are met only after repeated attempts or of staff must hold the nipple in the infant’s mouth and stimulate the infant to suck.
  • Score 0 if the infant is too sleepy or reluctant to nurse and does not latch on.

A = Audible swallowing

For mother reported scoring, ask, “Did you hear your infant swallow? How frequently did you hear it?”

  • Score 2 if swallowing is heard as a short, forceful expiration of air. During the first 24-48 hours, several bursts of sucking may precede the swallowing sound. At 3-4 days after birth, frequency of swallowing should increase.
  • Score 1 if swallowing is heard infrequently and usually only with stimulation.
  • Score 0 if no audible swallowing is noted.

T = Type of nipple

For mother reported scoring, ask, “Do your nipples stand out or do they flatten easily?”

  • Score 2 if the nipple is everted and projects outward at rest or after stimulation.
  • Score 1 if the nipple is flat or projects forward minimally.
  • Score 0 for inverted nipples.

C = Comfort

Nipple or breast pain inhibits let down and the mother’s willingness to continue breastfeeding. For mother reported scoring, ask, “Are your breasts becoming full and heavy?”

  • Score 2 if breast tissue is soft and elastic and nipples have no sign of cracking, bruising, blistering, redness, or bleeding. The nipples look rounded immediately after nursing.
  • Score 1 if nipples are reddened with small blisters, mother is stating she is experiencing mild to moderate tenderness, or if she is experiencing a decrease in tissue elasticity when her breasts fill.
  • Score 0 if mother indicates severe discomfort and has breasts that are engorged, firm, tender with inelastic tissue and nipples that are cracked, bleeding, very reddened, large blisters or bruises.

H = Help and Hold

For mother reported scoring ask,” Did someone help you put the infant to breast? Do you need help with the next feeding?”

  • Score 2 if the mother is able to position the baby so that the body is flexed, head aligned with the trunk, facing the breast. The breast should be supported from beneath. Mother directs the nipple toward the baby’s palate.
  • Score 1 if the mother needs assistance from the staff to position and attach the infant to the breast, but is able to independently achieve latch on at the second breast.
  • Score 0 if full assistance is required from staff to attach and hold infant at breast for the entire feeding.

References

The American Academy of Family Physicians. Family Physicians Supporting Breastfeeding: Breastfeeding Position Paper (2009). Retrieved from AAFP.ORG

American Dietetic Association: Promoting and Supporting Breastfeeding. Vol 109, Issue 11, pages 1926-194 (November 2009). Retrieved from Eatright.org

Academy of Breastfeeding Medicine (2009). Clinical Protocol #3: Hospital Guidelines for the Use of Supplementary Feedings in the Healthy Term Breastfed Newborn. Retrieved from BFMED.ORG

Hale, T.W. (2010). Medications and Mothers' Milk. 13th ed. Amarillo,Tx: Pharmasoft Medical Publishing.

Riordan, J.M. (2009). Breastfeeding and Human lactation. 3rd ed. Boston,MA: Jones and Bartlett Publishers.

American Academy of Pediatrics (2009). Redbook: 2003 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove, Il: American Academy of Pediatrics.

American Academy of Pediatrics, Committee of Fetus and Newborn (2010). Policy Statement: Hospital Stay for Healthy Term Newborns. Pediatrics, Vol. 125, No. 2, February, 2010.

American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome (2011). SIDS and Other Sleep Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment. Pediatrics, October 2011; 128; 1030-1039

Submitted by/Resources Person(s)

Director of Women’s and Children’s Services