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Review Version September 2011 DORSET BREASTFEEDING POLICY DATE OF POLICY SEPTEMBER 2007, Reviewed 2009, 2011 DATE FOR REVIEW: September 2013 ACKNOWLEDGEMENTS The Dorset Breastfeeding Strategy Groups are very grateful to all the many people who had input into this document. During the process of writing this policy volunteer groups of breastfeeding counsellors from many different organisations have had input at a local level, especially the National Childbirth Trust. The local mothers have given comments through their peer representation at Maternity Forum and on the Strategy Groups. We are very grateful to the numerous midwives, health visitors, dieticians and university tutors who have read and reread the many drafts and enabled us to make this such a relevant document to practice. The wealth of evidence to support the document is enormous and so we have focused on referencing the less well-known issues for the reader‟s convenience. Please Reference as: Dorset Breastfeeding Policy Strategy Group, 2011 Dorset Breastfeeding Policy. Section 3 of The Child and Maternal Nutrition Guidelines for Dorset. Dorset. County of Dorset NHS Trusts.

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TABLE OF CONTENTS

Page 1. POLICY STATEMENT……………………………………………………………………4 2. PHILOSOPHY……………………………………………………………………………. 4 3. INTRODUCTION ………………………………………………………………………… 4 4. SUPPORTING THE POLICY…………………………………………………………… 5 5. COMMUNICATING THE POLICY. ……………………………………………………..6 6. TRAINING………………………………………………………………………………... 6 7. DISCUSSION OF INFANT FEEDING DURING PREGNANCY……………………. 7 8. INITIATION OF BREASTFEEDING……………………………………………………. 7 9. EARLY SUPPORT WITH BREAST FEEDING………………………………………...7 10. BABY-LED FEEDING……………………………………………………………………. 8 11. SUPPLEMENTARY FEEDS……………………………………………………………..9 12. MILK EXPRESSION……………………………………………………………………... 9 13. BREASTFEEDING SUPPORT GROUPS……………………………………………...10 14. CONTINUED BREASTFEEDING……………………………………………………… 10 15. SUPPORTING BREASTFEEDING IN THE COMMUNITY……………………….... 11 16. CARE FOR MOTHERS WHO HAVE CHOSEN TO FEED THEIR NEWBORN WITH

INFANT FORMULA………………………………………………………………………11 APPENDIX 1: GUIDELINES FOR RELUCTANT BREASTFEEDERS/

SLEEPY BABIES WHO ARE GOING TO BREASTFEED………….. 24 APPENDIX 2: SOURCES OF FURTHER BREASTFEEDING SUPPORT………… 25 APPENDIX 3: POSITIONING AND ATTACHMENT PHOTOGRAPHS……………. 26

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INFORMATION IN SUPPORT OF THE POLICY Page 1. PREGNANCY……………………………………………………………………………. 11 2. AT BIRTH………………………………………………………………………………... 12 3. POSITIONING AND ATTACHMENT………………………………………………….. 13 4. DURATION AND FREQUENCY OF FEEDS………………………………………….14 5. NUTRITIONAL NEEDS OF A MOTHER……………………………………............. 14 6. NUTRITIONAL NEEDS OF A FULL-TERM, HEALTHY BABY……………………. 15 7. SORENESS……………………………………………………………………………… 16 8. CANDIDA ALBICANS (THRUSH)…………………………………………………….. 16 9. USE OF TEATS, NIPPLE SHIELDS AND DUMMIES………………………………. 17 10. EARLY ENGORGEMENT……………………………………………………………… 18 11. MILK ENGORGEMENT………………………………………………………………… 18 12. EXPRESSING BREAST MILK………………………………………………………….18 13. RELUCTANT FEEDERS……………………………………………………………….. 19 14. WEIGHT LOSS IN THE BREASTFED BABY………………………………………... 20 15. PHYSIOLOGICAL JAUNDICE………………………………………………………… 21 16. MAINTAINING LACTATION…………………………………………………………… 21 17. MASTITIS………………………………………………………………………………… 21 18. BREAST ABSCESS…………………………………………………………………….. 22 19. HIV/AIDS………………………………………………………………………………... 23 20. HEPATITIS…………………………………………………………………………….... 23 21. DRUGS AND BREASTFEEDING…………………………………………………….. 23

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THE DORSET BREASTFEEDING POLICY 1. POLICY STATEMENT 1.1 Patient care is delivered without discrimination, regardless of, gender/transgender,

race, disability, sexual orientation, age or religion/belief. Information is given to all patients and carers in a way in which they can understand.

2 PHILOSOPHY 2.1 Breastfeeding is the healthiest way women can feed their babies.1 2.2 Breastfeeding contributes to the health of both mother and child, in the short and

long term. Therefore health professionals have to raise awareness of the health benefits of breastfeeding- as well as the risks of not breastfeeding.2 Mothers who do not breastfeed have an increased risk of breast3 and ovarian cancers4 and may find it more difficult to return to their pre pregnancy weight.5 Lower rate of hip fractures in women over 65 is seen in those who breastfed.6 Babies who are not breastfed have an increased incidence of obesity7, otitis media8, gastroenteritis, respiratory infection9 and more hospitalisation in the first year of life.10 Where there is associated family history there is an increase in allergies11 and diabetes.12, 13

2.3 All mothers have the right to have access to information that will help them come to

an informed decision about how to feed their baby. 2.4 The ultimate decision on whether or not to breastfeed will remain that of the

individual woman and she will be supported in her choice of feeding method.14

2.5 In all cases concerning breastfeeding management, the mother will be given

unbiased, evidence based information to enable her to choose how her baby is fed. 2.6 The policy is appropriate for all babies. Where special circumstances pertain, this

will be reflected in the text. 3 INTRODUCTION 3.1 All recommendations in this policy are evidence based.

3.2 The long term health of the mother and baby is paramount. 3.3 This policy has been written to help midwives, health visitors, doctors and all other

relevant professionals and carers provide more effective and consistent information and support concerning breastfeeding.

3.4 This policy has been written under the guidance of the UNICEF UK Baby Friendly

Initiative to conform with, „The 10 Steps to Successful Breastfeeding‟ and „The Seven Point Plan‟.

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3.5 Ten Steps (for hospitals):

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

• Train all healthcare staff in the skills necessary to implement the breastfeeding policy.

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

• Help mothers initiate breastfeeding soon after birth. • Show mothers how to breastfeed and how to maintain lactation, even if

separated from their babies • Give newborn infants no food or drink other than breastmilk, unless

indicated. • Practice rooming-in, allowing mothers and infants to remain together 24

hours a day.. • Encourage breastfeeding on demand. • Give no artificial teats or dummies to breastfeeding infants. • Identify sources of national and local support for breastfeeding and ensure

that mothers know how to access these prior to discharge from hospital. 3.6 Seven Point Plan (for the community):

• Have a written breastfeeding policy that is routinely communicated to all healthcare staff.

• Train all staff involved in the care of mothers and babies in the skills necessary to implement the policy.

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

• Support mothers to initiate and maintain breastfeeding. • Encourage exclusive and continued breastfeeding, with appropriately- timed

introduction of complementary foods. • Provide a welcoming atmosphere for breastfeeding families. • Promote co-operation between healthcare staff and breastfeeding support

groups and the local community. 4 SUPPORTING THE POLICY 4.1 Compliance with the policy is mandatory for all staff. 4.2 Any deviation from the policy will need to be justified and documented. 4.3 Compliance with the policy will be audited annually using the Baby Friendly Audit

tool. 4.4 There will be no advertising or sale of breast milk substitutes, bottles, teats or

dummies in any health care facility. This includes free gifts to professionals, display of companies‟ logos and use of promotional literature. Promoting formula milk in this way has been shown to undermine breastfeeding.15, 16

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4.5 Representatives of formula companies will be seen by a designated staff member/s and by appointment only. All staff must refer to their local policy on meeting company representatives.

4.6 Discussion on formula feeding will be available on a one to one basis on request in

the antenatal/postnatal period for women who have made an informed decision to formula feed.

4.7 Group demonstration on making up formula feeds is not allowed. This practice has

been shown to undermine breastfeeding.15 4.8 Any discussion about feeding should be briefly documented in the mother‟s notes.

This will ensure continuity and safeguard against misunderstanding of information given by the health worker.

4.9 Women who choose to formula feed their babies will be shown how to prepare

feeds individually in the immediate postnatal period in line with the current Department of Health (DoH) guidelines17 and the results of The Infant Feeding Survey.18

4.10 All women will be encouraged to discuss with a health visitor or midwife changes in

feeding so that appropriate support and information can be given. 5. COMMUNICATING THE POLICY 5.1 The policy will be available in the maternity unit, NHS community premises and

Children‟s Centres and parents may have a copy on request. 5.2 A shortened form of the policy or a Mother‟s Guide will be displayed in the

Maternity Unit and all community facilities. It may be alongside or incorporating a sign saying “Welcome to Breastfeed” that stands out clearly from the policy.

5.3 It‟s the responsibility of the Health professionals to ensure that all information is

communicated to meet individual‟s needs and that all women are informed about the policy both antenatally and postnatally..

6. TRAINING 6.1 All staff will be orientated to the policy within one week of taking up post in the

maternity unit or community trust. Both parties should sign that the orientation has taken place.

6.2 All staff having contact with mothers and babies, including clerical and ancillary

staff, will receive training in breastfeeding appropriate to their role within six months of taking up post. Curricula will be available for all training which will include information about making up formula feeds.

6.3 Training on the policy is the responsibility of each organisation and suitably qualified

staff will be available to carry it out.

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6.4 The Dorset Breastfeeding Policy requires an annual up-date of all staff working to support breastfeeding. The format for this will be based on the results of the UNICEF Baby Friendly Initiative audits.19 This is to consolidate practices and to introduce current research. It will be documented in each practitioner‟s professional development record.

6.5 Paediatricians and General Practitioners will attend a training session on

breastfeeding relevant to their roles. 6.6 Ancillary staff will be aware of the policy and its implications in their area of work. 7 DISCUSSION OF INFANT FEEDING DURING PREGNANCY 7.1 All pregnant women will have the opportunity for a one-to-one discussion about the

benefits of breastfeeding, breast milk and the management of breastfeeding so that an informed decision can be made. This discussion will be before 32 weeks of pregnancy and will be with a trained health worker.

7.2 All antenatal classes and breastfeeding workshops will reinforce the benefits of

breastfeeding, breast milk and the management of breastfeeding. 7.3 Enquiring about and recording the woman's intention antenatally regarding feeding

is not considered helpful as it can close the door to further discussion and does not allow for a change of mind.19

7.4 All parents will be informed in the antenatal period of the health benefits of skin-to-

skin contact. 7.5 Staff will inform mothers about targeted community interventions to promote

breastfeeding aimed at those mothers least likely to breastfeed. 8 INITIATION OF BREASTFEEDING 8.1 At birth, all babies, regardless of method of feeding, will be dried and offered skin-

to-skin contact with their mother for at least an hour or until after the first feed, in an unhurried environment.20, 21 Washing the baby first is not necessary and this practice will be discouraged.

8.2 All mothers will be offered support to initiate breastfeeding and this documented

within the first hour after birth. Further help to breastfeed will be given within six hours.

8.3 If skin-to-skin contact has to be delayed or interrupted for medical reasons, it will

resume as soon as possible regardless of the length of time since birth. 8.4 In the absence of the mother, skin-to-skin contact with her partner or another close

family member can be offered to the baby. 9 EARLY SUPPORT WITH BREASTFEEDING 9.1 Further help to breastfeed will be given within six hours and this documented.

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9.2 Mothers and babies will be supported to learn attachment and how to recognise

effective milk transfer while in hospital. Prior to transfer home, all breastfeeding mothers will receive information, both verbal and in writing about how to recognize effective feeding to include:

the signs which indicate that their baby is receiving sufficient milk, 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).

trained health workers will provide support, encouragement and time for explaining positioning and attachment details.

9.3 Health professionals will be sensitive to those mothers needing extra support and

encouragement. 9.4 A hands-off approach to assisting a mother to breastfeed will be adopted by health

professionals and supporters. It is important that mother and baby are enabled to learn this skill for themselves.

9.5 A clear breastfeeding history will be handed over when care is transferred from

midwives to health visitors, verbally or in writing. 9.6 All mothers/babies should have a breastfeeding assessment on day 5 post delivery

and a further assessment by a member of the Health Visiting team at the primary visit. This assessment should include reviewing the evidence of effective milk transfer, looks for early signs of complications and checks that the mother feels confident about how her baby is positioned and attached. This should be documented.

10. BABY-LED FEEDING 10.1 Mothers will be encouraged to respond to their baby‟s feeding cues.22 They should

have no restrictions placed on the frequency or length of their baby‟s breastfeeds. They should be advised to breastfeed their babies whenever they are hungry and as often as the baby wants. Be aware that there are no set rules for the number or length of feeds in any 24-hour period unless there are clinical indications.

10.2 All mothers will be informed of the importance of and management of night feeds.

The benefits of keeping your baby in the same room, feeding lying down and the appropriate information about bed sharing, including the dangers of sleeping on the sofa, will be explained.23

10.3 Mothers, regardless of their method of feeding, will not be separated from their

babies unless there is a valid reason. If separated, the reason for and consent of the mother will be documented.15

10.4 Whilst in hospital, the practice of separating babies from their mothers and putting

them to sleep in the nursery has been shown to hinder the establishment of

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breastfeeding. Where possible mothers will be encouraged to have their babies sleeping close to them.15, 24

10.5 The benefits and contraindications of bed sharing will be fully discussed with all

mothers25, 26. 10.6 When at home, mothers will be encouraged to keep their babies near them so that

they are able to respond promptly to feeding cues.22, 24 10.7 Skin to skin contact at any stage is valuable in supporting breastfeeding.27 11. SUPPLEMENTARY FEEDS 11.1 Healthy, term newborns that are breastfeeding need not be screened for

hypoglycaemia and need no supplementary food or fluids.28 11.2 Colostrum and breast milk provide for the baby‟s entire nutritional needs as well as

having significant immunological properties.29 Extra fluids will not be given unless there are medical indications or after fully informed maternal choice.15

11.3 Mothers who request supplementary feeds for their babies will be helped to make

an informed decision bearing in mind the detrimental effect this can have on lactation and the implications for future health of the baby.15

11.4 Mothers will also be given the choice about how any necessary supplement or

expressed breast milk is given and informed of the possible detrimental effect on establishing lactation of using bottles and teats.23, 30 Cup, syringe feeding and spoon feeding are good alternatives.23 Consult flow chart titled: Guidelines for Reluctant Breast feeders / Sleepy Babies Who Are Going to Breastfeed. Appendix 1.

11.5 Dummies have been shown to have an adverse effect on breastfeeding, especially

when feeding is not established and mothers should be informed of this.15, 31 Further discussion about the use of teats and dummies should occur in the community stressing the importance of establishing breastfeeding first.

11.6 Nipple shields are recommended only in extreme circumstances and only under the

care of a skilled practitioner. Mothers should be informed of the disadvantages of nipple shields and support should be provided to ensure their use is discontinued as soon as possible.23, 32

11.7 If supplements, bottles, teats, nipple shield or dummies are used, the reasons for

this should be discussed with the parent and this conversation documented in case notes.

12. MILK EXPRESSION 12.1 All breastfeeding mothers will be given the opportunity to learn how to express their

milk by hand and pump so they can maintain lactation if separated from their baby and can manage possible breastfeeding problems in the future.

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12.2 Mothers who are separated from their babies will be encouraged to express their milk at least 8-10 times in each 24-hour period.33 Expressing will be initiated as soon as possible after birth but within the first six hours if physically possible15 to maintain the mother‟s milk supply it is advisable to express at least once at night.

12.3 In all cases, the woman will be given written information, (or access to alternative

formats), on hand expressing and advised how to get help if required. 12.4 Mothers who have to be, or who choose to be, separated from their babies in

instances such as hospitalisation or return to work, will be given information on how full or partial lactation may be maintained.

13. BREASTFEEDING SUPPORT GROUPS 13.1 All mothers will be given details of how to contact midwives, health visitors and local

breastfeeding counsellors on discharge from hospital. 13.2 Details of local support groups will be routinely displayed in hospital and community

premises and given to the women by the midwives at discharge. This will be checked and updated regularly.

13.3 Community staff will confirm that mothers have received this information and that

they know about the groups local to them. 14. CONTINUED BREASTFEEDING 14.1 Breastfeeding progress will be checked at each contact between health

professional and mother so that possible problems can be recognised early. 14.2 Mothers will receive support and information to help them continue to breastfeed on

returning to work. 14.3 Mothers will be given the opportunity to learn hand expressing and its value once in

the community. 14.4 Parents will be informed of the health benefits of any continued breastfeeding for at

least the first two years of baby‟s life in line with WHO recommendations or longer if mother and child prefer.34

14.5 The Department of Health recommend exclusive breastfeeding for the first six

months, and breastfeeding to continue to be an important part of the babies diet for the first year of life.35 WHO also recommend exclusive breastfeeding for the first six months, thereafter infants should receive complimentary foods while continuing to breastfeed for up to two years of age or beyond.33

14.6 Parents should be informed of the health benefits of delaying the introduction of

solids until around six months and of the developmental changes that determine readiness for this.36

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15. SUPPORTING BREASTFEEDING IN THE COMMUNITY 15.1 In line with the Equality Act 2010 this policy upholds that women should not be

discriminated against when breastfeeding. The new law makes it clear that it‟s against the law for you to get less favourable treatment because you‟re breastfeeding when receiving services for example in a café, on a bus, in a cinema, etc.

15.2 Breastfeeding will be regarded as the normal way to feed babies. There will be

signs in health care premises advising mothers that they are welcome to breastfeed in all public areas with privacy offered to those who prefer it.

15.3 All mothers who are breastfeeding will be given information about feeding in public

and any local Breastfeeding Welcome Schemes. 15.4 Formula milk will not be available in community health care premises. Health

professionals involved in their care should inform all eligible families of the Healthy Start scheme.

15.5 Health professionals and voluntary breastfeeding support groups will work together

to ensure the continued development and support of breastfeeding in the locality. 15.6 Voluntary breastfeeding support groups will be involved in policy development.

16 CARE FOR MOTHERS WHO HAVE CHOSEN TO FEED THEIR NEWBORN WITH INFANT FORMULA.

16.1 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.

16.2 Staff should ensure that mothers are aware of effective techniques for formula feeding their baby.

16.3 Community midwives will check and reinforce learning following the mothers transfer home.

16.4 All information given should follow guidance from the Department of Health. Information should be reinforced by offering the Department of Health Bottle Feeding leaflet (or local equivalent).

***************************************************************************************************** INFORMATION IN SUPPORT OF THE POLICY 1. PREGNANCY 1.1 Although choice of feeding method is affected by socially acquired attitudes and the

available support mothers feel they may or may not get from family and friends varies, attitudes may be changed by giving new information.37

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1.2 The physiological basis of breastfeeding will be clearly and simply explained to all

pregnant women, together with good management practices and some of the common experiences they may encounter. The aim will be to give women confidence in their ability to breastfeed.

1.3 The differences between breastfeeding and formula feeding will be discussed and

there will be no group demonstration on sterilising or making up feeds in the antenatal period. This will be done on a one-to-one basis after the baby is born.15

2 AT BIRTH 2.1 Babies who are nursed in skin-to-skin contact raise their core temperature quicker

and maintain it for longer than those who are wrapped and held. Skin-to-skin contact also assists in regulating baby's heart rate and breathing.21

2.2 Skin-to-skin contact has a stabilizing effect on mother‟s blood pressure and heart

rate38 and enhances bonding.39 2.3 Skin to skin contact should be actively encouraged and supported for all babies

regardless of gestation or health status, with appropriate supervision where necessary.

2.4 During this time babies who are held skin to skin usually locate the nipple and

initiate breastfeeding. 2.5 Weighing of the baby should be left until after the first breastfeed to allow

uninterrupted skin to skin. Weighing the baby immediately after the birth and then starting uninterrupted skin to skin may be necessary in some circumstances

2.6 Where delivery takes place in an operating theatre (eg by c/s) skin to skin contact

should be facilitated in the theatre whenever possible. However, this initial period will necessarily be limited (by the time it takes to complete surgery)and the mother‟s position may not be conducive to breastfeeding. Time spent in the recovery room and/or the postnatal ward should therefore be seen as the most appropriate opportunity for ensuring an unhurried period of skin contact and facilitation of the first feed.78

2.7 All mothers will be encouraged to hold their babies so that breastfeeding is enabled

and they will be aware of the benefits of this first feed even if their intention is to formula feed.

2.8 Babies who are removed for washing and dressing, and those whose mothers have

had opiate analgesia during labour will have delayed responses and often latch on incorrectly. These babies need more time and help to achieve the first feed.40

2.9 If skin contact has to be delayed or interrupted for medical reasons, it will be

resumed as soon as possible regardless of the length of time since birth. 2.10 Skin contact is an excellent way of calming a fretful baby of any age.21

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2.11 Mothers will be discouraged from using perfumed products, as the baby needs to recognize the mother‟s natural smell.41

3. POSITIONING AND ATTACHMENT See Appendix 3. for pictures 3.1 When helping a mother to breastfeed, carers will not intervene too quickly and will

adopt a hands-off approach but will encourage the mother‟s own efforts. However, it will be remembered that once the baby and also the mother have experienced a satisfactory feed, subsequent feeds will be easier.

3.2 Babies who find the breast themselves and attach unaided, often with

mother in the “laid back” position also described as the “biological nurturing position”, tend to achieve optimal attachment, as it triggers their innate feeding reflexes.42 A mother can be supported in this by health professionals recognising the natural behaviour of the baby and drawing her attention to it.

3.3 The following points are the same for any position the mother and baby find

comfortable.43

The baby will be held close.

Babies head is in line with his body with freedom to tilt his head back. (Pressure, however light, on the baby‟s head will prevent him extending his head and attaching correctly to the breast.)

Baby‟s nose will be opposite the nipple so that he has to extend his head to achieve a correct feeding position.

The baby will be supported behind the shoulders and neck. Wait until the baby‟s mouth is wide open and his tongue protrudes over his lower lip before moving him quickly to the breast. Aim the nipple over his tongue towards the back of his mouth.

Ensure the position is sustainable for the duration of the feed after the baby is correctly attached.

3.4 When the baby is correctly attached: 43

His chin will be against the breast leaving the nose clear.

The mouth will be wide open.

His cheeks will be full and rounded, not sucked in.

More areola is visible above the top lip than the bottom lip.

The lower lip is curled back (the mother may not be able to see this).

The feeding has a rhythmic suck/swallow pattern and the milk transfer can be heard.

When attachment is optimal a mother is unlikely to experience pain during feeding

3.5 For any baby who is reluctant to attach, unhurried skin-to-skin contact and

explanation of recognition of feeding cues to the mother is recommended.

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3.6 Signs of good milk transfer:

The baby will appear content and satisfied after most feeds.

The baby should be gaining weight by two weeks.

The baby should look healthy and well.

The mother‟s breasts and nipples should not be sore.

After the first couple of days the baby should have at least six wet nappies a day.

The baby should pass at least two yellow stools a day in the first few weeks. 4. DURATION AND FREQUENCY OF FEEDS 4.1 Mother will be encouraged to respond to her baby‟s feeding cues rather than

waiting for the baby to cry when he will need calming before feeding.

Eye movements.

Restlessness, wriggling.

Hand movements, often to mouth.

Rooting.

Licking, smacking lips

Sucking fingers/ fists 4.2 Let the baby finish feeding spontaneously from the first breast, then offer the

second breast. 4.3 If feeds are excessively long, observation of a breastfeed to assess milk transfer is

recommended by a health professional. 4.4 No extra fluids need be given15. 4.5 Babies who are compromised at birth need to be offered the breast at least every 2-

3 hours. Appendix 1 Reluctant Feeders 4.6 Mothers, regardless of their method of feeding, will not be separated from their

babies unless there is a valid reason. 5. NUTRITIONAL NEEDS OF A MOTHER 5.1 Breastfeeding mothers need not omit or take any particular food. 5.2 The lactating woman will regulate her fluid and food depending on her thirst and

appetite but women who are tired or stressed may need to be encouraged to eat and drink.

5.3 Women who are concerned about a family history of allergy may appreciate referral

to a dietician. 5.4 Women who are avoiding dairy produce will benefit from calcium supplementation

of 700 mg/day being normal recommended intake and 500 mg/day extra for lactating women.44

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5.5 Vitamin D supplements of 10 micrograms a day are valuable to all women who are

pregnant or breastfeeding but especially important for women who are obese, have limited skin exposure of sunlight or who are of South Asian, African, Caribbean or Middle Eastern Descent .45

5.6 Crash dieting will be discouraged as it releases environmental toxins into the

mother‟s blood stream.46 5.7 Alcohol will be discouraged because it can inhibit the milk ejection reflex and has a

mild sedative effect on the baby.47 5.8 Smoking lowers prolactin levels and mothers who smoke are advised not to smoke

for an hour and a half before feeds in order to reduce nicotine exposure to the baby. Cigarette smoking is associated with significant reduction in milk volume and milk fat concentration. However breastfeeding is still the best choice even if the mother cannot give up smoking.48

5.9 Parents who smoke will be discouraged from bed sharing with their baby, as it is

known to be an associated factor in Sudden Infant Death Syndrome (SIDS).49. 5.10 There is evidence to suggest that breastfeeding reduces the risk of

Sudden Infant Death by 50%.50

5.11 Parents who wish to give up smoking will be referred to the smoking cessation

service.

Contact telephone numbers. Bournemouth and Poole NHS Stop Smoking Service 0300 3038038 Dorset NHS Smoke Stop Service 0800 007 6653

6. NUTRITIONAL NEEDS OF A FULL-TERM, HEALTHY BABY 6.1 Colostrum and breast milk provide for the entire baby‟s nutritional needs as well as

having significant immunological properties. 6.2 The baby will be allowed to complete feeding from the first breast to ensure he

receives the high fat content, high calorie milk. The second breast will then be offered.51

6.3 Mothers, who want to give a formula feed to their babies, will be helped to make an

informed decision as to the detrimental effect this can have on lactation and the implications for future health of the baby. Mothers will also be given the choice about how any supplement is given, spoon, syringe or cup feeding being preferred over bottles and teats while lactation is being established.

6.4 Signs of adequate milk intake include at least two wet nappies at day two and

increasing to six a day around about day 5 or 6.79 Stools progressing from meconium to yellow within a few days of birth, an alert, happy baby and steady weight gain after an initial loss. Head circumference and length are more reliable indicators than weight alone.

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6.5 If weight gain falters, increasing the frequency of breastfeeds and offering both

breasts at each feed is the first line of management. 6.6 Exclusive breastfeeding is recommended by World Health Organisation (WHO) for

the first six months.52 Parents who decide not to will be supported, whatever their reason for reducing or stopping breastfeeding but should be made aware of the benefits of any breastfeeding.

6.7 From about six months as a baby shows signs of being ready, other food should be

offered in addition to breast milk. 6.8 The Department of Health recommend exclusive breastfeeding for the first six

months and breastfeeding to continue to be an important part of the babies diet for the first year of life35. WHO also recommend exclusive breastfeeding for the first six months, thereafter infants should receive complimentary foods while continuing to breastfeed for up to two years of age or beyond33.

7. SORENESS 7.1 When the baby is attached correctly to the breast, feeding will not be painful

although some women experience discomfort throughout lactation. 7.2 Nipple sensitivity is normal in the first few days of feeding. Women need

reassurance that this is a normal physiological response and is not due to trauma. 7.3 A stinging feeling on the areola at the beginning of each feed can also be

experienced. Reassurance that this only lasts until the „let down‟ reflex occurs (40 seconds approximately) is all that is required.

7.4 Nipple soreness is not related to the mother‟s skin type or colouring. 7.5 If nipples have become either cracked or bruised, correcting the feeding position

enables breastfeeding to continue, 53 moist wound healing using petroleum jelly or purified lanolin speeds healing54, 55.

7.6 There is no scientific basis for the use of other creams, sprays, lotions or ointments;

54, 55 they can cause an allergic reaction. 7.7 Tongue tie may be the cause of poor attachment /sore nipples and prompt referral

should be made to the appropriate clinicians for review and frenulotomy where necessary.56.

8. CANDIDA ALBICANS (THRUSH) 8.1 Both mother and baby can suffer from infection by Candida albicans57, 58.

8.2 In all cases of thrush it is beneficial to treat both mother and baby though only one

may display symptoms.

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8.3 In babies, thrush:

May manifest as white patches in the mouth, which may or may not appear to cause the baby pain.

May also cause an aggressive nappy rash.

May lead to fretfulness and wind.

Should be treated topically.

In mothers, thrush:

May be superficial and manifest as shiny, itchy areola often of a lighter colour than usual and this should be treated topically.

May be within the milk ducts.

Ductal thrush may either be associated with superficial thrush or have no external signs.

It is often acutely painful with a sharp stabbing pain which goes through to the shoulder blade, often persisting for long periods after a feed.57

Is almost always bilateral.57

Can be distinguished from pain caused by poor attachment by the fact that the pain persists after the feed while the worst of the pain from poor attachment goes away when the baby is not feeding.

Commonly occurs after painless breastfeeding has been established.

Is more likely following antibiotic treatment.57

May be present where damaged nipples are taking a long time to heal despite correct positioning.57

Is less likely to be the cause when the deep pain is in one breast only.57

Treatment

Initial treatment of the mother and baby with a topical agent should be followed quickly by systemic treatment for the mother if the problem does not resolve.58

The following websites have current information: http:/www.breastfeedingnetwork.org.uk http://www.ukmicentral.nhs.uk/drugpreg/qrg_p1.asp#Antifungals

9. USE OF TEATS, NIPPLE SHIELDS AND DUMMIES 9.1 Parents will be informed of the detrimental effect that teats, dummies and nipple

shields have on lactation, particularly while lactation is being established. 9.2 If supplements are necessary they can be given by spoon, syringe or cup. 9.3 Nipple shields, as well as being a potential source of infection, reduce the amount

of milk available to the baby, so will not be encouraged.59 Also, if used from the beginning, can lead to the baby refusing to latch-on without it.

9.4 Dummies have been shown to have an adverse effect on breastfeeding.60 If used to

prolong the interval between feeds, lactation will be compromised. 9.5 Getting a baby used to taking a bottle is better delayed until lactation is established

and breastfeeding trouble-free.

18

10. EARLY ENGORGEMENT 10.1 This occurs sometimes when the baby is not given free access to the breasts.

Gentle hand expressing can provide relief and reduce the build up of Feedback Inhibitor of Lactation (FIL)23. Expressing large amounts may perpetuate the problem.

10.2 Prevention and Treatment61, 24

The following actions will help in prevention and treatment:

Early initiation of breastfeeding.

No regulation of frequency or duration of feeds but reluctant feeders will be encouraged to feed more frequently.

Ensure correct feeding position and attachment.

Hand expression of enough milk to ensure comfort for the mother

Warm compresses/bathing before a feed encourages milk flow.

Disperse oedema of areola by gentle fingertip pressure away from the nipple. This makes it easier for the baby to latch on.

An alternative feeding position may help to assist the baby to attach.

After feeds, cold compresses are soothing and reduce inflammation.

Analgesia and anti-inflammatory medication if required.

Explanation to the mother that the condition is temporary can be reassuring. 11. MILK ENGORGEMENT 11.1 This rarely occurs when mothers are enabled to feed their babies „on demand‟ day

and night. It most commonly occurs during weaning from the breast, particularly if this is abrupt.

11.2 Prevention and Treatment:

Avoid sudden changes in feeding regime

Recognition of signs and early management

Treatment as for Early Engorgement 12. EXPRESSING BREAST MILK 12.1 Hand expressing is easily taught and empowers the mother to manage possible

breast problems in the future. All women will be taught this technique before discharge from hospital. In the case of a home birth the community midwife will take responsibility for this.

12.2 Instructions for hand expressing are available in a variety of formats.62, 63 12.3 Mothers who are particularly keen to ensure their baby receives no formula milk can

be encouraged to express antenatally from 36 weeks gestation. This is of particular importance to women with diabetes.64 This is because their babies are more likely to suffer from low blood sugar and if this arises, the saved colostrum can be given

19

in preference to either glucose or formula.64, 65 Any formula milk given to these babies very significantly increases the chances of them developing type one diabetes later in life.66 Small syringes can be supplied to these women for collecting colostrum and these will be stored safely in the hospital during labour.

12.4 Mothers who are expressing their milk for babies in hospital may prefer to use an

electric pump once adequate amounts of milk are being obtained. Dual pumping is considered to yield more milk.67 Breast pump equipment needs to be sterilised between episodes of expressing.

12. 5 Stored breast milk may be kept:

Up to 5 days in the main part of the fridge at 4ºC or lower (This preserves its properties better than freezing).

Up to two weeks in the freezing compartment of a fridge.

Up to six months in a domestic freezer at -18°C or lower.

Frozen milk should not be refrozen once thawed.68 12 .6 Donor expressed milk is used in the Neonatal units for premature and

sick babies. Any mother interested in donating milk should contact: Princess Anne Hospital, Southampton 02380 796009

13. RELUCTANT FEEDERS 13.1 If the mother had pethidine or an epidural in labour, the baby may be sleepy and

uninterested in feeding for 24 hours.69 13.2 Follow flow chart for reluctant feeders if concerned. (Appendix 1) 13.3 Babies of 37 weeks gestation can take up to three days to mature their suckling

patterns.70 13.4 When babies or mothers are washed before the first breastfeed, there will be

delayed responses and longer time will be needed in skin-to-skin contact.40,71

13.5 Some babies just want to rest after delivery. 13.6 “Mucousy” babies may be slow to feed and benefit from extra skin contact. Management 13.7 Ensure mother and baby are kept in close contact, skin-to-skin where possible, to

stimulate natural feeding responses and to encourage early response to feeding cues.20,21

13.8 When a baby has not fed and where there is a reason for the baby not initiating

feeding, the first line of action is to feed the baby expressed breast milk 2 hourly. This stimulates lactation and encourages the baby to commence full breastfeeding sooner.

20

13.9 Cup or syringe are appropriate methods of giving supplementary feeds and can prevent the baby learning an incorrect sucking action.

13.10 Parents will benefit from information about the small size of babies stomachs. It is

reassuring for them to know that very small amounts of colostrum are valuable. 13.11 Feed -Check -Review is more appropriate than blood glucose testing and

supplementary feeding. 13.12 At risk babies will need earlier intervention, where local policies will be followed. 13.13 Blood reagent sticks are known to be inaccurate and Haemacue or Acustix testing

gives a more accurate result. Blood sugar testing should be done according to local policies.

13.14 A baby who is unwilling to feed may be ill. Clinical observation for muscle tone,

fever, jaundice, tachyapnoea, colour and signs of readiness to feed will be made regularly and is more valuable than blood glucose testing alone.

14. WEIGHT LOSS AND SLOW WEIGHT GAIN IN THE BREASTFED BABY 14.1 Excessive early weight loss is always a reason to review the feeding frequency and

technique to ensure that a good attachment is present and the baby getting lots of access to the breast.

14.2 Weight loss that continues after 5 days or where the baby has not regained its birth

weight by 2 weeks is occasion to check again the attachment and milk transfer and ensure you observe throughout a full feed for clues as to why the baby is not getting adequate milk.

Is time at the breast limited?

Is only one breast ever being offered?

Are there signs of good milk transfer?

Is the frequency of feeding being baby led? 8-12 in 24hrs is normal under 6 weeks.

Is the baby showing signs of being unwell?

Is the baby having wet and dirty nappies? (6+ wet nappies a day and 2+ dirty nappies in a baby under 6 weeks)

Are nipple shields, teats or dummies being used? See Section 9

Does mum smoke?

Has the mother had breast surgery?

Is the mother unwell?

14.3 In an older baby review the feeding position and milk transfer throughout a feed and take a full history. Sometimes positions need to be adjusted as the infant grows to ensure a good deep latch. Also consider:

Is the baby leading the feeding frequency?

Have night time feeds just been stopped?

Has the baby been or is ill?

21

Is the baby always being distracted when feeding and so stopping prematurely?

Has the baby been receiving water or other low calorie supplements instead of a feed?

Have solid foods been introduced early i.e. before about six months, and breastfeeds reduced as a result?

Is the mother unwell?

14.4 Further support is available to the health professional or mother from organisations listed in appendix 2 when these avenues have been explored.

15. PHYSIOLOGICAL JAUNDICE 15.1 Additional fluids have no beneficial effect in the prevention or limitation of

physiological jaundice. 15.2 Babies becoming jaundiced in the first 24 hours and those who are persistently

jaundiced at 14 days will be referred to a paediatric unit. 15.3 Babies with jaundice, receiving phototherapy, may require additional fluids and may

be sleepy and need to be treated as reluctant feeders. Expressed Breast Milk (EBM) is the preferred option for additional fluids, which may be given by cup or syringe.

16. MAINTAINING LACTATION 16.1 Mothers who change to formula feeding soon after delivery can be given the

opportunity to change their minds to try breastfeeding again. 16.2 Mother‟s milk will be appropriate for her baby. It will not be too weak or too strong. If

there appears to be insufficient milk, attention to positioning and attachment, duration and frequency of feeds and offering the second breast, as well as expressing, will be tried before suggesting formula feeds.

16.3 Appetite spurts can occur at any time but are most common at around six weeks

and three months. Baby will feed more frequently during these times and the mother will be reassured this is normal and her milk supply will adjust to demand.

16.4 Babies given formula milk or any other supplement, including water or a dummy will

tend to suck less at the breast; the amount of stimulus to the breast will be reduced so the milk supply is likely to drop.

16.5 Weaning foods given before six months will usually replace breast milk intake rather

than supplement it. It is therefore usually not beneficial to offer other foods before six months unless for a medical reason, and on the advice from a dietician or paediatrician.

17. MASTITIS 72 17.1 Mastitis is caused by localised milk obstruction. 17.2 Prevention

22

Correct positioning and feeding technique is essential.

Frequent unrestricted feeds.

Gentle handling to prevent bruising and tissue damage.

Gentle massage/stroking during feeding and expressing

Avoidance of tight bras/clothing or any other constriction of the breast. 17.3 Signs/Symptoms

Lumpy, hot area in the breast.

Pain.

Redness of one segment, which may extend into axilla.

Flu-like symptoms may occur due to inflammatory process caused by the re-absorption of milk.

17.4 Management

Continue to breastfeed frequently and express milk by hand or pump to relieve stasis.

Change feeding position so that the baby‟s tongue is under affected area of breast.

Anti-inflammatory drugs will reduce symptoms and exclude the need for antibiotics in most cases.

Apply heat before feeds to help the milk flow and cold after feeds to help reduce inflammation.

If symptoms persist for more than eight hours prophylactic antibiotic cover may be appropriate.

Breastfeeding will continue on both breasts in order to prevent mastitis progressing to breast abscess.

Position mother so her breast is hanging into the babies‟ mouth i.e mother leaning forward on all fours over the baby. Gravity will then help to drain the breast.

Acute Infective Mastitis is rare and often confused with breast abscess. Treatment would be the same as for mastitis but with the addition of appropriate antibiotic medication.

18. BREAST ABSCESS 23

18.1 Can manifest suddenly without prior symptoms or signs. May form superficially,

often near the areola and may not be painful. 18.2 Treatment

Breastfeeding will continue as it speeds healing.

Visualisation under ultrasound, aspiration and treatment with appropriate antibiotics until culture is sterile. If surgery is necessary, breastfeeding will continue unless the position of the incision precludes it. If the baby is not feeding at the breast, then the breast should be expressed regularly to maintain lactation.

Feeding will always continue uninterrupted on the unaffected breast.

23

19. HIV/AIDS 19.1 In this country where alternatives to breastfeeding exist without a significant risk of

life-threatening gastro-enteritis, mothers who are HIV positive or have AIDS will be advised not to breastfeed.73,74

20. HEPATITIS 20.1 When a mother is Hepatitis B positive she may breastfeed provided that the baby is

given Hepatitis B immunoglobulin, plus Hepatitis B vaccine at birth. Additional doses of vaccine will be given at one month, two months and twelve months of age. All babies, of infected mothers, regardless of method of feeding, will be offered immunisation.75

20.2 Hepatitis C is not a contraindication to breastfeeding when the mother is

asymptomatic unless the nipples are bleeding which can lead to contamination from the blood.76

21. DRUGS AND BREASTFEEDING 21.1 Women will be encouraged to inform their medical practitioner that they are

breastfeeding when prescribed any medication. 21.2 Women who are breastfeeding an older child should be advised to remind their

medical practitioner that they are breastfeeding when they are prescribed medication.

21.3 Women using alternative therapies will be encouraged to seek professional advice. 21.4 Women using non prescribed drugs will be encouraged to seek professional advice.

For queries relating to drugs and breastfeeding contact the Breastfeeding Network drug helpline on 08700 604 233.

24

APPENDIX ONE:

GUIDELINES FOR RELUCTANT BREASTFEEDERS/SLEEPY BABIES WHO ARE GOING TO BREASTFEED 74

NB: These guidelines are for term healthy babies. In these guidelines for convenience the baby is referred to as “he”. (These guidelines should be used within the context of best practice management of breastfeeding i.e. the baby should be gently encouraged to feed soon after birth, helped by skin to skin contact. If he has not had his first feed by the time he is four hours old or his second six hours later follow the guideline below:)

See supporting Information Section 13 for causes to consider.

Look at the history- Pethidine? Cold? Low Apgars?

Infection?

Be pro-active this baby may not demand feed.

Encourage his mother to lead the feeding until he has

woken up and asked for a couple of breastfeeds and fed

well. Explain his feeding using cues to the mother

Is Baby/Room too hot? Is the baby well?

Undress the baby and place skin to skin with mum

Encourage mother to chat to baby and massage his

hands and feet

If he has still not fed two hours later, teach the mother to hand express colostrum

onto her nipple to tempt the baby.

Hand express and give the colostrum

Give as much colostrum as available, either from

syringe or mothers finger

Keep the baby and mother skin to skin

REPEAT IN TWO HOURS

Continue with mum hand expressing and giving colostrum at two hourly intervals

until the baby feeds well.

Keep the baby near the breast so that he gets lots of practice at breastfeeding

RE-ASSES the baby- his mother is the best person to

keep an eye on her baby with temp, respiration etc

Keep pace with baby’s food requirements when he is

two days old they will increase

25

APPENDIX TWO SOURCES OF FURTHER HELP AND INFORMATION: 1) National Breastfeeding Helpline

National Breastfeeding Helpline 0300 100 0212 2) National Childbirth Trust Breastfeeding Line.

Breastfeeding Line - 0300 330 0771

8am–10pm, seven days a week

3) Breastfeeding Network Helpline.

BfN Supporter line 0300 100 0210

Bengali / Sylheti Supporter line 0300 456 2421

4) Association of Breastfeeding Mothers.

Counselling Hotline 08444 122 949 5) La Leche League.

Call 0845 120 2918 6) Real Baby Milk

For Local Peer Support Information in NHS Dorset Rebecca Harris 07818 241356

National Website realbabymilk.org/Dorset

26

APPENDIX THREE POSITIONING AND ATTACHMENT PHOTOGRAPHS

Laid Back Nursing Position

© Real Baby Milk CIC

Cross Cradle Hold feeding position

© A.Cox

Wide open gape and lower lip well away from nipple.

© H.Shanahan

Mother’s eye view, nose free and chin pressed well into breast.

© A.Cox

27

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