The purpose of this policy is to facilitate and encourage successful breastfeeding
during hospitalization and after discharge. This policy has been developed
to meet the requirements recommended by the World Health Organization
(including Baby Friendly guidelines), the California Hospital Infant Feeding
Act, and The Joint Commission’s Perinatal Core Measure to increase
the proportion of infants being breastfed. Additionally, the policy supports
the Healthy People 2020 goal of reducing the percentage of breastfed infants
who receive formula before two days of age.
- Maternal Child Heath (MCH) staff and the Lactation Consultants, will educate,
inform, and assist patients with breastfeeding techniques and any needs
that arise concerning breastfeeding.
All staff will
support patients wishing to breastfeed their infants.
- To ensure consistent quality care and patient education, all nursing staff
will complete 15 hours of education and 5 hours of clinical competency.
The curriculum for this education will cover the 15 sessions identified
by Baby Friendly USA and compliance of education will be documented in
the employee education (blue) file and followed by the MCH Clinical Manager.
Initial lactation education will be completed within 6 months of hire
or transfer to MCH department. This facility does not accept training
prior to hire.
- Per Baby Friendly requirements, staff is required to complete two hours
of breastfeeding education every year to maintain their competencies.
Lactation Consultants attend monthly Coalition meetings for updates and
educational opportunities within Tulare County.
- The staff provides up-to-date and accurate, evidence-based, written information
and resources to all pregnant women (outpatient and inpatient) related
to lactation science and breastfeeding best practice. This information
includes benefits of breastfeeding and explanation of the practices implemented
in the MCH unit that support successful breastfeeding.
Sierra View Medical Center (SVMC) adheres to the International code of
Breastfeeding substitutes which states:
- Employees of manufacturers or distributors of breast milk substitutes,
bottles, nipples, and pacifiers have no direct communication with pregnant
women and mothers.
- The facility does not receive free gifts, non-scientific literature, materials,
equipment, money, or support for breastfeeding education or events from
manufacturers of breast milk substitutes, bottles, nipples, and pacifiers.
- No pregnant women, mothers, or families are given marketing materials,
samples, or gift packs by the facility that consists of breast milk substitutes,
bottles, nipples, pacifiers, or other infant feeding equipment or coupons
for the above items.
- Any educational materials distributed to breastfeeding mothers are free
from messages that promote or advertise infant food or drinks other than
- Sierra View Medical Center pays fair market value for breast milk substitutes
and this facility does not offer group education on the use of infant
formula or feeding bottles.
- This policy will be reviewed and revised according to the House-Wide Policy
& Procedure, “Policy and Procedure System.”
AFFECTED AREAS/PERSONNEL: ALL MCH/PEDIATRICS STAFF, PHYSICIANS, AND HOSPITAL STAFF CARING FOR INFANSTS
AND/OR LACTATING WOMEN
- Patients are educated about the benefits of breastfeeding. Once educated,
patients will choose a feeding preference for their infant. This preference
will be documented in both the patient’s and infant’s medical record.
- Patients are provided information about the risks of not breastfeeding
and the potential consequences of feeding infant formula (breast milk
Upon delivery and within the first three hours of life:
- The nursing staff present immediately after delivery has the responsibility
to create the optimal environment for transition of the infant and initiation
of the first breastfeeding. This encompasses placing the infant skin to
skin with the mother immediately after birth, assisting the mother to
recognize infant signs of readiness to feed and allowing the infant to
self-attach to the breast.
- All infants (regardless of infant feeding choice), unless there are medically
justifiable reasons for delayed contact (such as neonatal resuscitation,
physical signs of distress or abnormality), will be placed skin to skin
with mother. This contact will continue until the completion of the first
feeding. This practice is referred to as “The Golden Hour.”
- Skin to skin contact is defined as the infant being dressed only in a hat
and diaper and placed on the mothers or fathers bare chest. For vaginal
births, skin to skin contact is initiated within the first 5 minutes after
birth. For C-sections, skin to skin contact is initiated as soon as the
mom is alert and able to respond. Documentation of skin to skin start
and stop times are noted in the electronic medical record.
- Routine admission procedures such as assessment and vital signs should
be completed with the infant skin to skin with the mother. Procedures
requiring separation from the mother (e.g. bathing, and newborn medications)
can be delayed up to two hours after the initial period of skin to skin
contact and initial latch to promote breastfeeding and “The Golden
- Visitation should be kept to a minimum during these first 2 hours to allow
for parents -infant bonding (or those present at birth).
- The room should be kept warm to avoid thermal stress to the infant.
- Breastfeeding mothers should be offered assistance by MCH staff with initiating
breastfeeding in the LDR (labor room) or in the PP (postpartum) room (for
C-section recovery) within the first ½ hour of birth to take advantage
of the infant’s alert state, unless otherwise ordered by the physician.
- Assist the mother with proper positioning of the infant at the breast:
- Use extra pillows, folded blankets or towels to assist in proper positioning
of the infant.
Educate the mother on the Laid back position, Cross-cradle, Cradle, Football,
Side-lying, and various alternative positions.
- The Registered Nurse (RN) will document a LATCH assessment (see Attachment A)
- one time per shift or more often as needed. Breastfeeding assessments will optimally
- begin within the first two hours during the recovery period after birth,
but no longer
- than 6 hours after birth.
9. Instruct the mother about proper latch and assess breastfeeding technique.
- Help the mother position the baby so his/her nose is level to the mother’s
nipple. Bring the baby’s chin in contact with her breast. Instruct
the mother to lightly stroke the infant’s bottom lip with her nipple.
When the infant opens its mouth wide, the mother should move the baby
quickly and gently towards her, ensuring the infant’s tongue is
down and the chin makes first contact with her breast. Ensure that the
baby’s lips are flanged outward and his/her nose is slightly away
from the breast for easier breathing. Baby should be latching past the
nipple deep onto the areola to allow for more efficient milk transfer
- If the infant’s breathing is obstructed, the infant’s position
should be adjusted without the breast being depressed away from the infant’s
nose. Breathing is quite adequate through the side channels of the nares.
- Be sure the mother realizes that the breast fed infant does not suck continuously
but will stop and resume sucking at frequent intervals.
- Remove infant from breast by breaking suction with little finger inserted
into the side of the infant’s mouth.
- Instruct mother to burp infant after she/he finishes nursing, teaching
techniques for holding infant upright, applying gentle pressure against
the abdomen and patting or rubbing the back.
Ongoing care of the breastfeeding couplet:
- In collaboration with the RN Staff, all mothers are provided with Lactation
Consultant Services, bedside consultation, hands-on assistance with positioning,
ongoing assessment of effectiveness of breastfeeding, interventions for
sore nipples, latch concerns, engorgement, and breastfeeding education.
- Feeding Frequencies
- Educate the mother about infant-led feeding patterns including feeding
cues, feeding frequencies, average duration, and signs of effective latch
and suck. No limitations will be taught to mothers regarding feeding lengths
or number of feedings. Mothers should breastfeed or express their milk
at least eight times or more every twenty four hours to establish and
maintain their milk supply.
- Rooming in, or couplet care, is provided to promote bonding and uninterrupted
breastfeeding. As appropriate, all routine procedures will be performed
at the mother’s bedside.
3. Breast and nipple care:
- Daily bath or shower, no soap or lotion on nipple.
- Breast pads may be used but should be changed often.
- Reassure mothers that breastfeeding can continue or quickly resume with
the correction of problems such as:
- Painful or bleeding nipples
- Cracked or fissured nipples
- Engorged breasts
- Inverted nipples
4. Infant Separation
- Parents whose babies are being cared for in the special care nursery can
place the baby skin to skin as soon as the baby is considered ready for
- Education is provided regarding how to begin pumping and the importance
of pumping eight to twelve times in a twenty-four hour period to stimulate
milk production. If mother and infant are separated, the mother should
be instructed and assisted in pumping her breasts within six hours of delivery.
- Education regarding hand expression, and breast milk collection and storage
is provided. Patient is educated on cleaning the pump and collection parts
after each use.
- Supplies are available for collection of breast milk. Labeled containers
will be stored in the NICU breast milk refrigerator. (See Policy, Breast
Milk Collection and Storage).
5. Supplemental Feedings
- No supplemental feeding, other than breast milk, will be given unless medically
indicated and is ordered by the primary care provider.
- Medical indications for formula supplementation include, but are not limited
to the following:
- Hypoglycemia (less than or equal to 40 mg/dl).
- Latch not established in an infant greater than 6 hours. Consultation with
the Lactation Consultant is recommended.
- Weight loss greater than 10%.
- Elevated bilirubin (utilizing the Bhutani Nomogram and AAP guidelines for
- Unstable infant admitted to NICU. (Respiratory, GI, prematurity, Congenital
Supplementation should be done by gavage, cup, syringe, or supplemental
nursing system (SNS). Feedings should be provided at the breast whenever
possible. No more than 15 ml of supplementation is given at each feeding
unless otherwise ordered by the physician.
Pacifiers will not be given by the staff to breastfeeding babies.
Pacifiers may be used for the breastfeeding infant during painful procedures
and/or therapeutic medical procedures (e.g. blood draws, prematurity,
neonatal abstinence syndrome). Discard the pacifier after procedure. Pacifier
should not be with the infant when infant is returned to mother.
If a mother requests a pacifier, education will be provided and documented
as to why we don’t provide pacifiers. The potential hazards associated
with pacifier use may include, but are not limited to:
- Not latching and/or sucking properly at the breast (breast refusal or nipple
- Disruptions in milk supply
- Weight loss and/or slow weight gain
6. Contraindications for breastfeeding: Only a physician or Lactation Consultant
contraindications to breastfeeding. Documentation must be in the infant’s chart.
Contraindications may include, but are not limited to:
- Active Tuberculosis
- Active Hepatitis
- Current chemotherapy
- Human T-cell lymphotrophic virus
- Active herpes simplex lesions on the breast
- Mother is using or is dependent on illicit drug
- Contraindicated medications- (Medications and Mothers’ Milk, 2012,
by Thomas Hale)
7. Education and Support
- Inpatient and outpatient lactation support and education are provided to
patients by the MCH RN staff and/or Lactation Consultants. Prenatal childbirth
and separate breastfeeding classes which follow the Baby Friendly guidelines
and curriculum are offered monthly in English and Spanish.
- Lactation Consultants provide prenatal breastfeeding education curriculum
and supportive education to the outpatient OB and pediatric clinics. The
MCH RN staff and Lactation Consultants collaborate with the community-based
Women, Infants and Children (WIC) program, the Tulare County Breastfeeding
Coalition (TCBC) and county resources alongside First 5. These agencies
help to promote a consistent, coordinated message about health and the
importance of breastfeeding within our county.
- The MCH department has a breastfeeding help line (infant nutrition phone
line) and a Breastfeeding Support group that is available to the mothers
after discharge. Information about these support services are provided
at discharge from the postpartum unit.
- Discharge instructions will include the following:
- Assessment regarding long term feeding plans
- Education regarding the importance of exclusive breastfeeding for six months,
how to maintain lactation, signs of effective breastfeeding and adequate
nutrition (including urinary output, stool changes and weight gain), how
to hand express and/or use the breast pump, how to handle and store breast
milk, and maintain lactation if the mother is separated from the infant
or will not be exclusively breastfeeding after discharge
- Education is given regarding proper diet, increased fluid intake, and continuation
of prenatal vitamins and iron as prescribed by the physician. This will
aid in establishing and maintaining an adequate supply of breast milk
and also aid in the health of the mother and baby
- Information regarding current outpatient breastfeeding resources and breastfeeding
support utilizing community-based programs which provide individual and
group counseling on breastfeeding and collaborates together to assure
breastfeeding success. Outpatient support is offered to any patient requesting
a consultation with a lactation consultant after discharge.
- Mother’s feeding preference and any reason she deviated from her
preference will be documented in the Infant’s medical record.
Attachment A: Latch Score
L - Latch
* Too sleepy or reluctant
* No latch achieved
* Repeated attempts
* Hold nipple in mouth
* Stimulate to suck
* Grasps breast
* Tongue down
* Lips flanged
* Rhythmic sucking
A – Audible swallowing
A few with stimulation
* Spontaneous and intermittent < 24 hours old
* Spontaneous and frequent > 24 hours old
T – Type of nipple
Everted (after stimulation)
C – Comfort (breast/nipple)
* Cracked, bleeding, large blisters or bruises
* Severe discomfort
* Reddened small blisters or bruises
* Mild or moderate discomfort
H – Hold (positioning)
Full assist (staff holds infant at breast)
* Minimal assist (i.e., place pillows for support, elevate head of bed)
* Teach one side; mother does other
* Staff holds and then mother takes over
* No assist from staff
* Mother able to position and hold baby
Attachment B: Feeding Cues