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1.0 Introduction

Welcome to Breastfeeding Policy Orientation

In this short course you will be

  • reviewing your Unit's breastfeeding policy, noting how it correlates with the Baby Friendly Initiative criteria, and
  • reviewing your responsibilities and those of your Unit, as defined by the World Health Organization Code on the Marketing of Breast-milk Substitutes and subsequent WHA articles (referred to as the WHO Code, or simply The Code).

Your Unit's breastfeeding policy may be unique to your Unit. However, to ensure best-practice protocols for the care of mothers and babies in your Unit and to achieve and maintain Baby Friendly accreditation, your policy must incorporate internationally developed strategies that protect, promote and support breastfeeding.

The Baby Friendly Initiative 10 Steps to Successful Breastfeeding for hospital facilities, and the 7-Point Plan for community health centres, are supported by the Innocenti Declaration, the World Health Organisation Code on the Marketing of Breastmilk Substitutes and the Global Strategy for Infant and Young Child Feeding.
The Steps and Points of the Baby Friendly Initiative are the practical 'how-to' guides to ensure clinical practice conforms with these international standards.

What is a Policy?

A policy is a deliberate set of statements that will

  • ensure consistent, effective care;
  • provide a standard of practice that can be measured;
  • support actions.

A regulatory policy, such as the policies implemented by health care institutions, limit the discretion of individuals or compel certain types of behavior. That is, you have a legal requirement imposed on you by your employer to follow the policy. It is not a personal decision whether you will follow or ignore certain aspects of a policy.
A policy that has been developed to support evidence-based, best-practice principles not only prevents conflicts in care, but is your protection should anything untoward occur.

Know your institution's policies

It is imperative that you know and comply with all the policies of your workplace. Not only will this protect your patients or clients, but it is also for your own legal protection.

Breastfeeding Policy and Procedures

Throughout this course you will refer to your institution's breastfeeding policy and the accompanying procedures that detail how the policy should be implemented.
Obtain a copy of the Breastfeeding Policy and Procedures now, and have it beside you as you work through this course.

When you see the 'books' icon it will indicate to you that you should refer to these documents.

What should I remember?

  • the purpose of policy documents
  • your responsibilities related to those policies

2.0 The Baby Friendly Initiative

In 1989 the Ten Steps to Successful Breastfeeding were set out in the joint World Health Organization and UNICEF statement "Protecting, promoting and supporting breastfeeding: the special role of maternity services". Two years later world leaders met in Italy where the Innocenti Declaration was drafted and endorsed by the World Health Assembly, giving it world-wide status and acceptance.

There were 4 targets set:

  • The third target stated that maternity facilities should practice the recently published Ten Steps to Successful Breastfeeding.
This came at just the right time historically and resulted in the launching of the Baby Friendly Hospital Initiative, which has been the most important and powerful step ever taken to protect the health of the World's children. It has put breastfeeding on the health policy map in almost every country in the world.

The Steps

The Baby Friendly Hospital Initiative (BFHI) was launched by WHO and UNICEF in June 1991 at a meeting of the International Pediatric Association. The goal is to promote the adoption of the Ten Steps to Successful Breastfeeding in hospitals worldwide. It is designed to remove hospital barriers to breastfeeding by creating a supportive environment with trained and knowledgeable health workers. Adherence to the WHO Code on the Marketing of Breast-milk Substitutes is also a requirement of the Initiative.

The Ten Steps to Successful Breastfeeding

  1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
  2. Train all health care staff in skills necessary to implement this policy.
  3. Inform all pregnant women about the benefits and management of breastfeeding.
  4. Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour. Encourage mothers to recognize when their babies are ready to breastfeed and offer help if needed.
    (Replaced: 'Help mothers initiate breastfeeding within a half-hour of birth' in 2009).
  5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.
  6. Give newborn infants no food or drink other than breastmilk unless medically indicated.
  7. Practise rooming in - allow mothers and infants to remain together - 24 hours a day.
  8. Encourage breastfeeding on demand.
  9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
  10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

To continue the best practices initiated in the hospital situation, and to provide supportive care to the mother in the community the Seven-point Plan for Sustaining Breastfeeding in the Community was launched in the United Kingdom in 1998 and subsequently modified and adopted by many other countries.

The Seven-point Plan to Promote, Protect and Support Breastfeeding in the Community*

  1. Have a written breastfeeding 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 groups and the local community.
* Various countries have altered the wording of some of these points slightly.

Integrated Ten Steps (Breastfeeding Committee for Canada)

In 2011 the Breastfeeding Committee for Canada developed and adopted the Integrated Ten Steps & WHO Code Practice Outcome Indicators for Hospitals and Community Health Services.

  1. Have a written breastfeeding policy that is routinely communicated to all healthcare staff.
  2. Ensure all health care providers have the knowledge and skills necessary to implement the breastfeeding policy.
  3. Inform all pregnant women about the importance and process of breastfeeding.
  4. Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour. Encourage mothers to recognize when their babies are ready to breastfeed and offer help if needed.
  5. Assist mothers to breastfeed and maintain lactation should they face challenges including separation from their infants.
  6. Infants are not offered food or drink other than human milk for the first 6 months, unless medically indicated.
  7. Facilitate 24 hour rooming-in for all mothers: mothers and infants remain together.
  8. Encourage baby-led or cue-based breastfeeding.
    Encourage sustained breastfeeding beyond six months with appropriate introduction of complementary foods.
  9. Support mothers to feed and care for their breastfeeding babies without the use of artificial teats or pacifiers (dummies or soothers).
  10. Provide a seamless transition between the services provided by the hospital, community health services and peer support programs.

What should I remember?

  • the two international organisations that together launched the Baby Friendly Hospitals Initiative
  • what the Ten Steps for Successful Breastfeeding, and subsequently the 7-Point Plan for Breastfeeding in the Community, was designed to achieve

2.1 Steps 1 & 2; Points 1 & 2

These first two Steps/Points relate primarily to the responsibilities of the management team in your Unit, ensuring the Policy is evidence-based, widely distributed and all staff are competent to uphold the standard it describes.

1: Have a written breastfeeding policy that is routinely communciated to all healthcare staff

  • If you work in a hospital setting your breastfeeding policy must incorporate each of the Ten Steps to Successful Breastfeeding.
  • If you work in a community setting your policy will incorporate the 7-Point Plan.
Your policy will also reflect compliance with the relevant provisions of the WHO International Code on the Marketing of Breast-milk Substitutes and subsequent WHA Resolutions.

Implementation

  • A copy of the policy that incorporates the Baby Friendly criteria must be provided to all new staff at commencement of their employment and orientation to the policy scheduled for all new staff, including volunteers.
  • The policy, or a summary of the policy, must be displayed in all areas that serve mothers and babies.
    • Your policy should be available in easily understood language in the languages mostly commonly spoken by women using your Unit.

Activity

As you walk around your health facility look around to see where the policy (or summary of the policy) has been posted. It should be easy for you to see in such areas as the emergency department, the paediatric ward, the ultrasound and screening clinics, the birthing rooms, the baby-change or feeding rooms provided for the general public, as well as the more obvious places such as each room in the maternity/obstetric unit.

Evaluation:
In your Unit who has the responsibility for confirming that the Policy is displayed as required?
How frequently is this task performed?
Where is its successful completion recorded?

  • Indicate where you would access the Breastfeeding Policy in your Unit should a member of the public or another health professional (or the Baby Friendly assessor!) ask you for it
Display the breastfeeding policy in the most common languages spoken.

Display the breastfeeding policy in the most common languages spoken.
© D.Fisher, IBCLC

2: Health professional education in order to implement the policy

All new staff should be orientated to the breastfeeding policy within their first week of employment, and then fully trained to implement the breastfeeding policy, according to their role, within six months.

All staff who assist mothers with breastfeeding are required to complete a comprehensive course that incorporates the backgound knowledge and clinical skills needed in order to implement best practice standards successfully.

Implementation

Educational component

The knowledge required by different levels of staff determines the education they are required to undertake. For example, the nursing and midwifery staff who provide hands-on care for mothers and/or infants during the perinatal period require a minimum of 20-hours of education which includes all aspects of breastfeeding initiation and management, while doctors or midwives who supervise such care require a reduced number of hours. Other ancillary staff educational needs should be determined by the level of contact they have with mothers and infants.

Clinical competency

All staff must be able to provide education to mothers or their families on all aspects of infant-feeding decision-making, breastfeeding initiation and management, and artificial infant feeding.
Clinical competency in the following key skills must be assessed and recorded:
  • communication skills, in particular regarding infant-feeding counseling during the prenatal period
  • teaching positioning and latching of the baby to the breast
  • teaching hand expressing of breastmilk
  • teaching safe preparation and feeding of breastmilk substitutes
Hand expressing colostrum

Hand expressing colostrum.
© E.Grunis IBCLC

Refer to the Breastfeeding Policy

Find the section in the Policy that states what education each staff member has to receive.
Does the Procedure to implement it:
  • state the timing of that education in relation to commencement in the unit?
  • outline what should be covered in the didactic part of the education?
  • note that each individual staff member must be directly supervised in the clinical skills required?

What should I remember?

  • all the places you should see a summary of your Breastfeeding Policy displayed
  • where you can find a full copy of the Breastfeeding Policy
  • what the Breastfeeding Policy must include
  • when staff are to receive their education to implement the Policy
  • the clinical skills in which each staff member must be assessed to be competent to teach to mothers

2.2 Step/Point 3

Breastfeeding education during pregnancy

All mothers should receive sensitive counseling that will assist them to make an informed decision on the most appropriate infant feeding method for them. Informed decision-making is not possible when mothers have not received sufficient information on which to base their choice.

Information to be discussed

  • why breastfeeding is important and the risks associated with artificial feeding or supplements given before 6 months of age
  • non-pharmacological pain relief during labor, and the effect of drugs used in labour on both the newborn and the initiation of breastfeeding
  • the importance of early, uninterrupted skin-to-skin contact between mother and newborn until the first breastfeed, and why 24-hour rooming-in following this is important
  • why bottle teats (nipples) and dummies (pacifiers) are discouraged
  • basic breastfeeding management, including positioning and attachment, responding to feeding cues and frequency of feeding to ensure optimal milk production
  • indications that the infant is receiving sufficient breastmilk
  • the importance of 6 months of exclusive breastfeeding followed by continued breastfeeding with the addition of appropriate complementary foods
  • the availability of breastfeeding support groups and services in the community
There should be no group discussion or demonstration of artificial infant formula preparation or feeding.
The World Health Organization Code on the Marketing of Breastmilk Substitutes precludes the display of products covered by the Code and the promotion of those products.

Review your knowledge

When you completed the initial education required for Baby Friendly you will have studied each of these topics.
Look at them again now and make notes of the key points to discuss with mothers and their support people. If your knowledge needs refreshing re-read your original notes or speak with your Unit's educator.

It is important that you keep your knowledge up-to-date. Firstly the mothers in your care will benefit, but you may also be asked how you discuss any of those topics with mothers by the Baby Friendly assessor.

Clinical Skills Competency: Communicating with pregnant women about breastfeeding

Click on the link to download the Skills Competency. Even if this is not a requirement of you at this time it will provide good 'refresher' training, ensuring you continue to provide the very best care.
Review the study materials and notes you made during your initial breastfeeding education.

Implementation

How is this education scheduled for all parents in your Unit?
How is it recorded that each mother received this education?

Group sessions are acceptable, however all parents should also have the opportunity for private counseling and discussion if desired.

Activity

Team up with some colleagues and locate all the parent information literature on breastfeeding that is distributed during pregnancy. Review it for accuracy, recency and that the content covers the material to be discussed. If changes are warranted, draft them and present them to the appropriate authority in your Health Unit.

Who is the publisher or sponsor of the literature? Companies whose products infringe the WHO Code are not permitted to provide education directly to parents.

'Gifts' for mothers

Many hospitals give mothers a bag of promotional materials and samples when they book-in to have their baby. Randomly select one of these bags and review the contents.

Read all the literature contained in it to ensure it conforms to evidence-based recommendations. Look through any parenting magazines provided too - do their articles and advertisements conform to the WHO Code on the Marketing of Breast-milk Substitutes? What are the samples? Giving food samples or redeemable vouchers for food for the baby is not appropriate.

Is there a procedure in place for each 'batch' of new bags received to be reviewed? This is a worthwhile exercise.

Beware!

Don't violate the WHO Code

Look around your Unit. What can you see? Do you see breastfeeding supportive posters and literature?
Look carefully: is there any artificial infant formula manufacturer-sponsored literature or 'give aways' visible, eg. cups, tape measures, pens, diaries, mobiles, cot cards, note paper, posters, etc?

Refer to the Policy

Find the section that outlines the education to be provided for parents during pregnancy.

Does it cover the issues relevant to this Step/Point?

Only applicable if your health care facility provides antenatal services, such as a booking-in clinic, antenatal clinics, antenatal classes or antenatal inpatient care.

What should I remember?

  • by what stage of pregnancy each mother should have received breastfeeding education
  • the topics that must be covered with each mother, and how you will counsel her on these topics
  • the literature given to mothers and/or displayed in the unit should all be evidence-based, comply with the WHO Code on the Marketing of Breastmilk Substitutes, and not be sponsored by an organization that infringes the WHO Code.

2.3 Initiating, managing & maintaining breastfeeding

The goal of your Unit's breastfeeding policy, supported by the following Baby Friendly Steps and Points, is for every mother leaving your care to be able to confidently and independently exclusively breastfeed her infant for 6 months continuing for up to two years and beyond with the addition of appropriate complementary foods after six months of age.

Birthing facility care

Step 4

Place babies in skin-to-skin contact with their mother immediately following birth for at least an hour, and encourage mothers to recognize when their babies are ready to breastfeed, offering help if needed.

Step 5

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

Step 6

Give newborn infants no food or drink other than breastmilk unless medically indicated.

Step 7

Practise rooming in - allow mothers and infants to remain together - 24 hour a day.

Step 8

Encourage breastfeeding on demand.

Encourage baby-led or cue-based breastfeeding. Encourage sustained breastfeeding beyond six months with appropriate introduction of complementary foods. (Canada)

Step 9

Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.

Community-based care

Point 4

Support mothers to initiate (establish) and maintain (exclusive) breastfeeding (to 6 months). United Kingdom, New Zealand

Inform women and their families about the management of breastfeeding and support them to establish and maintain exclusive breastfeeding to 6 months. Australia

Point 5

Encourage exclusive and continued breastfeeding (beyond six months) (to two years or more), with appropriately-timed introduction of (adequate and safe) complementary foods.


2.3.1 Initiating breastfeeding

Step 4

Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour and encourage mothers to recognise when their babies are ready to breastfeed, offering help if needed.

To implement this Step the focus has changed from helping to breastfeed to facilitating the optimum environment to stimulate baby's innate feeding reflexes, breastfeeding occurring with the least intervention from health care staff.

This Step is one of the most critical Steps. Successful implementation of this Step ensures:

  • the rapid achievement of physiological stability in the neonate
  • optimum bonding at a critical time for mother and infant
  • facilitation of breastfeeding, and prevention of problems

Implementing skin-to-skin contact

  • Skin-to-skin contact at this time is interpreted as the baby being naked except for a bonnet, if necessary, with baby's chest and body directly in contact with the mother's bare abdomen and chest. A light blanket covering both mother and baby will prevent heat loss.
  • All routine procedures, such as drying the infant, Apgar score assessment, assessment of vital signs, are to be performed while in skin-to-skin contact with the mother.
  • Skin-to-skin contact in the operating theatre can also be achieved, however if this is not possible, it should occur within a very short time of the mother arriving in the recovery area, or of being able to respond to her baby if she has had a general anesthetic.
  • Babies are to be left undisturbed in skin-to-skin contact until after the first breastfeed.

This care is to be given to ALL infants, regardless of feeding intention, ie infants to be artificially fed will benefit significantly from this care too.

Physiological stability and bonding in one easy action.

Physiological stability and bonding in one easy action.
© K.Small MBBS

Exceptions: Medically justified reasons for delaying contact.

Initial resuscitation of the neonate

The Neonatal Resuscitation guide published by the American Academy of Pediatrics 1 states that

  • the newborn upper airway can be cleared by wiping the mouth and nose,
  • he can be dried,
  • assigned Apgar scores,
  • visually assessed, and
  • vital signs recorded
while in skin-to-skin contact with the mother .

The first breastfeed

Babies are born with innate reflexes that guide them to the breast and to breastfeed. Assisting the mother into a comfortable, semi-reclined position with her baby on her chest is the best way to facilitate this response.2

Guidance to the mother includes an explanation of the sequence of movements and actions through which the baby will progress before latching and suckling. These can be pointed out to the mother and her support persons as they occur. Emphasise the importance of not disturbing the baby until after the first breastfeed.

Refresh your memory

Click on the title or icon to open a paper that describes the sequence of movements and actions the baby will take before latching and suckling.

This is an ideal time to reinforce the knowledge shared during the prenatal period. Indicate:

  • early feeding cues and the need to respond to them promptly,
  • the wide gape baby makes as he latches, and the amount of breast tissue taken into his mouth,
  • the deep jaw excursions baby makes as he sucks.

Refer to your Policy

Identify the policy statement that addresses the immediate care of the newborn baby, and where that care is to occur.

What should I remember?

  • where the majority of infants should be to receive immediate post-birth care and resuscitation
  • how to facilitate skin-to-skin contact
  • how long the infant and mother should initially remain undisturbed in skin-to-skin contact
  • that infants have an innate ability to latch and breastfeed unassisted when placed in skin-to-skin contact

Notes

  1. # Kattwinkel J et al. (2010) Neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
  2. # Colson S et al. (2008) Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding.

2.3.2 Managing Breastfeeding

Positioning and Latching to the Breast

Every mother should be able to

  • describe the early feeding cues her baby exhibits, before he has the need to cry;
  • position and latch her baby independently and confidently;
  • indicate to you signs that the baby is well latched and breastfeeding effectively.

All staff should be competent to teach positioning and latching using a hands-off technique, and supervise the mother hand expressing her breastmilk after receiving instruction.

Early hunger cue.

Early hunger cue.
© E.Grunis IBCLC

Indicating signs that baby is well latched and breastfeeding effectively.

Indicating signs that baby is well latched and breastfeeding effectively.
© D.Fisher IBCLC


Clinical Skills Competency: Observing, assessing and assisting breastfeeding

Click on the link to download the Skills Competency. Even if this is not a requirement of you at this time it will provide good 'refresher' training, ensuring you continue to provide the very best care.
Review the study materials and notes you made during your initial breastfeeding education.

Recall:

  • normal breastfeeding frequency
  • the early breastfeeding cues
  • how to describe and assist a mother to position and latch her baby herself
  • the observations the mother can make of her baby that demonstrate good latch and effective breastfeeding.

When mothers and babies are separated

Mothers and babies may be separated for various reasons. In hospital it may be due to prematurity or illness in the baby, or the mother may be unwell or require additional medical care. In the community setting it may be due to work or social commitments.

Every mother must report she received individual instruction to

  • hand express her breastmilk, and
  • collect and store her breastmilk safely.
  • A written leaflet should be provided that describes safe collection, transport and storage of breastmilk.

Additionally, mothers whose babies require medical care in a neonatal nursery should report

  • they were supported to initiate lactation within a short time of birth if the mother's condition permitted, and
  • encouraged to express their breastmilk regularly, effectively and frequently to establish and maintain lactation

Clinical Skills Competency: Hand expressing and safe milk storage

Click on the link to download the Skills Competency. Even if this is not a requirement of you at this time it will provide good 'refresher' training, ensuring you continue to provide the very best care.

Rooming in: 24-hours a day

  • In hospital babies are to remain with their mothers, unless there is a medical reason that necessitates separation.
  • All separations of greater than one hour must be recorded, with duration and reason noted.
  • In the home situation, co-sleeping with the baby sleeping on a safe sleeping surface in close proximity to a responsive adult, preferably the mother, is most desirable.
  • Mothers should be able to describe why remaining together is important.

Implementation

The clinical protocols to support the policy will cover

  • when mothers are to be given individual instruction on how to breastfeed
  • additional information:

    • no restrictions on frequency or length of breastfeeds
    • breastfeeding encouraged whenever baby is hungry, or shows readiness to breastfeed
    • how the mother can recognise her baby is receiving sufficient breastmilk
  • when, and how, hand expressing is taught
  • the procedure to follow when a well baby is separated from his mother

Community protocols could also include

  • Provision to make appointments for early, routine review of all mothers and infants, as well as urgent appointments for mothers and babies experiencing difficulties
  • Observation of a breastfeed and provision to develop a breastfeeding plan at the first face-to-face visit.
  • Educational discussion at the first face-to-face visit should confirm maternal confidence in

    • skin-to-skin contact, which facilitates effective breastfeeding at any age
    • effective milk transfer, and what to do if she suspects it is insufficient
    • feeding cues and responding to her baby's needs, not limiting frequency nor duration of breastfeeding
    • co-sleeping for infant safety and to support breastfeeding

Refer to your Policy

Identify the statements that support

  • individual instruction and supervision of breastfeeding
  • breastfeeding support when mother and baby must be separated
  • how rooming-in is to be implemented and exceptions recorded
  • individual instruction on hand expressing and safe collection and storage of breastmilk

Identify in your Procedures or Protocols manual the method of recording which mothers have received individual assistance with positioning, latching and hand expressing.

How is this information communicated when the mother moves from her birthing facility care to community care? Is there a procedure in place to alert community health staff of the education the mother has received and what is still to be covered? How are difficulties the mother may be having that were not resolved prior to discharge from the birthing facility communicated?

Should you not have a procedure in place to ensure continuous care of the mother and baby, discuss with your colleagues and the other agency the development of a method to handover care.

What should I remember?

  • to teach mothers the behaviour that will FIRST alert her to her infant's need to breastfeed
  • to check her knowledge of the signs of milk transfer
  • which mothers are to be taught how to hand express their breastmilk
  • what must be recorded in the infant's and mother's notes should they be separated
  • to discuss the importance of 24-hour rooming-in and safe co-sleeping with all mothers

2.3.3 Maintenance of breastfeeding

Following extensive world-wide research the World Health Organization concluded that optimum health and developmental outcomes for children are achieved when they are breastfed for a minimum of two years with the addition of appropriate complementary foods after six months of age.

Exclusive breastfeeding

Mothers are to receive education and support to exclusively breastfeed their infants until their infants are 6 months old.

Obviously this standard of care must start from birth. Unless there is an acceptable medical indication breastfed babies in hospital should be exclusively breastfed.

All breastfeeding mothers should be offered information on how they can continue to breastfeed and provide breastmilk if and when they return to work.

Acceptable medical indications for full or partial breastmilk substitution:

  • Infant conditions:

    • Some inborn errors of metabolism; eg classic galactosaemia, maple syrup urine disease, phenylketonuria
    • very low birth weight or very preterm infants
    • hypoglycaemia in a compromised infant (eg preterm, SGA, significant hypoxic or ischaemic stress, ill, or infants of a mother with diabetes). Intravenous correction is the most successful management.
  • Maternal conditions:

    • HIV positive, where replacement feeding in the home situation will be acceptable, feasible, affordable, sustainable and safe
    • serious illness
    • some maternal medications, eg radioactive iodine, cytotoxic chemotherapy

The use of dummies (pacifiers)

What guidance does your hospital/community procedures give you for educating parents about dummy/pacifier use?

Does it include:

  • Dummy/pacifier use is discouraged for at least the first 4 weeks to permit establishment of breastfeeding.
  • If a mother wants to use a dummy

    • don't start it before 4 weeks, and then only if breastfeeding is well established
    • only use the dummy when settling the baby to sleep
    • don't use the dummy to delay, or mask feeding cues
    • be aware of the risk of reducing breastfeeding frequency and therefore breastmilk supply, which is the most common reason given for premature weaning

Commencing complementary foods

Breastmilk + appropriate complementary foods from 6 months.

Breastmilk + appropriate complementary foods from 6 months.

The education given to all mothers will include encouragement to exclusively breastfeed for 6 months before introducing appropriate complementary foods while continuing breastfeeding for at least another 6 - 18 months.

All staff should be able to explain why complementary foods and drinks are not recommended before 6 months, and why prolonged breastfeeding for 2 years or more is recommended by the World Health Organisation for all infants.


Overt support of breastfeeding

All written materials intended for mothers should be accurate and effective, and free from the promotion of breastmilk substitutes, bottles, artificial nipples/teats and dummies/pacifiers.

Breastmilk substitutes and equipment for artificial feeding are stored out of sight.

All handouts or sample bags given to new parents are free of promotion of artificial feeding and contain no samples of foods or drinks or artificial baby milk or redeemable vouchers for these products. When complementary foods are advertised it should state they are not suitable for an infant less than 6 months of age.

Free or low-cost samples or supplies of breastmilk substitutes are not given to mothers.

Refer to your Policy

Find the Policy statements that address:
  • the giving of supplements to newborn infants
  • the use of dummies (pacifiers) and teats (artificial nipples)
  • the duration of exclusive breastfeeding and educational information to be given regarding complementary foods
  • the regulation and display of materials covered by the WHO Code on the Marketing of Breastmilk Substitutes

Activity

Form a small group of colleagues to review all the literature that is given to mothers. Include literature on topics not directly related to breastfeeding also.

Review them for:

  • Compliance with the WHO Code - ie. free from promotion of breastmilk substitutes, bottles, teats and dummies
  • Accuracy and effectiveness of the content
  • Inclusion of the importance of breastfeeding in healthy eating literature, diabetes prevention literature, contraceptive choices, etc.

What should I remember?

  • the acceptable medical indications for a breastfed baby to receive complementary artificial formula or a breastmilk substitute
  • recording of all the information regarding the giving of a breastmilk substitute is required
  • the earliest age a parent should consider offering a pacifier/dummy to their infant
  • the earliest age an infant should be commenced on complementary foods
  • how long to recommend to mothers that they continue breastfeeding after commencing complementary foods

2.4 Step 10 / Point 7

Birthing Facility Care

Step 10

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

Community-based Care

Point 7

Promote co-operation (collaboration) between healthcare staff (and volunteers), breastfeeding support groups and the local community (in order to promote, protect and support breastfeeding).

Promote collaboration among health services, and between health services and the local community. (NZ)


Find the policy statement relating to:

  • how mothers are informed of breastfeeding support and follow-up services in the local community
  • the referral system from the birthing facility to community-based health care

Implementation

Mothers in the birthing facility:

  • should be encouraged to be seen by a breastfeeding-knowledgable health professional within 2 - 4 days after leaving the birthing facility care
  • should be aware of how to get help for infant feeding when they leave the facility
    • from breastfeeding-knowledgable health professionals, AND
    • from breastfeeding peer counsellors or support groups
  • This information should be provided in a written format, as well as during discussions.

Mothers in the community should be aware of:

  • how to contact an appropriate health professional for support with breastfeeding
  • the out-of-hours support available for infant feeding issues and how to access it
  • how to contact a peer-counselling service and access local support groups, where available

The procedure to be followed should include

  • a referral mechanism from birthing facility to community care, particularly for mothers or babies requiring additional assistance,
  • a method to record when follow-up care within the community (within 2 - 4 days) was recommended
  • Supporting documents should be clear about the follow-up appointment, and contain accurate contact information for community health care services and volunteer or peer-counselling services.

What should I remember?

  • your responsibility regarding breastfeeding support from health facilities in the community
  • your responsibility regarding volunteer or peer breastfeeding support

2.5 Point 6

Point 6: Provide a welcoming atmosphere for breastfeeding families.

Refer to your policy

Where can a mother breastfeed her child in your health-care facility?

How and when is breastfeeding in public discussed with mothers?

All health care facilities should welcome breastfeeding mothers. The Baby Friendly Community Initiative requires the community facility to make it explicit that women may breastfeed their child in any public area of the facility. All staff, including reception staff, must be aware of this policy, and be able to direct a mother to a private area if she would prefer.

Each facility must also have a mechanism in place to ensure discussion takes place regarding

  • information about local places known to welcome breastfeeding mothers, and
  • any issues about breastfeeding in public areas the mother may have.

What do you think?

Do you think it would be beneficial to new mothers to also advise them of their rights regarding breastfeeding in public areas, and workplace provisions for breastfeeding mothers?

If so, form a small working party to research these issues and discuss an appropriate method of communicating this information to new mothers.

International symbol, copyright-free

International symbol, copyright-free

Logo awarded by Australian Breastfeeding Association

Logo awarded by Australian Breastfeeding Association


An initiative of Sth Canterbury DHB, New Zealand

An initiative of Sth Canterbury DHB, New Zealand

Discuss breastfeeding in public with mothers

Discuss breastfeeding in public with mothers

2.6 Breast-milk Substitutes

When an infant is not to be breastfed, for whatever reason, the mother should leave your care feeling confident she can care for and feed her baby safely.

The WHO Code on the Marketing of Breast-milk Substitutes prevents manufacturers from targetting and marketing to mothers directly. By receiving all their education from knowledgeable health professionals, who have the best interests of mother and baby at heart, the decisions made will be based on what is best for each mother/baby couplet.

Safe preparation of breastmilk substitutes

The infant who is being fed on breastmilk substitutes has increased risks of poor health:

  • from acute and chronic diseases and developmental delays for which the breastfed infant is protected
  • from infection due to inadequate cleanliness during preparation and storage
  • from nutritional compromise, either over- or under-nutrition, as a result of improper preparation
  • from severe morbidity, or even mortality, caused bya potentially deadly bacteriafound in the powdered formula

The importance of every mother who is feeding her infant a breastmilk substitute being aware of these risks and receiving instruction on how to reduce them, cannot be underestimated.

Implementation

The World Health Organization states that instruction on preparation, feeding and storage should only be given on an individual basis, ie not in a group situation, and at the time it is needed, ie immediately prior to the mother commencing bottle feeding.

Clinical Skills Competency: Teaching formula preparation and feeding

Click on the link to download the Skills Competency. Even if this is not a requirement of you at this time it will provide good 'refresher' training, ensuring you continue to provide the very best care.
Review the study materials and notes you made during your initial breastfeeding education.

Refer to your Policy

Refer to the Policy and note that each of the following is included:
  • prohibits group instruction of infant formula preparation
  • outlines when artificially-feeding mothers are to receive instruction on formula preparation
  • outlines the procedure for safely preparing infant formula they are to be taught

What should I remember?

  • which mothers are to receive instruction on safe preparation of infant formula
  • when and how that instruction is to be given

3.0 International Policies

3.1 The WHO Code

International Code on the Marketing of Breast-milk Substitutes

Aim of the Code

The aim of this Code is to contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breast-feeding, and by ensuring the proper use of breast-milk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution.

Article 1: WHO Code

Scope of the Code

The Code applies to the marketing, and practices related thereto, of the following products:

  • breast-milk substitutes, including infant formula; other milk products, foods and beverages, including bottlefed complementary foods, when marketed or otherwise represented to be suitable, with or without modification, for use as a partial or total replacement of breast milk;
  • feeding bottles and teats.
It also applies to their quality and availability, and to information concerning their use.

Article 2. WHO Code

Review your Policy

Look through your Policy and find where it details the Unit's and the individual's responsibility to relation to the following:
  • no advertising of these products to the general public
  • no free samples to mothers, their families or to health workers
  • no promotion of these products, ie no products on view, no posters, no distribution of literature produced by manufacturers of these products, no use of company-paid personnel in your Unit
  • no gifts or samples to health workers
  • all literature provided to health workers must be factual and scientific, not promotional
  • no free or low-cost supplies of these products to any part of the health care system

Implementation

How are you affected?

What should you do in each of the following instances?
  • manufacturer of these products offers to pay your registration to a breastfeeding conference
  • industry spokes-person wishes to address the staff about their product
  • industry spokes-person offers to leave samples of their new product, and other gifts for the staff such as coffee cups, diaries, pens, etc
  • baby to be discharged home requiring formula supplements - mother tells you she has not yet purchased any formula, or cannot afford to
  • infant food manufacturer leaves samples of suitable complementary foods for the older infant, which notes they can be given from 4 months of age
  • literature available for promotion of follow-on formula for infants from 12 months of age
  • gift bags containing bottles, teats (nipples) and an insulated carry bag 'for the use of pumped breastmilk' are donated to your Unit
If you are unsure, discuss it with your colleagues and staff educator.

What should I remember?

  • the aim of the Code
  • the products that are covered under the Scope of the Code
  • the health care institution's and health professionals' responsibilities as outlined in the section referring to your Policy

3.2 Infant & Young Child Feeding

Global Strategy for Infant and Young Child Feeding

The World Health Assembly and UNICEF endorsed this strategy in 2002.

The aim of the Global Strategy is to improve, through optimal feeding

  • the nutritional status,
  • growth and development,
  • health,
  • and thus the survival of infants and young children.

The Global Strategy is based on the evidence of nutrition's significance in the early months and years of life, and of the crucial role that appropriate feeding practices play in achieving optimal health outcomes. Lack of breastfeeding, and especially lack of exclusive breastfeeding during the first half-year of life, are important risk factors for infant and childhood morbidity and mortality that are only compounded by inappropriate complementary feeding. The life-long impact includes poor school performance, reduced productivity, and impaired intellectual and social development. 1

It supports breastfeeding for two years and beyond, with the addition of adequate, safe and appropriate complementary feeding after the first six months. It also supports maternal nutrition, and social and community support.

[link: http://www.who.int/bookorders/anglais/detart1.jsp?sesslan=1&codlan=1&codcol=15&codcch=510]

Does your Unit have a copy of this document?[link: http://www.who.int/bookorders/anglais/detart1.jsp?sesslan=1&codlan=1&codcol=15&codcch=510]

If your Unit does not have a copy of this document it can be obtained, for a small cost, from the World Health Organisation website. Click on the icon to be taken to the order form. While at the website order Implementing the Global Strategy for Infant and Young Child Feeding at the same time - it is a free publication.

Alternatively, you could download the Strategy for no cost from PDFthe World Health Organisation website.[link: http://www.who.int/nutrition/publications/gs_infant_feeding_text_eng.pdf]

Global Strategy for Infant and Young Child Feeding

Global Strategy for Infant and Young Child Feeding

Notes

  1. # World Health Organization (2003) Global Strategy for Infant and Young Child Feeding