Breastfeeding and Baby Friendly Hospitals

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Breastfeeding is a natural biological process that has many benefits for human infants, children, and mothers. The promotion and preservation of successful breastfeeding during the first 2 years of life and beyond is a public health issue that can have long term positive effects on global health and survival, nutrition goals, as well as the economy and environment. In this course we will discuss strategies that nurses can use to promote successful breastfeeding and a baby friendly hospital environment, based on CDC guidelines and other relevant evidence.

Introduction   

Breastfeeding is a natural biological process that benefits human infants, children, and mothers. The promotion and preservation of successful breastfeeding during the first two years of life and beyond is a public health issue that can have long-term positive effects on individual health, global health, and the environment. 

While the barrier​s​ to breastfeeding vary globally, in the United States, there were several generations of mothers and babies where the full benefits of breastfeeding were not known, and formula feeding was advertised as an equal or superior option. This, along with a rising number of hospital births and increased interventions that interfere with first feedings, created a sort of loss of “the village” of support that helped women breastfeed successfully, and significant effort has been required to repair this breach in a biological norm over the last few years. 

As more and more evidence has emerged about the benefits, both long and short-term, of breastfeeding, there has been a shift in focus surrounding the newborn period and goals to return babies to their mothers​.​ ​Fostering ​successful breastfeeding relationships has become the forefront of maternal/infant healthcare. 

We now know that what takes place during an infant’s first hours of life and how the first few feedings are approached substantially impact the overall success and longevity of the breastfeeding journey. However, significant barriers still exist, including inconsistent knowledge and advice from healthcare professionals and varying hospital protocols and policies surrounding breastfeeding. This course aims to provide an evidence-based and up-to-date guide for healthcare professionals on the front lines of lactation support. 

Benefits of Breastfeeding 

Benefits to Infant 

It is widely known that “breast is best,” yet many people do not understand the full extent of just how powerful a substance breastmilk truly is. This unique human product is custom-made for each infant, providing them with the exact nutrients, calories, antibodies, and other ingredients necessary for optimum health, growth, and development. It provides infants with the energy and nutrition needed for not only physical growth but also neurological growth.  

Breast milk contains antibodies and immune properties that keep infants healthy and help prevent serious illness and even death during the first few years of life. The antibodies contained in breast milk change daily based on microorganisms the infant and mother encounter in their day-to-day life. It is well documented that breastfed infants experience fewer illnesses and acute visits to healthcare facilities (6).  

Breastfeeding contributes to reduced rates of: 

• Ear infections 
• Common colds 
• Croup 
• Pneumonia 
• Bronchiolitis 
• Gastroenteritis 
• Sudden Infant Death Syndrome (SIDS)  

(6) 

The benefits of breastfeeding do not stop when lactation does, and children who are breastfed as infants experience lower rates of chronic childhood conditions like: 

• Diabetes 
• Obesity 
• Asthma and allergies 
• Dental caries 
• Childhood cancers 
• Autoimmune diseases  

(6) 

Infants born prematurely can particularly benefit from breastmilk, as it has a unique combination of protein, minerals, and fat making it easier to digest and more calorically dense, to meet the specific needs of the preterm infant. Antibodies also help prevent serious or deadly conditions that frequently affect preterm infants, like necrotizing enterocolitis (8).  

There is some data to suggest breastfed infants also experience better social-emotional development and attachment, increased IQ, and better speech and school performance. However, more recent research indicates this may be related to social factors like support systems and socioeconomic status that allow mothers to successfully breastfeed and contribute to a stable and supportive upbringing for the child, rather than breastmilk itself (10).  

Maternal Benefits 

The benefits of breastfeeding also extend beyond the infant and can positively impact mothers, and the duration of breastfeeding is inversely related to the occurrence of cancers of the reproductive tract and breasts, diabetes, and cardiovascular disease (6). Studies also show higher rates of bonding and reduced incidence of postpartum depression for breastfeeding mothers (10).  

Global Impact 

On a larger scale, higher breastfeeding rates equate to a healthier society, with reduced rates of childhood illnesses and deaths globally. Recent data from an infant-maternal health initiative called Alive and Thrive estimates that 600,000 childhood deaths from diarrheal illnesses and pneumonia could be prevented annually by increasing breastfeeding rates. The same analysis estimates nearly 1 million childhood obesity cases and nearly 100,000 maternal deaths from reproductive and breast cancers could be prevented just by increased breastfeeding (25).  

Besides considering the impact on human life and suffering, there is also an economic impact, and the above examples equate to $1.1 billion in healthcare costs and $53.7 billion in lost wages/earnings by women and children who died prematurely or were disabled, or simply women who missed work due to taking care of sick children (25).  

When considering the environment, breastfeeding also produces less waste and is much more cost-efficient and sustainable. Formula manufacturing and packing creates greenhouse gases and increased pollution and waste and feeding formula requires energy to mix, heat, and refrigerate formula and clean bottles. Breastfeeding is not entirely waste-free, particularly for women who pump and store milk in any amount, but breastmilk production does not generate pollution, and any environmental impact is likely offset by the reduced illness and utilization of healthcare resources for breastfed infants (14).  

​​​Breastfeeding Goals and Initiatives​​​​ 

​​C​urrent Practice 

The mid-20th century saw the rise of hospital births as the safest and preferred way to give birth in developed countries, and, at the same time, human-milk substitutes like formula gained popularity and were marketed as easy, convenient, “trendy,” and even superior to breast milk.  

With a higher number of women giving birth in hospitals and feeding their babies formula, babies and mothers were often separated after birth, with babies staying in the hospital nursery for long periods and receiving feedings from nurses or other family members. This also mirrored the rise in feminism, and formula gave women more opportunity to be present outside of the home while allowing others to feed their infants. 

Even if a mother still chose to breastfeed, it was believed at the time that babies should be weighed, examined, bathed, and swaddled immediately after birth, often then being handed off to another family member so that the mother could “rest.” Many of these practices were not based on any science at all and, unknowingly, many barriers to successful breastfeeding were created (1,2). 

Current data on United States breastfeeding rates indicates that 83.2% of infants are breastfed at least once after birth, with only 55.8% still being breastfed at six months of life (27.2% exclusively), and 39.5% still being breastfed at 12 months (5). The public health initiative, Healthy People 2030, has a goal of increasing the percentage of exclusive breastfeeding from 6 months to 42.4% and breastfeeding in any capacity from 12 months to 54.1% (21.).  

Interventions to achieve these goals include:  

• Continuing to track breastfeeding data 
• Tracking individual states and facilities support of breastfeeding 
• Supporting and encouraging the 10-step Baby Friendly Hospital Initiative 
• Call to action from the Surgeon general for breastfeeding support from doctors and nurses including 
• Increased knowledge base and up to date training on breastfeeding 
• Early and frequent conversations with pregnant women about breastfeeding 
• Creating breastfeeding support teams within healthcare facilities, including certified lactation consultants to lead these teams 
• Being knowledgeable in community resources available for breastfeeding clients 
• Following the International Code for Marketing of Breastmilk Substitutes, avoiding formula advertising and free samples at their facilities 
• Recognizing barriers and risk factors for unsuccessful breastfeeding and promoting access to community resources for these populations 
• Advocating for childcare and early childhood education policy that supports continued breastfeeding (5,21) 

Baby-Friendly Hospital Initiative: 10-Step Plan 

In the late 80’s and early 90’s, scientists began exploring the benefits of breastmilk and the breastfeeding bond and a shift towards breastfeeding education and returning mothers to this natural form of feeding began. Many healthcare leaders recognized that those first few days of life in the hospital would need a major overhaul if breastfeeding goals were to be met, and in 1991, through the efforts of the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF), the Baby Friendly Hospital Initiative was born (2). 

In over 3 decades since it began, the 10-step process (along with recommendations for the marketing of breast milk substitutes) has created more than 20,000 baby-friendly birthing facilities across 150 countries (2). More than 28% of births in the United States take place in a Baby-Friendly hospital each year, and this number only continues to grow (2). 

With educated staff members equipped to provide patients with the help and information necessary to create confident mothers, these Baby Friendly facilities have helped increase the national rate of breastfeeding initiation (84.1% in 2021), continuation at 6 months (59.8%), and 12 months (39.5%) (7). While these numbers still have a long way to go to reach WHO and UNICEF goals, they are increasing steadily and are overall significantly higher than even just a few years ago. In 2009, for example, the rate of breastfeeding initiation was 76.1%, continued breastfeeding at 6 months was 46.6%, and at 12 months the rate was 24.6% (5). 

Each year, evidence on breastfeeding outcomes supports the continued implementation and maintenance of the Baby Friendly Hospital Initiative. It is well known that the first few hours and days of an infant’s life are the most crucial time for establishing a successful breastfeeding journey. With a majority of babies being born in hospitals or birthing centers, the standards of care and the support of staff play a critical role in a mother’s experience both in the early period of breastfeeding and long term.  

The Baby Friendly Hospital Initiative is a 10–step plan designed to standardize breastfeeding support and care in maternal-infant health care settings and help reach worldwide breastfeeding goals. 

Have a Written Breastfeeding Policy.

The first step of the Initiative is multifaceted. Facilities must have a written policy regarding breastfeeding practices and this policy must be frequently communicated to both staff and patients; it should be well-integrated into the culture of the facility. Specifically, it is recommended that 80% of staff identify at least 2 components of the Initiative upon random questioning (2). 

The details of the policy should be evidence-based and align with current WHO and UNICEF recommendations, as well as support their goals. The policy must comply with the International Code of Marketing of Breast-Milk Substitutes (which will be discussed in more depth later on). 

Finally, the policy must outline how data will be collected to track the progress of the program and how adjustments to implementation will be made accordingly. WHO specifically requires that facilities track rates of breastfeeding initiation and the exclusivity of breastfeeding during the hospital stay (2). 

Train Staff in Skills Needed to Effectively Implement the Policy.

The goals of the facility’s policy can only be accomplished if the staff on the frontlines of patient care are well-trained, knowledgeable, and effective educators and supporters of breastfeeding. 

Training is important to ensure that all staff members give consistent messages, and it helps streamline a patient’s experience even with changing shifts and a variety of staff members encountered during one hospital stay. Staff should be educated on basic communication techniques, facts about breast milk and breastfeeding, the proper way to assess a feeding, how to adjust and suggest changes during a feeding where the mother or baby is struggling and help troubleshoot common breastfeeding issues/concerns (2). 

Discuss the Benefits of Breastfeeding with Pregnant Women and Their Family Members.

In order to make the most informed decision about infant feeding, women should be given information and education about breastfeeding before the baby is born. They should be given time to explore options, ask questions, and think about their choices before the monumental event of birth has occurred. For birthing facilities that also manage antenatal care, information on breastfeeding should be added to prenatal visits early on. For facilities that do not provide any prenatal care, staff members should branch out into the community and work with local clinics and primary care settings to strengthen their prenatal breastfeeding education (2). 

This counseling should be tailored to each patient and family and any unique circumstances they may have. Ideally, the first infant feeding discussion would be during the first trimester so that there is still plenty of time to answer questions or revisit the topic as desired by the mother. One-on-one discussion, written information or pamphlets, and the option for classes or support groups should be included (2). 

Mothers and families should be educated on the benefits of breastmilk on health, growth, and development for the baby as well as health benefits for the mother. They should also receive information about feeding cues, the importance of initiating feeding within the first hour of life, skin-to-skin contact, and other important points that mothers may wish to include in a birth plan (2). 

Facilitate Immediate Skin-to-Skin Contact After Birth and Encourage Initiation of Breastfeeding Within the First Hour of Life.

abies should be placed prone on their mother’s chest immediately following delivery and this contact should be uninterrupted for that first hour of life whenever possible (2). Skin-to-skin contact helps to regulate temperature, heart rate, and breathing for the baby and is shown to maximize oxytocin release and bonding for both mother and baby (2). 

Preterm or low birth weight infants, who are at particular risk of poor temperature regulation, benefit greatly from this practice. The current standard after cesarean delivery is for the baby to be placed under a warmer until surgery has concluded, however, emerging evidence indicates that as long as mother and baby are medically stable, skin-to-skin immediately after delivery should still be implemented and maintained the same beneficial effects as skin to skin after vaginal delivery. This practice increased mother satisfaction with the birth experience after c-section as well (2). 

Not only does this close contact assist with body temperature regulation, but it also increases oxytocin secretion and milk production and facilitates early initiation of breastfeeding. The nutrient-rich colostrum a baby receives during the first few feedings is full of important antibodies and gives the baby health benefits beginning almost immediately after birth if the first feeding is not delayed. There is very little actual volume received, but frequent feedings and nipple stimulation will eventually lead to the mother’s full milk volume coming in (2). 

Show Mothers How to Initiate and Maintain Breastfeeding and How to Navigate Common Barriers. ​

While a natural process, breastfeeding does not always come naturally to infants or mothers, and practice is needed as the two get to know each other. Practical support of mothers through information, demonstration, and encouragement/emotional support is very important to the success of breastfeeding. Specific topics to educate mothers on include feeding cues, positioning baby, hand expressing milk, nipple care, and signs of an adequate feeding/satisfied baby (2). 

Do Not Give Breastfed Babies Food or Drink Other Than Breastmilk, Unless Medically Indicated. ​

Frequent feeding during the first few days and weeks of life is imperative to establishing milk supply; the more the baby is at the breast, the more a mother’s body is stimulated to make milk. If a baby is given supplements, such as formula, then feeding at the breast is missed and milk supply may suffer. There are also no foods nutritionally superior to breastmilk during the first 6 months of life. 

There are a few medically indicated circumstances when formula or supplementation may be recommended for the baby’s health, but these situations are rare and should be determined by a pediatrician or provider directly overseeing the baby’s care (2). Severe breast milk jaundice, true inadequate milk supply, or an allergy or intolerance to breast milk that does not resolve with maternal dietary changes. Poor staff knowledge, limited resources, and limited staff time are not good excuses to recommend formula (2). 

Practice Rooming-In and Minimize or Eliminate Separation of Mothers and Babies.

Infants and their mothers should be in the same room as each other day and night following delivery. This allows bonding and helps mothers learn to recognize feeding cues and respond quickly when the baby indicates hunger. 

Recent evidence suggests that mothers who practice rooming have a greater milk supplier earlier on, have longer duration of breastfeeding, and have higher rates of breastfeeding exclusivity than mothers who were separated from their infants. These women felt more empowered at discharge and had more positive feelings and fewer negative or depressive feelings about their breastfeeding experience as well (2). 

If babies and mothers do need to be separated during a routine stay, this separation should be limited to one hour. There are of course situations when rooming-in is not possible, such as when the baby or mother is ill or unstable following delivery. However, the routine use of nurseries to give mothers time to rest or to assess vital infants should no longer be part of maternity wards (2). 

Encourage Feeding On-Demand and Help Mothers Recognize Feeding Cues. ​

Frequent and spontaneous breastfeeding is imperative to establishing a good milk supply and mothers should be encouraged to feed their babies whenever they are giving cues of hunger, rather than restricting them to a schedule. Breastfed babies cannot be overfed and should be allowed access to the breast on an as desired basis. Early recognition of feeding cues is important as well, as babies latch more easily and are less frustrated when they are not in distress. Cues such as rooting, sucking on hands, and licking lips should be responded to before infants start crying, which is a late hunger cue (2). 

Discourage the Use of Artificial Nipples, Bottles, and Pacifiers. ​

During the first few days and weeks of breastfeeding, when good habits are being established, the use of artificial nipples should be discouraged. Once breastfeeding is well established, there are no strong opinions on restricting it, but until that time they should be avoided. Pacifier or bottle use can lead to reduced nipple stimulation and resulting poor supply, confusion for babies regarding the proper method of sucking to receive milk, increased hygiene risk, masking or unknowingly “holding-off” hunger cues (2). 

Coordinate Outside Support Groups and Services So That Mothers and Babies Will Have Continued Support Upon Discharge. ​

Excellent support and care during hospital admission for mother and baby will mean little if there is no continued support upon discharge. Breastfeeding relationships change as the baby grows and matures, new problems may arise, the mother may become exhausted or lack confidence, and the best solution for almost all of these issues is a good support system.  

Mothers should be given information on where to call or go for professional lactation services as well as support groups or meetings with other lactating mothers. Follow-up phone calls or appointments within the first week of discharge are strongly encouraged (2). 

The International Code of Marketing of Breastmilk Substitutes

Throughout the BFHI, it is discussed that formula or other substitutes should not be given to breastfeeding babies unless medically indicated. However, in a capitalist society where marketing goals are to draw in as many customers as possible, no matter the health risks of the product involved, it was quickly realized that the way formula was advertised and viewed in our society created many barriers to successful breastfeeding. 

An exhausted and insecure mother trying to breastfeed her crying baby in the middle of the night might be looking through her feeding information from the hospital and see a pamphlet of a peacefully sleeping baby being laid in a crib while the mother sets aside an empty formula bottle and think “That looks much better than what I am doing here!” Or a new mother may wonder, “If breast milk is so good for my baby, why did my pediatrician’s office give me this sample basket of formula?” 

To combat these potential issues, WHO created the International Code of Marketing of Breastmilk Substitutes which places restrictions on formula companies and any facility wishing to achieve Baby Friendly status (26). 

The ICMBS mandates that: 

1. Participating facilities may not advertise formula or other breast milk substitutes. 
2. Healthcare facilities may not give free samples or supplies related to bottle feeding. 
3. Facilities cannot give free or low-cost formulas. 
4. Marketing personnel cannot contact pregnant or breastfeeding mothers through mail, shopping displays, direct contact, or other means to offer samples, products, or information about formula. 
5. Formula companies cannot offer gifts or free samples to healthcare workers. 
6. Advertising for formula cannot contain words or pictures idealizing infant feeding. 
7. Information provided to healthcare workers about formula should be science and fact-based only. Marketing cannot play on emotions. 
8. All labels on the formula must contain a disclaimer about the costs and hazards of artificial feeding in comparison with breastfeeding. 
9. Products must be FDA-approved for quality and safety. 
10. Products must include storage and safe preparation information on labels. 

(26) 

When the code was developed in 1981, 84 countries signed it, however, the United States was not originally among them due to heavy lobbying by formula companies. The code has since been adopted in the US, in 2010, however, no legislation has been enacted to enforce it, and it is frequently ignored or violated. The BFHI references it frequently and may impact the actions of hospitals or birthing facilities, but overall, the baby food industry in the United States is not in compliance with the Code (24).  

Barriers to Breastfeeding 

The American College of Obstetricians and Gynecologists has identified several categories of barriers that impact the success of breastfeeding initiation and continuation, despite the myriads of evidence to support breastfeeding (1).  

Healthcare barriers

Include inconsistencies in the education, knowledge base, and advice given by clinicians caring for mother-infant dyads, particularly during pregnancy, in the immediate postpartum and newborn period, and throughout the infant’s first year of life. If clients are given conflicting or non-evidence-based advice, especially if they are experiencing problems or asking questions, this can lead to frustration and a lack of helpful interventions, ultimately reducing the success of breastfeeding. This is where adherence to the BFHI and standardized facility protocols is most useful (1).  

Societal barriers

Include factors like misinformation or poor advice passed from friends and family. Many women are unaware that breastfeeding is a skill that takes work to learn over time as the mother and infant get to know each other. If they experience early feeding struggles, they may feel they are failing and give up prematurely, particularly if they have no peers who have successfully breastfed to encourage them (1).  

While breastfeeding is now protected in all 50 states and feeding in public spaces is allowed, there may be social stigma or embarrassment that keeps women from feeling comfortable feeding when and where they need to (1).  

The short duration of maternal leave that is infamous in the United States also harms long-term breastfeeding, as many women return to work sooner than needed to develop an adequate supply and comfort with breastfeeding. Despite laws requiring employers to provide the space and time for lactating workers to express milk, pumping spaces are often suboptimal and there may be pressure to prioritize work over pumping breaks (1).  

There are also significant disparities among certain populations. Women of lower education levels, low socioeconomic status, and who are Black are more likely to lack the support and resources needed to successfully breastfeed. Of particular consideration is generational trauma and historic racism that negatively impacts the Black community when it comes to breastfeeding initiation and continuation (1, 4).  

Additional barriers

Include problems with location that cause pain or supply issues, such as nipple trauma, plugged ducts and mastitis, improper latch, and exhaustion or postpartum depression in mothers. More serious problems like cleft palate require extensive and multimodal intervention from the healthcare team.  

Mothers with chronic health conditions, mental health disorders, or substance use disorders also experience significant barriers. Certain populations are also more at risk such as LGBTQ+ parents, incarcerated parents, and adolescent parents (1).  

Lactation Support 

Physiology of Lactation 

It is necessary to have a good understanding of breast anatomy and the physiology of lactation in order to provide high-quality support and care to breastfeeding clients. In regard to lactation, breast anatomy includes two main parts; lobules and ducts. Lobules are tiny clusters of alveoli that fill with milk during lactation. They are connected by ducts, or small tubes, that carry milk from the lobules to the nipple for expression (27).  

Lobules first develop during puberty and have 4 main types.  

Type 1 Lobules develop when estrogen and progesterone levels first begin to fluctuate with menstruation in the teen years. There are few lobules, and they are small in size at this stage. By the end of puberty, they have increased in number and size and are known as Type 2 Lobules; all women reach. Type 3 Lobules occur during pregnancy when increased progesterone causes an increase in the number and size of lobules, as well as a mature epithelial lining that is prepared to secrete milk. The largest number and size of lobules occur when lactation is established and is known as Type 4 Lobules. After lactation ends, lobules return to Type 2 (22).  

In addition to lobule development, which all women experience, women who become pregnant will also go through lactogenesis, or the process of alveolar maturity and milk secretion. This occurs in 4 distinct stages.  

Lactogenesis 1, also known as secretory initiation, starts around 16-20 weeks of gestation due to high levels of progesterone from the placenta. Epithelial cells within the alveoli begin to mature and secrete small amounts of colostrum. Some women may even leak small amounts of colostrum before delivery, however, the presence or absence of this is unrelated to breastfeeding success after delivery.  

Once the placenta is delivered after birth, progesterone levels drop sharply, and prolactin, cortisol, and insulin begin to rise, which transitions the process into lactogenesis II, secretory activation. During this stage, the body produces an increased (often overabundant) milk supply around day 2-3 after delivery. For women who have never lactated before, or with anything that interrupts the typical hormone response following delivery (such as retained placenta, c-section, or diabetes), the transition into lactogenesis II can be delayed by a few days. The first two stages of lactation are driven by hormone processes and will occur regardless of whether a client puts the infant to the breast or not (22).  

Lactogenesis III is a supply and demand process that works through nipple stimulation, emptying of lobules, and the hormones prolactin and oxytocin. Nipple stimulation, as well as emptying of the lobules stimulates the secretion of prolactin from the anterior pituitary. Prolactin signals the body to produce more milk. Nipple stimulation also triggers the posterior pituitary to release oxytocin which signals contraction of the muscles around the alveoli, ejecting milk from the lobules and ducts, out through the nipple. Oxytocin also creates a calm, relaxed mental state that increases bonding for mothers while their infants are at the breast.  

From here, the process continues as long as nipple stimulation continues, and the breasts continue to be emptied. As pressure builds within the lobules (engorgement), prolactin secretion decreases. When the breasts are empty, prolactin secretion and milk production are highest, which is why frequent, on-demand feeding is the most effective way to increase milk production. Milk production slows for breasts that are not being emptied regularly or completely (22).  

Lactogenesis IV occurs with weaning. When nipple stimulation and milk removal stop, milk production subsequently ceases. The epithelial cells die off and breast tissue shrinks back down to type 2 and 3 lobules.  

If another pregnancy occurs, lobules will increase in number and size again and the process will return to lactogenesis I and start over (22).  

Assessment of Breastfeeding  

To properly assess the effectiveness of a breastfeeding relationship, it is important to collect a thorough history of the mother’s health, pregnancy, and delivery. When gathering information, consider how it plays into breast anatomy, hormone secretion, and progression through the phases of lactogenesis.  

Important information points include, but are not limited to (23): 

• Maternal medical history and current medications 
• Paying close attention to medications like beta blockers, narcotics, corticosteroids, antihistamines, methergine, hormones, and antipsychotics  
• History of breast problems (mastitis, cancer) or procedures (augmentation, reduction, mastectomy) 
• Obstetrical history; past pregnancies and most recent 
• History of labor and delivery: antibiotics, pain medication, other medications, length of labor, delivery method, complications 
• Number and characteristics of prior breastfeeding experiences 
• Birth history: gestational age of infant, weight, complications or NICU stay 
• Feeding experience so far: when was the infant first put to breast (within first hour of life?), hospital support, use of bottles/formula/pacifiers, understanding of hunger cues, how often feeding (23) 

It is also important to assess the effectiveness of the latch, which will be discussed more below. Because it is not possible to assess the exact amount of milk consumed during a feeding at the breast, many clients will worry about the infant getting enough milk or if a feeding has been sufficient.  

Assessment methods that can be used to determine that an infant is getting enough milk include: 

• Weight gain: All newborns lose some weight initially after birth, though this should be monitored closely and should not exceed 10% of their birth weight. Around 1 week old, most newborns begin gaining about one ounce per day, usually reaching their birth weight again by two weeks old. Appropriate weight gain is a good indicator that an infant is getting enough breast milk. It should be noted that the CDC growth charts are made from the data of US infants who were primarily formula-fed and may gain weight more quickly. Therefore, WHO growth charts are recommended as they use worldwide data where breastfeeding is more common and will more accurately represent the expected growth patterns of breast-fed infants (15). 

• Urine output: A well-hydrated infant should produce 8-10 diapers per day. It may take a day or two to reach this number as urine production is not much during the first few days of life (15) 

• Stools: The transition from meconium to soft, seedy, and yellow stools indicates that infants are taking in enough milk. During the first few weeks, infants have several stools per day. Around a month of age, the number of stools decreases as the intestine matures, however, they should remain soft (15) 

• Satiated between feedings: Newborns should be content, relaxed, or even asleep after a feeding. It may be useful to observe the level of tension during the progression of a feeding; often infants will have clenched fists when they start feeding and have a relaxed and open palm by the time they are finished.  

The recommendation is for feeding approximately every 3 hours (around 8-12 times per day), but breastfed infants can be fed more often, especially if they are exhibiting hunger cues. Frequent feedings (especially in the early weeks) with satisfied cues in between feedings is not an indication of inadequate supply (15). 

Support for Latch and Establishing Lactation 

The first hour after birth is known as Golden Hour and every effort should be made to place the infant skin-to-skin with the mother and encouraged to latch during this hour for the best breastfeeding results. During this period, newborns are very alert and calm and may engage in the “newborn crawl” where they scoot across a mother’s chest to find the breast. Regardless of whether the infant is allowed to “crawl” or is placed at the breast, this first feeding plays an important role in the hormone shifts necessary to move into Lactogenesis II. 

Once Golden Hour is over, newborns typically enter a very deep sleep for several hours. It is much more difficult to coach a newborn and mother through the first feeding once the Golden Hour has passed (12).  

For clinicians who work outside of labor and delivery, breastfeeding infants are already past this crucial period, though information about the first feeding and the Golden Hour should still be collected. Problems, either real or perceived, may already be occurring, especially if mothers are frustrated or discouraged with their breastfeeding experience so far. Poor or ineffective habits have not yet been formed during the first two weeks, however, so there is still plenty of time during the early days to evaluate and correct early latch.  

Observing a feeding is the best way to assess latch and breastfeeding relationships, regardless of how old the infant is. Clinicians should be sure to offer gentle guidance and ask permission before touching a client or her baby and the environment should be calm and relaxing (23).  

Observe the mother’s comfort level handling the baby and assess her understanding of early hunger cues:  

• Rooting 
• Sucking 
• Lip smacking 
• Being quiet and alert 
• Hands in the mouth 

It should be noted that crying or fussiness are late signs of hunger and make an infant more frustrated at the breast. If caregivers are frequently waiting until an infant is very hungry and upset, they are more likely to experience difficulty getting the infant to latch (16). 

Next, a comfortable position should be chosen. Regardless of the position chosen, proper alignment should be achieved with the infant’s ear, shoulder, and hip all aligned to avoid an ineffective position and latch (9,16).  

Common positions include:  

• Cradle: The mother holds the baby with the arm on the same side as the breast she is feeding on and the baby’s head rests on her forearm while her palm cradles the baby’s back. The mother’s opposite hand can support and shape her breast while guiding it to the infant’s mouth.  

• Cross cradle: The baby is supported on a pillow across the mother’s lap and the mother can use the hand on the opposite side of the feeding to support the baby’s head and neck while the hand on the same side holds and guides the breast.  

• Clutch or football: The baby is positioned along the mother’s side with legs and feet under the mother’s arm while the mother’s same-sided hand supports the head, and the opposite-sided hand supports the breast. This position keeps the baby off the mother’s abdomen and can be useful for women who have had a C-section.  

• Side-lying. The mother and infant lie on their sides facing each other and the baby is cradled in the mother’s bottom arm and feeds from the bottom breast. This position can be comfortable and allow for more rest during nighttime feedings; however, it can be more difficult to master for mothers new to breastfeeding (9,16) 

Next, assess the latch. To transfer milk efficiently and avoid trauma to the nipple, the latch should be deep, so the nipple reaches the back of the infant’s mouth. The infant’s tongue takes up the bottom half of the mouth, therefore the deepest leach is achieved by positioning the nipple into the top half of the infant’s mouth. Coach the mother to support the baby’s head and allow the baby to extend the neck and tip the head back. Then bring the baby closer to the breast, touching the chin to the breast first and then settling onto the nipple (16).  

Signs of a proper and deep latch include:  

• Wide mouth (around 140°) 
• Lips flanged outward 
• Baby’s nose and chin touching the breast 
• Nipple in the top half of baby’s mouth 
• Audible swallowing 
• Rocker motion of the jaw (not up and down) 
• Irregular bursts of two sucks per swallow 

(16) 

The mother should be encouraged to break the latch, reposition, and start over at any point if the latch feels uncomfortable to the mother or looks misaligned. Practicing and correcting improper latching is normal and over time will establish proper habits and longer-term breastfeeding success. An improper latch that is not corrected will quickly lead to nipple damage and pain (16).  

Troubleshooting Common Problems 

Despite efforts to facilitate good early latch and habits, or perhaps due to barriers and lack of support, problems do frequently occur, however, most can be easily addressed with evidence-based guidance.  

The most common problems include, but are not limited to:  

• Nipple pain or trauma: Improper or shallow latch can quickly contribute to erosion of the sensitive skin of the nipples and cracking and soreness are common. The priority intervention is to correct the latch. Once this has been done, efforts to heal the nipples include emollients like lanolin or medi-honey applied to the nipples after feedings, use of breast shields to keep clothing from chafing on the nipples in between feedings and changing positions with each feeding to prevent the infant’s gums rubbing on the same place each time. Improvement should occur quickly, but full healing can take 2-3 weeks (23). 

• Flat or inverted nipples: With a proper latch, infants typically form a teat of the nipple and surrounding breast tissue and pull it to the back of the mouth via suction, regardless of nipple shape or size. However, if newborns are struggling to elongate the nipple early on, methods such as manual nipple stimulation, pumping before feedings, and nipple shields may be useful (11).  

• Plugged duct/mastitis: If milk flow becomes blocked or milk is not removed frequently enough, redness and tenderness to the affected duct may occur. Frequent feedings or pumping and trying different positions will usually clear a plugged duct quickly. If the blockage persists, sometimes an entire section of breast tissue can become affected and redness and tenderness if more prominent.  

This is known as mastitis and, while antibiotics used to be routinely recommended, current evidence focuses on more conservative interventions such as frequent feedings, cold compresses, and anti-inflammatory medications. Worsening symptoms that include full body aches or fever should be evaluated by a healthcare provider and may require antibiotics (19).  

• Poor weight gain or hyperbilirubinemia: Poor weight gain or elevated bilirubin levels early on in the newborn period can be challenging to address while maintaining a solely on-demand, at-the-breast relationship. There is a balance to be struck between adequate nutrition for the infant as well as frequent nipple stimulation for the mother’s milk supply and the establishment of breastfeeding relationships. Every effort should be made to feed at the breast, but sometimes supplementation with either expressed breast milk or formula may be recommended (23).  

• Teething and nursing strikes: Tooth eruption can sometimes cause problems with breastfeeding because infants will occasionally bite to soothe sore gums. Biting is not part of the effect latch for milk transfer and infants are too young to be doing this for behavioral reasons, so typically handling this problem only requires the mother to stop feeding abruptly if a baby bites. If the baby associated biting with the premature end of a feeding, they would not repeat the behavior often (23).  

Sometimes, as infants grow, they will also enter a nursing strike where they refuse to stay latched for the duration of a feeding. This is usually during developmental leaps where infants are very interested in observing the world around them or working on motor skills and feel too busy to stop to feed. Patience and going to a dark, quiet room with minimal stimulation can help work through nursing strikes, which are usually over within a few days to a week (23).  

• Maternal illness or medications: Poor maternal health or mental health conditions may impact a mother’s ability or willingness to breastfeed for a period. Particularly mothers with postpartum depression or anxiety may feel overwhelming stress around feeding, being “touched-out,” or the extra effort required to be the main source of nutrition. Addressing mental health conditions and ensuring no thoughts of harming self or the infant exist is of the utmost importance and supersedes the benefits of breastfeeding. However, for mothers who do wish to continue breastfeeding while they address their health, pumping and allowing others to feed the infant is a good way to keep the milk supply up while sharing the responsibility of infant feeding (18).  

Mothers experiencing physical illnesses may also pump temporarily while they recover or whenever they are not feeling enough energy to feed at the breast. The majority of medications used for acute or chronic illnesses, including mental health medications like SSRIs, are present in only small amounts in breast milk and may be used with low risk while breastfeeding. Even mothers receiving general anesthesia, local anesthesia, or IV contrast may not need to “pump and dump” because these medications will leave the breast milk at the same rate as the bloodstream and may be gone from the breast milk before the next feeding. Any medications needed should be checked using reputable resources such as the Hale Guide and LactMed websites to review the unique considerations for each medication (18).  

Hormonal birth control, while safe to use when considering levels present in breast milk, may pose problems because of the effects of hormones on milk supply and lactation. Estrogen contained in pills, injections, implants, and IUDs can reduce milk supply and progesterone-only or low estrogen options may be recommended instead (13,18).

Contraindications 

Very few true contraindications to breastfeeding exist. Due to the risk of transmission, women with active and untreated tuberculosis should not breastfeed. Neither should mothers undergoing chemotherapy or receiving antimetabolites or radiation. Mothers using illicit substances like cocaine or methamphetamine should also not breastfeed (3).  

While extremely rare, galactosemia is a contraindication to breastfeeding as these infants have an inborn error of metabolism that inhibits them from breaking down galactose. Failure to feed a specialized, lactose-free formula can result in liver dysfunction, failure to thrive, and mental retardation (3).  

HIV used to be an absolute contraindication to breastfeeding, but recent evidence suggests that mothers receiving antiretroviral therapy with an undetectable viral load have a <1% chance of transmitting the virus to their infants through breastmilk and breastfeeding should be encouraged if desired (20) 

Case Study 1 

Scenario 

Beth is a 24-year-old primiparous client who gave birth at 39 weeks 2 days to a 7 lbs. 8 oz male infant, Benjamin, via c-section after a long labor that failed to progress. Due to the C-section, the baby was not able to be immediately placed with the mother, but they were reunited within about 35 minutes and Beth attempted a first feeding.  

She reports having a strong desire to breastfeed but not knowing any friends or family who have done so. The baby is able to latch and take some colostrum before falling into a deep sleep for the next few hours.  

Over the next 2 days in the postpartum unit, Beth expresses uncertainty about the efficacy of the baby’s latch and her milk supply. Over the course of the hospital stay, Beth is observed feeding the baby on demand about every 2-3 hours whenever he is alert and rooting. She gains confidence in positioning the baby and getting him to latch.  

His stools begin transitioning from meconium to a seedy yellow. He is putting out about 6 wet diapers per day. His weight has dropped 4 oz.  

Assessment 

This baby’s hospital stay is very typical and there are no red flags. He is feeding at regular intervals and has only lost a few oz, well within the 10% allotted for loss in the newborn period.  

Transitioning stools are reassuring and fewer wet diapers during the first two weeks of life are typical. A feeding is observed, and Benjamin is noted to have a wide latch with flanged lips, audible sucking and swallowing, and a rocker motion of the jaw. He is content between feedings and sleeps for several hours.  

Beth remains concerned about milk supply and how to know that he is getting enough, making maternal lack of confidence the biggest concern for this mother-baby dyad.  

Plan 

Before discharge, Benjamin is scheduled to follow up with his pediatrician for a weight check in two days.  

Beth is evaluated by the hospital’s certified lactation consultant who provides her with additional reassurance and discusses signs of a good latch and adequate milk intake. She is advised to utilize urine output, weight gain, stools, and the baby’s temperament after and between feedings to assess that he is getting enough.  

She is also connected with a support group for breastfeeding mothers in her neighborhood so that she can interact with other women who are successfully breastfeeding. 

Outcome evaluation 

Over the next several weeks, Beth’s confidence continues to grow, and Benjamin begins gaining weight at a steady 1 oz per week rate. He surpasses his birth weight by 2 weeks and is having 8-12 wet diapers per day. He is happy and content.  

Beth attends the breastfeeding support group which builds her confidence and provides a good support network for common questions and experiences she encounters over the next several months.  

The support and evidence-based care and advice she received in the hospital, as well as connection with community resources, allowed this mother-baby dyad the ability to successfully breastfeed despite some early barriers.  

Case Study 2 

Scenario 

Ginny is a 2-week-old infant presenting to the pediatric clinic for a weight check. She was born at 40 weeks 1 day via spontaneous vaginal delivery. Her mother, Rachel, is a first-time mother who is concerned about her eating habits. Rachel reports that Ginny is often fussy between feedings, does not sleep longer than an hour at a time, and wants to eat “all of the time.” She reports that latching is painful and states that the baby is fussy and pulls away from the breast often. She is worried she is not making enough milk but does not want to supplement with formula.  

The baby’s weight today is 6 lbs. 4 oz, down about 8% from her birth weight. Her mother reports 6-7 wet diapers per day.  

Neither the baby nor the mother has any significant health history, and neither is taking any medications currently.  

Assessment 

The nurse observes feeding in the office. The infant is alert and calm at the start of the visit, occasionally rooting and sucking on her hands. Rachel seems uncomfortable handling Ginny and getting her into a comfortable position for feeding. At the breast, the baby is frantic and fussy, latching onto the nipple shallowly and with curled lips, moving the jaw up and down for about 30 seconds before pulling off. Rachel’s nipples are raw and cracked.  

She has not gained back the weight lost from birth weight and is putting out inadequate urine, indicating she is not getting enough breast milk from each feeding.  

Plan 

The nurse provides gentle direction and suggestions to help get Ginny into a more comfortable position, choosing the cross cradle hold to allow Rachel more control over Ginny’s head while providing support with a pillow for her body.  

The nurse teaches Rachel to make sure Ginny’s ear, shoulder, and hip are aligned and to allow the baby to extend her neck back and open her mouth wide before guiding the breast into her mouth. With a wide mouth and Ginny’s chin touching the breast first, she is able to get Rachel’s nipple far back into her mouth and latch with flanged lips. Rachel reports this latch is more comfortable. The baby feeds on this side with audible sucking and swallowing for about 7 minutes. Rachel is then able to switch to the other side with continued guidance from the nurse. 

After a full feeding, Ginny is relaxed and sleeping. The nurse provides Rachel with an emollient to put on her nipples after feedings to help them heal and schedules a follow-up for 4 days later back in the office.  

Outcome evaluation 

When Rachel returns 4 days later, she reports she was able to recreate the nurse’s advice for most feedings at home and would break the latch and start over if the latch was uncomfortable or misaligned. Her nipples are starting to heal, and feeding is going well.  

Ginny has gained 5 oz since the previous visit and Rachel reports she is sleeping better and more content between feedings. She is now feeding about every 3 hours and is alert and content or sleeping in between feeds.  

Long-Term: At the 6-week check-up, the baby is thriving with continued exclusive breastfeeding, and the latch has improved significantly. Rachel reports that she is no longer concerned about the baby’s weight or latch and feels confident in her ability to meet the baby’s needs through breastfeeding alone. The infant’s growth curve is within normal limits, and the breastfeeding relationship has been successfully established. 

Conclusion

Without question, breastfeeding is an irreplaceable intervention to promote the health and well-being of both infants and mothers, making knowledge about its support and promotion an integral function for healthcare professionals working in antenatal and pediatric settings. Completing this course is a step towards the streamlined and evidenced-based interventions needed to provide the highest quality care. By ensuring they have the most up-to-date knowledge needed to support breastfeeding clients, clinicians can help work towards individual, facility, and national goals for breastfeeding and play an active role in improving national and global health.  

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