Hospital wide Interdepartmental X Department X Patient Care Non- Patient Care Policy History: Approval: Dates : Effective Date: 4/97

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1 Department: Section: Policies and Procedures, MBCU Number: Page 1 of 6 Hospital wide Interdepartmental X Department X Patient Care Non- Patient Care Policy History: Approval: Dates : Effective Date: 4/97 OB\GYN Committee: 9/98, 6/99, 6/00, 9/05,3/08 Revision Date(s): 2/02, 12/05, 1/08 Pediatrics Committee: 11/05 Review Date(s): 6/99, 6/00, 2/03, 7/03, 4/05, Record the review and revision dates for 6 years. Exception: Record the dates for policies that refer to minors for 8 years. PURPOSE: To train all nursing staff who care for the new mother - baby dyad in the skills necessary to implement this policy. To inform all pregnant patients about the benefits and management of breastfeeding. To assist the staff in providing consistent breastfeeding information to all maternity patients and assistance to the breastfeeding mother - baby couplet to best support exclusive breastfeeding for her baby for the first six months of life. POLICY: I. For the stable mother -baby dyad, the mother should be giv en her baby to hold with skin-to-skin contact within 30 minutes of birth and be allowed to remain skinto-skin until after the first breastfeed is complete, for at least half an hour, or longer if the patient desires, or in the ca se of a cesarean birt h, within one halfhour of when the mother is able to respond to her baby and of fered help by a staff member to initiate breastfeeding when the baby seems ready (at least within one hour of birth). II. The infant should be encouraged to breastfeed ad lib. The infant is to be encouraged to nurse approximately 8 to 12 feedings/24 hours. Every breastfeeding mother should be instructed in proper breastfeeding technique within 30 minutes of delivery or as soon as the mother is able to respond to her baby. All patients who ar e breastfeeding should be assessed for appropriate breastfeeding technique and receive assistance with positioning and attachment as needed, optimally, within 3 hours and no later than 6 hours of delivery. Prior to disc harge, the br eastfeeding mother should be educ ated on basic breastfeeding practices, including: 1) the importance of exclusive breastfeeding, 2) how to maintain lactation for exclus ive breastfeeding for about 6 months, 3) criteria to assess if the baby is getting enough breas tmilk, 4) how to express, handle and store breast milk, including manua l expression, and 5) how to sustain lactation if the mother is separated from her infant or will not be exclusively breastfeeding after discharge. At least one feeding per shift should be observed and documented by the nurse utilizing the LATCH assessment tool. V. When a LATCH ass essment identifies a dysfunction or signs of inadequate intake, a lactation consultant/educator should be notified. Breastfeeding assistance provided by the nurse should continue with each feeding until the couplet is proficient. VI. All mothers should be encouraged to keep their infants with them both day a nd night to facilitate bonding and the attachment process. The nurse should plan

2 Number: Page: 2 of 6 VII. V IX. with the mother and family for periods of rest and sleep. If possible, avoid separating the mother and infant for more than 1 hour in a 24 hour period. Mothers who wish to breastfeed and bottle-feed should be educated regarding the benefits of breastfeeding and encouraged to breastfeed exclusively. Mothers who are undeci ded about a feeding method should be encouraged to breastfeed exclusively. Pacifiers should only be used on an as needed basis f or medical indications i.e. as an intervention for pain during a procedure, for the breastfeeding infant. Supplementary formula may be given for certain clinical conditions as ordered by the physician or as medically indicated per policy. (See Supplementation of Breastfeeding Policy ) When a mother requests that her breastfeeding baby be given a pacifier, artificial nipple, or bottle fed, the nurse should explore the reasons for the request, address the concerns raised, educate her on the possible consequenc es to t he success of breastfeeding, and d iscuss alternative methods for soothing and feeding her baby. If the mother still requests a pacifier or artificial nipple, the process and informed decision should be documented. Also, for breastfeeding babies, the mother should be offered the opportunity to provide requested supplementation using a supp lemental nursing system (SNS), if the baby is able to do so, in preference to an artificial nipple or bottle. X. If within hours post-birth, feedings at the breast are incomplete, ineffective or the mother is separated from her infant, the mother should be instructed to begin regular expression of her breasts, with continued assistance by a Lactation Consultant/Educator. The colostrum or milk obtained by expression should be collected and provided to the infant unless otherwise indicated by the clinical situation. XI. XII. X X XV. Prior to dis charge, all mothers who choose to breastfeed their infants should be instructed in manual expression of their breastmilk. (See Breastmilk, Teaching Manual/Hand Expression of, Policy 6380/02020.) Every mother should receive the following brochures, Breast feeding Resources/Log, and Manual Expression of Breastmilk. Breast Milk Collec tion and Storage and Returning to Work handouts will be offered only to those mothers to whom it applies. Mothers c hoosing not to breastfeed should receive the following brochures Breast Care for Engorgement When Bottle-feeding and Breast Care When Bottle-feeding. At discharge, each mother should receive resource numbers to call for further feeding assistance. All classes and teaching materials will be considerate of the woman s cultural background, education and language and be free of any marketing that promotes or advertises the use of artificial milk substitutes. Support persons will be included in the lactation education and the decision making process.

3 Number: Page: 3 of 6 PROCEDURE: Breastfeeding I. Gather equipment Breastfeeding handouts/resources - Breast feeding Resources/Log, Breast Engorgement, Breast Milk Collection and Storage. Breast pump (if needed) Breast cream (if needed) Bed pillows or Breastfeeding pillow II. Within 30 minutes of delivery place the infant skin-to-skin across the mother s chest. Maintain infant's body temperature with a knit cap and warm blankets tucked close. Encourage eye contact and light touch. Encourage the mother to breast feed the infant within the first hour after birth, preferably within the first minutes, prior to initial bath. Assist mother with breast-feeding and provide teaching and support as indicated. Points to include are: A. Use pillows to support the mother s arms and to position infant level with the breast. B. Express a small amount of colostrum onto the nipple to interest the infant in sucking. C. Mother supports her breast using the "C hold. The thumb is placed on top of the breast and the four fingers support the breast underneath. All fingers should be well back from the areola. D. Mother tickles the center of the infant s lower lip with her nipple until the infant opens his mouth wide as possible. This may take several attempts to do. E. When infant s mouth is open very wide with the tongue down, mother should center her nipple quickly and draw the baby in close to her body. F. Infant s mouth and lips should form a flanged seal around the breast tissue. The tongue should be curved around the areola, cupping it and extending over the gum line. G. Infant s nose and chin should be touc hing the breast. There is no need to create an air space for most infants. H. Identify nutritive sucking, which is 8-10 long, drawing sucks w/ audible swallows followed with a 5-10 second rest period. Non-nutritive sucking is usually 2-3 short, choppy sucks that are ineffective. I. Identify quiet sounds of swallowing i.e. a k or h phonics sound. J. Infant should finish the first breast or self-detach before offering the second breast.

4 Number: Page: 4 of 6 K. De-latch the infant if feeding becomes uncomfortable, latch does not appear deep enough, or a non-nutritive sucking pattern is seen, by placing a clean finger in the side of the infant s mouth between his jaws to release the suction. Then assist mother to correctly re-latch the infant. L. Frequency and duration of feedings at the breast should be infant - led. M. Infant is expected to nurse approxim ately 8-12 times in 24 hours. Feeding sessions may last 5-50 minutes or longer. Breastfeeding Interventions I. If a mother has a flat or inverted nipple and the infant is unable to latch, the nurse may use a manual breast pump or inverted syringe to draw out nipple prior to initiating latch. After consulting with a lactation team member, consider a nipple shield to attain latch. II. Provide a functional asse ssment of the infant at t he breast during a feeding, utilizing the LATCH tool a minimum of once every shi ft, to be documented on infant s chart. The Lactation Consultant/Educator/mother-baby nurse examines nipples whenever mother expresses concerns or complaints of sore nipples. LC/LE/mother-baby nurse to observe/assess the next feeding. When prolonged separation of mother and infant is expected (i.e. premature, ill infant), help the mother init iate pumping as soon as medically feasible, optimally within 3 hours and no later than 6 hours after delivery. V. The colost rum or milk obtained by expression should be collected and made available to the baby when feedings begin. VI. For mothers experiencing a fetal demise or newborn loss, provide the Milk Suppression handout, Breast Care/Education I. Examine mother's breasts and nipples during daily shift assessments. The nurse can demonstrate breast care by teaching hand expression of colostrum/breast milk onto the areola after feeds, then allow to air dry. The nurse may provide breast cream if there are visible signs of redness, cracking or bleeding of the nipple or if the mother complains of soreness. II. Encourage exclusive breast feeding for the first 6 months of infant s life. If the mother insists on supplem enting after breastfeeding, recommend limiting the amount of formula to ½ - 1 oz and to discontinue supplementation once the milk has come in (approx imately day 3-5). Offer alternative feeding methods in lieu of traditional bottle- feeding and provide the printed handout on Breast feeding and Alternative Feeding Choices. Instruct the mother on pumping techniq ues using the electric breast pump, when the infant demonstrates inadequate suckling or if the mother-baby dyad are

5 Number: Page: 5 of 6 separated indefinitely. (See Breast Pump, Use of and Instruction to Patient) V. When pumping is necessary, provide written guidelines to the mother on pumping, collection bottles, labels and lids for expressed milk. The information will include resource numbers for rental of a hospital grade el ectric breast pump for use after discharge. VI. VII. V IX. Instruct all patients regarding infant-led feeding cues-watch the infant for signs of readiness to feed such as increased alertness or activity, mouthing or rooting, rapid eye movement while asleep, and hand-to-mouth movement. Crying is a late sign of hunger. If feeding cues are not responded to in a timely manner, the infant may not be cooperative. Instruct all patients regarding cluster feeding patterns-frequent feeding, during periods of increased wakefulness; a series of mini-feedings snacks or courses, usually followed by a period of deep sleep; normal in the first 3 weeks. Instruct all patients how to manually ex press their milk, in the eve nt a feeding is delayed, or they are separated from their infant. Instruct all patients in t he use of the feeding log, and to monitor diaper count for the first week of their infant s life; evidenc e of adequate nour ishment from the breast would be sufficient out put of urine and stool. Day 1>one urine, one st ool; Day 2>two urine, two stools; Day 3>three urine, two stools; etc.-day 6 and beyond>5-6 urine, 4+stools. Instruct mother to contact pediatrician if diaper count not as described on breastfeeding resource log. X. Instruct all patients in the Supply and Dem and principle of milk production- The more the infant breastfeeds, the more milk will be produced. During growth spurts infants nurse more often to stimulate the mother s milk supply to meet their new requirements. XI. XII. X Educate the mothers who are undecided about breastfeeding on the benefits of breastfeeding and human milk. Points to include are: American Academy of Pediatrics recommends exclusive breastfeeding for the first six months of life. Breast milk provides optimal composition for brain and eye development, decreases incidence of diarrhea, upper respiratory infections and some allergies, promotes bonding and mother/infant closeness, reduces incidence of postpartum hemorrhage for mother and is economical and convenient. Provide the mother with the postpartu m parent educational booklet on self-care, nutrition, infant care and infant feeding. Encourage the mother to watch the Newborn Channel to reinforce other teaching provided for infant care and feeding. Provide all patients with a breastfeeding packet with add itional breastfeeding recommendations including feeding/diaper log and resource numbers for breastfeeding assistance after discharge

6 Number: Page: 6 of 6 X Instruct mothers on normal infant weight loss. Documentation I. Document on the infant's chart t he att empt to get the infant to breast feed; if supplementation medically indicated, document rationale in electronic medical record prior to supplementation. II. Document the infant's response and the method of feeding used to provide nourishment to the infant. If the mother insists that the baby be fed in the nursery during the night, requests a pacifier or bottle supplementation, docum ent in the mother s electronic medical record the mother s request and the education provided as to the impact separation and/ or use of artificial nipples and/or formula, may have on the success of breastfeeding Document observed or patient reported LATCH assess ment with each feeding on infant s chart. REFERENCES: American A cademy of P ediatrics P olicy S tatement (2005) Breastfeeding and the use of human milk. Pediatrics, 115, Jensen, D., et al. (1993) LA TCH: A breastfe eding charting system and doc umentation Tool. JOGGN, 23 (1), Lawrence, R. M. & R. A. (2005). Breastfeeding: A guide f or the medical profession (6th Ed.). St. Louis: C.V. Mosby. Lawers, J., Swis her, A. (2000). Counseling the Nursing Mother (3 rd Edition). Sudbury, Massachusetts. Jones & Bartlett Publishers. Lazaroy, M., Fedlman, A. WHO/UNIFCEF Ten Steps to Successful Breastfeeding, United States Committee for UNICEF Annotated Bibliography for each step, Riordan, J. (2005). Breastfeeding and Human Lactation (3 rd Edition). Sudbury, Massachusetts. Jones & Bartlett Publishers. [Howard, C. R., et al. (1999). The effects of early pacifier use on breastfeeding duration. Pediatrics, 103, 659.] RELATED POLICIES / ATTACHMENTS / FORMS: MBCU Policy/Procedure: Breast Milk, Teaching Hand Expression of MBCU Policy/Procedure: Breast Pump, Use of and Instruction to Patient MBCU Policy/Procedure: Rooming-In Care of the Newborn, Providing # MBCU Policy/Procedure: Skin-to-Skin (SOFT) Care for the Newborn, Providing # MBCU Policy/Procedure: Supplementation of Breastfeeding Infants END