NICE Pathways bring together all NICE guidance, quality standards and other NICE information on a specific topic.

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1 Postnatal care: breastfeeding and formula feeding bring together all NICE guidance, quality standards and other NICE information on a specific topic. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest version of this pathway see: Pathway last updated: 15 December 2016 This document contains a single pathway diagram and uses numbering to link the boxes to the associated recommendations. All rights reserved

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3 1 Woman and her baby up to 8 weeks after birth No additional information 2 Breastfeeding policy and programmes Breastfeeding support should be made available regardless of the location of care. All healthcare providers (hospitals and community) should have a written breastfeeding policy that is communicated to all staff and parents. Each provider should identify a lead healthcare professional responsible for implementing this policy. All maternity care providers (whether working in hospital or in primary care) should implement an externally evaluated, structured programme that encourages breastfeeding, using the Baby Friendly Initiative as a minimum standard. Healthcare professionals should have sufficient time, as a priority, to give support to a woman and baby during initiation and continuation of breastfeeding. Where postnatal care is provided in hospital, attention should be paid to facilitating an environment conducive to breastfeeding. This includes making arrangements for: 24 hour rooming-in and continuing skin-to-skin contact when possible privacy adequate rest for women without interruption caused by hospital routine access to food and drink on demand. Formula milk should not be given to breastfed babies unless medically indicated. Commercial packs, for example those given to women when they are discharged from hospital, containing formula milk or advertisements for formula should not be distributed. Written breastfeeding education materials as a stand-alone intervention are not recommended. Commissioners and managers of maternity and children's services See services offering support and advice about breastfeeding and feeding babies in public in the NICE pathway on maternal and child nutrition. Page 3 of 14

4 NICE has produced a pathway on donor breast milk banks. Quality standards The following quality statement is relevant to this part of the pathway. Postnatal care 5. Breastfeeding 3 Information and support In the first 24 hours after birth, women should be given information on the benefits of breastfeeding, the benefits of colostrum and the timing of the first breastfeed. Support should be culturally appropriate. Women should be given information about local breastfeeding support groups. Women who leave hospital soon after birth should be reassured that this should not impact on breastfeeding duration. Women should be reassured that brief discomfort at the start of feeds in the first few days is not uncommon, but this should not persist. Unrestricted breastfeeding frequency and duration should be encouraged. See also advice about breastfeeding and advice about prescribing to breastfeeding women in the NICE pathway on maternal and child nutrition. Skin-to-skin contact Separation of a woman and her baby within the first hour of the birth for routine postnatal procedures, for example weighing, measuring and bathing, should be avoided unless these measurements are requested by the woman, or are necessary for the immediate care of the baby. Women should be encouraged to have skin-to-skin contact with their babies as soon as possible after the birth. Page 4 of 14

5 It is not recommended that women are asked about their proposed method of feeding until after the first skin-to-skin contact. Sleepy baby Women should be advised that skin-to-skin contact or massaging a baby's feet should be used to wake the baby. The baby's general health should be assessed if there is no improvement. Expression and storage of breast milk All breastfeeding women should be shown how to hand express their colostrum or breast milk and advised on how to correctly store and freeze it. Breast pumps should be available in hospital, particularly for women who have been separated from their babies, to establish lactation. All women who use a breast pump should be offered instructions on how to use it. 4 Vitamin D supplements for breastfeeding women Ensure health professionals recommend vitamin D supplements Local authorities, primary care and clinical commissioning groups should: Ensure computerised prompts on vitamin D are integrated into health and social care systems. Ensure health professionals recommend and record vitamin D supplement use among atrisk groups [See page 11] (and other family members, as appropriate) whenever possible. This could take place during registration appointments with new patients in general practice, flu, other vaccine and screening appointments. It could also take place during routine appointments and health checks including, for example: NHS Health Check diabetes check-ups falls appointments and check-ups health assessments for looked-after children the first contact with someone who is pregnant antenatal and postnatal appointments medicine use and prescription reviews health visitor appointments developmental checks for infants and children. Page 5 of 14

6 Developers of standardised electronic and handheld maternity notes and developers of personal child health records (the 'red book') should add specific questions about the use of vitamin D supplements. Testing vitamin D levels Health professionals should not routinely test people's vitamin D status unless: they have symptoms of deficiency they are considered to be at particularly high risk of deficiency (for example, they have very low exposure to sunlight) there is a clinical reason to do so (for example, they have osteomalacia or have had a fall). Increase availability of vitamin D supplements for at-risk groups Local authorities should ensure vitamin D supplements containing the recommended reference nutrient intake are widely available for all at-risk groups by: Establishing arrangements with a range of settings to promote and distribute them. This could include local pharmacies, children's centres, midwifery and health visiting services and GP reception areas. Considering providing free supplements for at-risk groups. Encouraging pharmacies and other outlets selling food supplements (such as supermarkets) to stock the lowest cost vitamin D supplements and promote them to at-risk groups. Ensure improvements in the availability of vitamin D supplements are supported by local awareness-raising activities (see raise awareness of the importance of vitamin D supplements and training and professional development in the NICE pathway on increasing vitamin D supplement use among at-risk groups). 5 When to start breastfeeding Initiation of breastfeeding should be encouraged as soon as possible after the birth, ideally within 1 hour. 6 Breastfeeding technique From the first feed, women should be offered skilled breastfeeding support (from a healthcare professional, mother-to-mother or peer support) to enable comfortable positioning of the mother Page 6 of 14

7 and baby and to ensure that the baby attaches correctly to the breast to establish effective feeding and prevent concerns such as sore nipples. Additional support with positioning and attachment should be offered to women who have had: narcotic or a general anaesthetic, as the baby may not initially be responsive to feeding a caesarean section, particularly to assist with handling and positioning the baby to protect the woman's abdominal wound initial contact with their baby delayed. Women should be advised that babies generally stop feeding when they are satisfied, which may follow a feed from only one breast. Babies should be offered the second breast if they do not appear to be satisfied following a feed from one breast. Women should be advised that if their baby is not attaching effectively he or she may be encouraged, for example by the woman teasing the baby's lips with the nipple to get him or her to open their mouth. Women should be advised of the indicators of good attachment, positioning and successful feeding for breastfeeding [See page 11]. Ensure a mother can demonstrate how to position and attach the baby to the breast and can identify signs that the baby is feeding well. This should be achieved (and be documented) before she leaves hospital or the birth centre (or before the midwife leaves the mother after a home birth). 7 Assessing and managing progress A woman's experience with breastfeeding should be discussed at each contact to assess if she is on course to breastfeed effectively and identify any need for additional support. Breastfeeding progress should then be assessed and documented in the postnatal care plan at each contact. If an insufficiency of milk is perceived by the woman, attachment and positioning should be reviewed and her baby's health should be evaluated. Reassurance should be offered to support the woman to gain confidence in her ability to produce enough milk for her baby. If the baby is not taking sufficient milk directly from the breast and supplementary feeds are necessary, expressed breast milk should be given by a cup or bottle. Page 7 of 14

8 Supplementation with fluids other than breast milk is not recommended. Ankyloglossia (tongue-tie) Evaluation for ankyloglossia should be made if breastfeeding concerns persist after a review of positioning and attachment by a skilled healthcare professional or peer counsellor. Babies who appear to have ankyloglossia should be evaluated further (non-urgent action). Division of ankyloglossia (tongue-tie) for breastfeeding NICE has published interventional procedures guidance on division of ankyloglossia (tongue-tie) for breastfeeding with normal arrangements for consent, audit and clinical governance. Quality standards The following quality statement is relevant to this part of the pathway. Postnatal care 1. Continuity of care 8 Problems that may be caused by breastfeeding Nipple pain Women should be advised that if their nipples are painful or cracked, it is probably due to incorrect attachment. If nipple pain persists after repositioning and re-attachment, assessment for thrush should be considered. Engorgement Women should be advised that their breasts may feel tender, firm and painful when milk 'comes in' at or around 3 days after birth. A woman should be advised to wear a well-fitting bra that does not restrict her breasts. Breast engorgement should be treated with: Page 8 of 14

9 frequent unlimited breastfeeding including prolonged feeding from the affected breast breast massage and, if necessary, hand expression analgesia. Mastitis Women should be advised to report any signs and symptoms of mastitis including flu like symptoms, red, tender and painful breasts to their healthcare professional urgently. Women with signs and symptoms of mastitis should be offered assistance with positioning and attachment and advised to: continue breastfeeding and/or hand expression to ensure effective milk removal; if necessary, this should be with gentle massaging of the breast to overcome any blockage take analgesia compatible with breastfeeding, for example paracetamol increase fluid intake. If signs and symptoms of mastitis continue for more than a few hours of self management, a woman should be advised to contact her healthcare professional again (urgent action). If the signs and symptoms of mastitis have not eased, the woman should be evaluated as she may need antibiotic therapy (urgent action). Inverted nipples Women with inverted nipples should receive extra support and care to ensure successful breastfeeding. Thrush If thrush is identified in the baby, the breastfeeding woman should be offered information and guidance about relevant hygiene practices. Thrush should be treated with an appropriate antifungal medication if the symptoms are causing pain to the woman or the baby or feeding concerns to either. If thrush is non-symptomatic, women should be advised that antifungal treatment is not required. Page 9 of 14

10 9 Formula feeding All parents and carers who are giving their babies formula feed should be offered appropriate and tailored advice on formula feeding to ensure this is undertaken as safely as possible, in order to enhance infant development and health, and fulfil nutritional needs. A woman who wishes to feed her baby formula milk should be taught how to make feeds using correct, measured quantities of formula, as based on the manufacturer's instructions, and how to clean and sterilise bottles and teats and how to store formula milk. Parents and family members should be advised that milk, either expressed milk or formula should not be warmed in a microwave. Breastfeeding women who want information on how to prepare formula feeds should be advised on how to do this. Midwives should ensure mothers who choose to use infant formula are shown how to make up a feed before leaving hospital or the birth centre (or before the mother is left after a home birth). This advice should follow the most recent guidance from the Department of Health about bottle feeding. Commissioners and managers of maternity and children's services See services offering advice about infant formula in the NICE pathway on maternal and child nutrition. Quality standards The following quality statement is relevant to this part of the pathway. Postnatal care 6. Formula feeding Page 10 of 14

11 Population groups at higher risk of having a low vitamin D status include: All pregnant and breastfeeding women, particularly teenagers and young women Infants and children under 5 years People over 65 People who have low or no exposure to the sun. For example, those who cover their skin for cultural reasons, who are housebound or confined indoors for long periods People who have darker skin, for example, people of African, African-Caribbean and South Asian origin. Breastfeeding Indicators of good attachment and positioning: mouth wide open less areola visible underneath the chin than above the nipple chin touching the breast, lower lip rolled down, and nose free no pain. Indicators of successful feeding in babies: audible and visible swallowing sustained rhythmic suck relaxed arms and hands moist mouth regular soaked/heavy nappies. Indicators of successful breastfeeding in women: breast softening no compression of the nipple at the end of the feed woman feels relaxed and sleepy. Page 11 of 14

12 Glossary Co-sleeping parents or carers sleeping on a bed or sofa or chair with an infant Diet in this pathway, the term 'diet' refers to the habitual eating patterns of individuals and groups of people who are not slimming or eating to manage or treat a medical condition Emergency life-threatening or potential life-threatening situation Follow-on formula under UK law, follow-on formula may provide the liquid component of a progressively varied diet for healthy infants aged over 6 months Healthy eating there is no standard definition. However it is widely accepted that 'healthy eating' means following a diet which is low in fat (particularly saturated fat), sugar and salt, and high in fruit, vegetables and fibre-rich starchy foods. More details are available from NHS Choices Infant formula under UK law, infant formula is the term used to describe a food intended to satisfy, by itself, the nutritional needs of infants during the first months of life. The Department of Health advises that infant formula may be used on its own for the first 6 months MMR measles, mumps, rubella Non-urgent continue to monitor and assess Page 12 of 14

13 NSAID non-steroidal anti-inflammatory Reference nutrient intake amount of a nutrient needed to meet the needs of around 97% of individuals in a group SIDS sudden infant death syndrome Urgent potentially serious situation, which needs appropriate action Weaning weaning or 'complementary feeding' is the transition from an exclusively milk-based diet to a diet based on solid foods Sources Postnatal care up to 8 weeks after birth (2006 updated 2015) NICE guideline CG37 Vitamin D: increasing supplement use among at-risk groups (2014) NICE guideline PH56 Maternal and child nutrition (2008 updated 2014) NICE guideline PH11 Your responsibility The guidance in this pathway represents the view of NICE, which was arrived at after careful consideration of the evidence available. Those working in the NHS, local authorities, the wider public, voluntary and community sectors and the private sector should take it into account when carrying out their professional, managerial or voluntary duties. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of Page 13 of 14

14 opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. Copyright Copyright National Institute for Health and Care Excellence All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE. Contact NICE National Institute for Health and Care Excellence Level 1A, City Tower Piccadilly Plaza Manchester M1 4BT nice@nice.org.uk Page 14 of 14