Assessing The Breastfeeding

9:00-10:10 Assessing the Breastfeeding Dyad
I. Goals, objectives and outline

A. Goal: Identify when babies are not sucking effectively.
B. Objectives: At the end of this educational activity, the learner will be able to:
1. Describe the appearances of the baby sucking at the breast that is indicative of an
effective feeding.
2. Describe visible signs of potential sucking problems.
C. Outline:
1. Effective sucking
2. Ineffective sucking
II. Visible signs of sucking
A. Effective sucking
1. Watch for the eyes to be wide-open at the start of the feeding when the baby is a week old
2. Look for a wide-open mouth, flanged lips, asymmetric latch, chin in close, the nose free
(If nose is touching, be sure baby can breathe.)
3. Count 10+ sucks in a row at the start of the feeding (Do not tell mom)
4. Pauses should be shorter than 10 seconds, at the start of the feeding
5. Baby should start sucking again on her own and continue this pattern for many minutes
6. Cheeks should remain rounded, no dimpling
7. No clicking sounds
8. After the milk ejection reflex (MER) sucks should be one per second and audible swallows
should occur before discharge
9. Sucking should feel like tugging or pulling, not pinching or biting (feel like a pump)
10. Mother should not feel pain after the first 30 seconds
11. Baby is able to drink an appropriate amount of milk (pre and post feeding weights)
12. Baby is calm or asleep at the end of the feeding (not always a good indication)
B. Ineffective sucking
1. Narrow angle at the corner of the babys mouth
2. Sucks less than 10 times in a row before pausing at the start of the feeding
3. Pauses greater than 10 seconds at the start of the feeding
4. Dimples the cheeks, pulling in of the cheeks
Deeper latch
5. Over use of the lips to keep the seal, pulling of the breast
6. Pain throughout the feeding/nipple misshapen
7. Weak suck, falls off breast, no suction
Try latching on again. Check palate and tongue. Try chin support or DANCER hand
position to decrease intra-oral space and support the lower jaw, named by Sarah
Danner, CNM and Edward Cerutti, MD. Feed with cup/spoon/syringe until baby is
stronger. At discharge switch to bottle, if the baby can suck some.
8. Makes clicking sounds, breaks suction frequently.
Chin support
9. Wide jaw excursions
10. Milk leaks out of the corner of babys mouth
11. Cannot hear swallowing
12. After one week, eyes closed at the start of the feeding
13. Not enough milk is transferred during the feeding (pre and post feeding weights)
Kay Hoover, Med, IBLCL, 613 Yale Avenue, Morton, PA 19070-1922 kay@hoover.net
1
14. Baby fussy and unsettled at the end of the feeding while being held (not always a good
indicator that the baby is not getting enough)
a. Some babies are fussy after a feeding because they need to burp
b. Or they drank too much and may spit up
c. Parents cannot distinguish satiation from exhaustion
If weight issue, might try supplementer at the breast.
15.
Motion at the mouth, no movement of the ears or masseter and temporalis muscles (Allow
to suck on parents finger with tip of finger at juncture of hard and soft palates.)
16. Sucking tongue on roof of mouth (Suck on parents thumb or provide chin support.)
17. Tongue not over the lower gum
a. Charm hold
b. Breastfeed in a prone position for the baby
c. Imitate sticking tongue out and opening mouth wide
d. Lip tapping
e. Cup feed or place milk on babys chin to bring tongue forward
f. Sucking on moms finger, so can feel when tongue comes forward
18. Incorrect tongue motion
a. Reverse suck
b. In and out sawing motion
c. Up-down motion with center of tongue
d. Rubbing along the breast with the tip of the tongue
Suck training
2
Bibliography
BuLock F, Woolridge MW, Baum JD: Development of co-ordination of sucking, swallowing and
breathing: ultrasound study of term and preterm infants. Dev Med Child Neurol 32:669-678, 1990
Chiu S-H, Anderson GC, Burkhammer MD: Skin-to-skin contact for culturally diverse women having
breastfeeding difficulties during early postpartum. Breastfeeding Medicine 3(4):231-237, 2008
Colson SD, Meek JH, Hawdon JM: Optimal positions for the release of primitive neonatal reflexes
stimulating breastfeeding. Early Human Development, 84(7):441-449, 2008
Donath SM, Amir LH: Effect of gestation on initiation and duration of breastfeeding. Arch Dis Child
Fetal Neonatal Ed 93(6):F448-450, 2008
Genna CW: Supporting Sucking Skills in Breastfeeding Infants (2nd edition). Sudbury, MA: Jones and
Bartlett Publishers, 2013
Haggstrom AN, Lammer EJ, Schneider RA, et al.: Patterns of infantile hemangiomas: new clues to
hemangioma pathogenesis and embryonic facial development. Pediatrics 117(3):698-703, 2006
Jensen D, Wallace S, Kelsay P: LATCH: A breastfeeding charting system and documentation tool.
JOGNN 23, 27-32, 1994
Kutner L: Breastfeeding management of the reluctant nurser. J of Human Lactation 4(1):14-15, 1988
Lawrence RA, Lawrence RM: Breastfeeding: A Guide for the Medical Profession (7th edition).
Philadelphia: Elsevier Mosby, 2011
McMillan JA (editor). Oskis Pediatrics: Principles and Practice 4th ed. Philadelphia: Lippincott,
Williams, & Wilkins, 2006, p 382
Maher SM: An overview of solutions to breastfeeding and sucking problems. Schaumburg, IL: La
Leche League International, 1988
Marmet C: Training neonates to suck correctly. MCN 9(6):401-407, 1984
Miller CK, Willging JP: The implications of upper-airway obstruction on successful infant feeding.
Semin Speech Lang 28(3):190-203, 2007
Milligan RA, Flenniken PM, Pugh LC: Positioning intervention to minimize fatigue in breastfeeding
women. Appl Nurs Res 9(2):67-70, 1996
Mulford C: The mother-baby assessment (MBA): an apgar score for breastfeeding. Journal of
Human Lactation 8(2):79-82, 1992
Mulford C: Subtle signs and symptoms of the let-down reflex. J of Hum Lact 6(4):177-178, 1990
Pugh LC, Milligan RA: Nursing intervention to increase the duration of breastfeeding. Applied
Nursing Research 11(4):190-194, 1998
Riordan J, Wambach K: Breastfeeding and Human Lactation (4th edition). Boston, MA: Jones and
Bartlett Publishers, 2010
Riordan JM, Koehn M: Reliability and validity testing of three breastfeeding assessment tools. JOGNN
26(2):181-187, 1997
Riordan J, Gill-Hopple K, Angeron J: Indicators of effective breastfeeding and estimates of breast milk
intake. J Hum Lact 21(4):406-412, 2005
Stables D, Hewitt G: The effect of lateral asymmetries on breastfeeding skills: can midwives holding
interventions overcome unilateral breastfeeding problems. Midwifery 11(1):28-36, 1995
Taki M, Mizuno K, Murase M, et al. Maturational changes in the feeding behavior of infants-a
comparison between breastfeeding and bottle-feeding. Acta Paediatr 99:61-67, 2010
Wilson-Clay B, Hoover K: The Breastfeeding Atlas (5th edition). Austin, TX: LactNews Press, 2013
3
10:30-11:40 Supplementing the Breastfeeding Infant

1. Inborn errors of metabolism, such as
a. Maple syrup urine disease
b. Galactosemia
c. Tyrosinemia
d. Phenylketonuria (PKU) in some cases plus breastmilk and careful monitoring
2. Infants for whom breast milk remains the best feeding option, but who may need other
food in addition to breast milk for a limited period
a. Very low birth weightless than 1,500 grams
b. Very pretermless than 32 weeks of gestational age
c. Hypoglycemia if baby does not respond to skin-to-skin, breastfeeding, and
breast milk feeding
d. Dehydration
e. Weight loss greater than 10%
If the baby has lost 15% or more, the babys electrolytes need to be checked immediately.
3. Non-latching baby or baby who is not breastfeeding effectively (e.g. Cleft palate,
tongue-tie, maternal large, flat, or inverted nipples)
4. Maternal condition that may justify temporary avoidance of breastfeeding
a. Severe illness that prevents the mother from caring for her infant, for example,
sepsis
b. Herpes simplex virus lesions on the mothers breast until lesions have healed.
Baby can breastfeed on the other breast, if there are no lesions.
Women with herpes simplex virus type I or II may continue to breastfeed as
usual, unless there are herpes lesions on the nipple or areola. Herpes is
spread through contact, so the sores should be covered. If there are lesions
on the nipple or areola, the mother should not breastfeed on that breast. She
can pump or hand express milk from that breast until the sores clear.
Pumping will keep up her milk supply and prevent the breasts from getting
engorged or overly full. If the parts of the breast pump that contact the milk
also touch the sores while pumping, the milk should be discarded
(Lawrence, 7th ed. 2011, pp. 436, 599).
5. Maternal treatment with contraindicated medicine
a. Chemotherapy, until medication is out of her system
b. Radiation therapy
c. Sedating psychotherapeutic drugs
d. Drugs of abuse
e. Alcohol abuse
5. Separation of mother and baby
a. A mother with active, untreated tuberculosis (TB) should not be in the presence
of her baby. At the hospital, they will be isolated from each other. Once she has
been effectively treated, which usually takes about two weeks, the two of them
can be together. During the time of isolation, the mother can express her milk
and someone else can feed the infant the expressed milk. The mother can
4
express her milk because the tuberculosis infection is acquired through

respiratory transmission not via the milk. While being treated she should wash
her hands well and mask for pumping and storing her milk. However, in the rare
case of a mother with TB mastitis, she should neither breastfeed nor provide
breast milk until the lesion is healed, which usually takes at least two weeks
(Lawrence 2011, Table 13-1, p 424). She should pump and discard her milk to
maintain her milk supply. Once she is no longer infected, she may breastfeed.
b. Active varicella virus (chicken pox) of the mother is only a contraindication if
the maternal rash develops 5 days or less before delivery or within 2 days after
delivery (Lawrence, 7th ed. pp. 452-454). In that case, the mother should be
isolated and the infant should be given Varicella Zoster Immune Globulin
(VZIG). Expressed milk can be fed to the baby, if there are no breast lesions.
The mother can resume nursing when she is no longer contagious. For shingles
(zoster virus), same as for herpes simplex virus type I and II, and consider VZIG
for the baby.
c. Women with brucellosis, an extremely rare infection, should pump and discard
their milk from both breasts until they have been appropriately treated for 48 to
96 hours (Lawrence 2011).
7. When the mother is (temporarily or permanently) not producing sufficient milk
a. Maternal anatomical abnormalities (e.g. breast surgery, hypoplasia)
b. Maternal conditions causing delayed lactogenesis II (e.g. diabetes, obesity,
hormone imbalance, thyroid conditions)
8. Intolerable maternal pain during breastfeeding
9. Permanent contraindication to breastfeeding in the USA (not in a developing nation)
When the mother has HIV
Milk Volumes
Volumes for supplementation recommended by the Academy of Breastfeeding Medicine
Per feeding based on 8 feedings in 24 hours
Day 1 2 to 10 mL/feed
TOTAL in 24 hours
Day 1
Day 2
Day 3
Day 4
2.5 x babys weight in pounds = oz/24 hours

oz/24 hr
165 x babys weight in kilograms = mL/24 hours
oz/24 hr
Use birth weight until back to birth weight; once beyond birth weight, use current weight
If the baby has been underfed, it might take up to 3 days to get to the total volume.
5
The Deem article said in 48 mothers less than 20 years of age on Day 4, infants took 7.4 oz.; Day 7,
11.8 oz.; Day 10, 14.4 oz. And in 52 primiparae over 20 years Day 4, 6.4 oz.; Day 7. 12.7 oz.; Day 10,
15.4 oz.
Villalpando said Day 3 milk production about 360 ml (12.8 oz.); Day 15 about 550 ml (19.6 oz.)
The study was based on 30 women. By 74 hours after birth all babies had regained their birth weight.
Measured intakes indicate that 850 ml is a reasonable average. Even in the second year of life, it is
by no means unusual for a mother to give her baby approximately 500 ml of breast milk each day.
(Whitehead, 1995)
725 to 850 ml/day during months 2 to 6 are average intakes for fully breastfed infants. p. 125
(Neville 1987)
...there was an average increase in breast milk intake of about 24 ml/month from months 1 to 6 with
an average intake around 760 ml/day over this period. page 126 (Neville 1987)
The amount of milk consumed by the breastfed group...was significantly lower than that consumed by
the formula-fed group. Length and weight gains...were similar between breast and formula-fed
infants during the first 24 weeks of life. (Motil 1997)
Breastfed and artificially fed infants take in different quantities of milk and have different growth
patterns. By 8 months breastfed infants have consumed 30,000 kcal less than artificially fed infants.
(Garza 1987)
Milk volume in the first 24 hours
4 to 26 ml (Santoro, 2010)
3 to 32 ml (Casey, 1986)
average 13 mL
Average daily output in 98 mothers of term infants (Hill 2005)

Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Day 6-7
Day 14
Day 21
Day 28
Day 35
Day 42
494.6 mL
555.9 mL
612.4 mL
647.7 mL
665.9 mL
668.2 mL
17.4 oz
19.6 oz
21.6 oz
22.8 oz
23.4 oz
23.5 oz
Volumes of milk consumed during the first year after birth (Heinig, 1993)
3 months
6 months
9 months
12 months
Human milk
812
769
646
448
Formula
905
941
806
732
6
The goal is to feed the baby and pump in an hour

Once baby is over 24 hours old
Feed your baby at least every 3 hours. Offer your breast whenever you see feeding cues.
Wake if necessary: spend 10 minutes or less trying to help baby latch-on.
Use an alternate feeding method if baby has not latched-on by 10 minutes.
Keep baby skin-to-skin between feedings as much as possible: sling, cuddling.
Picture the circle as one hour.
0
The goals is to feed the baby
and pump your milk
within one hour.
TIPS TO
Then you have a break
LATCH BABY ON:
for two hours,
before starting
PUMP if necessary:
Drip milk
again.
If feeding with alternate method
Pump 1 to 2 minutes
If used nipple shield
Prefeed 5 to 15 ml
50
If baby had a poor feeding
Nipple shield
10
Settle baby
Breastfeed
or
Use alternate method
By cup, finger-feeding,
or slow flow nipple
40
Goals:
At least 8 to 10 feedings in 24 hours with 20+ minutes of sucking
Urine after the 3rd day: 6+ wet diapers
Bowel movements after the 3rd day: 3 to 4 yellow seedy stools
Barbara L. Boston 1994
7
Milk Volumes
ABM Clinical Protocol #3: Hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate. Breastfeeding Medicine
4(3):175182, 2009
Casey CE, Neifert MR, Seacat JM, Neville MC: Nutrient intake by breastfed infants during the first five days after birth. Am J Dis Child 140(9):933-936,
1986
Cregan MD, Mitoulas LR, Hartmann PE: Milk prolactin, feed volume, and duration between feeds in women breastfeeding their full-term infants over a
24-hour period. Exp Physiol 87(2):207-214, 2002
de Carvalho M, Robertson S, Friedman A, Klaus M: Effect of frequent breastfeeding on early milk production and infant weight gain. Pediatrics
72(3):307-311, 1983
de Carvalho M, Robertson S, Merkatz R, Klaus M: Milk intake and frequency of feeding in breastfed infants. Early Hum Dev 7(2):155-163, 1982
Deem H, McGeorge M: Breastfeeding. New Zealand Medical Journal 57:539-556, 1958
Doganay M, Avsar F: Effects of labor time on secretion time and quantity of breast milk. Int J Gynecol Obstet 76(2):207-211, 2002
Evans KC, Evans RG, Royal R, Esterman AJ, James SL: Effect of caesarean section on breast milk transfer to the normal term newborn over the first
week of life. Arch Dis Child Fetal Neonatal Ed 88(5):F380-F382, 2003
Hill PD, Aldag JC, Chatterton RT, Zinaman M: Comparison of milk output between mothers of preterm and term infants: the first 6 weeks after birth. J
Hum Lact 21(1):22-30, 2005
Lawrence RA, Lawrence RM: Breastfeeding: A Guide for the Medical Profession (7th Ed). Philadelphia: Mosby, 2011
Neville MC, Keller R, Seacat J, Lutes V, Neifert M, Casey C, Allen J, Archer P: Studies in human lactation: milk volumes in lactating women during the
on set of lactation and full lactation. Am J Clin Nutr 48:1375-86, 1988
Neville M: Physiology of lactation in Wagner CL, Purohit DM (Guest Editors): Clinics in Perinatology: Clinical Aspects of Human Milk and Lactation
26(2) Philadelphia: WB Saunders Company, June 1999, pp. 251-279
Salazar G, Vio F, Garcia C, et al: Energy requirements in Chilean infants. Arch Dis Child 83(2):F120-F123, 2000
Santoro W Jr, Martinez FE, Ricco RG, et al.: Colostrum ingested during the first day of life by exclusively breastfed healthy newborn infants. J Pediatr
156(1):29-32, 2010
Scanlon KS, Alexander MP, Serdula MK, et al.: Assessment of infant feeding: the validity of measuring milk intake. Nutrition Reviews 60(8):235-251,
2002
Scammon RE, Doyle LO: Observations on the capacity of the stomach in the first ten days of postnatal life. American Journal of Diseases of Children
20:516-538, 1920
Smith L: How to supplement a supposedly breastfed baby. J Hum Lact 14(2):145-146, 1998
Stellwagen LM, Hubbard E, Wolf A: The late preterm infant: a little baby with big needs. Contemporary Pediatrics Nov, 2007
Stettler N, Stallings VA, Troxel AB, et al.: Weight gain in the first week of life and overweight in adulthood. Circulation 111:1897-1903, 2005
UNICEF: Feeding low birth weight babies. (video) 3 UN Plaza, New York, NY 10017
Villalpando S, Flores-Huerta S, Lpez-Alarcn M, Cisneros-Silva I: Social and biological determinants of lactation. Food and Nutrition Bulletin
17(4):328-335, 1996
Supplementation Policy
Academy of Breastfeeding Medicine Clinical Protocol #3: Hospital Guidelines for the Use of Supplementary Feedings in the Healthy Term Breastfed
Neonate, Revised 2009
Hoover K. Extreme weight loss in the breastfed newborn. J Hum Lact. 1998 Dec;14(4):288.
World Health Organization. Acceptable medical reasons for use of breast-milk substitutes
8
1:00-2:10 Hospital Practices that Support Breastfeeding

I. Goals, objectives and outline
A. Goal: To be aware of the large body of literature supporting changes in hospital practices
to improve breastfeeding initiation, duration and exclusivity
B. Objectives: At the end of this educational activity, the learner will be able to:
1. Enumerate labor and delivery practices that affect breastfeeding.
2. Describe skin-to-skin care to improve breastfeeding outcomes
3. List the evidence-based Ten Steps to Successful Breastfeeding
4. Explain ways WIC can help hospitals to support breastfeeding
C. Outline
1. Labor and delivery practices that affect breastfeeding
2. Skin-to-skin care to improve breastfeeding outcomes
3. Ten Steps to Successful Breastfeeding
4. How WIC can help hospitals
II. Birth practices that affect breastfeeding

A. Doula support during labor (positively affects breastfeeding)
1. Reduces the perception of pain (Kennell 1991)
2. Shortens the length of labor
3. Decreases Cesarean deliveries
4. Increases exclusive breastfeeding (Hofmeyr 1991)
5. Experience fewer breastfeeding problems
6. Socially disadvantaged mothers more likely to initiate breastfeeding (Gruber, 2013)
B. In the past, epidural and narcotic analgesia have been implicated in (negative affect)
1. Reducing sucking ability
2. Increases the time to effective feeding
3. Can affect neurobehavioral status
C. Routine suctioning
(negative affect)
Gastric suctioning is associated with delayed sucking and rooting movements
(Widstrom 1987)
When the newborn is vigorousthere is no evidence that nasopharyngeal suctioning is
necessary. (AAP 2012)
D. Instrumental deliveries (vacuum or forceps) increases feeding difficulties (Demissie 2004)
E. Kind of birth
1. Cesarean birth
a. Experience delay in milk increasing in volume
b. More likely to be separated
2. Epidural
In post hoc analyses stratified by Baby Friendly Hospital (BFH) status, epidural
anesthesia significantly predicted breastfeeding cessation Dozier, 2013
F. Waiting to clamp the cord
(positive affect)
1. Would bring about these results in full-term babies
a. Reduction in iron deficiency anemia
b. Increased duration of early breastfeeding
c. Lower blood lead concentrations at 6 months
9
2. Would bring about these results in preterm babies

a. Decreased intraventricular hemorrhage
b. Decreased need for blood transfusion
c. Higher circulating blood volume
d. Increased iron (milk deficiency may be associated with cognitive deficits)
e. Improved cerebral oxygenation (fewer days of ventilation)
f. Reduced late-onset infections
g. Better cardiopulmonary adaptation
h. Higher blood pressure
i. Less likely to be discharged on oxygen
j. Higher initial glucose levels
3. Studies vary in research protocols for defining the timing of delayed cord clamping
a. 1 to 1.5 minutes
b. At least 2 minutes
c. At least 3 minutes
d. Within 30 seconds vs 3 minutes
e. 10 seconds vs 2 minutes
f. 5-10 seconds vs 30-45 seconds
g. Before 30 seconds after 30 seconds max of 120 seconds
h. 5 to 10 seconds vs 30 to 45 seconds
i. 15 seconds, 1 minute, 3 minutes
4. Temperature change causes the umbilical cord to clamp down on itself to stop the
blood flow from the mother to the baby by about 5 minutes after birth
5. ACOG December 2012 Timing of Umbilical Cord Clamping after Birth
Committee Opinionwait at least 30 to 60 seconds
G. Separation of newborn and mother
(negative affect)
1. Interrupts the ability to self-attach and suck correctly (Righard 1990)
2. Maternal separation may be a stressor the human neonate is not well-evolved to
cope with and may not be benign. (Morgan BE, Horn AR, Bergman NJ. Should
neonates sleep alone? Biol Psychiatry 70(9):817-825, 2011)
3. Identification (e.g. bands and foot prints) can be done while baby is skin-to-skin and
breastfeeding.
4. Routine care can be done after the first breastfeeding and while baby is skin-to-skin
with mother (e.g. vitamin K, eye treatment)
H. Delay the first bath 12+ hours increases breastfeeding exclusivity in the hospital (Preer 2013)
(positive affect)
I. Reducing infant pain
(positive affect)
1. Vaccinationbreastfeeding vs. topical EMLA (Gupta 2013)
2. Vaccinationbreastfeeding vs. vapocoolant spray (Boroumandfar 2013)
3. Heel stick (McNair 2013)
4. Heel sticksucrose vs. SSC vs. sucrose + SSC vs breastfeeding + SSC
(Marin Gabriel 2013)
5. Heel stick in preterm babiesbreast milk lowered pain scores (Ou-Yang 2013)
6. Brain activity with breastfeeding not with glucose (Bembich 2013)
10
III. Ten Steps to Successful Breastfeeding: A global hospital initiative using evidenced-based practices
A. What is wrong with this picture? A mothers request as she enters our hospital
I want to formula feed my baby100% get what they want.
I want to combination feed my baby100% get what they want.
I want to exclusively breastfeed my babyless than 50% get what they want.
B. Following the Ten Steps increases breastfeeding exclusivity
(Martis 2013, Forrester-Knauss 2013)
C. 20-hours of education makes a difference in the breastfeeding supportive practices of health
care professionals (Zakarija-Grkovic 2010)
D. Transforming careExclusive breastfeeding is defined as providing nothing other than
human milk feedings. Exclusivity rates rose from 6% to 44% (Magri 2013)
E. Maine hospitals, BFHI vs. not; BFHI designated hospitals were not keeping their practices
up-to-date (Hawkins 2014)
F. Sending home formula decreases exclusivity (Feldman-Winter 2012, Sadacharan 2014)
G. None of the hospitals had a searchable system for feedings ( Labbok 2013)
H. From research to practice takes 17 years.
I. Women who experienced all 4 hospital practices had higher odds of breastfeeding at one
month and 4 months than women who experienced fewer than 4, being BFHI designated
did not make a difference. (Brodribb 2013)
J. Breastfeeding within the 1st hour compared to more than one hour reduces risk of earlyonset feeding problems in term neonates (DiFrisco 2011, Carberry 2013, Raghavan 2013)
K. Skin-to-skin for 2+ hours after birth (Thukral 2012)
L. Still breastfeeding at 6 months higher in group who had skin-to-skin in the first hour; more
formula use when first time mother or C-birth and shorten duration (Augustin 2014)
M. Visitors are a barrier to skin-to-skin care (Ferarrello 2014)
N. Cost analysis, no significant difference in the cost of following the Ten Steps
(DelliFraine 2011, Allen 2013)
O. If 90% of women breastfed exclusively for 6 months and continued with appropriate
complementary foods for over one year over 900 fewer deaths in the first year (Bartick
2010) and 4,000 fewer maternal deaths (Bartick 2013)
P. NICU at Boston Medical Center ten years after Baby-Friendly designation initiation rates
rose from 74% to 85% (1999-2009) (Parker M 2013)
Q. More hospitals designated as BFHI in 2011 than any previous year in USA (CDC 2013)
R. October 2014 there are 199 Baby-Friendly Hospitals in the USA
S. Missouri Hannibal Regional Hospital, Hannibal, MO (07/09)
VII. What can WIC do to help hospitals
A. Breastfeeding in-service program
B. Educational materials on state website
C. Make bulletin boards for the hospital maternity unit, ultrasound unit, etc.
D. Peer counselors who come to the hospital to see WIC clients
E. Give feedback from your clients about how the hospital is doing
F. Provide a list of local breastfeeding resources and up-date regularly
G. Conduct a breastfeeding mothers group at the hospital
H. Send an employee to be a member of the hospital breastfeeding committee and the local
and state breastfeeding coalitions
I. Run a breastfeeding mothers group at the hospital
11
J. Find free patient handouts that may be copied and are translated into many languages
K. Start a hospital collaborativeget several hospitals in an area to meet together to help
support each other in making changes.
L. Provide classes for fathers and grandmothers
12
Mothers Breastfeeding Checklist

I know holding my baby skin to skin is a good for both of us.
I know how the baby tells me it is time for a feeding.

I know how to latch my baby onto both breasts.
I know I should take turns with the breast I feed from first.
I know when my baby is finished breastfeeding that he or she will let go on his or
her own and be relaxed. And I know that my baby needs to finish on the first breast
before I feed the baby on the other breast.
I can hear my baby swallowing milk during the breastfeeding sessions.
I know breastfeeding should not hurt after 30 seconds.
I know when and where to call if I have any breastfeeding questions.
I know how to squeeze milk out of my breasts.
I know my baby should eat only my milk for the first six months.
I know how to tell that my baby is getting enough milk.
I know how to fill out the feeding record for the first week.
I know a wet diaper is as heavy as 3 tablespoons of water.
I know my baby should be back to birth weight by 14 days.
I know when my baby is back to birth weight, I no longer need to

keep a feeding record
Once my baby is back to birth weight, I know my baby should gain
at least 5 to 8 ounces each week (for the first 2 months).
I have an appointment to see the pediatrician or family doctor
in 2 or 3 days after we leave the hospital.
I know I can bring the babys feeding record with us to the doctors appointment.
Babys birth weight

Babys discharge weight
Babys weight 2-3 days after discharge
Babys weight at 10 to 14 days
_________________________
_________________________
__________________________
__________________________
Adapted with permission from Marsha Walker
13
Complete this questionnaire as if you were one of the mothers who

recently delivered at your hospital or the closest hospital to you.
YES
NO
1. Before my baby was born, I was told why and how to breastfeed.
2. The staff were knowledgeable and supportive of breastfeeding.
3. I was shown how to breastfeed my baby.
4. I was encouraged and helped to breastfeed without the use of

any other liquids for my baby.
5. My breasts were examined before and after my babys birth.
6. I was instructed to breastfeed whenever my baby wanted

to suck or cried.
7. At birth, my babys weight was recorded and given to me.
8. My baby and I had skin-to-skin contact immediately after the birth.

9. I offered my baby the breast for the first time within:
30 minutes
one hour
more than one hour
10. My baby was not given anything to drink by the staff.
11. My baby and I were not separated at any time during

our hospital stay unless requested by me.
12. My baby was not given a pacifier by the staff.
13. I was not given any formula, bottles, or rubber nipples

when I left the hospital.
14. I was told when my baby would need to be examined and weighed
and how to schedule an appointment for her/him.
15. I was told how to contact a breastfeeding mothers support group
before I left the hospital.
16. Overall, I believe my breastfeeding experience was improved
by this facility.
This questionnaire was taken from a WABA folder for World Breastfeeding Week.
14
10 Steps to Successful Breastfeeding

According to WHO/UNICEF, every facility providing maternity services and
care for newborns should:
1. Have a written breastfeeding policy that is routinely communicated
to all health care staff.
2. Train all health care staff in the skills necessary to implement this
policy.
3. Inform all pregnant women about the benefits and management of
breastfeeding.
4. Place babies immediately skin-to-skin to stabilize the newborn and
help the baby initiate breastfeeding within an hour of birth.
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 breast milk, unless
medically indicated.
7. Practice rooming-inallow mothers and infants to remain
together24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers to breastfeeding infants.
10. Organize and provide follow-up in the community after discharge.
15
Visually Promote Breastfeeding

On you
Button
Name tag
Bumper sticker
Carry a breastfeeding book
Tote bag
Education of entire staff

In-service programs
Attend conferences
College courses
Library of resource books
Local breastfeeding resources file
In your space
Posters
Photos of staff with baby and positive
message
Videos playing in waiting area
Bulletin board of photos of clients who
breastfed
Wall of clients who breastfed for one year
The words we use

When (not if)
Ask, What do you know about
breastfeeding? (not breast or bottle, she can
do both)
Discuss advantages to the mother. (People
know about the advantages to the baby.)
Items you use

Pens
Mugs
Paper
Water bottle
Incentives
Gift basket
Large gift
Monthly gift
Payment
Certificates
Mail to send out

Stickers
Envelopes
Encourage breastfeeding in the waiting room

Comfortable chairs
Others to set an example
In your organization
Peer counselors
Employee pumping station
Encourage staff to talk about breastfeeding with

clients
Dispel myths
Take care of potential problems
Handouts with accurate information

Culturally appropriate
Language appropriate
Colorful and attractive
Ad specialty items with positive breastfeeding
information
Bookmarkers
Magnets
Bags
Education outside of your walls

Establish lending library of books and videos
for parents
Classes on breastfeeding for mother and her
family members
Get pregnant together with breastfeeding
women
Telephone numbers to call if have questions
16
Establishing Practices that Promote, Protect, and Support Hospital Breastfeeding Policies
American Academy of Pediatrics Workgroup on Breastfeeding: Breastfeeding and the Use of Human Milk. Pediatrics 100(6):1035-1039, 1997
Anand RK: Transforming health colleagues into breastfeeding advocates. WABA Activity Sheet #3, (undated) adapted from Lyra Srinivasan's stages of
change, published by SARAR International and World Neighbours in Action
Anderson G: Risk in mother-infant separation postbirth. Image: J of Nursing Scholarship 21:196-199, 1989
Bono BJ: Assessment and documentation of the breastfeeding couple by health care professionals. Journal of Human Lactation 8(1):17-22, 1992
Chezem J, Friesen C, Montgomery P, Fortman T, Clark H: Lactation duration: influences of human milk replacements and formula samples on women
planning postpartum employment. JOGNN 27(6):646-651, 1998
Christensson K: Temperature, metabolic adaptation and crying in healthy newborns cared for skin-to-skin or in a cot. Acta Paediatr 81:488-493, 1992
Coalition for Improving Maternity Services: The mother-friendly childbirth initiative. J of Nurse-Midwifery 42(1):59-63, 1997
de Carvalho M, Robertson S, Friedman A, Klaus M: Effect of frequent breastfeeding on early milk production and infant weight gain. Pediatrics 72(3):307311, 1983
de Carvalho M, Robertson S, Klaus M: Fecal bilirubin excretion and serum bilirubin concentrations in breast-fed and bottle-fed infants. Journal of Pediatrics
107(5):786-789, 1985
de Carvalho M, Robertson S, Merkatz R, Klaus M: Milk intake and frequency of feeding in breastfed infants. Early Hum Dev 7:155-163, 1982
Dungy CI, et al.: Effect of discharge samples on duration of breastfeeding. Pediatrics 90(2):233-237, 1992
Ellis DJ: Supporting breastfeeding: how to implement agency change. NAACOGs Clinical Issues 3(4):560-564, 1992
Freeman C, Lowe N: Breastfeeding care in Ohio hospitals: a gap between research and practice. JOGNN 22:447-453, 1993
Glover J: Supplementation of breastfeeding newborns: a flow chart for decision making. Journal of Human Lactation 11(2):127-131, 1995
Hannon PR, Ehlert-Abler P, Aberman S, Williams R, Carlos M: A Multidisciplinary approach to promoting a baby friendly environment at an urban
university medical center. Journal of Human Lactation 15(4):289-296, 1999
Henrikson M: A policy for supplementary/complementary feedings for breastfed newborn infants. J Human Lactation 6(1):11-14, 1990
Huggins K: What every nursing mother should know at discharge: breastfeeding instructions for the first week. Mother Baby Journal 2(3):43-45, 1997
International Lactation Consultant Association: Evidence-Based Guidelines for Breastfeeding Management during the First Fourteen Days. Raleigh,
NC: ILCA, 1999
Jenks M: Latch assessment documentation in the hospital nursery. J Human Lactation 7(1):19-20, 1991
Jensen D, Wallace S, Kelsay P: LATCH: a breastfeeding charting system and documentation tool. JOGNN 23(1):27-32, 1994
Johnson R, et al.: Effect of post-delivery care on neonatal body temperature. Act Paediatori 81:859-863, 1992
Keefe M: Comparison of neonatal nighttime sleep-wake patterns in nursery rooming-in environments. Nursing Research 36:140-144, 1989
Kovach AC: Hospital breastfeeding policies in the Philadelphia area: a comparison with the ten steps to successful breastfeeding. Birth 24(1):41-48, 1997
Kramer MS, Chalmers B, Hodnett ED, et al.: Promotion of breastfeeding intervention trial (PROBIT): a randomized trial in the Republic of Belarus. JAMA
285(4):413-420, 2001
Lang S, Lawrence CJ, Orme RL: Cup feeding: an alternative method of infant feeding. Arch Dis Child 71(4):365-369, 1994
Lawrence RA: Breastfeeding in Belarus. JAMA 285(4):463-464, 2001
Lawrence RA, Lawrence RM: Breastfeeding: A Guide for the Medical Profession (7th edition). Maryland Heights, MO: ElsevierMosby, 2012
Matthews MK: The relationship between maternal labour analgesia and delay in the initiation of breastfeeding in healthy neonates in the early postpartum
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Mulford C: Swimming upstream: breastfeeding care in a nonbreastfeeding culture. JOGNN 24(5):464-74, 1995
Neifert M: Early assessment of the breastfeeding infant. Contemporary Pediatrics 13(10):142-66, 1996
Neifert M, Lawrence R, Seacat J: Nipple confusion: toward a formal definition. J Pediatr 126:123-129, 1995
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Powers NG, Naylor AJ, Wester RA: Hospital policies: crucial to breastfeeding success. Seminars in Perinatology 18(6):517-524, 1994
Righard L, Alade MO: Effect of delivery room routines on success of first breast-feed. Lancet 336(8723):1105-1107, 1990
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1997
US Com for UNICEF: Barriers and Solutions to the Global Ten Steps to Successful Breastfeeding. 110 Maryland Ave, NE, Box 36, Washington, DC
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25
kay@hoover.net
Post Birth Care to Support Early and Exclusive Breastfeeding

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kay@hoover.net
de Carvalho M, Robertson S, Merkatz R, Klaus M: Milk intake and frequency of feeding in breastfed infants. Early Human Development 7:155-163, 1982
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Delayed Cord Clamping
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Chaparro CM, Fornes R, Neufeld LM, et al.: Early umbilical cord clamping contributes to elevated blood lead levels among infants with higher lead
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Comment in: BJOG 115(9):1190-1191, 2008
Skin-to-skin to increase the blood glucose level
Christensson K: Fathers can effectively achieve heat conservation in healthy newborn infants. Acta Paediatrica 85(11):1354-60, 1996
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Mazurek T, Mikiel-Kostyra K, Mazur J, et. al.: Influence of immediate newborn care on infant adaptation to the environment. Med Wieku Rozwoj 3(2):215224, 1999
Walters MW, Boggs KM, Ludington-Hoe S, et al: Kangaroo care at birth for full term infants. MCN 32(6):375-381, 2007
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2006
Unexpected Collapse of Healthy Newborns
AAP: Task Force on Sudden Infant Death Syndrome: SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping
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Videos
Boston Medical Center, The Breastfeeding Center: From Bottles to Breast to Baby-Friendly: The Challenge to Change. DVD
Righard L: Delivery Self-Attachment. Available from Health Education Associates, wwwhealthed.cc and Geddes Productions:
http://www.geddesproductioncom/breast-feeding-delivery-selfattachment.html
UNICEF: Learning to be Baby-Friendly
Widstrom A-M: Breastfeeding isBabys Choice. Stocholm, Sweden, BKG Productions. Health Education Associates, www.healthed.cc
Bergman N: Kangaroo Mother Care, Geddes Productions: http://www.geddesproductioncom/breast-feeding-delivery-selfattachment.html
Special Delivery, Injoy Productions, Bouder, CO
U-Tube
Skin-to-skin after a c-birth http://www.youtube.com/watch?v=m5RIcaK98Yg
Baby-Friendly Rap Music video http://www.youtube.com/watch?v=N9KptD3t110&feature=youtu.be
Association Statements
Academy of Breastfeeding Medicine: Clinical Protocol #5: Peripartum Breastfeeding Management for the Healthy Mother and Infant at Term. Revision,
June 2008
American Academy of Pediatrics: Neonatal Resuscitation Guidelines. Pediatrics 117(5):e989-1004, 2006
American Academy of Pediatrics, Committee on Fetus and Newborn: Guidelines for Perinatal Care (7th Edition) Elk Grove Village, Illinois: AAP, 2012
American Academy of Pediatrics Section on Breastfeeding, Eidelman AI, Schanler RJ: Breastfeeding and the Use of Human Milk. Pediatrics 29(3):e827e841, 2012
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Assessing The Breastfeeding

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Assessing The Breastfeeding

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9:00-10:10 Assessing the Breastfeeding Dyad

I. Goals, objectives and outline

10:30-11:40 Supplementing the Breastfeeding Infant

express her milk because the tuberculosis infection is acquired through

2.5 x babys weight in pounds = oz/24 hours

Average daily output in 98 mothers of term infants (Hill 2005)

The goal is to feed the baby and pump in an hour

Barbara L. Boston 1994

1:00-2:10 Hospital Practices that Support Breastfeeding

II. Birth practices that affect breastfeeding

2. Would bring about these results in preterm babies

Mothers Breastfeeding Checklist

I know how the baby tells me it is time for a feeding.

I know my baby should be back to birth weight by 14 days.

I know when my baby is back to birth weight, I no longer need to

Babys birth weight

Complete this questionnaire as if you were one of the mothers who

3. I was shown how to breastfeed my baby.

4. I was encouraged and helped to breastfeed without the use of

5. My breasts were examined before and after my babys birth.

6. I was instructed to breastfeed whenever my baby wanted

8. My baby and I had skin-to-skin contact immediately after the birth.

11. My baby and I were not separated at any time during

12. My baby was not given a pacifier by the staff.

13. I was not given any formula, bottles, or rubber nipples

10 Steps to Successful Breastfeeding

Visually Promote Breastfeeding

Education of entire staff

The words we use

Items you use

Mail to send out

Encourage breastfeeding in the waiting room

Encourage staff to talk about breastfeeding with

Handouts with accurate information

Education outside of your walls

Post Birth Care to Support Early and Exclusive Breastfeeding

Pain for the newborn

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