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MO-07-0033 BFP

Nurses, certified nurse midwives, physicians and other health professionals with expertise regarding the benefits and management of breastfeeding should educate pregnant and postpartum women when the opportunity for education exists, for example, during prenatal classes, in clinical settings, and at discharge teaching.




2.1 Pregnant and postpartum women should be provided information prior to birth, following birth, and before discharge regarding the benefits and management of breastfeeding and the risks associated with artificial feeding.

This information should include how to maintain lactation when separated from their infants.

Classes and teaching materials should be selected which consider the woman’s cultural background, education and preferred language.







2.1 Knowledge and support improve the breastfeeding experience. Most women make their decision about breastfeeding prior to delivery. 2,6,7,8,9,10,15,20,21,23


2.2 Education should be provided using a combination of techniques such as one-to-one teaching, group classes, pamphlets and/or video taped instruction.

Hospitals should work with prenatal providers to inform and encourage pregnant women and their partners to attend available breastfeeding classes during the prenatal period.


2.2 Consistency of information provides a similar frame of reference. The mother can refer to educational materials during and after her hospital stay to reinforce learning. 12,16,19,24


Sources of educational materials for patients (Word)Opens a new browser window.

Health Literacy:

Sources of free Breastfeeding education materials include:

Sources of information about California Laws related to breastfeeding

2.3    Classes, pamphlets and videos should reflect the cultural background, education, and language of the population being served.


2.3 Understanding the cultural and socioeconomic context of infant feeding practices is necessary to provide clients with relevant education. 5,21


2.4 Materials that promote the use of commercial products known to interfere with breastfeeding should not be used to teach breastfeeding.


2.4 All materials used for breastfeeding promotion and education should be produced by companies whose interests are not in conflict with the promotion of breastfeeding. 15,20


  • Perform an office assessment by using: "Appendix 4-I: Marketing materials scavenger hunt" found in the following Appendix

2.5 Teaching methods should be tailored to the age of the client.

2.5 Teens may prefer alternative learning opportunities such as field trips, games and videos when appropriate.4


2.6 Regardless of feeding choice, discharge teaching should include the benefits of keeping the baby in close physical proximity.

As part of the continuum of care, mothers should be provided discharge education on sleeping with their infants.


2.6 When mothers and babies are in close proximity, mothers are able to identify their infants’ hunger cues and readiness to feed. 2,4,15,16,19,20

The American Academy of Pediatrics (AAP) guidelines regarding parents sleeping with their infants should be followed. 3


Example of a flyer that addresses safe sleeping alternatives. (Solano county – Your Baby Matters (PDF)Opens a new browser window.)

Sources of patient information that address cue feeding:

2.7 Physicians should be encouraged to support breastfeeding enthusiastically, according to the recommendation of the American Academy of Pediatrics, and should educate patients based on AAP guidelines.


2.7 Physicians can influence their patients’ health behavior choices during the perinatal period. 22,23

Many professional organizations actively encourage breastfeeding including the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, American College of Nurse-Midwives, the American Hospital Association, the Association of Women’s Health, Obstetric and Neonatal Nurses and the American Dietetic Association.


Additional information on normal breastfeeding issues can be found in:

Additional Professional information:
Ten Steps to Support Parents’ Choice to Breastfeed Their Baby: (PDF)Opens a new browser window.

2.8 Mothers should be instructed in a method of hand expression of breastmilk. Instruction should be offered to all mothers regardless of feeding choice, prior to hospital discharge.

2.8 Breastfeeding women may have unexpected separations from their newborns. Hand expression is the easiest way to empower new mothers to manage normal breastfeeding emergencies. Hand expression may produce more milk due to the breast massage and skin contact. 17

Non breastfeeding mothers may require relief from engorgement.

Information on Hand Expression:

On-line video of hand expressing colostrum:  Stanford School of Medicine: Hand Expression of Breastmilk

Videos to purchase that demonstrate hand expression once milk is well-established:

2.9 The breastfeeding mother should be instructed in the correct use of a hospital grade electric breast pump by an experienced perinatal caregiver when the infant consistently demonstrates inadequate suckling or when prolonged separation of the mother and infant is expected because of prematurity or illness. The mother should be given the opportunity to pump as soon after birth as medically feasible.

2.9 Feeding the infant expressed milk validates the mother’s efforts and provides health benefits to the baby. 11,13,15

2.9.1 The electric pumping system is time-saving for the mother. Piston electric pumps attempt to imitate the suckling cycle of the infant.11,13,15,18

2. 9.2 Breast stimulation and breast emptying are necessary to initiate and maintain lactation. 9

2.9.3 Following a protocol for pumping helps maintain consistency of technique and information between care providers.

2.10 Discharge planning for breastfeeding mothers who are likely to be separated from their infants should include methods of expressing breastmilk including hand expression and/or pumping. A support person should be included in the teaching process.

2.10 Emphasize the importance of regular breast expression in maintaining lactation. Pumping frequency and length guidelines are based on the method of expression, taking into account baby’s age and mother’s ability to maintain enough volume to support her infant’s needs. If her supply begins to decrease, increased frequency and duration of pumping may increase production. Mother’s who have support are likely to sustain pumping for a longer period of time. 14,17,18,20

When dealing with sick or premature infants, go to the California Perinatal Quality Care Collaborative: http://www.cpqcc.org/ and see the policies for the nutritional support of the VLBW Infant, Part I and II.

The Human Milk Banking Association of North America has released their newest, 2005, Best Practice for Expressing, Storing, and Handling Human Milk in Hospitals, Homes and Child Care Settings.

Policy #2 References:

1. American College of Obstetrics and Gynecology Educational Bulletin #258 (July, 2000). Breastfeeding: Maternal and Infant Aspects. Available to members at http://www.acog.org/navbar/current/publications.cfm
2. American Academy of Pediatrics policy statement. (2005). Breastfeeding and the use of human milk, Pediatrics, 115, 495-506. (2005 Version)
3. American Academy of Pediatrics. (2000). Changing concepts of sudden infant death syndrome: Implications for infant sleeping environment and sleep position (RE9946). Pediatrics, 105(3), 650-656. Full Version
4. Bachman, J. (1993). Self-described learning needs of pregnant teen participants in an innovative university/community partnership. Maternal-Child Nursing Journal, 21(2), 65-71. Abstract
5. Bertelsen, C. & Auerbach, K. (1987). Nutrition and breastfeeding: The cultural connection. Lactation Consultant Series. La Leche League International, Garden City Park, NY: Avery Publishing Group, Inc.
6. Blyth, R., Creedy, D. K., Dennis, C. L., Moyle, W., Pratt, J., & De Vries. S. M. (2002). Effect of maternal Confidence on breastfeeding durations: An application of breastfeeding self-efficacy theory. Birth, 29(4). 278-284. Abstract
7. Chezem, J., Friesen, C., & Boettcher, J. (2003). Breastfeeding knowledge, breastfeeding confidence, and infant feeding plans: Effects on actual feeding practices. Journal of Obstetric, Gynecologic and Neonatal Nursing, 32(1), 40-47. Abstract
8. Colin, W. B., & Scott, J. A. (2002). Breastfeeding: Reasons for starting, reasons for stopping and problems along the way. Breastfeeding Review, 10(2), 13-19. Abstract
9. Daly, S. & Hartmann, P. (1995). Infant demand and milk supply. Part 2: The short-term control of milk synthesis in lactating women. Journal of Human Lactation, 11, 27-37. Abstract
10. Donath, S. M., & Amir, L. H. (2003). Relationship between prenatal infant feeding intention and initiation and duration of breastfeeding : A cohort study. Acta Paediatrica, 92(3), 352-356. Abstract
11. Frantz, K. (1994). Breastfeeding Product Guide. Sunland, CA: Geddes Productions.
12. Ingram, J., Johnson, D., & Greenwood, R. (2002). Breastfeeding in Bristol: Teaching good positioning, and support from fathers and families. Midwifery, 18(2), 87-101. Abstract
13. Huggins, K. (1999). The Nursing Mother’s Companion (4th ed.). (pp. 85-97). Boston: Harvard Common Press
14. Lawrence, R. A. (1987). The management of lactation as a physiologic process. Clinics in Perinatology, 14(1), 1-10.
15. Lawrence, R. A., & Lawrence, R. M. (2005). Breastfeeding: A Guide for the Medical Profession (6th ed.). St. Louis, MO: Mosby. (pp. 227, 768, 781-794).
16. Libbus, M. K. (1994). Lactation education practice and procedure: Information and support offered to economically disadvantaged women. Journal of Community Health Nursing, 11(1), 1-10.
17. Marmet, C. (1988). Manual Expression of Breastmilk: Marmet Technique. Encino, CA: The Lactation Institute.
18. Marmet, C., & Shell, E. (1988). Instruments used in breastfeeding: A guide. In D. B. Jelliffe, & E. F. Jelliffe (Eds.), Programmes to Promote Breastfeeding (pp. 330-339). Oxford: University Press.
19. Righard, L. & Alade, M. (1990). Effect of delivery room routines on success of first breast-feed. The Lancet, 336, 1105-1107. Abstract
20. Riordan, J. C. (2005). Breastfeeding and Human Lactation (3rd ed.). Sudbury, MA: Jones and Bartlett. (pp. 694, 703, 323-349).
21. Rossiter, J. C. (1994). The effect of a culture-specific education program to promote breastfeeding among Vietnamese women in Sydney. International Journal of Nursing Studies, 31(4), 369-379. Abstract
22. Taveras, E. M., Ruowei, L., Grummer-Strawn, L., Richardson, M., Marshall, R., Rego, V. H., Miroshnik, I., et al. (2004). Mothers’ and clinicians’ perspectives on breastfeeding counseling during routine preventive visits. Pediatrics, 113, 405-411. Full text
23. Wiles, L. (1984, July/August). The effect of prenatal breastfeeding education on breastfeeding success and maternal perception of the infant. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 253-257. Abstract
24. World Health Organization, Division of Child Health and Development. (1998). Evidence for the Ten Steps to Successful Breastfeeding (PDF)Opens a new browser window.. Geneva: World Health Organization.

Additional References:

Chantry CJ, Howard CR, & Auinger P: “Full Breastfeeding Duration and Associated Decrease in Respiratory Tract Infection in US Children” Pediatrics 2006 Feb; 117(2):425-32 (Abstract)

Chung M, Raman G, Trikalinos T, Lau J, Ip S. “Interventions in Primary Care to Promote Breastfeeding: An Evidence Review for the US Preventive Services Task Force”. Annals of Internal Medicine, 2008.
             Evidence suggests that breastfeeding interventions are more effective than usual care in increasing short- and long-term breastfeeding rates. Combined pre- and postnatal interventions and inclusion of lay support in a multi-component intervention may be beneficial.

DiGirolamo, Grummer-Strawn et al. “Effect of maternity-Care Practices on Breastfeeding”. Pediatrics, 10/2008.
             N=1970 Women not experiencing breastfeeding initiation within the first hour of life, breast milk given only, breastfeeding on demand, rooming in, no pacifiers and fostering breastfeeding support groups were 13X more likely to stop breastfeeding early. Those stopping early tended to be younger, lower education and income, unmarried, primiparity, smoking prenatally and have fewer friends and relatives who breastfed, intending to work postpartum and have less favorable attitudes toward breastfeeding.
             Behaviors that were protective: breastfeeding initiation within first hour; only breast milk given, breastfeeding on demand and no pacifiers; others included bringing infant to mother’s room for feeding at night (if not rooming-in) and not giving mother pain meds during labor.

Guise et al: “The Effectiveness of Primary Care-Based Interventions to Promote Breastfeeding: Systematic Evidence Review and Meta-analysis for the US Preventive Services Task Force” Annals of Family Medicine – Abstract Vol. 1 No. 2 July/August 2003

Hannula L, Kaunonen M, Tarkaa, M. “A systematic review of professional support interventions for breastfeeding”. Journal of Clinical Nursing, 06/30/2007.
              This study consisted of a systematic review of breastfeeding practices during pregnancy, at maternity hospitals and during the postpartum period and to find out how effective interventions are in supporting breastfeeding. Found that during pregnancy the effective interventions were interactive, involving mothers in conversation. The BFHI as well as practical hands-off teaching were effective approaches. Postnatally effective were home visits, telephone support and breastfeeding centers combined with peer support.

Hill, P. D., Aldag, J. C., & Chatterton, R. T. (1999). “Effects of pumping style on milk production in mothers of non-nursing preterm infants”. J Hum Lact, 15(3), 209-216.

Hill, P. D., Aldag, J. C., & Chatterton, R. T. (2001). “Initiation and frequency of pumping and milk production in mothers of non-nursing preterm infants”. J Hum Lact, 17(1), 9-13.

Ip, S., Chung, M., Raman, G., Chew, P., Magula, N., DeVine, D., et al. (2007). “Breastfeeding and maternal and infant health outcomes in developed countries”. Evid Rep Technol Assess (Full Rep)(153), 1-186.

Jones, F., & Tully, M. R. (2005). Best Practice for Expressing, Storing and Handling Human Milk in Hospitals, Homes and Child Care Settings. Raleigh, North Carolina: Human Milk Banking Association of North America (HMBANA).

Kent JC, Mitoulas, LR, Cregan MD, Ramsay, DT, Doherty DA, & Hartmann, PE; Volume and Frequency of Breastfeeding and Fat Content of breast Milk Throughout the Day. Pediatrics 2006;117;387-395 [Full text (PDF)Opens a new browser window.]

Lawrence Ruth and Manganello, Jennifer. “Breastfeeding and the New Media
University of Albany School of Public Health; Women’s Health Grand Rounds originally broadcast August 4, 2011.

Persad, M. D., & Mensinger, J. L. (2008). “Maternal breastfeeding attitudes: association with breastfeeding intent and socio-demographics among urban primiparas”. J Community Health, 33(2), 53-60.

U.S. Preventive Services Task Force"Primary care interventions to promote breastfeeding: U.S. Preventive Services Task Force Recommendation Statement" Ann Intern Med 2008; 149: 560-564.

Wiessinger D, West D, Pitman T (2010) The Womanly Art of Breastfeeding, La Leche League International, Schaumberg, IL B003IBWECK

Hospital Self-Appraisal Questionnaire (Word)Opens a new browser window.

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Last modified on: 7/9/2013 2:55 PM