EXPANDED HOSPITAL POLICY #6:

INTERVENTION / MANAGEMENT

RATIONALE

RESOURCES

6.1 Nurses, certified nurse midwives and physicians should assist the mother with breastfeeding and provide guidance and support.

6.1.1 When an assessment identifies a dysfunction or the infant displays signs of inadequate intake, a lactation consultation should be ordered.

6.1.2 A functional reassessment of the infant at the breast should be performed by a trained physician, certified nurse midwife, nurse, or lactation specialist within 8 hours of birth, by utilizing an assessment tool (FAIB or LATCH) and at least once every 8 hours while in the hospital.

6.1 New mothers need consistent information and assistance in recognizing an adequate feeding. 2,3,9

6.1.1 An assessment provides for early identification of latch-on difficulties and direct observation of the infant at breast to assure adequate breastfeeding prior to discharge.4,7,12

6.1.2 Although scoring can be misleading and inconsistent, assessment tools can help the provider identify areas of need for intervention. 1,13,14,15

International Lactation Consultant Association. Clinical Guidelines for the Establishment of Exclusive Breastfeeding (PDF)ILCA, 2005.

Norms for the First 3 Days of Life(PDF)

Videos to order that can be used to teach staff about Latch includes:

Rebecca Glover:
Dr. Jane Morton’s videos

Examples of breastfeeding evaluation forms/methods

Breastfeeding Assessment Score: BAS (link)
Breastfeeding Assessment Tool, for the First 4 weeks:
LATCHES

See example of a Breastfeeding Assessment policy (PDF)

Example of a Hospital Breastfeeding Policy (PDF)

6.2 Pillows should be available to support mother’s arms and bring the baby to breast level.

6.2 Nipple trauma can be prevented and nipple soreness minimized with proper attachment and positioning. Support and comfort of the mother and baby prevents fatigue and facilitates proper positioning of the baby at breast. 5,6,10,17

FAQs about positioning can be found at La Leche League International:

• How do I position my baby to breastfeed?
• How do I prevent sore nipples?

Patient handouts with drawings can be found in Dr. Jack Newman’s Handouts (link)

Link to web-based video clips on asymmetrical latch

• Dr. Newman [link]
• Breastfeeding.com [link]

6.3 Nurses, certified nurse midwives, and physicians should respond to complaints of nipple soreness by assessing the source of the discomfort and assisting the mother in resolving the problem.

6.3 Physiological nipple tenderness may occur during the first few minutes of a feeding and eases during the same feeding. 8,10


Nipple soreness is considered abnormal when a mother complains of nipple soreness throughout an entire feeding or between feedings. 5,10,12,166

Links to show short videos on asymmetrical latch can be found at: http://www.thebirthden.com/Newman.html

When evaluating infant’s mouth, be aware of possible problems due to tongue-tie (ankyloglossia) See References

6.4 Mothers should be educated on the “supply and demand” principle of milk production.

6.4 Understanding of basic physiology enhances the lactation process. 2,3

See studies by Daly and Hartmann in References

6.5 Frequency and duration of feedings at the breast should be infant-led. Non-timed feedings and cue-based offerings will be the basis for mother-infant care. The infant needs to have active suckling and swallowing time at the breast during each feeding.

6.5 It often takes 1½-2 minutes after the onset of suckling for oxytocin release and subsequent milk ejection reflex. At times it may take as long as 6-10 minutes for oxytocin release.

Limiting suckling time has not been shown to reduce nipple soreness or trauma and may result in a decreased milk supply and a delay of lactogenesis..8,17,9,10

Patient Instruction Materials should be evaluated to assure they recommend allowing the infant to breastfeed until he/she releases rather than timed feedings.

Examples:

Massachusetts Breastfeeding Coalition - scroll down the page to locate the handouts
Bright Futures Lactation Resources Center has some of Jack Newman’s articles (link)

6.6 Mothers should be assisted in identifying infant’s hunger cues and readiness to feed.

6.6.1 Breastfeeding according to baby’s cues should be supported by nurses and physicians who will help mothers respond to those cues.

6.6.2 Mothers should be encouraged to monitor their own and the infant’s signs of adequate/inadequate intake and output.



6.6.3 If the nurse or physician is concerned with the baby’s intake before discharge, consultation should be sought and the problem defined and addressed prior to discharge.

6.6 Newborns should be breastfed whenever they show signs of hunger such as increased alertness or activity, mouthing or rooting, rapid eye movement sleep, and hand-to-mouth movement.

6.6.1 Infants are more organized in their behavior and will breastfeed more successfully if they are not crying. Crying is a late sign of hunger.

6.6.2 Breastmilk is digested in approximately 90 minutes. Eight to twelve feedings every 24 hours has been associated with increased meconium passage and lower serum bilirubin levels in the infant.

6.6.3 Maternal prolactin levels fall three hours after breastfeeding. Frequent and early feedings enhance duration of breastfeeding and enhance milk production. It is within normal range for babies to “cluster feed” by feeding several times close together and then going several hours without feeding. Normal, healthy newborns may breastfeed every hour, or several times in one hour, during the first days of life. 4,9,10,11,17

Video on Infant Cues – A Feeding Guide is available through the Texas Department of Health (PDF, 2.4MB)

6.7 The nurse, certified nurse midwife or physician should discuss the importance of colostrum with the mother. After appropriate education, however, a mother who feels very uncomfortable giving colostrum should be encouraged to pump and may discard the colostrum. This may be all that is needed to ensure an adequate beginning with breastfeeding. The nurse, certified nurse midwife, or physician should be aware of cultural differences regarding colostrum and be trained to address these issues sensitively.

6.7 Some mothers may choose not to initiate early breastfeeding due to misinformation about the nature of colostrum. Some nurses and physicians have reported that encouraging mothers to express and discard a small amount of the first milk has sufficed to get breastfeeding started.3

See the handouts in the Appendix of the Peer Counselor Manual found in the website; http://www.wicworks.ca.gov/ for information on cultural beliefs that can affect breastfeeding (Ethnic Awareness (PDF))