Promotion of breastfeeding

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Authors

Andritsou F, Oude-Reimer M, Camba F, Ceccatelli M, Nagy Bonnard L, Hankes-Drielsma I, Jørgensen E, Silva E

Click on the image to read the standard in brief.

Target group

Infants, parents, and families


User group

Healthcare professionals, neonatal units, hospitals, and health services & stakeholders


Statement of standard

All mothers are supported to feed their infants exclusively with human milk (expressed mother’s milk or donor human milk) during the hospital stay and after discharge.


Rationale

Breastfeeding is the biological norm for all mammals, including humans and it is the natural way of providing nurturing, nutrients, and energy needed for physical and neurological growth and development. Exclusive breastfeeding gives every infant and child the right to the highest standard of health and a fair start in life, without inequalities or social injustice. (1,2)

By receiving evidence-based information and lactation counselling, nursing parents can be enabled to breastfeed and express milk, if they feel supported by their partner, family, the healthcare system and society at large, and are protected from commercial interests that negatively impact on breastfeeding. (3) Staff needs to enable informed decision-making while remaining sensitive to maternal choice and providing alternative solutions like donor human milk for women who are unable to provide any or sufficient breastmilk (see standard Providing mother’s own milk for preterm and ill term infants).

Initiation of breastfeeding within the first hour after birth or as soon as possible and immediate and uninterrupted skin-to-skin contact are important for the establishment of breastfeeding, to facilitate mother and infant bonding, and for newborn infants’ and children’s survival and development. (3,4) The early initiation of breastfeeding results in early and successful expression of colostrum, the ‘very first food’ and the perfect food for every newborn infant, as WHO recommended and stated. (3)

Mothers are supported in their decision how to feed their infants. Regarding that exclusive breastfeeding is recommended from WHO and AAP for at least the first 6 months of life and up to 2 years of age. After the first six months breastfeeding is recommended as long as both, mother and child are comfortable with this. This is often culturally and societally based. (1,5)

The Baby Friendly Hospital Initiative (BFHI) is a global effort that focuses on providing optimal clinical care for new mothers and their infants. The initiative was launched by WHO and UNICEF in 1991, following the Innocent Declaration of 1990. The Baby-friendly initiative helps and motivates maternity and infant services, and facilities worldwide to implement practices that provide optimal breastfeeding care for mothers and infants. (6) All hospitals are eligible to seek BFHI accreditation. (7)


Benefits

Short-term benefits

Long-term benefits


Components of the standard

Component

Grading of evidence

Indicator of meeting the standard

For parents and family

  1. All pregnant women and their partners are supported antenatally by healthcare professionals to understand the connection between labour interventions and lactation, and to recognise the value and the benefits of breastfeeding and early relationships. (20,21)

A (High quality)
B (High quality)

Patient information sheet, training documentation

  1. Parents are informed and guided by healthcare professionals before or directly after birth on early initiation of skin-to-skin care (where possible), positioning and attachment, hand-expression, responsive feeding, potential challenges of breastfeeding a preterm infant, informed decision-making regarding the introduction of donor human milk, artificial formula, nutritional supplements, or fluids other than breastmilk. (6,22)

A (High quality)
B (High quality)

Guideline, patient information sheet1, training documentation

For healthcare professionals

  1. A unit guideline on breastfeeding and expression, and non-nutritive sucking until breastfeeding is established and adhered to by all responsible healthcare professionals. (22)

A (High quality)
B (High quality)

Guideline

  1. Training on the importance of breastfeeding and how to use listening and learning skills for counselling a nursing parent, building confidence, and giving emotional and practical support is attended by all responsible healthcare professionals. (4)

B (High quality)

Training documentation

  1. All infants (including term and preterm) are supported to be placed in direct skin-to-skin contact with their mothers immediately following birth for at least an hour (where possible), where possible, to encourage oxytocin release by establishing a zero separation policy that promotes the initiation of breastfeeding and bonding. (23–25)

A (High quality)
B (High quality)

Guideline

  1. All infants receive no other milk than human milk (mother’s or donor’s) for at least 24 hours after birth, unless other forms of feeding are medically indicated (see Nutrition) (6)

A (High quality)
B (High quality)

Clinical records, guideline

  1. Breastfeeding is encouraged on demand without limiting breastfeeding time schedule unless medically indicated (see Nutrition) (26)

A (Moderate quality)

Clinical records, guideline

  1. Feeding bottles, teats, and pacifiers are not offered to infants whose mothers wish to exclusively breastfeed unless the mother has given consent and has been counselled on their benefits and risks. With professional respect and support on parents’ decision in regards to feeding, alternative methods of feeding are also discussed. (12)

A (Moderate quality)
B (High quality)

Clinical records, guideline

For neonatal unit

  1. A unit guideline for supporting breastfeeding and milk expression in all infants is available and regularly updated. For preterm infants who are unable to breastfeed directly, oral stimulation and non-nutritive sucking that involve the use of pacifiers, a gloved finger or a breast that is not yet producing milk are encouraged until breastfeeding is established, and for stress and pain reduction for the infant. (22)

A (High quality)
B (High quality)

Guideline

  1. Appropriate facilities to support the expression and storage of mother’s milk are available. (see NICU design)

B (High quality)

Audit report2

  1. Implementation of an education programme, sufficient knowledge, competence, and practical skills that cover all breastfeeding standards are provided to all responsible healthcare professionals. (3,27)

B (High quality)

Training documentation

  1. A preterm infant nutrition and lactation core team with Lactation Consultants and healthcare professionals trained in breastfeeding who support breastfeeding for parents and respect informed decision-making is established. (26)

A (High quality)
B (High quality)

Clinical records, guideline

For hospital

  1. A written policy that covers all WHO and UNICEF breastfeeding standards is established and communicated to staff and parents. Established facility policies drive consistent practice during and after the hospital stay to achieve equal and appropriate care. (4,27)

A (High quality) B (High quality)

Policy statement, training documentation

  1. The International Code of Marketing of Breastmilk Substitutes and protective mechanisms from the pervasive advertising of breastmilk substitutes, bottles, teats, or pacifiers in any part of the facility or by any of the staff are fully complied. (1,12)

A (High quality)

Audit report2, guideline

  1. Breastfeeding training programmes for healthcare professionals working in clinical and community settings is provided and all relevant services are supported and funded. (27)

A (High quality) B (High quality)

Guideline, training documentation

  1. Continuous monitoring and data-management systems are in place to monitor compliance and quality improvement. (27)

B (High quality)

Audit report2

  1. Appropriate facilities to support the expression of mother’s milk are available, including private rooms/space for breastfeeding and expressing milk (see Nutrition, NICU design).

B (High quality)

Audit report2

  1. Accreditation by the WHO & UNICEF Baby Friendly Hospital Initiative (BFHI) is in place. (28)

B (High quality)

Audit report2, certificates of award

For health service & stakeholders

  1. A national strategy to improve infant and children feeding practices from governments and political parties that through national policies and legislation will commit actions supporting breastfeeding is in place and regularly updated. (12,27)

A (High quality) B (High quality)

Guideline, national policy

  1. Post discharge breastfeeding support and support for breastfeeding alternatives from skilled healthcare professionals based in the community is provided. (29,30)

A (Moderate quality)
B (High quality)

Audit report2, guideline

1The indicator “patient information sheet” is an example for written, detailed information, in which digital solutions are included, such as web-based systems, apps, brochures, information leaflets, and booklets.

2The indicator “audit report” can also be defined as a benchmarking report.


Where to go

Further development

Grading of evidence

For parents and family

  • Continuous collaboration between parents and healthcare professionals with regard to the breastfeeding wheel is established. (22)

A (Low quality)
B (Moderate quality)

For healthcare professionals

N/A

For neonatal unit

  • Peer-to-peer support and parent groups who experienced a NICU stay are provided in NICU and after discharge. (31,32)

A (High quality)
B (Low quality)

For hospital

  • Liaise with special breastfeeding care services in the community with Lactation Consultants for parents after discharge.

B (High quality)

For health service & stakeholders

  • Develop a policy to support exclusive breastfeeding for at least six months. (33)

A (High quality)
B (Moderate quality)

  • Develop a national policy and legislation that could commit maternity leave policies for at least 6 months and paid parental leave. (27)

A (High quality)
B (Moderate quality)

  • Support research on breastfeeding and commit to undertake an infant feeding survey.

A (High quality)
B (Moderate quality)

  • Sustainably fund universal breastfeeding support programmes and charitable organisations who play a key-role in supporting families and communities that campaign towards infant’s feeding.

A (High quality)
B (Moderate quality)


Getting started

Initial steps

For parents and family

  • Parents are informed verbally and in writing about the importance and benefits of breastfeeding.
  • Parents are encouraged to initiate skin-to-skin contact immediately after birth, where possible.
  • Mothers and nursing parents are guided to understand the newborn’s responsivefeeding cues and behaviours.

For healthcare professionals

  • Attend training on the importance of breastfeeding and how to encourage and guide mothers to breastfeed and express breastmilk.

For neonatal unit

  • Develop and implement a unit guideline on breastfeeding and breastmilk expression including transition from non-nutritive to nutritive sucking.
  • Develop information material on the benefits of breastfeeding.
  • Provide appropriate equipment for expression of mother’s milk.

For hospital

  • Support healthcare professionals to participate in training on the importance of breastfeeding and how to encourage and guide mothers to breastfeed and express breastmilk.

For health service

  • Develop and implement a national guideline on breastfeeding and expression.
  • Develop awareness-campaigns and educational programmes for parents and healthcare professionals regarding the benefits of breastfeeding.

Breastfeeding wheel (23)

Language and gender

To better reflect the current reality, this statement reflects the changes in language that occurred over the last decade. For this edition, the words “mother”, “mother’s milk”, or “breastfeeding” are used together with more inclusive terms such as “nursing parent”. We acknowledge that our work and care include a wide range of parents and nurturing families.

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  2. WHO. Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services: the revised Baby-friendly Hospital Initiative [Internet]. 2018 [cited 2021 Jun 11]. Available from: https://apps.who.int/iris/bitstream/handle/10665/272943/9789241513807-eng.pdf
  3. World Health Organization. Standards for improving quality of maternal and newborn care in health facilities [Internet]. Geneva: World Health Organization; 2016 [cited 2023 Jul 7]. 73 p. Available from: https://apps.who.int/iris/handle/10665/249155
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Second edition / September 2022 / previous edition reviewed by Gianni ML / next revision: 2025


Recommended citation

EFCNI, Andritsou F, Oude-Reimer M et al., European Standards of Care for Newborn Health: Promotion of breastfeeding. 2022.