Promotion of breastfeeding

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Authors

Frauenfelder O, Oude-Reimer M, Camba F, Ceccatelli M, Hankes-Drielsma I, Jørgensen E, Silva E

© Christian Klant Photography

Target group

Infants, parents, and families


User group

Healthcare professionals, neonatal units, hospitals, and health services


Statement of standard

Infants are exclusively fed with human milk during their hospital stay and mothers are supported to exclusively breastfeed after discharge.


Rationale

Breastfeeding is the natural way of providing infants with the nutrients they need for healthy growth and development. Virtually all mothers can breastfeed, provided they are supported by their partner, family, the healthcare system and society at large.

Colostrum, the first breast milk produced around the time of delivery, is recommended by the World Health Organization (WHO) as the perfect food for newborn infants. (1) Feeding or expressing breast milk should be initiated within the first hour after birth or as soon as possible at least within the first 6 hours after birth. Exclusive breastfeeding is recommended up to 6 months 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 based. (1,2)

The Baby Friendly Hospital Initiative (BFHI) is a global effort to implement practices that protect and promote breastfeeding. The initiative was launched by WHO and UNICEF in 1991, following the Innocent Declaration of 1990. The initiative is a global effort to implement practices that protect and promote breastfeeding. (2) All hospitals are eligible to seek BFHI accreditation. (3)


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 informed by healthcare professionals about the benefits of breastfeeding. (1)

A (High quality)
B (High quality)

Patient information sheet1

  1. Parents are informed and guided by healthcare professionals before or directly after birth on how to breastfeed and express, how to maintain lactation, and the importance of early skin-to-skin care and breastfeeding immediately after delivery, where possible. (2,15)

A (High quality)
B (High quality)

Guideline, patient information sheet1, training documentation

For healthcare professionals

  1. A unit guideline on breastfeeding and expression including transition from non-nutritive to nutritive sucking is adhered to by all responsible healthcare professionals. (15)

A (High quality)
B (High quality)

Guideline

  1. Training on the importance of breastfeeding and how to encourage and guide mothers to breastfeed and express is attended by all responsible healthcare professionals.

B (High quality)

Training documentation

  1. All infants are placed in direct skin-to-skin contact with their mothers immediately following birth for at least an hour, where possible, to encourage oxytocin release and establish initial feeding. (16,17)

A (High quality)
B (High quality)

Guideline

  1. Newborn infants receive no other milk than human milk, unless medically indicated for at least 24 hours after birth. (2) (see Nutrition)

A (High quality)
B (High quality)

Clinical records, guideline

  1. Breastfeeding is encouraged on demand unless medically indicated. (18) (see Nutrition)

A (Moderate quality)

Clinical records, guideline

  1. Bottles are not offered to preterm infants whose mothers wish to breastfeed unless the mother has given permission and alternative methods of feeding have been discussed. (8)

A (Moderate quality)
B (High quality)

Clinical records, guideline

For neonatal unit

  1. A unit guideline on breastfeeding and expression including transition from non-nutritive to nutritive sucking is available and regularly updated. (15)

A (High quality)
B (High quality)

Guideline

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

B (High quality)

Audit report2

  1. Training on the importance of breastfeeding and how to encourage and guide mothers to breastfeed and express is provided.

B (High quality)

Training documentation

  1. Lactation consultants are available to support breastfeeding for parents and healthcare professionals. (18)

A (High quality)
B (High quality)

Clinical records, guideline

For hospital

  1. Training on the importance of breastfeeding and how to encourage and guide mothers to breastfeed and express is ensured.

B (High quality)

Training documentation

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

B (High quality)

Audit report2

  1. Accreditation by the WHO Baby friendly hospital initiative (BFHI) is in place. (19)

B (High quality)

Audit report2

For health service

  1. A national guideline on breastfeeding and expression is available and regularly updated.

B (High quality)

Guideline

  1. Post discharge support regarding breastfeeding is provided. (20,21)

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

  • Collaborate with healthcare professionals with regard to the breastfeeding wheel. (15)

A (Low quality)
B (Moderate quality)

For healthcare professionals

N/A

For neonatal unit

N/A

For hospital

N/A

For health service

  • Develop a policy to support exclusive breastfeeding for at least six months. (22)

A (High quality)


Getting started

Initial steps

For parents and family

  • Parents are verbally informed about the benefits of breastfeeding.
  • Parents are encouraged to use skin-to-skin contact immediately after birth, where possible.
  • Guide mothers to understand the behavioural signs of hunger.

For healthcare professionals

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

For neonatal unit

  • Develop and implement a unit guideline on breastfeeding and 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.

For health service

  • Develop and implement a national guideline on breastfeeding and expression.
  • Develop awareness-campaigns regarding the benefits of breastfeeding.

Breastfeeding wheel (23)

  1. World Health Organization. Infant and young child feeding: Model Chapter for textbooks for medical students and allied health professionals. Geneva: World Health Organization; 2009.
  2. World Health Organization. Breastfeeding [Internet]. WHO. [cited 2018 Jun 14]. Available from: http://www.who.int/topics/breastfeeding/en/
  3. World Health Organization (WHO). Implementation of the Baby-friendly Hospital Initiative [Internet]. WHO. [cited 2018 Jun 14]. Available from: http://www.who.int/elena/bbc/implementation_bfhi/en/
  4. Fallon EM, Nehra D, Potemkin AK, Gura KM, Simpser E, Compher C, et al. A.S.P.E.N. clinical guidelines: nutrition support of neonatal patients at risk for necrotizing enterocolitis. JPEN J Parenter Enteral Nutr. 2012 Sep;36(5):506–23.
  5. Oddy WH. Breastfeeding protects against illness and infection in infants and children: a review of the evidence. Breastfeed Rev Prof Publ Nurs Mothers Assoc Aust. 2001 Jul;9(2):11–8.
  6. Cacho NT, Parker LA, Neu J. Necrotizing Enterocolitis and Human Milk Feeding: A Systematic Review. Clin Perinatol. 2017 Mar;44(1):49–67.
  7. Schwarze CE, Hellhammer DH, Stroehle V, Lieb K, Mobascher A. Lack of Breastfeeding: A Potential Risk Factor in the Multifactorial Genesis of Borderline Personality Disorder and Impaired Maternal Bonding. J Personal Disord. 2015 Oct;29(5):610–26.
  8. World Health Organization. Early initiation of breastfeeding to promote exclusive breastfeeding [Internet]. WHO. [cited 2018 Jun 14]. Available from: http://www.who.int/elena/titles/early_breastfeeding/en/
  9. Uwaezuoke SN, Eneh CI, Ndu IK. Relationship Between Exclusive Breastfeeding and Lower Risk of Childhood Obesity: A Narrative Review of Published Evidence. Clin Med Insights Pediatr. 2017;11:1179556517690196.
  10. Raheem RA, Binns CW, Chih HJ. Protective effects of breastfeeding against acute respiratory tract infections and diarrhoea: Findings of a cohort study. J Paediatr Child Health. 2017 Mar;53(3):271–6.
  11. Horta BL, Loret de Mola C, Victora CG. Breastfeeding and intelligence: a systematic review and meta-analysis. Acta Paediatr Oslo Nor 1992. 2015 Dec;104(467):14–9.
  12. Victora CG, Horta BL, de Mola CL, Quevedo L, Pinheiro RT, Gigante DP, et al. Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age: a prospective birth cohort study from Brazil. Lancet Glob Health. 2015;3(4):e199–e205.
  13. Chowdhury R, Sinha B, Sankar MJ, Taneja S, Bhandari N, Rollins N, et al. Breastfeeding and maternal health outcomes: a systematic review and meta-analysis. Acta Paediatr. 2015 Dec;104:96–113.
  14. Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet. 2016;387(10017):475–490.
  15. Becker GE, Smith HA, Cooney F. Methods of milk expression for lactating women. Cochrane Database Syst Rev. 2016 Sep 29;9:CD006170.
  16. Oras P, Thernström Blomqvist Y, Hedberg Nyqvist K, Gradin M, Rubertsson C, Hellström-Westas L, et al. Skin-to-skin contact is associated with earlier breastfeeding attainment in preterm infants. Acta Paediatr Oslo Nor 1992. 2016 Jul;105(7):783–9.
  17. Cong X, Ludington-Hoe SM, Hussain N, Cusson RM, Walsh S, Vazquez V, et al. Parental oxytocin responses during skin-to-skin contact in pre-term infants. Early Hum Dev. 2015 Jul;91(7):401–6.
  18. Meier PP, Johnson TJ, Patel AL, Rossman B. Evidence-Based Methods That Promote Human Milk Feeding of Preterm Infants: An Expert Review. Clin Perinatol. 2017 Mar;44(1):1–22.
  19. World Health Organization. Baby-friendly Hospital Initiative [Internet]. WHO. [cited 2018 Jun 14]. Available from: http://www.who.int/nutrition/topics/bfhi/en/
  20. Fleurant E, Schoeny M, Hoban R, Asiodu IV, Riley B, Meier PP, et al. Barriers to Human Milk Feeding at Discharge of Very-Low-Birth-Weight Infants: Maternal Goal Setting as a Key Social Factor. Breastfeed Med Off J Acad Breastfeed Med. 2017 Feb;12:20–7.
  21. Briere C-E, McGrath JM, Cong X, Brownell E, Cusson R. Direct-breastfeeding in the neonatal intensive care unit and breastfeeding duration for premature infants. Appl Nurs Res ANR. 2016;32:47–51.
  22. Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, et al. Why invest, and what it will take to improve breastfeeding practices? Lancet Lond Engl. 2016 Jan 30;387(10017):491–504.
  23. Husebye ES, Kleven IA, Kroken LK, Torsvik IK, Haaland OA, Markestad T. Targeted Program for Provision of Mother’s Own Milk to Very Low Birth Weight Infants. PEDIATRICS. 2014 Aug 1;134(2):e489–95.

November 2018 / 1st edition / next revision: 2023


Recommended citation

EFCNI, Frauenfelder O, Oude-Reimer M et al., European Standards of Care for Newborn Health: Promotion of breastfeeding. 2018