Breastfeeding is recognised as the optimal nutrition for infants with significant health benefits for both mother and baby. Skilled professional support during the early initiation of breastfeeding has been shown to have a positive influence on the success and duration of breastfeeding.

The aims of this guideline are to:

• Provide evidence based information, support and advice to parents regarding breastfeeding the healthy term newborn
• Facilitate the early initiation and establishment of breastfeeding
• Increase the incidence and duration of of breastfeeding in the community
• Nurture a mother's confidence in her ability to breastfeed her baby
• Guide consultation and referral to appropriate healthcare professionals when indicated.

Healthy Term Newborn Baby

• 37 completed weeks gestation or greater
• >2500gm birth weight
• no known obstetric or neonatal medical morbidities

This guideline applies primarily to the healthy term newborn baby.

If the baby or mother are unwell, or breastfeeding problems develop, its principles may still be applied with variations according to individual and medical needs.

1. Initiation of breastfeeding in the birth room

1.1 Immediate skin-to-skin contact

• Place the baby skin-to-skin on its mothers chest and cover both mother and baby with a warm blanket

• Position the baby with the head slightly extended to enable a clear airway whilst in skin-to-skin contact

• Leave undisturbed for at least one hour or until after the first breastfeed is initiated

• Maintain observation of the baby's breathing, colour and muscle tone whilst in skin-to-skin contact

• Routine newborn vital signs can be assessed while the baby is in skin-to-skin contact

• Babies born by caesarean section should be placed skin-to-skin (SSC) with their mothers as soon as the mothers and baby's condition allows this. SSC can commence on the theatre table and continue in post anaesthetic recovery (PAR), or if this is not possible, soon after the mother returns to the postnatal ward. Refer to CPG0187 Mother Baby Skin To Skin Contact In The Operating Suite.

1.2 Keeping baby safe during skin-to-skin contact

If the mother has received narcotic analgesia during labour, a support person or midwife should remain in the room at all times whilst the baby is in skin-to-skin contact.

If the midwife leaves the birth room whilst baby is in skin-to-skin contact, instruct the mother and birth support persons to:

• Observe the baby's breathing and colour. The baby should be breathing easily and the lips should be pink

• Observe the baby's muscle tone by gently lifting the baby's arm up then releasing the baby will pull the arm back towards the body

• If the baby's lips are not pink or the arm is limp, call the midwife immediately.

1.3  First feed

• Assist the mother to recognise early baby feeding cues such as crawling movements, mouthing, vocalising, hand-to-mouth movements, searching for the nipple

• Assist mother and baby into a comfortable position to facilitate baby-led feeding, offering help with attachment if needed

• Showering the mother and weighing the baby, as well as any other routine, non-urgent procedures should be delayed until after the first feed

• Allow the first feed to continue uninterrupted until the baby appears to have finished feeding.  

2. Subsequent feeds first 24 hours - Refer to flow chart [appendix 1]

• Subsequent feeds will depend on how the baby breastfeeds in the immediate post birth period

• It is common for some babies to be disinterested in breastfeeding in the first 24 hours. This can be managed by observing the baby, frequent skin-to-skin and breast contact to stimulate sucking reflexes and instincts, and giving expressed colostrum if available.

• Babies who have been observed to have breastfed well within 2 hours of birth may be allowed to sleep for up to 6 hours after this feed and then should be woken and offered breastfeeds and/or expressed colostrum 8-10 times/24 hours

• Babies who have not breastfed well within 2 hours of birth should be given expressed colostrum at 2 hours, then offered 8-10 breastfeeds and/or expressed colostrum per 24 hours. The mother should be assisted to commence hand expressing at 2 hours and continue expressing at least 8 to 10 times per 24 hours to establish lactation until the baby is breastfeeding regularly.

• Formula supplementation is not indicated in the first 24 hours for a healthy term baby

• If the baby is not interested in feeding, observe for signs that the baby is unwell or hypoglycaemic as per the following Grampians Health Ballarat guideline:

  • CPG 0110 Neonatal Hypoglycaemia Prevention and Management

3. After the first 24 hours

Provide education to mothers regarding the following:

• Responding to the baby's needs and unrestricted breastfeeding 24 hours per day

• After the first twenty-four hours, most newborn babies need at least 8-10 feeds per 24 hours

• Length of feeds may vary greatly and this does not indicate feeding effectiveness

• The supply and demand principles of breastfeeding

• Avoidance of long intervals between feeds as this may negatively affect the establishment of an adequate breast milk supply and contribute to weight loss, jaundice, lethargy or unsettled baby

• During each feed the mother should:

  • Offer both breasts at each feeding, alternate the starting breast. The baby may feed from one or both breasts

  • Allow the baby to finish the first breast before offering the second. The baby may need a short break before taking the second breast

• Observe for and educate the mother regarding effective sucking and swallowing and signs of milk transfer

• Continued skin-to-skin contact during the postnatal stay can facilitate effective establishment of breastfeeding.

• Educate all mothers about routine breast and nipple care

4. Positioning and Attachment

• Ensure the mother is aware of how to correctly position and attach her baby to the breast

• A hands off or hands over approach is preferable when teaching these skills to mothers

• The use of positioning and attachment pamphlets, cot-side teaching aids, breast model and doll are helpful to coach the mother, enabling her to more quickly gain confidence in attaching her baby to the breast. Dolls and breasts are available in the postnatal ward and special care nursery.

• Consider baby led attachment or 'laid back' approaches especially if the baby is becoming distressed at repeated attempts to attach him/her to the breast

• In some situations, the midwife may need to fully assist the mother to position and attach her baby e.g. first 24 hours following caesarean section.

4.1 Facilitation of correct positioning and attachment

• The mother should be comfortably sitting, or lying back slightly with her back well supported

• Side lying may be more comfortable if the mother has a very tender perineum, a caesarean wound or is very tired

• The mother should hold the baby on his/her side, chest to chest (or tummy to tummy) with the mother supporting the baby's back with the palm of their hand

• The baby's head, neck and body should be aligned, not twisted

• Ensure that the baby's head is not held as this will restrict the baby's instinctive head extension prior to attachment

• Gently separating the arms to 'hug' the mother may enable the baby to move closer to the breast, however many babies resist having their arms separated and are more relaxed with their arms folded in front

• The baby's chin should point towards the breast

• The mother can support her breast by cupping it in her hand, using a 'U' hold to shape the breast in the same angle as the baby's mouth

• The nipple can be tilted upwards with the thumb to position it towards the baby's nose

• Gently rub the lower areola over the baby's bottom lip to stimulate the baby to open its' mouth wide

• When the baby's mouth is wide open the mother selects a contact point for the baby's bottom lip well down on the underside of the areola, moves the baby quickly onto the breast and eases in the tilted nipple with her thumb

• If the mother feels pain, even if the attachment appears satisfactory, she should detach the baby and reattach.

4.2 Signs of correct positioning and attachment

• The baby's head and body are facing the mother's chest and in close contact with the mothers body

• The head is slightly extended

• The mouth is wide open. Both lips are flanged outwards (not sucked in)

• The chin is pressed into the breast

• The baby's cheeks are well rounded and should rest on the breast

• The areola is well into the mouth. Less of the areola is visible below the bottom lip than top lip

• The nose is not burrowed into the breast

• After the initial short sucks, the baby sucks strongly and rhythmically

• The whole jaw moves rhythmically, the movement extends to the earlobes

• Swallowing can be seen and heard once the milk is 'in' and letdown has occurred

• The mother feels no or minimal discomfort

• Once the baby is well attached and sucking effectively there is no or minimal nipple discomfort or pain

• After the feed the nipple looks the same shape and colour that it did prior to the breastfeed and there is no nipple trauma.

4.3 Signs of poor positioning and attachment

• The baby's body is too far away from mother

• The baby is lying on his/her back with head twisted to breast

• The baby's mouth is not wide open and the lips are close together ('prissy lipped')

• The baby is attached only to the nipple and a large amount of the areola is visible

• There is a gap between the baby's chin and the breast

• There is an audible tongue click, or feeding is noisy

• There is excessive breast movement in and out of the mouth

• Drawing in of the cheeks can be seen

• The baby feeds with rapid, non nutritive sucks instead of deep nutritive sucking

• The mother feels nipple pain

• The nipple is compressed, misshapen or damaged after feeding

5. Assessment of breastfeeding (see Appendix 3: Assessment of breastfeeding)

5.1 Assess breastfeeding at least once each shift during the hospital stay. Assess the following:

• Condition of breasts and nipples

• Baby feeding cues and alertness (see point 6)

• Positioning and attachment skills (see point 4)

• Signs of effective milk transfer (see point 7)

• Frequency and duration of feeds

• Urine and stool output number and character (see point 7)

• Hydration

• Presence of jaundice

• Mothers understanding of normal breastfeeding patterns

• Assess weight loss after 48 hours (see point 8)

5.2 Effective breastfeeding in the first few days of life is indicated by the following signs:

• After the first 24 hours, the baby is feeding between 8 -12 times per 24 hours

• Baby is waking for feeds and is alert during feeds

• Baby is attaching well to the breast

• Deep rhythmic sucking is observed and some swallowing is noted

• Breastfeeding codes 4-5 are achieved (see point 5.3)

• At least 3 clear wet nappies and one meconium stool are seen by 48 hours

• Stools are changing from meconium to transitional stools after 48 hours

• Baby appears well hydrated

• The mothers breasts start to fill at around 48 - 72 hours (may be wide variation)

5.3 Breastfeeding progress score

• The breastfeeding progress score is a guide to assessing effectiveness of breastfeeding in the newborn baby

• Mothers should be given education about how to document feeds according to the progress score

• Each breastfeed should be scored and documented using the codes on the Infant Care Chart MR/450.

• A baby who is still scoring a code of 1-3 after 24 hours may require a written feeding plan and/or assessment by a Lactation Consultant. Refer to BF the Health Term Newborn Baby flow chart (See Appendix 1)

6. Recognition of baby feeding cues

• All mothers should be taught how to recognise baby feeding cues and signs of effective milk transfer - use the feeding cues poster on the cot-side teaching aid if required

• Provide mother with a copy of the Australian Breastfeeding Associations handout Normal Nappies: what to expect prior to discharge

• Encourage the mother to offer the breast to her baby whenever her baby shows feeding cues, before the baby is crying and distressed

• Baby feeding cues include the following:

  • Mouthing opening and closing mouth

  • Rooting - turning head from side to side

  • Rapid eye movements, waking from sleep and becoming restless

  • Opening mouth and making cooing or sighing noises or sucking fist or fingers

  • Nuzzling into breast. Change in facial expression

  • Crying is a late hunger cue

7. Signs of adequate milk intake and output

Educate women about the signs of adequate milk transfer and intake which include:

• The baby is well attached at the breast

• During breastfeeds rhythmic sucking and swallowing can be seen and heard (once the milk is in)

• The baby is mostly settled between feeds, although unsettled periods where the baby will feed very frequently are common

• The mothers breast is fuller at the start of the feed and softer at the end of the feed (once the milk is in)

• The baby has appropriate output as follows:

8. Assessing newborn weight loss

Weight loss of up to 10% of birth weight is normal in the first week of life. Once the milk is in, the average weight gain for the first 3 months is around 20-30 gm per day or 150-200gm per week, but this can vary. Ideally the baby is back to birth weight by day 10-14.

• Babies are re-weighed after 48 hours

• Discharge weight is not required for healthy term babies discharged home before 48 hours unless there are risk factors or breastfeeding concerns identified.

• If weight loss after 48 hours is 8-10%, refer to Appendix 2a

• If weight loss after 48 hours is greater than 10%, refer to Appendix 2b

• For a guide to supplementary feeds for a healthy term baby who has lost >10% weight after 48 hours, refer to Appendix 2c

• A full breastfeeding assessment is required for a baby who has lost > 8% weight after 48 hours of life - refer to Appendix 3.

9. Management of babies who are sleepy and/or feeding poorly

After the initial alert period following birth, many healthy babies will become sleepy for a number of hours. It is important that the baby has skin to skin contact immediately after birth and ongoing in the postnatal area to facilitate early breastfeeds before this sleepy period begins.

• There are a number of reasons for babies to be sleepy or feed poorly after birth

• A review of mother's history should be undertaken to identify any risk factors that may contribute to poor feeding

• Sleepy babies who feed effectively when woken require only routine assessment and observation of feeding and well-being

• Persistently sleepy babies who do not feed effectively when woken should be observed for signs of hypoglycaemia or illness

• A blood glucose level should be taken if indicated - refer to the BHS CPG 0110 Neonatal Hypoglycaemia Prevention and Management

• Following thorough assessment of breastfeeding, persistent sleepiness and poor feeding after 36 - 48 hours requires a medical assessment and a Lactation Consultant assessment

• Initial medical assessment to be conducted by obstetric HMO with referral to Paediatric team if indictaed

• Refer to Breastfeeding the Healthy Term Newborn Baby flow chart (Appendix 1).

9.1 Techniques to rouse and feed a sleepy baby

• Encourage mother to offer the breast whenever the baby demonstrates feeding cues as per point 6 above

• Encourage frequent and prolonged skin to skin contact

• Unwrap baby and check/change nappy

• Express a few drops of colostrum directly onto the baby's lips

• Spoon/cup/syringe or finger feed a small amount of colostrum to stimulate the appetite

• Provide full support with positioning and attachment

• Refer to Breastfeeding the Healthy Term Newborn Baby flow chart (Appendix 1). for management of poor feeding.

10. Supplementary feeds

• Supplementation is not required in the first 24 hours in the healthy term newborn baby [Academy of Breastfeeding Medicine Clinical Protocol #3 2017]

• Expressed breastmilk is the first choice if supplementary feeds are considered necessary. All women should be taught how to express their breastmilk by hand or using a breast pump. Refer to CPG0186 Breastmilk: Expressing, storing and feeding

• Donor breastmilk may be used if requested and CPP0395 Donor Breastmilk is followed

• Formula supplementation should only be given if there are acceptable medical indications AND there is insufficient expressed breastmilk available [see appendix 4 - Acceptable Medical Reasons for the use of Breastmilk Substitutes]

• Supplementary feeds, if required, should be given by finger feed, cup, or spoon.

• Avoid or minimize the use of bottles, teats or pacifiers in the first few weeks as these may negatively affect the establishment of breastfeeding

• Refer to the CPG 0074 Supplementary Feeding of the Breastfed Baby for guidelines regarding volumes of supplementation if considered necessary

11. Maintaining lactation if other and baby are separated, or baby is not feeding effectively.

• Refer to CPG0186 Breastmilk: Expressing, storing and feeding

• Refer to CPG0165 Breastfeeding the Vulnerable Newborn