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Guideline Summary
Guideline Title
Model breastfeeding policy.
Bibliographic Source(s)
Philipp BL, Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #7: model breastfeeding policy (revision 2010). Breastfeed Med. 2010 Aug;5(4):173-7. [37 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #7: model breastfeeding policy. Breastfeed Med 2007 Mar;2(1):50-5. [22 references]

Academy of Breastfeeding Medicine protocols expire five years from the date of publication. Evidence-based revisions are made within five years or sooner if there are significant changes in evidence.

Scope

Disease/Condition(s)

Infant health and nutrition

Guideline Category
Counseling
Evaluation
Management
Prevention
Risk Assessment
Clinical Specialty
Family Practice
Nutrition
Obstetrics and Gynecology
Pediatrics
Preventive Medicine
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Nurses
Physician Assistants
Physicians
Guideline Objective(s)
  • To promote a philosophy and practice of maternal–infant care that advocates breastfeeding
  • To support the normal physiologic functions involved in the establishment of this maternal–infant process
  • To assist families choosing to breastfeed with initiating and developing a successful and satisfying experience
Target Population
  • All pregnant women and their support people
  • New mothers and their healthy, term infants
Interventions and Practices Considered
  1. Active support of breastfeeding as the preferred method of providing nutrition to infants, including establishment of a multidisciplinary team to identify and eliminate institutional barriers to breastfeeding
  2. Establishment of a written breastfeeding policy
  3. Education and counseling of all pregnant women, including information on latch and positioning, nutritive suckling, milk production, frequency of feedings and feeding cues, expression of milk, assessment of infant nourishment, and reasons to contact the clinician
  4. Documentation of breastfeeding
  5. Skin-to-skin contact and initiation of breastfeeding soon after birth
  6. Encouragement of rooming in
  7. Assessment of feeding at each shift
  8. Referral to a lactation consultant or specialist, if necessary
  9. Use of supplemental feedings only if specifically ordered or requested
  10. Alternative feeding methods (syringe or spoon feeding), when necessary
  11. Avoidance of pacifier use (unless as a method of pain management)
  12. Assessment of infant for hypoglycemia and dehydration
  13. Use of nipple shields (in conjunction with a lactation consultant)
  14. Breast massage and hand expression of colostrum or milk, if no adequate latch within 24 hours
  15. Provision of discharge instructions
  16. Post-discharge follow-up appointment schedule
  17. Provision of information on community breastfeeding resources
  18. Management of mothers who are separated from their sick or premature infants
  19. Staff development

Note: The following were considered but not recommended: routine glucose monitoring for full-term healthy infants, use of antilactation drugs, and routine use of nipple creams, ointments, or other topical preparations.

Major Outcomes Considered
  • Breastfeeding initiated within one hour of birth
  • Rate of exclusive breastfeeding

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The literature search included articles written in English in the past 20 years in the fields of medicine, psychiatry, psychology, and basic biological science to identify the relevant literature for review. Any literature databases that cover these areas are valid to be used; the committee used PubMed for this guideline. Every reference list in every study was looked at to ensure that all studies were captured. In addition, older sentinel articles were included.

Only articles written in English were included. Search terms were breastfeeding, breastfeeding policy, Baby-Friendly, Ten Steps, rooming in, pacifiers, skin-to-skin, and lactation.

Once the articles are gathered, the papers are evaluated for scientific accuracy and significance.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus (Committee)
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence

I Evidence obtained from at least one properly randomized controlled trial

II-1 Evidence obtained from well-designed controlled trials without randomization

II-2 Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group

II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence.

III Opinions of respected authorities, based on clinical experience, descriptive studies and case reports; or reports of expert committees

Methods Used to Analyze the Evidence
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

An expert panel is identified and appointed to develop a draft protocol using evidence based methodology. An annotated bibliography (literature review), including salient gaps in the literature, is submitted by the expert panel to the Protocol Committee.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Draft protocol is peer reviewed by individuals outside of lead author/expert panel, including specific review for international applicability. Protocol Committee's sub-group of international experts recommends appropriate international reviewers. Chair (co-chairs) institutes and facilitates process. Reviews submitted to committee Chair (co-chairs).

Draft protocol is submitted to The Academy of Breastfeeding Medicine (ABM) Board for review and approval. Comments for revision will be accepted for three weeks following submission. Chair (co-chairs) and protocol author(s) amend protocol as needed.

Following all revisions, protocol has final review by original author(s) to make final suggestions and ascertain whether to maintain lead authorship.

Final protocol is submitted to the Board of Directors of ABM for approval.

Recommendations

Major Recommendations

Policy Statements

  1. The "name of institution" staff will actively support breastfeeding as the preferred method of providing nutrition to infants. A multidisciplinary, culturally appropriate team comprising hospital administrators, physician and nursing staff, lactation consultants and specialists, nutrition staff, other appropriate staff, and parents shall be established and maintained to identify and eliminate institutional barriers to breastfeeding. On a yearly basis, this group will compile and evaluate data relevant to breastfeeding support services and formulate a plan of action to implement needed changes.
  2. A written breastfeeding policy will be developed and communicated to all health care staff. The "name of institution" breastfeeding policy will be reviewed and updated biannually using current research as an evidence-based guide.
  3. All pregnant women and their support people as appropriate will be provided with information on breastfeeding and counseled on the benefits of breastfeeding, contraindications to breastfeeding, and risk of formula feeding (Academy of Breastfeeding Medicine Protocol Committee, "Clinical protocol #19," 2009).
  4. The woman's desire to breastfeed will be documented in her medical record.
  5. Mothers will be encouraged to exclusively breastfeed unless medically contraindicated. The method of feeding will be documented in the medical record of every infant. (Exclusive breastfeeding is defined as providing breast milk as the sole source of nutrition.) Exclusively breastfed babies receive no other liquids or solids, with the exception of oral medications prescribed by a medical care provider for the infant.)
  6. At birth or soon thereafter all newborns, if baby and mother are stable, will be placed skin-to-skin with the mother. Skin-to-skin contact involves placing the naked baby prone on the mother's bare chest. The infant and mother can then be dried and remain together in this position with warm blankets covering them as appropriate. Mother–infant couples will be given the opportunity to initiate breastfeeding within 1 hour of birth. Post-cesarean-birth babies will be encouraged to breastfeed as soon as possible, potentially in the operating room or recovery area (see Table 1 in the original guideline document). The administration of vitamin K and prophylactic antibiotics to prevent ophthalmia neonatorum should be delayed for the first hour after birth to allow uninterrupted mother–infant contact and breastfeeding (Academy of Breastfeeding Medicine Protocol Committee, "ABM clinical protocol #3," 2009; Mikiel-Kostyra, Mazur, & Boltruszko, 2002; Righard & Alade, 1990).
  7. Breastfeeding mother–infant couples will be encouraged to remain together throughout their hospital stay, including at night (rooming-in). Skin-to-skin contact will be encouraged as much as possible.
  8. Breastfeeding assessment, teaching, and documentation will be done on each shift and whenever possible with each staff contact with the mother. Each feeding will be documented, including latch, position, and any problems encountered, in the infant's medical record. For feedings not directly observed, maternal report may be used. Every shift, a direct observation of the baby's position and latch-on during feeding will be performed and documented.
  9. Mothers will be encouraged to utilize available breastfeeding resources including classes, written materials, and video presentations, as appropriate. If clinically indicated, the healthcare professional or nurse will make a referral to a lactation consultant or specialist for additional education or assistance.
  10. Breastfeeding mothers will be instructed about:
    1. Proper positioning and latch on
    2. Nutritive suckling and swallowing
    3. Milk production and release
    4. Frequency of feeding/feeding cues
    5. Hand expression of breast milk and use of a pump if indicated
    6. How to assess if infant is adequately nourished
    7. Reasons for contacting the healthcare professional

    These skills will be taught to primiparous and multiparous women, provided in written form (Eidelman, Hoffmann, & Kaitz, 1993), and reviewed before the mother goes home.

  1. Parents will be taught that breastfeeding infants, including cesarean-birth babies, should be put to breast at least 8 to 12 times each 24 hours, with some infants needing to be fed more frequently. Infant feeding cues (e.g., increased alertness or activity, mouthing, or rooting) will be used as indicators of the baby's readiness for feeding. Breastfeeding babies will be breastfed at night.
  2. Time limits for breastfeeding on each side will be avoided. Infants can be offered both breasts at each feeding but may be interested in feeding only on one side at a feeding during the early days.
  3. No supplemental water, glucose water, or formula will be given unless specifically ordered by a healthcare professional (e.g., physician, certified nurse midwife, or nurse practitioner) or by the mother's documented and informed request. Prior to non-medically indicated supplementation, mothers will be informed of the risks of supplementing. The supplement should be fed to the baby by cup if possible and will be no more than 10 to 15 mL (per feeding) in a term baby (during the first 1 to 2 days of life). Alternative feeding methods such as syringe or spoon feeding may also be used; however, these methods have not been shown to be effective in preserving breastfeeding. Bottles will not be placed in a breastfeeding infant's bassinet (Howard et al., 2003; Howard et al., 1999; Marinelli, Burke, & Dodd, 2001).
  4. This institution does not give group instruction in the use of formula. Those parents who, after appropriate counseling, choose to formula feed their infants will be provided individual instruction.
  5. Pacifiers will not be given to normal full-term breastfeeding infants. The pacifier guidelines at "name of institution" state that preterm infants in the Neonatal Intensive Care or Special Care Unit or infants with specific medical conditions (e.g., neonatal abstinence syndrome) may be given pacifiers for non-nutritive sucking. Newborns undergoing painful procedures (e.g., circumcision) may be given a pacifier as a method of pain management during the procedure. The infant will not return to the mother with the pacifier. "Name of institution" encourages "pain-free newborn care," which may include breastfeeding during the heel stick procedure for the newborn metabolic screening tests (Gray et al., 2002).
  6. Routine blood glucose monitoring of full-term healthy appropriate-for-gestational age infants is not indicated. Assessment for clinical signs of hypoglycemia and dehydration will be ongoing (Wight, Marinelli, & Academy of Breastfeeding Medicine Clinical Protocol Committee, 2006).
  7. Antilactation drugs will not be given to any postpartum mother.
  8. Routine use of nipple creams, ointments, or other topical preparations will be avoided unless such therapy has been indicated for a dermatologic problem. Mothers with sore nipples will be observed for latch-on techniques and will be instructed to apply expressed colostrum or breast milk to the areola/nipple after each feeding.
  9. Nipple shields or bottle nipples will not be routinely used to cover a mother's nipples, to treat latch-on problems, or to prevent or manage sore or cracked nipples or used when a mother has flat or inverted nipples. Nipple shields will be used only in conjunction with a lactation consultation and after other attempts to correct the difficulty have failed.
  10. After 24 hours of life, if the infant has not latched on or fed effectively, the mother will be instructed to begin to massage her breasts and hand express colostrum into the baby's mouth during feeding attempts. Skin-to-skin contact will be encouraged. Parents will be instructed to watch closely for feeding cues and whenever these are observed to awaken and feed the infant. If the baby continues to feed poorly, hand expression by the mother or a double set-up electric breast pump will be initiated and maintained approximately every 3 hours or a minimum of eight times per day. Any expressed colostrum or mother's milk will be fed to the baby by an alternative method. The mother will be reminded that she may not obtain much milk or even any milk the first few times she expresses her breasts. Until the mother's milk is available, a collaborative decision should be made among the mother, nurse, and healthcare professional (e.g., physician/nurse practitioner/certified nurse midwife) regarding the need to supplement the baby. Each day the responsible healthcare professional will be consulted regarding the volume and type of the supplement. Pacifiers will be avoided. In cases of problem feeding, the lactation consultant or specialist will be consulted (Academy of Breastfeeding Medicine Protocol Committee, "ABM clinical protocol #3," 2009).
  11. If the baby is still not latching on well or feeding well when discharged to home, the feeding/expression/supplementing plan will be reviewed in addition to routine breastfeeding instructions. A follow-up visit or contact will be scheduled within 24 hours. Depending on the clinical situation it may be appropriate to delay discharge of the couplet to provide further breastfeeding intervention, support, and education.
  12. All babies should be seen for follow-up within the first few days postpartum. This visit should be with a physician (pediatrician or family physician) or other qualified health care practitioner for a formal evaluation of breastfeeding performance, a weight check, assessment of jaundice and age appropriate elimination: (a) for infants discharged at less than 2 days of age (<48 hours), follow-up at 2 to 4 days of age; (b) for infants discharged between 48 and 72 hours, follow-up at 4 to 5 days of age. Infants discharged after 5 to 6 days may be seen 1 week later.
  13. Mothers who are separated from their sick or premature infants will be
    1. Instructed on how to use skilled hand expression or the double set up electric breast pump. Instructions will include expression at least eight times per day or approximately every 3 hours for 15 minutes (or until milk flow stops, whichever is greater) around the clock and the importance of not missing an expression session during the night
    2. Encouraged to breastfeed on demand as soon as the infant's condition permits
    3. Taught proper storage and labeling of human milk
    4. Assisted in learning skilled hand expression or obtaining a double set-up electric breast pump prior to going home
  1. Before leaving the hospital (Academy of Breastfeeding Medicine Clinical Protocol Committee, 2007), breastfeeding mothers should be able to:
    1. Position the baby correctly at the breast with no pain during the feeding
    2. Latch the baby to breast properly
    3. State when the baby is swallowing milk
    4. State that the baby should be nursed a minimum of eight to 12 times a day until satiety, with some infants needing to be fed more frequently
    5. State age-appropriate elimination patterns (at least six urinations per day and three to four stools per day by the fourth day of life)
    6. List indications for calling a healthcare professional
    7. Manually express milk from their breasts
  1. Prior to going home, mothers will be given the names and telephone numbers of community resources to contact for help with breastfeeding, including (the support group or resource recommended by "name of institution").
  2. "Name of institution" does not accept free formula or free breast milk substitutes. Nursery or Neonatal Intensive Care Unit discharge bags offered to all mothers will not contain infant formula, coupons for formula, logos of formula companies, or literature with formula company logos.
  3. "Name of institution" health professionals will attend educational sessions on lactation management and breastfeeding promotion to ensure that correct, current, and consistent information is provided to all mothers wishing to breastfeed (American Academy of Pediatrics, American Academy of Obstetricians and Gynecologists, 2006).
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated.

This policy is based on recommendations from the most recent breastfeeding policy statements published by the Office on Women's Health of the U.S. Department of Health and Human Services, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, the World Health Organization (WHO), the Academy of Breastfeeding Medicine, and the UNICEF/WHO evidence-based "Ten Steps to Successful Breastfeeding."

The recommendations were based primarily on a comprehensive review of the existing literature. In cases where the literature does not appear conclusive, recommendations were based on the consensus opinion of the group of experts.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Improved breastfeeding outcomes for mothers and infants

Potential Harms

Not stated

Contraindications

Contraindications

Breastfeeding is contraindicated in the following situations:

  • Mothers who are human immunodeficiency virus (HIV)-positive in locations where artificial feeding is acceptable, feasible, affordable, sustainable, and safe
  • Mothers currently using illicit drugs (e.g., cocaine, heroin) unless specifically approved by the infant's healthcare provider on a case-by-case basis
  • Mothers taking certain medications. Most prescribed and over-the-counter drugs are safe for the breastfeeding infant. Some medications may make it necessary to interrupt breastfeeding, such as radioactive isotopes, antimetabolites, cancer chemotherapy, some psychotropic medications and a small number of other medications.
  • Mothers with active, untreated tuberculosis. A mother can express her milk until she is no longer contagious.
  • Infants with galactosemia
  • Mothers with active herpetic lesions on her breast(s). Breastfeeding can be recommended on the unaffected breast. (The Infectious Disease Service will be consulted for problematic infectious disease issues.)
  • Mothers with onset of varicella within 5 days before or up to 48 hours after delivery, until they are no longer infectious
  • Mothers with human T-cell lymphotropic virus type I or type II

Qualifying Statements

Qualifying Statements

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Foreign Language Translations
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Philipp BL, Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #7: model breastfeeding policy (revision 2010). Breastfeed Med. 2010 Aug;5(4):173-7. [37 references] PubMed External Web Site Policy
Adaptation

The original version of this guideline was partially adapted from the following sources:

  • U.S. Department of Health and Human Services. HHS Blueprint for Action on Breastfeeding. U.S. Department of Health and Human Services, Office on Women's Health, Washington, DC, 2000.
  • Gartner LM, Morton J, Lawrence RA, et al. Breastfeeding and the use of human milk. Pediatrics 2005;115:496–506.
  • Queenan JT (ed). Breastfeeding: ACOG Educational Bulletin Number 258. Maternal and Infant Aspects. The American College of Obstetricians and Gynecologists, Committees on Health Care for Underserved Women and Obstetric Practice, Washington, DC, 2000.
  • The American Academy of Family Physicians Breastfeeding Advisory Committee. Family Physicians Supporting Breastfeeding: Breastfeeding Position Paper 2008. The American Academy of Family Physicians, Kansas City, MO, 2008. Available at: http://www.aafp.org/online/en/home/policy/policies/b/breastfeedingpositionpaper.html External Web Site Policy.
  • World Health Organization, United Nations Children's Fund. Protecting, promoting and supporting breastfeeding: The special role of maternity services (a joint WHO/UNICEF statement). Int J Gynecol Obstet 1990;31(Suppl 1):171–183.
  • Academy of Breastfeeding Medicine Board of Directors. Position on breastfeeding. Breastfeed Med 2008;3:267–270.
  • WHO/UNICEF meeting on infant and young child feeding. J Nurse Midwifery 1980;25:31–38.
  • World Health Organization and United Nations Children's Fund. Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding. UNICEF, New York, 1990.
  • World Health Organization, United Nations Children's Fund, Academy of Breastfeeding Medicine Board of Directors. Celebrating Innocenti 1990–2005: Achievements, Challenges and Future Imperatives. World Alliance for Breastfeeding Action. www.innocenti15.net/index.htm External Web Site Policy (accessed March 24, 2010).
  • United Nations Children's Fund, World Health Organization. Section 1. In: Baby Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care. World Health Organization, UNICEF and Wellstart International, Geneva, 2009.
Date Released
2004 (revised 2010)
Guideline Developer(s)
Academy of Breastfeeding Medicine - Professional Association
Source(s) of Funding

Academy of Breastfeeding Medicine

This work was supported in part by a grant from the Maternal and Child Health Bureau, U.S. Department of Health and Human Services

Guideline Committee

Academy of Breastfeeding Medicine Protocol Committee

Composition of Group That Authored the Guideline

Lead Author: Barbara L. Philipp, MD, FABM

Committee Members: Maya Bunik, MD, MSPH, FABM; Caroline J. Chantry, MD, FABM (Co-Chairperson); Cynthia R. Howard, MD, MPH, FABM (Co-Chairperson); Ruth A. Lawrence, MD, FABM; Kathleen A. Marinelli, MD, FABM (Co-Chairperson); Lawrence Noble, MD, FABM (Translations Chairperson); Nancy G. Powers, MD, FABM; Julie Scott Taylor, MD, MSc, FABM

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #7: model breastfeeding policy. Breastfeed Med 2007 Mar;2(1):50-5. [22 references]

Academy of Breastfeeding Medicine protocols expire five years from the date of publication. Evidence-based revisions are made within five years or sooner if there are significant changes in evidence.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Academy of Breastfeeding Medicine Web site External Web Site Policy.

Print copies: Available from the Academy of Breastfeeding Medicine, 140 Huguenot Street, 3rd floor, New Rochelle, New York 10801.

Availability of Companion Documents

The following is available:

  • Procedure for protocol development and approval. Academy of Breastfeeding Medicine. 2007 Mar. 2 p.

Print copies: Available from the Academy of Breastfeeding Medicine, 140 Huguenot Street, 3rd floor, New Rochelle, New York 10801.

A Chinese translation of the original guideline document is available from the Academy of Breastfeeding Medicine Web site External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on October 30, 2007. The information was verified by the guideline developer on November 12, 2008. This NGC summary was updated by ECRI Institute on October 19, 2010.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Single copies may be downloaded for personal use. Copyright permission to be requested for use of multiple copies by e-mailing requests to abm@bfmed.org. An official request form will be sent electronically to person requesting multiple copy use.

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