Which client action might lead to an infant avoiding latching on to the breast

Note: This guideline is currently under review. 

Introduction 

Aim

Definition of Terms

Information for staff

Assessment

Management

Special Considerations

Companion Documents

References and Links

Evidence Table

Introduction

The Royal Children’s Hospital is committed to the promotion, support and protection of breastfeeding as the optimal method to feed neonates and infants.  Breastmilk provides complete nutrition for an infant to 6 months of age, with the type and level of protein, carbohydrate and fat ideal for the optimal growth and development of the infant throughout that time.  The World Health Organisation recommends neonates and infants are exclusively breastfed for the first 6 months of life, and thereafter receive complementary foods with continued breastfeeding for up to 1 year or beyond.  Breast milk is readily available and contains anti-infective and anti-inflammatory properties that assists in preventing infections and necrotising enterocolitis.  Long term benefits include improved neurodevelopmental outcomes and reduced risk of obesity.  Benefits to the breastfeeding mother include enhanced bonding, reduced anxiety, reduced risk of ovarian and breast cancer and post-partum weight loss.  For neonates and infants who require hospitalisation, access to the benefits of breast milk should be encouraged, and the mother supported throughout.

Aim

The aim of this clinical practice guideline is to enable all clinical staff to actively support and promote breastfeeding as the most beneficial form of nutrition for neonates and infants throughout all departments of the RCH.
The following guideline contains information to assist families with initiation, establishment and continuation of breastfeeding. Details of the referral processes to further support services are also included.

Definition of Terms

• Neonate: An infant under 28 days of age
  
• Infant: A child under 1 year of age
  
• Term: A baby born after 37 weeks of completed gestation
  
• Preterm: A baby born before 37 weeks of completed gestation
  
• Late Preterm: A baby born between 32 and 36+6 weeks of completed gestation
  
• Very Preterm: A baby born between 28 and 31+6 weeks of completed gestation
  
• Extremely Preterm: A baby born before 28 weeks completed gestation
  
• BM: Breast milk
  
• EBM: Expressed breast milk
  
• PDM: Pasteurised donor breast milk
  
• Milk Substitute: Represented as partial or total replacement for breast milk (generally infant formula). 
  
• Fortification: Additions made to breast milk to increase protein and caloric content
  
• Galactagogue: Medications or herbs that may increase breastmilk supply.  Advice or prescription should be under the consultation of lactation consultants or medical practitioners.
  
• NGT/OGT: Nasogastric Tube/Orogastric Tube
  
• NEC: Necrotising enterocolitis
  
• LC: Lactation Consultant
  
• MCHN: Maternal Child Health Nurse
  
• PMU: Postnatal Mothers Unit

Information for staff

• The RCH does not endorse one brand of milk substitute, and promotional materials for such are not permitted.  This is in line with the WHO International Code of Marketing of Breast-Milk Substitutes to ensure the provision of safe and adequate nutrition for infants, including the use of milk substitutes where necessary, without interfering with the protection and promotion of breastfeeding.
  
• In conjunction with this clinical practice guideline, all staff are encouraged to attend education sessions on lactation management and breastfeeding support.  This is to ensure that correct, current and consistent information and support is provided to all mother’s wishing to breast feed or to provide their infant with expressed breast milk.  Additional resource links are provided below.
  
• All staff should be aware of their responsibilities under the WHO code for Health Workers in Australia.
  

Assessment

Structure of the Female Adult Breast

The breast is composed of glandular (secretory) and adipose (fatty) tissue that is supported by fibrous connective tissue known as Cooper’s ligaments.  The glandular tissue consists of 15-20 lobes, each containing clusters of 10-100 alveoli (which comprise a lobule), and this is where breast milk is synthesised and stored. Surrounding the secretory cells of the alveoli is a network of myoepithelial cells that, with the influence of oxytocin, contract and eject the milk towards the ductules that lead from the alveoli. Ductules join to form a lactiferous duct, draining towards the areola.  Ultrasound studies by Ramsay et al (2005) on lactating breasts found an average of 9 lactiferous ducts opening onto the nipple (range 4-11).  Surrounding the areola are Montgomery’s glands which secrete an oily substance to protect the skin during lactation.

Stages of Lactation 

Infant Reflexes and Sucking

• Rooting reflex - this reflex progressively strengthens from 32 weeks’ gestation and is important in helping the infant find the nipple to attach to the breast. It is elicited by touching the infant’s cheek or corner of mouth, with the infant readily turning their head towards the stimulus while also gaping the mouth and tilting the head slightly upwards. The tongue will drop from the roof of the mouth, moving forwards to lick the nipple. It is important to note that a crying infant will position their tongue in their palate, and attempting to place an infant to the breast in this state inhibits the rooting reflex and the development of sucking.  
  
• Tongue thrust reflex - when the lips are touched, the infant’s tongue will extend out of the mouth to take in the nipple
  
• Gag reflex - elicited by stimulation to the back of the tongue and soft palate, causing the muscles of the soft palate to contract
  
• Sucking reflex - when the infant’s hard palate is stimulated and liquid transfers into the mouth, the tongue moves it to the back of the mouth for swallowing. This reflex is present from 24 weeks’ gestation and begins to strengthen as a suck/swallow/breathe cycle at 28 weeks. By 32 weeks’ gestation the infant begins to coordinate the reflex in repeated bursts, however, effective coordination for sustained breastfeeding often does not develop until 37 weeks.   An infant displaying feeding cues from 32-37 weeks’ gestation will benefit from being placed skin to skin and allowed to attempt breastfeeding, but full top up of the feed via the nasogastric/orogastric may be required (refer to Assessing Feed Quality).  Sucking and swallowing occurs at a frequency of at least once per second when breastmilk is actively flowing but will increase if the milk flow lessens or ceases.  Feeding therefore begins as short and fast bursts of sucking, but progresses to long and continuous sucks as the feed is established.
  
• Suck and swallow cycle:
  
  • The infant draws the nipple, areola and underlying breast tissue deep into their mouth, creating a seal with their lips and cheeks. The infant’s lips should appear flanged outwards.
    
  • The tip of the tongue remains over the lower gum while the anterior tongue cups the areola and breast
    
  • The suction created by the infant’s mouth elongates the nipple to extend to the junction between the hard and soft palates. The nipple is held between the upper gum and the tongue that is covering the lower gum.
    
  • The infant’s jaw moves the tongue upwards to compress the breast
    
  • The anterior aspect of the tongue is raised while the posterior aspect is depressed. Peristaltic motions of the tongue form a grove that moves milk to the back of the oral cavity to stimulate swallowing.  The soft palate rises and closes off nasal passages, with the larynx moving up and forward to close the trachea and propel milk into the oesophagus.
    
  • The larynx moves to the previous position and the infant lowers their jaw to begin a new cycle.
    
  • As neonates are predominately nose-breathers, breathing continues throughout the cycle, however if the bulk of the milk bolus enters the pharynx at the onset of swallowing, brief swallowing apnoea occurs. If further apnoeas occur with feeding, or the feeds are disorganised, pacing and review by Speech and Language Therapy may be required.
    

Admission Documentation

On admission each neonate, infant or child will have a feeding history documented within by the admitting doctor and nurse.  This includes:

• Intention to breastfeed or breastfeeding history
  
• Current nutritional requirements and feeding regime, including any recent alterations to this pattern
  
• Infant growth, hydration and development
  
• Medications and allergies
  
• Comorbidities 
  
• Reported feeding difficulties for the patient or mother 
  
• If the family do not wish to breastfeed, any requested milk substitutes should be noted and consent should be obtained and documented
  
• Consent should also be sought for the use of dummies for non-nutritive sucking
  
• Where possible, breastfeeding mothers are encouraged to stay with their child during admission to facilitate unrestricted breastfeeding. Any circumstances that might make it difficult for the mother to be present during the admission should be discussed, and the times that she will be available to optimise breast feeding documented.

This information will be recorded in the infant’s electronic medical record (EMR; ADT Navigators – Admission – Caregiver Assessment, Admission Note and Progress Notes).  Referral for further breastfeeding support should be completed if feeding difficulties are identified (refer to below).  

Growth monitoring

Anthropometric measurements, including analysis of weight, head circumference and length, are an integral aspect to the medical and nutritional management of neonates, infants and children. Extrauterine growth restriction, which commonly occurs with hospital admission, is a recognised risk factor for impaired neurodevelopment, therefore, supporting nutritional care is a very high priority. 

• Butterfly – growth measurements are taken on admission, transfer and discharge. Twice weekly measurements occur on Sunday night for discussion on Monday ward round, and Wednesday night for discussion on Thursday ward round. Please refer to the ‘Neonatal Growth Monitoring’ guideline for further information on contraindications, procedures and management. (Growth Monitoring Guideline)
  
• Wards – growth monitoring requirements vary dependant both on the ward and the patient.  Please see a member of the local nursing education team for further information and assistance.
  
• Demand breastfed infants may have weights recorded more frequently to gauge a more accurate assessment of feeding.
  

Management

Breastfeeding Support

Readiness to feed

• Beginning oral feeding is a team decision that places the infant and their family at the centre of the care, and as such, parents should be included in these early discussions.  Clinically, this decision is based on the medical status of the infant, the ability to maintain respiratory and cardiovascular stability, to remain alert for feeding, to coordinate suck, swallow and breathe patterns, to communicate hunger and fullness, and to cope with the positioning and handling associated with feeding.
  
• Communicating feed timing with parents is vital.  This ensures that the infant and mother are provided with maximum opportunities for breastfeeding.
  
• Hunger cues include stirring before a feed or at feed times, increasing movements and becoming more active, rooting reflexes, hand to mouth movements, sucking, opening the mouth in response to touch.  Crying is a late sign of hunger.
  
• COCOON page with Baby Feeding Cues Poster and  Circle Of Care Optimising Outcomes for Newborns (COCOON).
  
• Disengagement cues include cessation of sucking, closing their mouth, spilling milk from their mouth, turning their head away from the breast, putting a hand up, gagging and pushing the nipple out of their mouth with their tongue.
  
• While a rapid transition to sleep may be a disengagement cue, some infants who are just learning to breastfeed may need to be woken or prompted during their feed. Unwrapping the infant, exposing and stimulating a foot, or stroking the jaw line may assist them to continue showing interest in their feed.
  
• Readiness to feed should be documented within the feed assessment (refer to below).
  

Positioning and attachment 

• The health professional should be skilled in assisting mothers to consistently achieve correct positioning and attachment at each breast. Where possible mothers should be shown a ‘hands off’ approach to correct positioning and attachment. Mothers will then feel more confident and skilful in their ability to independently attach and position their baby to their breast to feed. 
  
• To avoid muscular strain and soreness, it is important that the mother finds a comfortable position to breastfeed. Select a comfortable chair to support to the back and shoulders, footstools ensure the mother’s feet are stable and pillows assist in supporting the baby.  Ensure privacy is facilitated.
  
• A hand placed between the infant’s shoulder blades provides enough support to the head and neck while keeping the infant’s head free to move towards and latch to the breast.
  
• • Reclined Position:  The mother lies in a semi-reclined position, well supported with pillows.  The baby is positioned prone on the mother’s chest with the nipple level to the baby’s nose.  As the baby’s chin touches the breast, the baby can attach easily as the tongue and jaw fall forward to grasp the breast. This position is particularly useful if the baby is having difficulty attaching or require assistance for fast milk flow.
    
  • Cradle Hold: this is the most common feeding position.  The baby’s nose will be level to the nipple, with the baby well supported by the mother’s forearm. The baby’s arm may be around the mother’s waist, or against her abdomen with their bottom resting on the mother’s thigh. The mother’s elbow will be at her side, the heel of her hand or supporting arm will be between the baby’s shoulder blades. In the cross-cradle hold, the baby is held using the opposite arm to the breast being used.
    
  • Underarm hold/football hold: the baby lies supported on a pillow under their mother’s forearm, with their body turned against the mother’s side with the baby’s chest, legs and feet tucked around to the mother’s back. The mother supports the baby’s shoulders with her hand and the baby’s body rests on her forearms. This position is useful for women with twins, those after a caesarean birth, those with large breasts or who are overweight/obese.  
    
• Signs of correct positioning and attachment:
• The rooting reflex is initiated, and the baby’s mouth will be wide open with both lips relaxed on the breast and flanged outwards.
• The baby’s head is slightly extended and the chin pressed to the breast
• Rhythmic jaw movement with wriggling of the ears
• Swallowing sounds heard or observed
• The baby’s nose is free without the mother needing to hold back her breast
• Absence of clicking sounds
• Signs of incorrect positioning and attachment:
• Nipple pain or trauma
• The baby’s lips are rolled inwards
• Clicking or smacking sounds at the breast
• Biting sensations during the feed
• The nipple slips out of the mouth when the baby pauses
• Poor weight gain
• A poorly positioned baby may show frustration, crying and fussing at the breast.  To ensure that feeding is not a negative experience, break the cycle and settle the baby before again trying at the breast.  Ensure that the baby has sufficient postural support to stabilise their position at the breast.
• If for any reason the baby needs to be taken off the breast due to poor attachment, healthcare workers can educate the mother to avoid pulling the baby away from her breast. Instead, encourage the mother to break the suction by inserting her little finger into the corner of the baby’s mouth between the gums, and gently remove the baby away from the breast.
• Video Resources ( http://raisingchildren.net.au)
  • Breastfeeding and baby led attachment
  • How to breastfeed – breast feeding positions
  • How to breastfeed – getting good attachment
    
• Assessing feed quality - Comings soon!
  

Cue-based breastfeeding

• For inpatients who have established breastfeeding, ‘cue-led’ or ‘baby-led’ feeding will be ordered via the EMR; Diet Orders – NICU Feeding Schedule.  This involves responding to the infant’s readiness to feed cues (and disengagement cues) to offer feeds that are not guided solely by volume. After assessing readiness to feed, and ensuring the mother is comfortable to attend to the breastfeed, feeding is documented via EMR; Flowsheets – Fluid Balance – Intake – Breastfeed Occurrence. 
  
• Pre and post breastfeeding weighs are often used on the Koala Ward to assess intake for cardiac and renal infants.  If the infant has gained 10grams at the end of the feed it is estimated that the infant has had 10mls during the breast feed.
  
• See ‘Breastfeeding Challenges’ below if the mother is not present, or there are problems identified with feed quality.
  

Expressing breast milk

• EBM can be obtained for purposes of:
  
  • Collecting breastmilk for the preterm neonate/ill infant
    
  • During infant and mother separation
    
  • Storing breastmilk
    
  • Relieving the breasts of fullness due to engorgement, or with blocked ducts or mastitis
    
  • Establishing and building a milk supply
    
  • Initiating or maintaining supply when the infant is unable to feed at the breast
    
• A mother can either hand express, or express with a manual or electric breast pump
  
• Expressing frequency to establish a good supply should be 8-10 times a day (including overnight)
  
• Ensure EBM is correctly labelled and stored (refer to below)
  
• EBM is a body fluid and must be handled using standard precautions (e.g. glove use and preventing contamination of environmental surfaces)
  
• Ensure mothers are educated on hand hygiene, and wash their hands with soap and warm water prior to and after expressing
  
• Hand Expressing:
  
  • Often utilised in the first few days postpartum to obtain colostrum (volume varies from a few drops to a few millilitres, increasing over time)
    
  • This is the gentlest way to express as there is no pressure to the nipple itself, instead focus is on compression of the breast tissue. The thumb and forefinger should be placed vertically, either side of the areola, about 3cm from the nipple. Gently press the thumb and the forefinger back into the breast to feel the breast tissue and then press them towards each other. This compresses the lactiferous ducts to push milk out of the nipple. Continue the compressing action in a rhythmical way. 
    
  • Hand expressing some milk from very full breasts immediately prior to a feed may help the infant attachment as well.
    
  • RWH FACTSHEET
    
• Manual Breast Pumps:
  • Manual breast pumps use a vacuum to create a suction to remove breastmilk from the breast.  The mother controls the amount of suction applied by the squeezing or pulling action of the pump.  It is important to ensure excessive suction is not applied so that nipple trauma is prevented.
    
  • Usual recommendations are to express for 10 minutes on each side, and then repeating again for another 5 minutes on each side.
    
• Electric Breast Pumps:
  
  • The RCH has electric breast pumps available in the expressing rooms, postnatal mothers unit and the wards. Pumps are also available for hire through the Equipment Distribution Centre (Extension number 55325) and pharmacies. 
    
  • Expressing kits are available for each mother. Different sized shields are available, with Medela ( MEDELA GUIDE ON SIZE) stocking these in Small (21mm), Medium (24mm), Large (27mm) and Extra Large (30mm). After each use, breast shields should be rinsed with cold water, cleaned with warm soapy water, rinsed with hot running water and allowed to air dry. Kits should be replaced as per manufacturer’s instructions on the packet. 
    
  • The electric breast pumps have adjustable suction pressures and mothers should begin with the lowest and increase without causing pain or trauma. 
    
  • Expressing for 20-30 minutes is common, expressing one breast until the flow slows to drips, and then switching breasts. Double pumping, or expressing both breasts at the same time, reduces expressing time to around 15 minutes and increases prolactin levels. 
    
  • Medela pump information sheet on set up
    
• Equipment Cleaning:
  
• Infant feeding equipment must be processed to prevent contamination of equipment and transmission of infection.
  
  • Infant feeding equipment meets the Spaulding classification of semi-critical medical devices. Semi-critical medical devices have contact with intact mucous membranes or non-intact skin. Semi-critical reusable medical devices require high-level disinfection at a minimum. 
    
  • Breast milk is classified as a body fluid and may contain potentially infectious matter that is microorganisms, blood and blood-borne viruses.
    
• Equipment is not to be washed in hand basins or baby baths in the patient’s room. Use formula preparation area, kitchen/pantry area.
  
• At RCH all teats, caps and bottles must be returned to the Central Formula Room where they can be reprocessed and reused.  These items must be rinsed and placed in the designated collection bins in the patient room or ward formula room.
  
• Infant milk warmers shall be safely managed for daily use, cleaning and maintenance which includes:
  
  • Emptied of water, and dried after each use
    
  • Cross contamination with milk and water avoided
    
  • Electrically safe and well maintained such a monthly descaling 
    

Storage and use of EBM 

• Refer to ‘ Management of Expressed Breast Milk for Inpatients at the Royal Children’s Hospital’ procedure
  
• EBM must be correctly identified as belonging to the mother and infant.  EBM must be correctly labelled and correctly checked prior to administration by:
  
  • 2 nursing staff or 1 nursing staff and the infant’s parent
    
  • Identifying correct EBM (patient name, MRN number) to patient ID band
    
  • EBM within use by date
    
  • If EBM is decanted into another bottle to be warmed, this must be labelled correctly and the label checked again
    
  • All intake of EBM is recoded within EMR; Flowsheets – Fluid Balance – Intake – Breast milk, add comment to the line to insert “checked by ..” on each administration
    
• Warm the required volume of EBM for one feed to room temperature in an approved bottle warmer (available on all wards). 
  
  • EBM must not be warmed in a microwave due to uneven heating, risk of burns and destroying cellular components
    
  • Once warmed, gently swirl the bottle to ensure the fat and nutrients are mixed evenly through the milk
    
  • EBM may be offered by a bottle, syringe or feeding tube
    
  • Ensure that the patient receives the EBM as soon as possible after warming
    
  • Discard any warmed EBM that has not been consumed during a single feed
    
  • Discard EBM that has been left at room temperature (out of the refrigerator) for more than 4 hours
    
• If the incorrect breast milk is given to a patient, please adhere to the RCH policy ‘Breast Milk – Administration to the Wrong Infant’
• Infant Mouth Care with Colostrum or EBM

• Providing colostrum or EBM for mouth care in infants who are preterm or unwell decreases the time taken to achieve oral feeding, assists in establishing breastfeeding and reduces the time requiring total parenteral nutrition and central vascular access devices.  It is theorised that it also has potential to deliver oral immune therapy. Even for infants who are nil by mouth, mouth care must be provided with each set of cares.  Replacing the use of water, 0.2ml of the mother’s colostrum (utilised first until complete) or EBM should be placed on a cotton swab, and gently placed inside the infant’s mouth, swabbing both sides of the buccal mucosa and the tongue.  
  

Non-Nutritive sucking

Non-nutritive sucking is any sucking that the infant will do without milk transfer, be it at empty breast or dummy. This assists to build positive associations between sensations in the mouth and hunger satisfaction, improves coordination and muscle tone, calms the infant to conserve energy and assists in the transition to oral feeding.  Consent for the use of dummies should be sought and documented at admission.  See  COCOON

Skin to skin care

Skin-to-skin care, also known as kangaroo care, refers to the method of holding an infant in an upright and prone position, skin-to-skin, on the parent’s chest for a period of time.  Clothing or blankets are wrapped around the infant to provide a secure kangaroo-like pouch. Skin-to-skin care has numerous benefits including increased maternal breast milk supply, increased breast feeding incidence and duration, a greater ability to recognise infant cues and increased parent-infant bonding.  See Skin-to-skin Care nursing guideline. 

Sham feeding 

Sham feeding is offered only on the Butterfly Ward to allow infants with unrepaired long-gap oesophageal atresia to learn to feed orally. A Replogle Tube connected to suction drains the milk that the infant sucks from the breast or bottle from the upper oesophageal pouch to prevent aspiration, and the feed is then re-fed via the gastrostomy tube to allow the development of the association of oral feeding with milk entering the stomach.  (See Sham Feeding Nursing Guideline)  

Breastfeeding mother meals

To assist in breastfeeding support and promotion, and reduce separation, lunch and/or dinner is provided for breastfeeding mothers with inpatient children less than 2 year of age. Nursing staff must code the mother as ‘Breastfeeding Mother’ in EMR (Orders – Place New Order – Breastfeeding Mother Meal). Indicate in the comments if the mother has any allergies or dietary requirements.  Once ordered, the mother will need to take a patient MRN sticker from the ward to the RCH kitchen (located on B2, via the green lifts) to collect their meals at lunch (1145 – 1230) and dinner (1730 – 1815). 

Breastfeeding Challenges

Absence of Mother

• Contact the mother to ascertain when they intend to come to the ward
  
• If the infant’s feed cannot be delayed until the mother’s arrival, offer EBM if available.  This may be stored in the ward fridge, the patient fridge (Butterfly and Rosella Wards), the ward freezer (Butterfly Ward) or in the Central Formula Room (extension 55123).  Use the EBM expressed at the earliest date first.
  
• Adhere to the correct identification and checking process prior to administration of EBM to the patient (see Storage and Use of EBM)
  
• Ensure the EBM is warmed to room temperature via a bottle warmer prior to administration.  
  
• Review the mode of feeding plan for the patient via EMR; Orders – Diet and Nutrition. The EBM can be administered via NGT/OGT (see guideline), drops given by a syringe into the mouth or by bottle.  Consent is required for administration of the feed via the bottle. Information on specialised bottles or teats (varied size and flow speed) is available via COCOON.
  
• Document feed in EMR; Flowsheets – Fluid Balance – Intake – Breast Milk.

No EBM available

• Contact the mother to ascertain if they will be bringing EBM soon 
  
• If feeding cannot be delayed, and EBM will not be available for the foreseeable future, consent to give formula is required.  This is found via EMR; ADT Navigator – Admission – Caregiver Assessment – Consent for Formula Given (YES/NO). A milk substitute must not be given unless consent is obtained and documented.
  

Infant Fasting

• For patients less than 6 months of age, breastfeeding is permitted up until 3 hours prior to surgery
  
• Provide breastfeeding mothers with an expressing kit (and assistance if required) to both maintain their supply and relieve discomfort, until their infants are able to breastfeed again post-operatively.
  

Low Supply

• Low breast milk supply is one of the most common reasons for early cessation of breastfeeding. If the supply is low, it is usually a temporary situation that can be improved with the right support
  
• Insufficient removal of milk from the breasts leads to decreased milk production and this is the most common cause of low breast milk supply. This is may be due to poor attachment, insufficient feeding/expressing regime, mother-infant separation, unresolved engorgement, inverted nipples, prematurity, tongue-tie and infant oral cavity abnormalities
  
• Maternal considerations, such as stress/illness, medications, medical conditions, breast reduction, drug use and smoking may also decrease supply
  
• Signs of low breast milk supply may be indicated by limited evidence of milk transfer during feeds, and breasts that remain soft between feeds. The neonate or infant may present as being unsettled shortly after feeds, persistently sleepy, have decreased wet nappies, concentrated urine, persistent jaundice, poor weight gain or weight loss greater than 10% of birth weight.  
  
• Observe and assess for correct positioning and attachment, nipple trauma, and signs of milk transfer with the suck and swallow pattern
  
• Encourage the mother to increase the frequency of breastfeeds, waking the infant if required, and feed from both sides. Advise the mother to utilise skin-to-skin care to assist in increasing breast milk supply. 
  
• Additional breast stimulation and drainage via regular expressing after breastfeeds will assist in establishing the supply
  
• EBM is the first choice for supplementation of breastfeeds and this should be at a volume to maintain the infant’s nutritional status while still promoting and supporting frequent breastfeeding.  Monitoring of the infant’s growth and output is required. Refer to a
  LC for ongoing support during this time.
  
• If low breast milk supply continues to be a problem, refer the mother to their GP, as galactogogues, such as Domperidone, may be required to assist in increasing prolactin levels and stimulating milk production. Note that some galactogogues have potential side effects for those with cardiac conditions or arrhythmias and may therefore not be appropriate.  
  
• For extremely preterm infants or those at high risk of NEC, PDM may be offered while the mother’s breast milk supply increases (PDM guideline coming soon). 
• See RWH FACT SHEETS
  • Domperidone for increasing breast milk supply 
  • Expressing breast milk for sick premature babies

Engorgement

• Breasts may become very full when lactogenesis II occurs after birth. Full breasts may develop engorgement whereby the venous and lymphatic drainage is obstructed, hindering milk flow and increasing the pressure in the milk ducts. This is often caused by delayed or ineffective feeding, or inadequate milk removal.
• The mother will describe her breasts as swollen and distended, painful, hot and with poor milk flow
• If positioning and attachment is correct on assessment, encourage the mother to express to drain both breasts to comfort
  

Blocked Ducts

• A blocked milk duct may cause milk to build up behind the blockage, causing inflammation to the surrounding tissue  
  
• Blocked ducts are often caused by suboptimal management of engorgement, missed feeds/expressions, and a large supply 
  
• The breast will have a tender and palpable lump, with the surrounding skin red and warm to touch
  
• Encourage the mother to feed from the affected side first, observing positioning and attachment, and positioning the infants chin towards the blockage if possible to assist in draining 
  
• Advise the mother to gently massage the affected area towards the nipple during feeding/expressing or when in the shower
  
• Blocked ducts may develop into mastitis, so discuss signs and symptoms of this with the mother
  
• If the blockage does not clear, advise the mother to seek medical advice from her GP
  

Mastitis 

• Mastitis is an inflammation of the breast tissue which may lead to infection. It is commonly caused by poor attachment, nipple damage, blocked milk ducts, missed feeds and engorgement or chronic oversupply. Signs and symptoms include a red, swollen and painful area in the affected breast, flu-like symptoms and fever.
  
• Breastfeeding and expressing from the affected breast is still safe. Observe and assist with correct positioning and attachment (refer to LC if concerns raised). 
  
• Advise the mother that the use of heat packs on the affected area prior to feeding, and gentle massage of breast lumps (towards the nipple) when feeding, expressing or while having a warm shower may help with milk flow
  
• If there is no improvement, advise the mother to present to her GP as antibiotics may be required
  
• See RWH FACT SHEET
  

Flat or Inverted Nipples

• Flat or inverted nipples commonly impact the infant’s ability to attach successfully at the breast  
  
• With LC review, a nipple shield may be offered to assist effective milk transfer
  
• Encourage the mother to express a few drops of milk onto the outside of the shield so that the scent can be detected by the baby. Feed duration may be longer due to reduced milk flow.
  
• A nipple shield should be rinsed and then washed in hot soapy water, before rinsing again and leaving to drain and air dry in a clean covered container.
  
• Advise the mother that with appropriate supports, the use of the shield is in most cases a temporary feeding aid.
  
• Wood Pharmacy, located on the ground floor of the RCH also stocks different shield sizes.
  
• See RWH FACT SHEET
  

Nipple thrush

• Nipple thrush is caused by an overgrowth of Candida albicans. The mother may describe a burning or stinging nipple pain that continues both during and after the feed. The nipples will be tender and appear red.
  
• If the mother has evidence of nipple thrush, it should be assumed that the breastfeeding infant is colonised. The infant may have signs of oral thrush, with white oral plaques on the tongue and inside cheeks, or a red papular rash around the nappy region. 
  
• Both the mother and the infant will be prescribed oral and/or topical antifungal 
  
• See RWH FACT SHEET
  

Tongue-tie

• Tongue-tie (ankyloglossia) is a congenital condition in which the lingual frenulum is abnormally short and restricts tongue mobility. The ability of the infant to latch and suck effectively may be impaired and the mother may experience nipple pain and trauma. 
  
• Tongue-ties do generally not require release.  Referral to a LC, speech pathologist or paediatric surgeon for an assessment of the tongue-tie and the infant during a feed is required.
  

Severe Combined Immunodeficiency (SCID) Infants

For infants diagnosed with SCID, whose mother is CMV serology positive, breastfeeding is strongly discouraged.  At diagnosis, breastfeeding should be stopped while an urgent CMV serology on the mother and plasma PCR on the infant is completed. The mother should be supported to express breast milk to maintain supply while the results are pending.  If the mother returns CMV negative or the infant’s CMV PCR is positive, breastfeeding can be reinstituted.  If breastfeeding must be ceased, refer to
Suppressing Lactation (below).  

Suppressing lactation

• When lactation needs to be suppressed due to the death of a neonate or infant, to protect immunocompromised infants or for maternal choice, the process must be done safely to prevent the development of engorgement or mastitis
  
• Please contact the RCH LC for support (brochures available).  Further assistance can be found from the Australian Breastfeeding Association and SANDS (Stillbirth and Neonatal Death Support), if appropriate.
  

Further Breastfeeding Support

Lactation Consultants at the RCH are International Board Certified Lactation Consultants (IBCLCs) and are located on Koala and Butterfly wards.

• Koala LC (Monday – Friday, excluding public holidays)
  Pager 4776 for patients on Koala, or cardiac patients on Rosella
  
• Butterfly LC (Wednesday)
  Pager 6659 for all other inpatients
  
• Postnatal Midwife (7 days per week)
  Pager 6659 or ASCOM 52764 for all postnatal assistance and further breast feeding support.  Please note that the postnatal midwives attend to women admitted to the PMU, and while based in Butterfly, will assist other wards when available.  
  
• MCHN (Limited days)
  Pager 6163 or Extension 56163
  

Special Considerations

Breastfeeding/EBM for Procedural Pain Management

The sweet taste of breastmilk is proven to have an analgesic effect, and where available, is preferable over oral sucrose for mild procedural pain management such as for venepuncture, immunisation and heel lancing.  Providing oral EBM, or by placing the infant to the breast where able, can assist in calming the infant’s response to pain, and by promoting the mother-infant comfort bond.  (**LINK to sucrose GL**)

Maternal Considerations

Medications

• As the health benefits of breastfeeding are so important to the neonate and infant, breastfeeding should only be ceased in circumstances where there is evidence that the medication could be transferred to the infant in breastmilk and cause harm. These include cytotoxic, some antipsychotics and immunosuppressive medications.
  
• It is not always possible to avoid taking medications during pregnancy and breastfeeding  
  
• The medical team, pharmacists and lactation consultants will be able to assist with advice regarding the safety of breastfeeding and specific medication use
  

Alcohol

• Maternal alcohol abuse is documented within the EMR; ADT Navigators – Delivery History/Maternal History – Maternal Substance Abuse, as well as the Admission Note.
  
• Alcohol is rapidly absorbed and has a peak concentration within breastmilk within 30-60 minutes after consuming (90 minutes if with food).
  
• The concentration of alcohol present in breastmilk is comparable to simultaneously measured maternal blood alcohol levels 
  
• Mothers who choose to consume alcohol should limit their intake and allow between two hours (one standard drink) to four hours (two standard drinks) before breastfeeding. If larger quantities are absorbed, mothers may express and discard the milk.  The
  Australian Breastfeeding Association has developed a mobile app, Feed Safe (**link**) that assists breastfeeding mothers to make the best decisions about alcohol consumption
  

Smoking

• Maternal smoking is documented within the EMR; ADT Navigators – Delivery History/Maternal History – Maternal Substance Abuse, as well as the Admission Note.
  
• Smoking interferes with prolactin and oxytocin levels and therefore may impede breast milk supply. Nicotine in breast milk can also cause gastrointestinal irritability in the infant.
  
• Passive smoking is a risk for infants and smoking should therefore not occur in the same room as the infant  
  
• Mothers who wish to cease smoking should be provided with appropriate supports, including the QUIT line number
  
• Visit the website or telephone 13 78 48
• If ceasing smoking is not an obtainable option for mothers, smoking should be avoided both an hour before, and during feeding
  

Recreational Drugs

• Maternal Drug Use is documented within the EMR; ADT Navigators – Delivery History/Maternal History – Maternal Substance Abuse, as well as the Admission Note.
  
• Recreational drugs are excreted into breast milk in varying amounts. This is dependent on drug type, administration, dosage and time of exposure.  
  
• Narcotics may make the breastfed baby sleepy, whereas stimulants may cause infant irritability 
  
• The Finnegan Score Chart is utilised to grade Neonatal Abstinence Syndrome (NAS). The scoring criteria and documentation is within the EMR; Flowsheets – Observations – NAS. If NAS scoring is required, scores should be discussed during the ward round.
  
• The Royal Hospital for Women ‘ The Women’s Alcohol and Drug Service (WADS) provides medical care, counselling and support to women with complex substance use, dependence or those within a methadone stabilisation program.  
  

Caffeine

• Caffeine diffuses slowly in to breast milk with a long half-life. Peak levels of caffeine in breastmilk are reached approximately one hour after consumption of caffeine-containing beverages.
  
• Excessive maternal caffeine ingestion may cause irritability and poor sleeping in the infant
  
• 2 cups a day is the recommended limit for caffeine consumption.
  

Companion Documents

RCH Policies and Procedures

• Management of Expressed Breast Milk for Inpatients at the Royal Children’s Hospital’ procedure  (RCH viewing only)
  
• Breast Milk - Administration to the Wrong Infant (RCH viewing only)

RCH Clinical Practice Guidelines

• Neonatal Growth Monitoring
  
• Skin-to-Skin Care for Newborns
  
• Sham Feeding for Infants with Unrepaired Long-Gap Oesophageal Atresia
• Pasteurised Donor Milk for Infants - coming soon
  
• Sucrose (oral) for Procedural Pain Management in Infants

Breastfeeding Staff Members (via RCH HR department) - coming soon

Parent Information 

• Kids Health Info: Fact Sheet – Breastfeeding a baby in Hospital
• Kids Health Info: Fact Sheet – Breastfeeding at the Royal Children’s Hospital
• Kids Health Info: Fact Sheet – Loss of your baby: Breastfeeding.
  
• COCOON – Feeding, the Journey to Feeding your Baby

References and Links

• Australian Breastfeeding Association – HELPLINE 24 hour 1800 686 268
  
  • General Breastfeeding Information 
    
  • Supressing Lactation https://www.breastfeeding.asn.au/system/files/LOW_lactation%20suppression_JUN%202018.pdf
    
• Australian Commission on Safety and Quality in Health care (2010),  Australian Guidelines for the Prevention and Control of Infection in Healthcare, http://www.nhmrc.gov.au/book/australian-guidelines-prevention-and-control-infection-healthcare-2010
  
• Brodribb, W (2012), Breastfeeding Management in Australia, Australian Breastfeeding Association, Victoria.
  
• Medela Symphony Pump Instructions for Use
  https://www.medela.com.au/breastfeeding/products/breast-pumps/symphony-rental
  
• National Health and Medical Research Council (NHMRC) Department of Health and Ageing (2012), ‘Eat for Health: Infant Feeding Guidelines’, Canberra https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/n56_infant_feeding_guidelines.pdf
  
• Ramsay, DT., Kent, JC., Hartmann, RA & Hartman, PE (2005), ‘Anatomy of the lactating human breast redefined with ultrasound imaging’, Journal of Anatomy, 206(6): pp 525-534.
  
• Riordan., J & Wambach., K (2009), Breastfeeding and Human Lactation, Fourth Edition, Jones and Bartlett Learning, United States of America.
  
• Royal Women’s Hospital (RWH) Fact Sheets
  • Expressing Breast Milk 
    • https://thewomens.r.worldssl.net/images/uploads/fact-sheets/Expressing-breast-milk-2018.pdf
    • https://thewomens.r.worldssl.net/images/uploads/fact-sheets/Breastfeeding-Expressing-breast-milk-for-sick-preterm-babies-090517.pdf
  • Low Milk Supply
  • Mastitis
  • Nipple Shields
  • Breast and Nipple Thrush
• SANDS 
  
• Scott C, Bradford J, Gillespie E (2010), ‘Achieving best practice in the management of infant-feeding equipment’, Healthcare Infection, vol. 15, pp 89-92.
  
• State Government Victoria - Department of Education and Early Childhood Development (2014), ‘ Promoting Breastfeeding: Victorian Breastfeeding Guidelines’
  
• Video Resources ( http://raisingchildren.net.au)
  
  • Breastfeeding and baby led attachment
  • How to breastfeed – breast feeding positions
  • How to breastfeed – getting good attachment
• World Health Organisation
  
  • ‘ International Code of Marketing of Breast-Milk Substitutes’ (1981)
    
  • Eat for Health: Infant Feeding Guidelines, information for health workers’ (2012)
    

Evidence Table

Breastfeeding Support and Promotion evidence table. 

 Please remember to read the disclaimer.

The development of this nursing guideline was coordinated by Tara Doyle, ANUM, Butterfly approved by the Nursing Clinical Effectiveness Committee. Published December 2018.  

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