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Canberra Hospital and Health ServicesClinical GuidelineBreastfeedingContents

Contents...................................................................................................................................1

Introduction............................................................................................................................. 5

Background.............................................................................................................................. 5

Key Objectives..........................................................................................................................6

Section 1 - The WHO Code.......................................................................................................6

Section 2 - The Ten Steps.........................................................................................................8

Step 1 – Have a written breastfeeding policy that is routinely communicated to all health care staff...............................................................................................................................9

Step 2 – Train all health care staff in skills necessary to implement this policy....................9

Step 3 – Inform all pregnant women about the benefits and management of breastfeeding....................................................................................................................... 9

Step 4 – Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour and encourage mothers to recognise when their babies are ready to be breastfed, offering help if needed...................................................................10

Step 5 – Show mothers how to breastfeed and maintain lactation even if they should be separated from their infants..............................................................................................10

Step 6 – Give newborn infants no food or drink other than breastmilk unless medically indicated.............................................................................................................................11

Step 7 – Practise rooming in- allow mothers and infants to remain together 24 hours a day......................................................................................................................................11

Step 8 – Encourage breastfeeding on demand...................................................................12

Step 9 – Give no artificial teats or pacifiers (dummies) to breastfeeding infants...............12

Step 10 – Foster the establishment of breastfeeding support groups and refer mothers to them...................................................................................................................................12

Section 3 - Breastfeeding Management.................................................................................12

3.1 - The natural pattern of breastfeeding.........................................................................13

3.2 - Exclusive breastfeeding..............................................................................................17

3.3 - Positioning and attachment at the breast..................................................................17

3.4 - Assessing milk transfer at a breastfeed......................................................................19

3.5 - First Feed....................................................................................................................19Doc Number Version Issued Review Date Area Responsible PageCHHS16/042 1.1 02/03/2016 01/03/2019 WY&C 1 of 85

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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3.6 - Baby-led or demand feeding......................................................................................21

3.7 - Rooming-in.................................................................................................................22

3.8 - Breastfeeding after Caesarean Section.......................................................................23

Section 4 - Breastfeeding challenges in the immediate and longer postnatal period............24

4.1 - Inverted nipples..........................................................................................................24

4.2 - Nipple pain and trauma..............................................................................................26

4.3 - Bacterial infection of the nipple.................................................................................29

4.4 - Nipple vasospasm.......................................................................................................29

4.5 - Breast and nipple thrush............................................................................................29

4.6 - Herpes simplex virus..................................................................................................31

4.7 - Lactation Consultant Referrals...................................................................................31

4.8 - Speech Pathology Referrals........................................................................................32

4.9 - Delay in Lactation or Low supply................................................................................32

4.10 - Breast surgery and breastfeeding.............................................................................35

4.11 - Breastfeeding a preterm or unwell baby..................................................................36

Section 5 - Breastmilk expression...........................................................................................37

5.1 - General principles of expressing in all settings via any method.................................38

5.2 - Expressing by hand.....................................................................................................38

5.3 - Expressing by electric pump.......................................................................................38

5.4 - Antenatal Expressing..................................................................................................39

5.5 - Storage of Breastmilk.................................................................................................40

Section 6 - Breast related issues.............................................................................................42

6.1 - Blocked lactiferous ducts............................................................................................42

6.2 - White spot/nipple bleb..............................................................................................43

6.3 - Full breasts and engorgement....................................................................................43

6.4 – Mastitis......................................................................................................................45

6.5 - Physiotherapy Management of Blocked Ducts and Lactational Mastitis....................47

Referral...............................................................................................................................47

Initial Assessment...............................................................................................................47

Physiotherapy Management..............................................................................................48

6.6 - Breast abscess............................................................................................................50

6.7 - Blood in the breastmilk..............................................................................................51

Section 7 - Lactation Aids.......................................................................................................51

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7.2- Cup Feeding.................................................................................................................53

7.3 - Supply line..................................................................................................................55

7.4 Syringe drop feeding....................................................................................................56

7.5 Finger Feeding..............................................................................................................56

Section 8 - Baby-related breastfeeding issues.......................................................................58

8.1 - The sleepy baby..........................................................................................................58

8.2 - The unsettled baby.....................................................................................................59

8.3 - Excessive crying..........................................................................................................60

8.4 - Breast refusal.............................................................................................................61

8.5 - Breastfeeding multiple babies....................................................................................62

8.6 - Breastfeeding during pregnancy and tandem breastfeeding (feeding a baby and an older child)......................................................................................................................... 63

Section 9 – Complementary feeding......................................................................................63

9.1 Complementary feeding...............................................................................................63

Section 10 - Artificial Feeding/Infant formula.......................................................................65

10.1 - Artificial Feeding.......................................................................................................65

10.2- Cleaning and sterilising of feeding equipment..........................................................68

Boiling.................................................................................................................................68

Steam Sterilising.................................................................................................................68

10.3 - Suppression of Lactation..........................................................................................69

Section 11 – Dummies and Pacifiers.......................................................................................70

Section 12 – Contraception and breastfeeding......................................................................71

12.1 Lactational amenorrhea method................................................................................71

12.2 Hormonal methods.....................................................................................................72

Implementation......................................................................................................................72

Definitions..............................................................................................................................72

Related Policies, Procedures, Guidelines and Legislation.......................................................72

References..............................................................................................................................73

Search Terms..........................................................................................................................75

Attachments...........................................................................................................................75

Attachment 1: Breastfeeding Policy Summary...................................................................76

Attachment 2: Parent Information Sheet - Antenatal Expressing.......................................78

Attachment 3: Parent Information Sheet - Nipple shields..................................................80

Attachment 4: ACT Breastfeeding Referral Flowchart........................................................83Doc Number Version Issued Review Date Area Responsible PageCHHS16/042 1.1 02/03/2016 01/03/2019 WY&C 3 of 85


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Introduction

The division of Women, Youth and Children recognise that breastfeeding is the healthiest way for a woman to feed her baby. Important health benefits exist for both the mother and her child. Our staff will promote, protect, and support breastfeeding by implementing “UNICEF/WHO Ten Steps to Successful Breastfeeding". The health benefits of breastfeeding and the potential health risks of formula feeding are discussed with all women so that they can make an informed choice about how to feed their babies.

The Canberra Hospital and Health Services are committed to providing an environment that protects, promotes and supports breastfeeding as the optimal way for a woman to feed her baby.

The Canberra Hospital and Health Services are accredited by the Australian College of Midwives supported by the World Health Organisation (WHO) and the United Nations Children’s Fund (UNICEF), as a ‘baby friendly hospital’ as part of the Baby Friendly Health Initiative (BFHI).

In addition, Canberra Hospital and Health Services supports careful scrutiny at the institutional level, of any research which involves mothers and babies for potential implications on infant feeding or interference with the full implementation of this guideline.

The BFHI, a global accreditation process, was launched in 1991 by the WHO and UNICEF. The aim of this accreditation is to increase breastfeeding rates by encouraging hospitals to implement the Ten Steps to Successful Breastfeeding as a minimal standard and adopt practices that ‘protect, promote and support’ breastfeeding. Hospitals and health services can apply for this status and are assessed by an external team of trained assessors. Once awarded, this accreditation lasts for three (3) years.

The needs of women, babies and young children will change between stages and health care settings. It is important that activities and interventions that are provided to protect, promote and support breastfeeding are responsive to these changes.

Back to Table of Contents

Background

This Guideline applies to all health care professionals and will provide those involved in the care of a woman and her baby across the care continuum with accurate and consistent breastfeeding principles, knowledge and information.




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Key Objectives

Communication of a clear and consistent set of principles that protect, promote and support breastfeeding.


Section 1 - The WHO Code

The International Code of Marketing Breastmilk Substitutes was developed in 1981 by the General Assembly of the World Health Organization, following consultation with key stakeholders, including governments and infant food manufacturers. In subsequent years additional World Health Assembly resolutions have further defined and strengthened the Code.

The aim of the WHO Code is:To contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution: The International Code of Marketing of Breastmilk substitutes of 1981 (The WHO Code)

was drawn up because of the concern that many artificial milk (formula) companies were marketing their products inappropriately. The Code was implemented so that artificial milks would be used as they were originally intended, that is, as a life saving tool and not as a routine.

In 1981 in the World Health Assembly Australia ratified the WHO Code. In 1992 all Australian manufacturers and importers of infant formula signed an

agreement with the Australian Government giving ‘effect in Australia to the principles of the WHO Code, which included the agreement not to advertise any formula to the general public, including follow-on formula, for infants under twelve months of age. The Department of Health and Ageing (DoHA) monitors the industry agreement the ‘Marketing Agreement of Infant Formulas’ (MAIF).

The MAIF Agreement was developed by the Australian Government and member companies of the Infant Nutrition Council (previously the ‘Formula Manufacturers’ Association of Australia’) and was authorised in 1992.The MAIF Agreement is a voluntary self-regulatory code of conduct between the manufacturers and importers of infant formula in Australia. It is Australia’s response to the World Health Organization’s International Code of Marketing of Breast-milk Substitutes 1981 (WHO Code). The MAIF Agreement applies to those Australian manufacturers and importers of infant formula who are signatories to the MAIF Agreement. The MAIF Agreement aims to contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding and by ensuring the proper use of breast milk substitutes, when they are necessary, on the basis of adequate information through appropriate marketing and distribution.



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Products covered under the WHO Code: Infant formula Other milk products Cereals Juices and baby teas Follow-on milks Feeding bottles and teats.

The ten (10) main provisions of the Code are:1. No advertising of breastmilk substitutes to the public

a) No products including formula, bottles and teats should be advertised or promoted.2. No free samples or supplies to mothers

a) No staff member in the unit is to give free samples of formula to any breastfeeding mother. To give a breastfeeding woman some formula ‘just in case’ will reinforce to the mother that she is not capable of breastfeeding. At the Centenary Hospital for Women and Children there should be no contact between formula company representatives and midwifery or nursing personnel in the wards or clinical areas.

3. No promotion of products through health care facilitiesa) Care should be taken that no posters with a formula company name are displayed in

maternity areas. Tins of formula should not be left out in the ward on display for women and families to see.

b) Magazines with advertising of products covered by the code (including bottles and teats) should not be distributed to women.

c) There should be no brand names on donated equipment, including videos. The equipment and materials may bear a company name, but should not refer to any proprietary product within the scope of the Code.

d) In 1986 the Code was amended to include hospitals or health facilities paying close to market price (at least 80%) for infant formula and refusing free or low cost supplies.

4. No contact between company marketing personnel and womena) No representatives from companies which manufacture, market or distribute infant

formula should seek to contact pregnant women, or mothers of babies or young children.

5. No gifts or personal samples to health workersa) Gifts from formula companies should not be offered to or accepted by health

professionals. b) Samples of infant formula or other products covered by the Code should not be

given to health professionals. Samples should not be passed on to parents.c) Samples may be used for research at the institutional level or for professional

evaluation.d) Any grants for research, study or travel made to health professionals by the formula

companies should be declined.6. No words or pictures idealising artificial feeding, including pictures of infants on the

labels of products



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a) Health professionals should be aware of the formula companies and manufacturers of bottles and teats who violate the Code in this way.

7. Information to health workers should be scientific and factuala) Health professionals need to be aware of new products on the market, but only

scientific and evidence based information about infant feeding products should be supplied to health professionals from the formula companies. This information should emphasise that breastfeeding is normal and artificial feeding is inferior. At The Canberra Hospital there should be no contact with pharmaceutical representatives and health professionals in the wards or clinical areas.

8. All information on artificial infant feeding, including the labels on formula cans, should explain the benefits of breastfeeding, and the costs and hazards associated with artificial feeding.a) Any informational and educational materials about infant feeding given, or shown

(audio or visual) to pregnant women and mothers should include information about: the benefits and superiority of breastmilk the negative effect on breastfeeding of introducing partial bottle feeding maternal nutrition and the preparation for and maintenance of breastfeeding the difficulty of reversing the decision not to breastfeed

if needed, the proper use of infant formula.9. Unsuitable products, such as sweetened condensed milk should not be promoted for

babies.a) This includes the promotion of follow-on milks. Babies may continue to be fed on

initial formula with additional weaning foods in the second six months of life. Follow-on milks are not necessary.

10. All products should be of a high quality and take account of the climatic and storage conditions of the country where they are used.

WHO/UNICEF 1996 Resolutions to clarify the WHO Code Reaffirm local family food to complement the diet of breastfeeding babies beyond 6

months of age. End free or low cost distribution of artificial baby milk to newly parturient women in the

hospital. Proscribe receipt of funds from manufacturers or distributors of artificial baby milk or

feeding suppliers to be used for professional training in infant and child health or for financial support of any organisation that monitors compliance of the international code.


Section 2 - The Ten Steps

Step 1 – Have a written breastfeeding policy that is routinely communicated to all health care staffThis Breastfeeding Clinical Guideline must be communicated and available to all health care staff involved in the care of pregnant women and mothers. This extends to all health care Doc Number Version Issued Review Date Area Responsible PageCHHS16/042 1.1 02/03/2016 01/03/2019 WY&C 8 of 85


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environments across the care continuum including, but not limited to, Maternity, Neonates, Paediatrics, Community Programs and any clinical area having admitted a lactating woman. A summary is displayed in areas where mothers and babies are cared for. (Attachment 1)

Step 2 – Train all health care staff in skills necessary to implement this policyHealth care professionals have a responsibility to facilitate and support breastfeeding in all environments where health care is delivered. The information provided to women must be evidenced based and consistent across the care continuum.

All staff who have contact with pregnant women, mothers, babies, and/or young children (in the care of the facility) have received orientation to and education on the breastfeeding and infant feeding policy and the skills necessary to implement the policy. Staff have also been educated on providing support for non-breastfeeding mothers. All professional staff providing care to pregnant women and mothers will be trained in breastfeeding support and management to a level that is appropriate to their clinical area of work.

Information contained in this clinical guideline is intended to provide a consistent set of principles for all health care professionals involved in the care of pregnant women and babies. These principles will be expanded during education as outlined above.

Step 3 – Inform all pregnant women about the benefits and management of breastfeedingBreastfeeding education is provided to pregnant women accessing maternity services. The antenatal service does not promote artificial feeding or products used for this purpose: all women are asked about their breastfeeding knowledge and previous experience

with baby feeding women who did not breastfeed a previous child or had problems with breastfeeding are

offered antenatal counselling for breastfeeding.

The antenatal education/discussion includes the following key points: why breastfeeding is important the risks associated with not breastfeeding the importance of early uninterrupted skin-to-skin contact and the first feed why 24-hour rooming-in is important why bottle teats and dummies are discouraged while breastfeeding is being established exclusive breastfeeding for the first six months and that breastfeeding continues to be

important after six months when other foods are introduced basic breastfeeding and lactation management, including positioning and attachment,

feeding cues and frequency of feeding indications that a baby is getting enough milk maintaining and increasing breastmilk supply breastfeeding support groups and services in the community.



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Step 4 – Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour and encourage mothers to recognise when their babies are ready to be breastfed, offering help if neededAll women are encouraged and facilitated to keep their babies in skin-to-skin contact as soon as possible for at least an hour after birth, unless there are specific medical reasons for not doing so.When the mother plans to breastfeed, the first breastfeed is allowed to occur when the baby is ready.

This should be facilitated in all birth environments including theatre or post anaesthetic care facilities if a woman’s baby has been born via caesarean section. Where skin-to-skin contact is interrupted for a specific clinical reason, it should be recommenced as soon as possible.

A successful first breastfeed has numerous positive effects on both the woman and baby. It stimulates uterine contractions, provides immunological benefits for the baby in receiving colostrum, stimulates the baby’s digestive function, provides confidence for the woman to continue breastfeeding and enhances mother and baby bonding and attachment.

As all babies are different, if the baby does not feed in this period, offer reassurance and encourage the women to leave the baby in skin-to-skin contact that will facilitate and encourage the baby to attach when ready.

Step 5 – Show mothers how to breastfeed and maintain lactation even if they should be separated from their infantsAll postnatal mothers who plan to breastfeed are taught the necessary skills and provided with appropriate support and information to initiate and maintain lactation and to breastfeed their babies.

staff will provide women with assistance with breastfeeding as required staff will educate women on correct positioning and attachment women can recognise whether the baby is well attached on the breast and

breastfeeding effectively women are able to recognise at least 2 feeding cues (other than crying) women are to be taught how to hand express and are provided with written

information on how to store and use their expressed breastmilk (if their babies are 24 or more hours old)

If a baby is admitted to a nursery due to illness or preterm gestation the woman should be assisted to commence expressing breastmilk by hand before leaving the birth room. Women are to be taught how to express their breastmilk and provided with assistance as required. Women expressing for babies being cared for in a nursery should be encouraged to express frequently to maintain their lactation by expressing as often as a baby would usually breastfeed i.e. at least 8 times within 24 hours, including overnight. Further, the use of a breast pump can be commenced once the milk has come in. Discussion and written information is provided on how to store, transport and use their expressed breastmilk. Doc Number Version Issued Review Date Area Responsible PageCHHS16/042 1.1 02/03/2016 01/03/2019 WY&C 10 of 85


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Step 6 – Give newborn infants no food or drink other than breastmilk unless medically indicatedNo fluid other than breastmilk will be offered to a baby unless medically indicated or with fully informed parental choice. There are very few absolute contraindications to breastfeeding relating to either baby or woman.

Conditions relating to the infant for which breastmilk is unlikely to be appropriate include some inborn errors of metabolism including Maple Syrup Urine Disease and Phenylketonuria. Breastmilk is absolutely contraindicated in Galactosaemia. Such babies will require care and guidance from a neonatologist and/or paediatrician.

Babies with very low birth weight (<1500g) or pre-term (<32 weeks gestation) may require supplementation with formula or breastmilk. This will be prescribed and guided by a neonatologist.

Babies at risk of hypoglycaemia which is unimproved by increased breastfeeding and/or breastmilk feedings require close monitoring and may require supplementation with formula or breastmilk. Please see Hypoglycaemia of the Newborn SOP for risk factor assessment, actions and interventions.

Maternal contraindications for breastfeeding include HIV positive, active tuberculosis, treatment for breast cancer, brucellosis and statin use. Maternal situations that require specific consideration and advice include Hepatitis B and C positive, severe illness, recently acquired syphilis, chemotherapy, radioactive iodine-131, illicit drug use and prescribed psychotherapeutics, antiepileptics and long term opioid drug use, active herpes lesion on areola or nipple. Women who smoke should be counselled regarding the negative impact smoking has on breastmilk supply and encouraged to seek assistance to quit. It is recommended that women not consume alcohol whilst breastfeeding.

Step 7 – Practise rooming in- allow mothers and infants to remain together 24 hours a dayBabies room-in with their mothers 24 hours per day except: when there is a documented medical reason that necessitates separation at the mother’s request, after having made an informed decision, which is documented.

The circumstances and duration of all separations lasting more than one hour are to be documented.

This expectation will be explained in the antenatal period with emphasis of the benefits of rooming in which include bonding and learning/responding to her baby’s feeding cues and reduction of infection.

Readmission of either the woman or baby to the acute health care environment for illness or medical treatment should also follow these principles whether in the paediatric or adult inpatient areas.Doc Number Version Issued Review Date Area Responsible PageCHHS16/042 1.1 02/03/2016 01/03/2019 WY&C 11 of 85


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Step 8 – Encourage breastfeeding on demandBabies are to be offered unrestricted access to the breast. No restrictions should be placed on the frequency and length of a baby’s breastfeeding. Women are to be taught to recognise their baby’s feeding cues and to breastfeed whenever their babies are hungry or show readiness to feed. The woman should be encouraged to respond and feed to her baby’s cues.

Step 9 – Give no artificial teats or pacifiers (dummies) to breastfeeding infantsDummies are discouraged during the initiation and establishment of breastfeeding. The early introduction of a dummy has been correlated with a shorter duration of breastfeeding. Dummies are not supplied within maternity facilities. A woman wishing to provide a dummy to her baby should be informed of the risks associated when establishing breastfeeding.Staff in maternity facilities do not accept or distribute to mothers free or low cost teats, bottles or dummies.Dummies, bottles and teats are not to be displayed in a promotional way in the hospital shop or kiosk and should not be included in baby gift packs for sale within the facility.

Step 10 – Foster the establishment of breastfeeding support groups and refer mothers to themAll women on discharge from the acute care setting will be referred to community based services and be provided with information on where to get help, support and advice specifically relating to breastfeeding. Availability of resources on breastfeeding will be reinforced by Maternal and Child Health (MACH) servicesWomen are provided with written information on Breastfeeding Support in the Community this includes the Australian Breastfeeding Association (ABA) and MACH.


Section 3 - Breastfeeding Management

All women who intend to breastfeed will be offered assistance to establish and maintainbreastfeeding, with a focus on optimal positioning and attachment. This will ensure that breastfeeding is comfortable for the woman and baby, prevents sore nipples and ensures the baby has adequate intake.

All babies must be assessed for rate of weight loss, presence of jaundice and stool and urine output prior to discharge from immediate postnatal services. Signs of infant wellbeing and wellness that are appropriate in both immediate and longer postnatal care delivery include weight gain after the first week, 6-8 wet nappies per day with pale or colourless urine, generally loose, mustard yellow stools, periods of contentedness following feeding and alertness.



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Breastfeeding effectiveness should be assessed prior to discharge of the mother from postnatal services. This allows issues to be addressed where help and support is easily and readily available.

It is important to note that ongoing support may be required following discharge from immediate postnatal services; for some women, clinical handover between in-patient maternity services and community services should occur. A priority referral for breastfeeding issues may be required. Continuity of care in these circumstances will result in better outcomes for the woman and her baby.

All women should be encouraged to make an early appointment to see the local MACH nurse, contact the Australian Breastfeeding Association, and visit their general practitioner (GP) (See Attachment 3).

3.1 - The natural pattern of breastfeedingStates of readiness for breastfeedingUsually breastfeeding is initiated in response to feeding cues from the infant. Understanding the states of alertness can be helpful in identifying when infants are ready to breastfeed. Refer to the table below.

Baby states of alertness Behavioural State Feeding Cues Readiness to FeedDeep sleep – not easily roused None No

Light sleep – rousable but likely to fall back to sleep

None No

Drowsy – yawning, eyes opening intermittently

Early – wiggling, moving arms and legs, rooting, fingers to mouth, licking

Early – yes

Quiet alert – looking around, regular breathing, body still

Early – wiggling, moving arms and legs, licking, searching

Early – yes

Active alert – moving arms and legs, sensitive to environment

Mid – fussing , squeaky noises,restless, hand to mouth, stretching

Mid – yes

Crying – agitated, disorganised, needs comforting

Late – full cry, colour turns red Late – no

Feeding according to need/baby-led feedingResearch indicates there are wide variations in infant feeding patterns, maternal milk production and breast storage capacity. Therefore, ‘breastfed babies should be encouraged to feed on demand, day and night, rather than conform to an average that may not be appropriate for the mother–baby dyad’ (Kent et al, 2006). There are advantages for mother and baby when feeding according to need/demand feeding patterns is followed.Doc Number Version Issued Review Date Area Responsible PageCHHS16/042 1.1 02/03/2016 01/03/2019 WY&C 13 of 85


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Reasons for feeding according to need Mother InfantMother Baby

Increases the rate of successfully establishing lactation

Increases breastfeeding duration

Reduces the incidence of breast engorgement Decreases the incidence and severity of physiological jaundiceBaby will be more content

Establishes a supply and demand pattern

When a healthy baby born at term is feeding effectively there should be no restrictions on: frequency of feeding duration of feeds night feeds.Mother InfantEarly breastfeeding patternsMany babies have a period of deep sleep for several hours following the first feed after birth, and then increased interest in feeding. During this time babies may feed frequently in a cluster-like pattern. Prolonged periods of not feeding require investigation; specific guidance regarding frequency and length of feeds should be reserved for babies who are not feeding well.

Most healthy babies who are feeding effectively will feed between 8 – 12 times in a 24 hour period. Research indicates that the total length of time at each breast does not correlate with amount of milk transferred.

If the baby is breastfeeding well, the mother should breastfeed on the first breast and then offer the second breast when the: baby detaches spontaneously baby appears to have finished the first breast mother feels the first breast is softer baby refuses the first breast but continues to display feeding behaviours.

Sucking patternsBoth non-nutritive and nutritive sucking occurs throughout a breastfeed. The table below describes the differences in sucking. It is important for mothers to be able to recognise effective feeding and the difference between the sucking patterns.

Sucking nutritive sucking Nutritive suckingNon-nutritive Sucking Nutritive Sucking

rapid and shallow 2 sucks per second infrequent swallows occurs with periods of slow milk flow:

o at the beginning of a feedo prior to a milk ejection

deeper and slower approximately 1 suck per second swallows after every 1 or 2 sucks occurs with periods of rapid milk flow:

o after a milk ejection



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Let-down reflex/milk ejection reflex, (MER)MER (also known as ‘let-down’) is the expulsion of breastmilk from the alveoli into the milk ducts and is hormonally controlled. It is important to note that: MER usually occurs a number of times during a feed most women will only be aware of the initial MER and may not be able to sense

subsequent milk ejections many women experience a sensation of warmth or tingling in their breasts some women experience ‘afterbirth’/abdominal pain or discomfort during MER some women are unaware of the MER changes in the baby’s sucking pattern throughout the feed will indicate that MER is

occurring (nutritive sucking). Maternal anxiety or hyper-alert states may influence the MER.

The sucking processReflexes in the babyThe baby’s reflexes are important for appropriate breastfeeding. The main reflexes are rooting, sucking and swallowing. When something touches a baby’s lips or cheek, the baby turns to find the stimulus, and opens his or her mouth, putting his or her tongue down and forward. This is the rooting reflex and is usually present from 32 weeks of pregnancy. When something touches a baby’s palate, he or she starts to suck it. This is the sucking reflex. When the baby’s mouth fills with milk, he or she swallows. This is the swallowing reflex.

Preterm babies have capacity to grasp the areola and nipple from approximately 29 weeks gestational age, and they can suckle and remove some milk from about 31 weeks. Coordination of suckling, swallowing and breathing develops at approximately 36 weeks and full breastfeeding may be attained between 36 and 38 weeks.

The WHO states that when health professionals are supporting a mother and baby to initiate and establish breastfeeding, it is important they understand the maturation of these reflexes, as this will guide whether a baby can breastfeed directly, or temporarily requires another feeding method.

Sucking actionGeddes and colleagues (2008) have described removal of milk from the breast in terms of a vacuum applied by the baby, as in the following description. When the infant sucks, the areola and nipple press upward against the upper gum and the hard palate. The negative pressure of the baby’s suck transfers milk with much greater milk flow when the tongue is down than when the tongue is up. The negative pressure, along with the alternative compression and release of the gums, move the milk through the milk ducts and out the nipple. When the baby’s jaw drops, the increased negative pressure allows the milk to move from the nipple to the baby’s mouth. In contrast, Wooldridge (1986) argues that compression of the breast and peristalsis of the infant’s tongue play an important role in milk removal. Recent 3D ultrasound images confirm that infants’ tongues move both up and down and with a peristaltic motion even within the same feed. Further research is needed



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to clarify the relative contributions of peristalsis and negative pressure in removal of milk from the breast.

SwallowingSwallowing is an important sign of effective breastfeeding and milk transfer that reassures both the mother and the health professional: swallowing sounds are normally subtle, with a quiet ‘cuh’ sound with a new milk ejection, swallowing may become slightly louder and more frequent speech pathologist can be consulted for assessment of any swallowing concerns

3.2 - Exclusive breastfeedingAustralian NHMRC Infant Feeding Guidelines for Health Workers (2012) recommend that babies are breastfed exclusively until around six months of age when solid foods are introduced. WHO and UNICEF global recommendations for optimal infant feeding as set out in the Global Strategy for Infant and Young Child Feeding (2003) are: exclusive breastfeeding for 6 months nutritionally adequate and safe complementary feeding starting from the age of 6

months with continued breastfeeding up to 2 years of age or beyond.

Exclusive breastfeeding means that an infant receives only breastmilk from his or her mother or expressed breastmilk, and no other liquids or solids, including water, with the exception of oral re-hydration solution, drops or syrups consisting of vitamins, minerals supplements or medicines (WHO, 2001).

3.3 - Positioning and attachment at the breastEffective positioning and attachment of a baby for breastfeeding is essential for establishing and maintaining breastfeeding. It is a learnt skill and can take time for the mother-baby dyad to establish. Some babies will move to position themselves at the breast while others will be assisted by the mother to achieve a position for breastfeeding that will be comfortable for both mother and baby. Midwives are to adopt the ‘hands off’ approach to assisting mothers as they are learning to breastfeed. This can provide the mother the opportunity to practice breastfeeding while being verbally guided by a skilled professional.

PositioningThe following principles are relevant regardless of the mother’s choice of breastfeeding position: Mother is positioned enabling her baby to have easy access to the breast. Consider: mother’s comfort, including adequate pain relief for post birth pain privacy baby’s position. Baby is held close to the mother’s body at the same level of the breast

with:o whole body turned towards the mothero trunk and head aligned



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o mouth at nipple levelo head slightly tilted back with support from across back and the shoulders, not the

head.

Signs of effective attachmentNipple sensitivity and tenderness is common in the first few days. However, painful breastfeeding is abnormal and may indicate ineffective attachment.

Signs of effective attachment include: a baby that looks comfortable, relaxed and is not tense, frowning/grimacing with:

o mouth open wide against the breast with the nipple and surrounding breast tissue included in the gape

o chin against the breasto observed deep jaw movementso cheeks not sucked ino swallowing that can be seen/heard once the milk ejection reflex (MER) occurs

after feeding nipples will appear slightly longer but should not be flattened, white or ridged.

If signs of effective attachment are not present, or poor attachment is suspected e.g. the above signs are not present, the mother should be advised to detach the baby by sliding her finger into the corner of baby’s mouth between his/her gums which will: cause baby to release the breast enable removal of the breast from baby’s mouth.

The mother can then reattach baby using positioning principles.

Baby-led attachmentOften mothers and their babies find it easier to learn how to breastfeed by using a baby-led or biological nurturing style of attachment. This allows mothers and babies to work together and use natural reflexes to assist with attachment and breastfeeding.

The mother leans back slightly and holds the baby in close to her chest and breasts following her natural body contour. Her baby is positioned chest to chest with his/her mouth on the breast close to the nipple. The mother is able to support, stroke and calm her baby. The baby is able to mouth, lick and smell the breast. These behaviours lead to latching onto the breast, sucking and swallowing breastmilk through an active and nutritional feed.

Some mothers are more comfortable sitting and bringing their baby up to the breast in a cross-chest hold. The baby is still able to be held securely and the baby’s mouth, nose and upper lip can be lined up to the mother’s nipple and breast. The mother may need to shape her breast to help the baby attach with a good mouthful of breast tissue and not just the nipple.



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The mother will often feel a gentle tugging on her breast and nipple. If she describes pain, the attachment is usually incorrect and the baby needs to be carefully detached and the process started again.

Side-lying position for breastfeedingIn the side-lying position for breastfeeding, the mother is: lying on her side, with her head and neck supported. Some women may need back

support and/or a pillow between her legs for additional support her baby tucked in close to her with the baby‘s nose in line with her nipple, also lying on his side. Some mothers do support their baby’s head with their arm; others find it more comfortable to use their lower arm for their own support. Sometimes a pillow to help support the baby may be used. This should be placed close to baby’s bottom and lower back, NOT close to baby’s head

the mother can use her upper arm to shape and guide the breast as her baby gapes open the mouth to attach

when feeding in a side-lying position, it is important that the mother change which side she is laying on for feeding.

Key points to help a mother achieve good positioning and attachment or latch include: encourage the mother to bring the baby in close and hold securely the baby’s chest is touching mother’s chest and breast the baby’s chin is touching mum’s breast/lower areola the baby’s nose and/or upper lip is touching mother’s nipple.

3.4 - Assessing milk transfer at a breastfeedNo one aspect should be used as the only assessment tool for adequate intake of a baby. It is important for the midwife or lactation consultant to observe a full breastfeed in order to be able to observe appropriate milk transfer. Each baby needs to be assessed individually, including: feeding frequency per 24 hours according to gestational age quality of breastfeeds - sucking patterns according to stage of lactation length of time of breastfeed, effectiveness of the milk ejection reflex, swallowing of milk

seen or heard weight gain urinary and bowel output baby and maternal behaviour during the feed.

3.5 - First FeedThe importance of the first breastfeed nipple stimulation through skin-to-skin contact and breastfeeding encourages the

uterus to contract, therefore aiding in the expulsion of the placenta and controlling blood loss after birth

from 20-60 minutes after birth the baby's sucking reflex is most intense and the baby is most willing to suck



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the ‘imprinting process’ starts to take place at the first feed and this is important for future breastfeeds as the baby learns what to do

the mother/baby relationship (attachment and bonding) are positively influenced women will usually breastfeed for longer duration if skin-to-skin contact and

subsequent breastfeeding is initiated early the baby‘s temperature is more regulated whilst on the mother’s chest.

At BirthInnate feeding behavioursIn skin-to-skin contact the baby usually demonstrates the following well-defined sequence of innate behaviour: opens eyes, quietly looks around and searches for mother’s nipple uncurls fists and makes grasping movements toward nipple makes small ‘licking’ movements demonstrates ‘rooting’ behaviour which may include:

o opening moutho turning head towards the nippleo nuzzling chin into breasto attempting to self-attach

babies, unaffected by medication, will attach themselves to the breast if left undisturbed

babies have an innate olfactory sense, which gives them the ability to smell and know their mothers. Women are advised not to shower until the baby has attached and sucked well at the first breastfeed.

The instinct to suck is especially strong soon after birth and this can establish a pattern for future feeds. When possible, the baby should be allowed to seek the breast and attach spontaneously within the first 1–2 hours of life. Delaying procedures such as weighing, measuring and Vitamin K administration enhance the early mother–baby interaction. While the mother and baby are in skin-to-skin contact after birth, encourage the mother to interest the baby in sucking by: holding the baby skin-to-skin between her breasts letting him/her nuzzle and mouth the nipple allow him/her to suck at the breast once interest is aroused if the baby does not attach for a breastfeed, keep mother and baby skin-to-skin if

possible and try again at least every 1-2 hours until successful it is important that the breastfeed is not interrupted by routine procedures until the

baby indicates satiety by:o spontaneously detaching from the nipple without further rooting behaviouro falling asleep at the breast.

If the baby does not feed assess the baby for any risk factors and notify the neonatal registrar if appropriate reassure the woman if her baby is unwilling to feed soon after birth



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encourage her to leave the baby skin-to-skin, close to her breast, allowing the baby to attach when ready

explain that some babies may take more time to attach for their first feed show the woman how to hand express as per this guideline ‘Expression of Breastmilk’

and drop the colostrum into the baby’s mouth.

Document the first breastfeed or EBM feeding in the baby’s clinical record.

Situations where extra support may be required in the initiation of breastfeedingWomen who have had complicated births such as caesarean section, postpartum haemorrhage or third/fourth degree tears may require extra support in initiating skin-to-skin contact and breastfeeding due to pain, reduced mobility and the effects of the birth and pain relief. To ensure the comfort of the mother, and thus an efficient let-down reflex, assistance and education should be provided to minimise pain through: facilitating a comfortable breastfeeding position appropriate and effective analgesia offering assistance and support as needed.

Events during labour and birth may have a significant influence on lactogenesis. Explanation and reassurance should be given to mothers that supportive measures will overcome most challenges.

3.6 - Baby-led or demand feedingAntenatally: discuss with the woman that demand feeding or ‘baby-led’ feeding are terms used to

describe a baby having unrestricted access to the breast educate the woman about the benefits of demand feeding including:

o encouraging early milk production and maintenance of milk production o facilitating early passage of meconium and therefore decreasing the likelihood of

jaundiceo association with better weight gain in babieso association with longer and more successful lactationo flexible feeding or feeding according to need provides a supply of milk which is

equal to the baby's needs.

Discuss with the woman the importance of the first feed after birth and how vital it is that her baby is left to attach to the breast independently as per this guideline.

Postnatally: ask the woman about the first breastfeed and whether the baby attached and sucked

well independently discuss the feeding behaviour of babies including:

o in the first 24-72 hours the term healthy baby may demonstrate a variety of feeding patterns



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o some babies demand very frequently while others may feed for a few times only and have long sleep times; both patterns are normal newborn behaviour

o it is likely during the first 72 hours that the baby will increase the amount of feeds it demands and it is quite normal for that baby to demand up to 12 feeds or more in 24 hours

o once the milk supply is established the baby should have at a minimum 8-10 feeds in 24 hours

o the normal suck/swallow pattern and recognising the change in sucking pattern from colostrum feeds which is many sucks to one swallow compared with the more obvious suck/ swallow pattern that occurs when there is milk available

explain the importance of early correct positioning and attachment to prevent damage to the nipples; remind the woman to check the shape and colour of her nipples after a feed and if there is pain during the feed encourage the woman to remove the baby and re-attach as per this guideline ‘Positioning and Attachment’

observe baby breastfeeding at least once each shift offering midwifery advice as indicated

discuss with the woman the expected normal elimination patterns of her baby as per guideline ‘Monitoring the Healthy Baby’s Wellbeing’

assess the baby’s wellbeing each shift as per guideline (as above) provide the woman with the following information once her milk has ‘come in’ to assist

her in determining when to offer 1 or 2 breasts:o explain to the woman that her breasts will never be emptied so it is advisable that

the baby drains one breast before the second breast is offeredo discuss with the woman the signs that may indicate her baby has finished feeding

from the first breast which include no more suck swallows, baby falling asleep or getting restless; the second breast should now be offered

o inform the woman that it is recommended that both breasts are offered at each feed, but remind her that the baby may not wish to take the second breast

o teach women to allow their babies to detach when satisfied o remind women never to let the baby continue to suck on the breast if it is painful.

3.7 - Rooming-inRooming-in should be encouraged as it allows the woman and her baby to have close contact, facilitating attachment and bonding. It is associated with the following benefits: uninterrupted skin-to-skin contact to maximise hormonal response in the mother and

thermo regulation for the baby unrestricted breastfeeding access increased breastfeeding duration increased opportunity for mothers to become familiar with their baby’s feeding cues,

behaviour and feeding patterns prior to discharge promotion of relaxation and sleep for mother and baby the family has the opportunity for closer contact with the baby reduced risk of SIDS associated with earlier initiation of lactation and successful breastfeeding



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facilitates frequent suckling and reduces crying and stress for the baby, thereby decreasing energy consumption and contributing to better weight gain

the hormone oxytocin which is responsible for the milk ‘let down’ is released as the baby stirs, so when the baby demands and attaches milk is ready to ‘let down’ and satisfy the baby without delay

enhances maternal rest and sleep minimises cross-infection.

All women are to be provided education antenatally about the benefits of rooming in with their babies: staff must provide support to enable the woman and baby to remain together at all

times provide education on breastfeeding and settling if the woman requests for her baby to be minded by staff so she can rest, health

professionals must provide the woman with information and education around demand breastfeeding and settling

a baby who is continually unsettled should be investigated.

3.8 - Breastfeeding after Caesarean Section Antenatally discuss with the woman that she will be able to have skin-to-skin contact and

breastfeed her baby in the theatre or Post Acute Care Unit (PACU) (unless medical condition of the woman or her baby is not stable)

explain the importance of early feeding discuss the possible effects of epidural analgesia on baby behaviour i.e. up to 6 weeks

postpartum there may be diminished hand to mouth movements and a decrease in visual skills and alertness (there is not a lot of strong evidence to support this)

explain narcotics may have a depressive effect on the baby explain that establishing breastfeeding following a caesarean section may require more

time and patience as the baby may be affected to some extent by medication.

PostnatallyOperating Room and PACUThe midwife will be responsible for the care of the baby in the PACU and together with the PACU nurse a family friendly environment will be fostered: maintain skin-to-skin contact at all times unless absolutely necessary welcome the partner into the PACU document the date, time and description of the breastfeed in the woman’s clinical

record.

Breastfeeding following a caesareanWomen may be shown how to breastfeed while lying on their side when recovering from surgery. In the immediate post-surgery period, a mother who may be drowsy, drug-affected and immobile should be closely monitored by staff or their support person during



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breastfeeds. In these circumstances, it is recommended the baby should be returned to the cot when the breastfeed is completed, please refer to CHHS Standard Operating ProcedureDepartment of Neonatology - Safe Sleeping Guidelines for Neonates (up to 28 days of age)and CHHS Clinical Procedure Falls Prevention and Management (including safe use of bed rails).

For women who have had a caesarean birth, breastfeeding in a lying-back position may reduce stress on the incision site. In this position, the baby’s legs can be angled to reduce pressure or irritation on the incision.

Women under sedationWomen who are receiving any form of sedating medication post caesarean section need to be closely observed to ensure safety of the baby during breastfeeds this includes: lights to be turned on woman assisted to sit up cot sides up woman offered a cold drink a suitable family member can be asked to supervise the woman to ensure the baby’s

safety.

The health professional must use professional judgement to assess the family member’s willingness and suitability to supervise the woman and baby, providing appropriate instructions, as needed.

A varying level of supervision during breastfeeds will be required depending on the woman’s clinical condition; any woman experiencing any of the following will require close supervision when feeding her baby: Patient Controlled Analgesia (PCA) inability to remain alert (MEWS sedation > 2) restricted movement BMI >35.


Section 4 - Breastfeeding challenges in the immediate and longer postnatal period

4.1 - Inverted nipplesIdentify inverted nipples by the following description:Inverted Nipples: A nipple that turns inward rather than projecting outward or retracts when the areola is pinched is defined as an inverted nipple. Some nipples appear apparently well formed but retract when the areola is pinched. This is called pseudo inversion. Often the inversion is on one breast only.



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Inverted nipples do not necessarily cause breastfeeding problems and it should not be assumed that the woman will be unable to breastfeed. However, there may be difficulties in attaching the baby initially and the establishment of breastfeeding may be delayed.

Note that lack of full protraction of the nipple, when using the pinch test, is fairly common in primigravid women.

AntenatallyDiscuss the following with a woman who has inverted nipples: during pregnancy inverted nipples often become more protractile and increase in size

because of hormonal changes when breastfeeding the baby attaches to the breast rather than the nipple therefore

the actual shape of the nipple may not be a problem nipple protraction improves with each pregnancy and lactation experience that there is evidence to support the use of breast shields/shells or Hoffman’s exercises

antenatally encourage the woman to contact her local ABA group women may benefit from a Lactation Consultant Clinic appointment during pregnancy

to discuss potential management strategies.

Postnatally be positive about breastfeeding success when caring for and talking to the woman encourage early and frequent skin to skin contact, to allow the baby to learn the

woman’s anatomy and facilitate self attach encourage the woman to be patient recognising that it may take time for the baby to

latch onto the breast; noting that there are many reasons why a baby may not latch in the first few days after birth, therefore skin-to-skin should be encouraged and the baby should be assessed fully for underlying reasons e.g. labour medications

encourage the woman to breastfeed frequently in the first few days while the breasts are soft and easier to grasp

teach the woman how to stimulate her nipple before feeds, to roll her nipple and stretch it alternatively the woman may use a hand or electric pump to draw the nipple out before the feed.

advise the woman to try the other breast; most women have one breast/nipple that is easier for the baby to grasp

suggest the woman to try different feeding positions e.g. cradle, twin or side lying assist and educate the woman to position her baby correctly when attaching to the

breast and to be aware of good attachment throughout the feed as per Section 3.3 of this Guideline Positioning and Attachment at the Breast .

If the baby cannot grasp the breast: teach the woman how to hand express her colostrum as per Section 5 of this Guideline

‘Breastmilk Expression the breasts should be expressed frequently to encourage supply and be comfortable when her milk comes in



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educate the woman to feed the colostrum to her baby using a cup or syringe avoid giving the baby a teat, dummy, finger feed or nipple shield in the first few days document the breastfeeding plan as a variance on the Clinical Pathway maintain close observation of the baby's output and discuss normal urine and stool

output with the woman once the milk is in, if the baby is still unable to attach to the breast, consider the use of

a nipple shield and arrange for ongoing care by a lactation consultant or experienced clinician.

When the woman and her baby are discharged: refer her with consent to the MACH nurse as a high priority by faxing the referral to

Community Health Intake (CHI) for breastfeeding support, especially if she is using a nipple shield

recommend the woman make contact with ABA for additional support.

4.2 - Nipple pain and traumaMany new mothers experience transient nipple pain or discomfort in the first few days after birth. However, pain that is severe, persistent, or occurs between feeds should be investigated. Nipple pain is the most common reason for early cessation of breastfeeding.

Nipple appearancePainful nipples may appear normal, or associated nipple trauma may be apparent. Nipple trauma ranges from mild inflammation, small blisters and grazes through to compression stripes, cracks and fissures. Other indications of nipple pathology include: exudate or yellow crust plaques or flaky skin shiny skin pustules blanching.

Causes: poor positioning and attachment (the most common) engorgement nipple variations such as flatness, retraction, inversion inappropriate use of breast pump breast pump shield too small or incorrectly placed suction too high candida infection eczema/dermatitis bacterial infection herpes simplex nipple vasospasm white spot (blocked nipple pore)

anatomical variations in the baby such as:o a high arched, flattened or bubble palate



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o disorganised sucking actiono tongue-tie (ankyloglossia)o biting

hormonal sensitivity; for example, during ovulation, menstruation or a new pregnancy.

Routine nipple care and prevention of traumaPrevention of nipple damage centres on good management and assessment of breastfeeding from birth. Routine nipple care includes: antenatal education on correct positioning and attachment support and assist the woman to correctly position and attach her baby in the early

postnatal period until she demonstrates she is confident to manage independently and is maintained throughout the entire feed

avoiding the use of soaps, shampoos and non-medically prescribed ointments avoiding synthetic bras – cotton is preferred avoiding plastic-backed breast pads changing breast pads frequently if the mother needs to remove the baby from the breast before the baby has finished

feeding, she should first break the suction by inserting a clean finger gently into the baby’s mouth

topical use of expressed breastmilk.

Management Management involves identification of the cause and initiation of appropriate treatment. A full breastfeeding assessment should be conducted as per the section on ‘Positioning and attachment ’. offer the least sore nipple first soften the areola if engorged prior to attachment stimulate let-down before attaching the baby to the breast correct positioning and attachment; try different positions try baby-led attachment; that is, placing baby skin-to-skin in upright position on the

mother’s chest and allow to seek the breast and attach spontaneously treat any associated engorgement consider hydrogel dressings, to relieve pain; take care with hydrogel dressings if nipples

are damaged as the risk of infection may be increased use moist wound healing principles e.g. apply expressed breastmilk or purified lanolin

after feeds (attend to hand hygiene before touching nipples/applying expressed breastmilk (EBM) or purified lanolin)

reassure and support the mother – this is vital review the woman for possible causes of ongoing pain, if the pain is not resolving discuss the importance of not limiting feeding times as repeated detachment of baby

can contribute to nipple trauma and subsequent ineffective milk transfer discuss the effect of dummies or teats as having a potential to change the sucking

behaviour inform women to change breast pads frequently and to air nipples after feeding



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remind the woman to always remove the baby from the breast if pain persists during the feed or if the woman suddenly experiences nipple pain; check the woman knows to remove her baby by gently breaking the suction

recommend she air her breasts after feeding suggest rinsing nipple/areola with clean water and bathing the crack with fresh

expressed breast milk to aid healing and prevent bacterial infection recommend that dummy/pacifier/teat be discontinued offer analgesia.

If the nipples are too sore to feed reassess to determine the cause and treat appropriately, be aware that prolonged sore

nipples may also indicate that the problem has not been correctly identified or treated; consider referring the woman to a Lactation Consultant

the woman may need to ‘rest and express’ the affected nipple/breast until pain subsides

This may be for a few feeds or a few days; it may be from one or both breasts if using a breast pump, ensure the breast pump shield is placed centrally over the

nipple, is of sufficient diameter, and that suction pressures are comfortable for the woman

express enough to drain the breast well to prevent engorgement or mastitis feed the baby the expressed breastmilk by dropper, spoon or cup; avoid use of bottles

and teats if possible, particularly in a very young baby and if the cause of nipple trauma is poor attachment.

Use of nipple shields for nipple pain and traumaThere is limited evidence to support the use of nipple shields for management of nipple pain and trauma without first correcting the cause. The indiscriminate use of shields may exacerbate the problem and cause early weaning from the breast. In some cases, with the guidance of a knowledgeable clinician, judicious use of a nipple shield may protect sore nipples during healing and enable the mother to continue to breastfeed. If the nipples are so painful that the mother cannot breastfeed, the clinician should discuss the choice to ‘rest and express’ or use a nipple shield with the woman.

On discharge if the nipple pain continues or the trauma is not healing: recommend the woman seek medical advice if an infection or dermatological condition

is suspected refer the woman with nipple pain or damage to the MACH nurse for post discharge

support.

4.3 - Bacterial infection of the nippleCracks and fissures in the nipple may be colonised with pathogenic bacteria, most frequently with Staphylococcus aureus. This presents as nipple inflammation, weeping, crusting lesions or pustules, and may result in delayed wound healing and an increased risk of mastitis.



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Management review by medical officer who may prescribe topical antibacterial cream or oral

antibiotics if risk of mastitis is high.

4.4 - Nipple vasospasmVasospasm of the nipple is often unrecognised as a cause of nipple pain. It may be associated with a history of nipple trauma due to poor attachment or nipple infection. Vasospasm may be exacerbated by cold temperatures or nicotine and caffeine due to their vasoconstrictive properties. The clinician may need to ask a woman with pain to observe the timing of pain, and appearance of her nipples during pain, to identify any associated colour changes, in order to make the diagnosis.

Signs and symptoms nipple pain immediately after or between feeds, or pain precipitated by cold, such as

when getting out of the shower pain may range from mild to intense and last for a few minutes or longer pain may radiate into breast maybe associated with triphasic colour changes of the nipple – from white, to blue, to

red.

Management avoid exposure to cold; wear warm clothing and breastfeed in a warm environment avoid airing the nipples after feeds use warm packs and nipple warmers after and between breastfeeds avoid caffeine and nicotine refer for review by doctor who may consider:

o elemental magnesium supplements which may assist in vasodilation o prescribing vasodilators if pain does not resolve with above measures, or in women

with primary vasospasm.

4.5 - Breast and nipple thrushBreast and nipple thrush is the over-growth of candida albicans, in the nipples and in breast ducts. The diagnosis of breast or nipple thrush is usually made after consideration of the mother’s symptoms; differential diagnoses should be considered (see below).

Signs and symptomsNipple/areola women may describe burning, stinging nipple pain that continues during and after the

feed the nipples are often very tender to touch and even light clothing can cause pain nipples may appear pink and/or shiny and areola may be reddened, dry or slightly flaky.

Breast women may describe shooting, stabbing, or deep aching breast pain; pain may also be

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the breast pain typically occurs after feeding or expressing; the let-down reflex may be more painful than normal

the pain may be localised to one nipple or breast or may be bilateral breasts will appear normal; if inflamed, consider mastitis.

BabyThe baby may have signs of thrush such as white oral plaques in the mouth (tongue and inside cheeks) or red papular rash with satellite lesions around the anus and genitals. Although these signs are not always present, it should be assumed that the infant is colonised with the organism if the mother has evidence of nipple thrush. Once a diagnosis of nipple and or breast thrush has been made both mother and infant should be treated at the same time to prevent re-infection.

Differential diagnoses bacterial infection: if nipple damage is present nipple vasospasm: if nipple pain is exacerbated by cold and/or nipples blanch nipple eczema/dermatitis: if significant itching and/or rash are present trauma from infant tongue-tie or other nipple trauma.

ManagementGeneralTreat any other site of fungal infection in the whole family i.e. vagina, nappy rash, feet. Advise the woman to keep nipples dry by frequently changing breast pads, as thrush thrives in a moist and warm environment. Clean any feeding equipment thoroughly after use in hot soapy water and boil for 5 minutes; replace weekly if possible. To prevent the spread of thrush, advise the woman to wash her hands thoroughly after nappy changes and before and after applying any creams/lotions.

BabyOral Baby’s mouth: use anti-fungal gel as prescribed by medical officer or other health care

prescriber.

Topical Apply anti-fungal cream as prescribed by medical officer or other health care prescriber

to nappy area.

MotherTopical Nipple treatment for mother: anti-fungal gel/cream applied as prescribed by medical

officer to nipples after each feed (or 3–4 hourly during the day). The gel/cream should be applied thinly and does not need to be wiped off before the next breastfeed.

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4.6 - Herpes simplex virus Herpes simplex is highly contagious and infection in the neonate can be life-threatening. In the neonatal period, the presence of herpes lesions on the breast is a contraindication for breastfeeding until the lesions have completely resolved. In older children, the infection may originate from herpes stomatitis in the child, and therefore the child is already infected.

Signs and symptomsLesions may occur on the areola or breast and are usually extremely painful.

Management in the neonatal period avoid direct contact between the baby and the lesions; the

woman should not breastfeed or offer skin-to-skin contact the affected breast must be regularly drained through expressing to maintain the milk

supply expressed breastmilk from the affected breast must NOT be fed to the infant and

should be discarded the infant may be fed from the unaffected breast the woman may be prescribed acyclovir; this is considered compatible with lactation educate the mother about the importance of hand-washing.

4.7 - Lactation Consultant ReferralsFor further support of breastfeeding challenges, the woman may be referred to a Lactation Consultant both within the acute or community health environment. A Lactation Consultant will undertake a comprehensive maternal and infant assessment, review the current feeding plan and make adjustments where necessary. Referral to a GP, neonatologist or paediatrician may be required.

Lactation consultation referrals are for antenatal and postnatal clients under the care of the hospital and domiciliary services (Midcall or Continuity Programs). Any mother or baby outside this scope should be referred to MACH services, including the Early Days Service, the Australian Breastfeeding Association (ABA), private lactation services or the family GP.

Lactation consultant referrals are for women and babies with complex problems not within the normal scope of midwifery. These can include: pregnant women who are anticipating possible breastfeeding difficulties e.g. have

experienced breastfeeding problems with a previous baby or who have a history of breast surgery

babies born with anatomical anomalies which will impact on breastfeeding e.g. cleft palate

minor problems which persist despite midwifery intervention e.g. damaged nipples unimproved by correcting positioning and attachment

babies with tongue-tie which may require frenotomy babies brought to the emergency department or admitted to paediatrics with

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4.8 - Speech Pathology ReferralsFor further support of breast feeding difficulties, woman and babies may be referred to Acute Support Speech Pathology. Speech Pathology referrals are for women and babies withcomplex problems, such as sucking/swallowing difficulties, cleft lip and/or palate which require assessment the speech pathologist provides a comprehensive assessment of the baby’s oromotor reflexes and will provided recommendation of therapeutic interventions to support success with establishment of breast feeding. Referrals can be made for babies <8wks corrected age, presenting with difficulty establishing oral feeding.

4.9 - Delay in Lactation or Low supplyThis is a common area of concern for breastfeeding women and is one of the more cited reasons for reducing breastfeeding duration. There is little evidence of maternal inability to produce adequate milk supply. A woman with perceived low milk supply can be reassured regarding volume and quality if the baby is gaining weight after the first week, has 6-8 wet nappies per day with pale or colourless urine, has generally loose, mustard yellow stools, has periods of contentedness following feeding and is alert. These are referred to as ‘signs of baby wellness or wellbeing’.

Postnatally if the woman appears to have a delay in lactation or low milk supply an assessment of the woman and her baby needs to be attended.

Insufficient removal of milk from the breasts leading to a reduction in milk production is the most likely cause of low supply.

This is associated with: poor attachment insufficient breastfeeding restricting breastfeeds sleepy baby mother-infant separation unresolved engorgement use of artificial infant formula, teats and pacifiers ankyloglossia (tongue-tie) and other oral cavity abnormalities.

Other reported causes of low milk supply may include: maternal smoking, overuse of caffeine and other substance use maternal alcohol consumption may slow the milk ejection reflex, thus reducing breast

drainage and milk production maternal medical problems; for example, retained products, severe postpartum

haemorrhage, serious maternal illness severe anaemia, maternal diabetes, obesity, maternal medications, hypothyroidism, polycystic ovary syndrome, Sheehan’s Syndrome, hormonal imbalance, inverted nipples

menstruation and/or subsequent pregnancy; some women perceive a reduction in milk supply during menstruation or early pregnancy



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use of combined oral contraceptive medications excessive exercise baby medical problems interfering with breastfeeding; for example, congenital

abnormalities, cardiac problems, prematurity, illness, oromotor dysfunction early introduction of solids insufficient glandular tissue, which may be:

o primary; for example, hypoplastic breastso secondary; for example, surgery such as reduction mammoplasty.

Signs and symptomsLow supply may be indicated by the following clinical signs. However, a careful history and examination is necessary, as the presence of some of these may not necessarily indicate low supply.

Baby: fewer than 3 wet nappies/24 hours by day 3 fewer than 5–6 heavy wet nappies/24 hours after day 5 concentrated urine no change to normal breastmilk stools by day 3–4 and scant stools thereafter dry mucous membranes weight loss greater than 10% birth weight further weight loss after day 3–4 less than 20gm weight gain/day after day 3–4 failure to regain birth weight by 2 weeks of age limited evidence of milk transfer during feeds prolonged or continuous feeding with little evidence of satiety persistent jaundice persistently sleepy or lethargic infant excessive crying, weak cry baby appears unwell inadequate number of feeds per day <6-8 feeds/24 hours sleepy baby sub optimal positioning and attachment during breastfeeding incorrect sucking technique (sucking disorganisation or dysfunction) sleepy baby baby mouth, tongue or palate structural concerns baby affected by medication that the mother received in labour using a dummy/pacifier (see Section 11 in this document ‘Dummies and Pacifiers’) use of medically indicated breastmilk substitutes in the first few days use of complementary feedings requested by mother.

Woman: separation of mother and baby (mother or baby unwell) no signs of lactogenesis 2 on day 3–4 (breast fullness and heaviness) breasts remain soft in between feeds (normal after around 4 weeks)Doc Number Version Issued Review Date Area Responsible PageCHHS16/042 1.1 02/03/2016 01/03/2019 WY&C 33 of 85


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nipple trauma retained products previous breast surgery insufficient glandular development of the breast use of a nipple shield insulin dependent diabetes mellitus traumatic labour and/or birth postpartum haemorrhage (PPH) hypothyroidism polycystic ovaries.

Identification, assessment and measures to improve milk supply or delayed lactation or low supply will be in consultation with the woman. explain the rationale of frequent ‘baby-led’ feeding to the woman support and encourage the woman during the establishment of her breastmilk supply assess for correct positioning and attachment and encourage to feed frequently

according to the cues of her baby recommend frequent emptying of the breast by adequate feeding or/and expressing by

hand and transitioning to pumping the baby should be assessed for signs of wellness or wellbeing offering top-up feeds at the breast offering comfort feeds at the breast discuss with the woman reasons why ‘letdown’ is delayed e.g. by extreme cold, pain

and emotional distress express post cibum (p.c.) to increase milk supply discuss with the woman ways to manage feeding sleepy babies offering supplementary feeds at the breast e.g. Supply Line the woman can articulate signs of adequate milk transfer in her baby the woman can articulate how to identify a satisfactory output per day for her baby.

If careful assessment of positioning and attachment of the baby on the breast and the above management suggestions have not been successful in increasing milk supply then the midwife or lactation consultant may refer to a doctor who may consider the use of a galactogogue. refer the woman on discharge to MACH as a priority via Community Health Intake (CHI) for ongoing low supply, referral to a lactation consultant can be considered in either the

acute or community setting.

4.10 - Breast surgery and breastfeedingAll surgical breast procedures have potential to affect breastfeeding. It is important in the antenatal period to ask if the woman has had any breast surgery, take a history of what is known about the surgery and discuss what may be the possible breastfeeding outcomes.

Antenatal assessment for a woman who has had breast surgery: age at which surgery occurredDoc Number Version Issued Review Date Area Responsible PageCHHS16/042 1.1 02/03/2016 01/03/2019 WY&C 34 of 85


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reason for the surgery type of surgery (e.g. breast reduction, breast augmentation, nipple surgery, malignant

or non-malignant breast lump removal) breast development during puberty and pregnancy (particularity relevant for

augmentation) breastfeeding outcome if she has breastfed before.

Removal of breast lumps or cystsRemoval of lumps or cysts may or may not impact on breastfeeding, depending on the site of the incision and amount of breast tissue removed.

Nipple piercingsThere is limited evidence regarding the effects of nipple piercing on lactation. Complete removal of nipple jewellery is generally recommended in order to avoid potential baby choking if jewellery is dislodged. Although milk supply is generally unaffected, cases in which milk supply was reduced in the affected breast have been reported. Scar tissue may also lead to blocked ducts or mastitis.

Breast augmentation (breast implants)Augmentation is usually achieved with silicone or saline implant. Periareolar incision for implants has been associated with insufficient lactation. Other difficulties relate to: surgical complications – haematoma, infection, implant rupture nerve injury – loss of nipple sensation (~10%); can interfere with milk ejection reflex ductal injury – milk production will not continue in glandular tissue without intact

drainage implant may exert pressure on glandular tissue leading to pain/atrophy of glandular

tissue/blocking ducts.

If the augmentation was carried out due to unilateral or bilateral hypoplastic breasts, consider that there may not be adequate breast tissue for exclusive breastfeeding; close observation of the baby’s intake and output should occur. Breastfeeding may be successful, particularly if the incision is NOT periareolar, and women should be encouraged to breastfeed. The effects of augmentation on breastfeeding will be dependent on the reason for the surgery and the procedure used for the surgery.

Breast reduction surgery (breast reduction mammoplasty)Breast reduction surgery will usually have a negative impact on breastmilk production and it is impossible to predict accurately how the surgery will impact on breastfeeding for each woman. Two breast reduction techniques are commonly used: the pedicle technique, where the nipple and areola remain on a stalk of breast tissue retaining much of the blood and nerve supply; or the free graft technique where the nipple is removed and replaced on the breast. The free nipple graft technique has often resulted in impaired or no lactation. Women who have had breast reduction surgery may need to supplement their breastfeeding with other infant milk as full supply may not be achieved. The decision to



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supplement should be made after all attempts— such as extra expressing and using expressed breastmilk for the baby—to achieve full breastfeeding have been exhausted.

Lactogenesis II will occur as normal for the woman and her breasts will feel full, but careful observation of the milk transfer must occur as the milk ducts may have been severed with the surgery and little or no milk may be available for the baby. Observation of the baby’s breastfeeds, output and weight loss/gain should be carefully monitored and supplementation should occur as required. Women may consider the use of a supply line to provide all the milk while still fully breastfeeding. Partial breastfeeding may still be considered a successful breastfeeding outcome for the woman who has had breast reduction surgery, so a ‘wait and see’ approach with close monitoring of mother and baby is recommended.

General advice when a woman has had any breast surgery: obtain a history from the woman about her breast surgery – the type of surgery and

reason for the surgery will usually define the breastfeeding outcome it is possible to breastfeed – most women can produce some amount of milk during establishment of lactation it will be important to monitor the baby for signs of

adequate milk intake and growth breast reduction surgery is the type of surgery most likely to negatively affect lactation

capability.

4.11 - Breastfeeding a preterm or unwell babyIn the immediate postnatal period, a preterm or unwell baby will be admitted to the Neonatal Intensive care Unit (NICU), Special Care Nursery (SCN) or Postnatal ward under the care of a neonatologist. Breastfeeding or receiving breastmilk is extremely important for the health of these babies. However, the positioning of the baby and duration of feed will need to be determined and supported by midwife/nurse caring for the woman and her baby in conjunction with the medical team.

Low birth weight and extremely low birth weight babies may have delays with sucking and require enteral feeding. Breastmilk has an important role for these babies and expressing of breastmilk should be encouraged and facilitated by midwifery/nursing staff as soon as possible in the birthing room after the birth of the baby. Women should be encouraged to express 8-12 times per day to establish sufficient supply. Double pumping can be used to increase and maintain supply.

Breastmilk expressed by the baby’s own mother remains the first choice of feed for the preterm baby. There are a number of significant short and long term benefits for babies who receive breastmilk which include better feed tolerance, reduced risk of necrotising enterocolitis (NEC) and late onset sepsis and potential for better neuro-developmental outcome.



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Contributing to the process of feeding her baby through expressing allows the woman to fulfil her role as natural caregiver despite illness and prematurity. See below for information on how to express.Unwell babies and toddlers, either at home or requiring readmission into the paediatric environment, will benefit from breastfeeding on demand. Smaller more frequent feeds should be encouraged where appropriate.


Section 5 - Breastmilk expression

Expression of breastmilk is enhanced when both physical and psychological factors are met to elicit the milk ejection reflex.

Physical stimulation of the very sensitive nipple/areola.

Psychological hearing a baby cry thinking about her baby smelling her baby – maybe the baby’s nightgown or blanket seeing her baby or a photo touching her baby.

The environment where a woman expresses is equally important as the milk ejection reflex can be inhibited by fear, anxiety, pain and embarrassment.

5.1 - General principles of expressing in all settings via any methodExpression of breast milk is a recommended strategy in response to many of the challenges of breastfeeding. It facilitates continuation of breastfeeding if the mother and baby are separated for medical reasons. Expressing may allow a woman to continue to breastfeed whilst returning to paid work. Expressing can occur via hand, hand pump or electric pump. the woman should express in a comfortable and private place with all equipment

assembled and ready to use it may help to have a picture of her baby close by the woman should have a glass of water nearby some women may prefer to use combined methods of expressing alternating hand and

pump to maximise yield discuss the use of breast compression during expression to increase milk yield disposable breast pump kits may be used for 24 hours or 8 expressions the breastmilk should be labelled with the baby’s sticker and stored in the appropriate

fridge.

For at home storage of breast milk, the woman can be referred to the ABA website for accurate information.



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5.2 - Expressing by handAll women are shown to hand express on day 2 postpartum or earlier if her baby has not attached and sucked at the breast: teaching the woman how to position her hand in a ‘C’ position placing the thumb and

forefinger on either side of the areola instructing the woman to gently push her hand into her chest wall and gently roll her

thumb and finger towards each other in a rhythmical motion using the other hand, a clean plastic container should be positioned to collect the milk moving the fingers to another position once the flow has stopped, ensuring all lobes of

the breast are emptied repeating the process on the other breast changing from breast to breast until the required amount is collected, or waiting and

trying again later.

5.3 - Expressing by electric pump the woman will be shown how to assemble the pump according to manufacturer’s

instructions the woman should be encouraged to gently massage the breast prior to pumping it may help for the woman to hand express prior to pumping the suction strength of an electric pump should be started on low and increased as long

as there is no discomfort expressing should continue until the breast is soft repeating the process on the other breast, or alternatively the woman can be shown

how to double pump, using two pump kits concurrently changing from breast to breast until the required amount is collected, or waiting and

trying again later.

5.4 - Antenatal ExpressingAntenatal expressing supports exclusive breastfeeding from birth for women with conditions that increase the potential for hypoglycaemia of the newborn.

Women who have indications for risk of hypoglycaemia in the newborn will be offered information and demonstration on antenatal expression of colostrum. Colostrum should be the first food for the newborn. It is high in immunoglobulins, protein, fat soluble vitamins and assists in the passage of meconium.

Antenatal expressing can be commenced from 36 weeks in women:

Indications with diabetes in pregnancy whose baby will be born by elective caesarean section

whose babies have been diagnosed antenatally with cleft lip and palate where there is as strong family history of dairy intolerance



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whose babies have been diagnosed antenatally with congenital conditions which may include Down Syndrome or cardiac disorders.

Procedure advise the woman to commence antenatal expressing at > 36 weeks pregnant the woman is provided with written information and demonstration regarding

expressing of colostrum (Attachment 1) supply initial start-up expressing kit (available from Lactation Consultant) the woman should be instructed to express 2 times a day see this document section

‘Expression of Breastmilk’ educate the woman to express for 5 minutes each breast and repeat the cycle once advise the woman that small volumes of colostrum are expected educate the woman re storage of colostrum as per this document ‘Storage of

Breastmilk’ advise the woman to bring the frozen colostrum to hospital when she is admitted for

the birth colostrum should be stored appropriately in the relevant hospital fridge/freezer (please

refer to Storage and Use of Breastmilk in Hospital section below).

Alert:Women with high risk pregnancy for threatened preterm labour or shortened cervix should be excluded. Advise the woman that if she experiences symptoms of preterm labour she should cease expressing and contact Birthing, their midwife or medical officer.

5.5 - Storage of Breastmilk Women will receive education on storage of breastmilk which includes the following: the importance of hand washing before expressing and using expression equipment the most appropriate containers to use the appropriate methods of cleaning and sterilisation as section in this guideline

‘Cleaning and Sterilising of feeding equipment’ the appropriate method and time of storage of breast milk at room temperature, in the

refrigerator and in the freezer that breast milk is ideally stored in polypropylene plastic containers. Disposable plastic

denture containers, plastic feeding bottles, yellow top jars or if the amount to be stored is only small, sterile syringes may be used in hospital. When at home a cleaned ice cube container placed in a plastic bag may be used and when frozen transferred into a plastic bag

whilst in hospital all containers are to be placed in the room fridge and are to be labelled with the woman’s name, date and time of expression

when at home the milk should be labelled with the date and time so that the woman knows which milk to use first.



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Refrigeration expressed breast milk should be refrigerated or frozen immediately especially if the

woman is expressing for a baby in the NICU/SCN. Preterm or high risk babies with immature immune systems may be at greater risk from bacterial growth in breastmilk

refrigerated milk separates and the container will have to be shaken before the milk is fed to the baby

while the woman is in hospital, the breast milk must be labelled with the date and time and may be stored in the refrigerator for 24 hours and should then be frozen

For further information regarding refrigeration/freezing of EBM see table below.

Freezing frozen breast milk may be stored in a freezer within a fridge for 2 weeks frozen breast milk may be stored in a freezer section with a separate door for 3 months if the woman has a cyclic defrost refrigerator or freezer, then the containers of breast

milk should be packed between frozen foods to prevent any partial thawing of breastmilk that may occur during the cycle

frozen breastmilk may be stored in a deep freeze i.e. 20 degrees for 6-12 months. fresh EBM can be added to a partially filled container of frozen milk but the milk must

be cooled first to prevent the warm milk from thawing the top layer of frozen milk each container should be labelled and dated.

Thawing use the oldest milk first ideally breastmilk should be thawed in the fridge otherwise place the container in a pan

or jug of tepid water thawed milk should be refrigerated if not used immediately shake the container to evenly distribute the fat discard any thawed milk not used within 24 hours.

Storage and Use of Breastmilk in Hospital All expressed breast milk syringes/containers must be individually labelled, with the

appropriate patient identifiers as outlined below, and may be stored in the designated ward refrigerator/freezer as per table below.o Maternity: EBM must be stored in the medication room and all breastmilk will be

signed into the designated fridge, labelled with the mothers name and the date and time of expression, by a Registered Nurse/Midwife/Enrolled Nurse and signed out by either two RM/RN/ENs or an RN/RM/EN and the mother or her partner. The feed including amount given, is documented on the baby’s feed chart.

o Paediatrics: EBM is signed into the formula room fridge, with the patient identification label attached, by two RN/RM/ENs. It is signed out by two RN/RM/ENs noting volume provided and is double signed on the child’s fluid balance chart.

o SCN/NICU: Appropriate fridges are available in each patient room and the EBM is signed into the fridge, with the patient identification label attached, by one



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RN/RM/EN and a parent, or two RN/RM/ENs. When the EBM is taken out of the fridge for use it is double signed by 2 RN/RM/ENs on the baby’s feed chart.

Storage of Expressed Breast MilkBreastmilk Room Temperature Refrigerator Freezer

Freshly expressed into a closed container

6–8 hrs (26ºC or lower). If refrigeration is available store milk there

3–5 days (4ºC or lower) Store in back of refrigerator where it is coldest

2 weeks in freezer compartment inside refrigerator.3 months in freezer section of refrigerator with separate door.6–12 months in deep freeze(-18ºC or lower).

Previously frozen -thawed in refrigerator but not warmed

4 hours or less(i.e. the next feeding)

Store in refrigerator24 hours Do not refreeze

Thawed outside refrigerator in warm water

For completion of feeding Hold for 4 hours or until next feeding Do not refreeze

Baby has begun feeding

Only for completion of feeding, then discard Discard Discard

(Australian Breastfeeding Association, 2012)

HeatingHeating breastmilk: place the breastmilk in a container of warm to very warm water do not use the microwave oven to heat the breastmilk due to uneven heating of the

breastmilk, which may lead to scolding the baby discard any unused heated breastmilk.

On Discharge: provide the woman the leaflet ‘Storage of Human Milk at Home’ to take home and

discuss the guidelines for storing breastmilk at home (available in the Maternity Unit in hard copy or on the ACT Health website under ‘Breastfeeding Fact Sheets’).

encourage the woman to ask any questions concerning the information if the woman has a baby in NICU or SCN ask if she has been provided by the nursery

staff with the ‘Collecting and Storing your Breastmilk’ pamphlet refer the woman to the ACT Health Breastfeeding e-resource ‘Expressing and storing

breastmilk’ section: http://www.health.act.gov.au/our-services/women-youth-and-children/breastfeeding-act-e-resources/expressing-and-storing-breast


Section 6 - Breast related issues



http://www.health.act.gov.au/our-services/women-youth-and-children/breastfeeding-act-e-resources/expressing-and-storing-breast

http://www.health.act.gov.au/our-services/women-youth-and-children/breastfeeding-act-e-resources/expressing-and-storing-breast

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6.1 - Blocked lactiferous ductsA A blocked milk duct presents as a reddened area or segment of the breast which is tender/painful and feels hard: the woman with a blocked duct feels well and does not usually have any systemic

symptoms such as fever and rigours blocked ducts are usually seen after 7 days postpartum but very occasionally occur in

the early postpartum period.

Predisposing Factors blocked ducts may occur in women who have an abundant milk supply and who are

unable to drain each breast poor attachment or incorrect suckling constriction to the breast preventing adequate drainage from holding the breast or

tight or ill-fitting bra/clothing. Car seat belts or baby packs or slings can also cause constriction

repeated blocked ducts occurring after discharge from hospital may be due to a poor diet, or fatigue.

Management of a blocked duct explain to the woman the importance of treating the blocked duct immediately check the attachment of the baby to the breast and how many breastfeeds her baby is

having per day position the baby on the breast so that the bottom jaw is on the affected side of the

breast and feed from the affected side first explain to the woman that she may like to vary the feeding positions to help empty the

breast suggest to the woman that she gently massages the lump towards the nipple during

(and after) feeding her baby application of warmth to the affected area before a feed may help initiate "let-down" or

the milk ejection reflex. refer to Physiotherapy for treatment of blocked duct (see section 6.5)

AlertAdvise the woman to seek medical treatment if she starts to feel unwell and has ‘flu like’ symptoms or a fever.

Advise the woman there is no need for antibiotic treatment unless a fever or mastitis develops.

On discharge from hospital: provide the woman with the maternity information leaflet on ‘Mastitis’ (available in the

Maternity Unit in hard copy or on the ACT Health website under ‘Breastfeeding Fact Sheets’).

advise the woman to seek further assistance from a lactation consultant, MACH nurse, the ABA, or her GP if a blocked duct occurs again.



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6.2 - White spot/nipple blebA blockage at the nipple pore may appear as a white spot on the nipple surface. Milk may leak under the epidermis causing an opaque, raised white bleb, which is often associated with painful nipples during feeding. The cause is not always known, however, they often occur following nipple damage and when healing skin grows over the nipple pore, some women experience recurrent white spots.

Management softening the nipple skin with a wet, warm compress immediately prior to a breastfeed

has been anecdotally reported to be helpful in removing the white spot. This may need to be repeated a number of times until the blockage resolves

the white spot may soften with the use of olive oil. removing the white spot with a sterile needle may be required. The woman should be

referred to medical practitioner familiar with this procedure.

6.3 - Full breasts and engorgement Full BreastsThe breasts may become very full when secretory activation (lactogenesis II) occurs after birth. This physiological event usually resolves rapidly with regular, effective suckling and removal of milk by the baby.



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PreventionEarly initiation of breastfeeding (or expressing if mother and infant are separated) followed by frequent, effective and unrestricted breastfeeding or by expressing 8–10 times in 24 hours correct positioning and attachment avoid the use of dummies, artificial teats and supplementary feeds.

Management continue to offer frequent and unrestricted breastfeeds soften the areola before feeds by expressing a small amount of milk or apply reverse

pressure softening allow the baby to finish the first breast before offering the second. If the infant only

feeds from one side and the second side is uncomfortably full, express a small amount until the breast feels comfortable

alternate feeding positions to facilitate drainage of all breast segments allow milk to drip from one side while feeding from the other express after feeds if the breast still feels full until it feels comfortable. Some women

will do a one-off complete expressing of their breasts to break the fullness cycle and help facilitate the baby being able to effectively attach for the next feed

apply cold packs after feeds gently massage the breasts whilst under the shower, allowing milk to flow

spontaneously recommend analgesia such as paracetamol or ibuprofen maintain good drainage and comfort until breast fullness resolves, usually within a few

days teach woman how to check for lumps and follow guidelines for blocked ducts if

required teach women how to recognise signs of mastitis and seek professional advice if

necessary.

EngorgementFull breasts may develop into engorgement. Engorgement is caused by a build up of milk and vascular congestion and oedema in the breast tissue. Venous and lymphatic drainage are obstructed, milk flow is hindered, and the pressure in the milk ducts and alveoli rises. It typically occurs on day 3-5 following birth and may result in pain and discomfort for the woman.

PreventionEngorgement is prevented by following guidelines for prevention and management of full breasts with attention on correct positioning and attachment of the baby when feeding. The woman should be encouraged to feed frequently from birth responding to the cues of her baby; time feeding at the breast should not be limited.



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Once engorgement is apparent management includes: encouraging the woman to empty one breast at each feed and alternate which breast is

offered first the application of warmth to the breasts prior to feeding will help to trigger the let-

down reflex check positioning and attachment of the baby at the breast recommending frequent baby-led feeding if the woman is in pain offer a mild analgesic prior to feeding to lessen pain and

therefore assist ‘let-down’ suggest to the woman that a comfortable bra or no bra at all will relieve breast

discomfort use cold packs to alleviate pain between feeds for the next 12-24 hours empty at least one breast at each feed .

Full breasts and engorgement Full Breasts EngorgementBreasts warm, heavy, tender hot, oedematous, painfulSkin normal appearance, possible

marblingshiny, streaky or diffuse red areas

Areola firm may be stretched flat and oedematous

Milk flow milk flows well, infant can still suckle and remove milk easily

poor or no milk flow, difficult for the baby to attach

Fever usually absent may have a mild fever

Expressing may be effective in relieving pain from engorgement. This should be used as a ‘one off’ strategy. Whilst multiple other interventions have been suggested including acupuncture or pharmaceutical forms of analgesia, systematic review of evidence to date has not suggested that these provide any benefit.

6.4 – MastitisMastitis is inflammation of the breast tissue that can occur in a lactating woman through a continuum of breast milk stasis, engorgement, non-infective inflammation and infective inflammation.

Signs & SymptomsThe breast will appear red, swollen hot and painful. Systemic symptoms are usually only seen in infective mastitis and include: feeling unwell, fever (usually over 38.5C) lethargy headache



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nausea anxiety ‘flu like’ symptoms such as aching joints..

Risk Factors previous history of mastitis tight restrictive clothing such as a tight/poor fitting bra, underwire bra missing feeds and abrupt weaning white spot on nipple or blocked duct incomplete emptying of the breast incorrect positioning of the baby at the breast which may lead to poor drainage and

trauma of the nipples rough handling of the breasts poor hygiene such as not washing hands before breastfeeding, application of nipple

creams poor diet and anaemia stress and fatigue are the most common factors associated with mastitis once a

woman’s discharged home.

Early Management The most important intervention in responding to mastitis is effective milk removal; unless the woman is weaning, breastfeeding should continue: continue breastfeeding assess positioning and attachment, frequency of feeding and adequate milk removal offer affected side first apply heat on the affected area or a warm shower prior to feeds, and cold pack

between feeds to reduce inflammation simple analgesia avoid pressure on breast tissue from bras, tight clothing or baby carriers supportive measures such as rest, adequate nutrition and fluids refer to LC for feeding assessment and advice..

If the affected breast is extremely painful: the baby could feed first from the unaffected breast until the MER is initiated, then the

baby can be put onto the affected breast the electric breast-pump may be used to empty the affected breast try varying the feeding positions, to make it more comfortable as the baby attaches and

to more effectively drain the breast e.g. position the underside of the baby's chin in the direction of the blockage.

Subsequent managementIf the symptoms are not resolving within 12-24 hours a medical review is needed as antibiotic therapy may be required continue to maintain breastfeeding or effective milk removal by expressing.



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Antibiotic regime as per the Therapeutic Guidelines advise the woman to complete the entire course of antibiotics provide the woman with the ACT Health Breastfeeding fact sheet – ‘Blocked Ducts and

Mastitis’ refer the woman to the MACH nurse for ongoing support.

Discourage the woman from weaning whilst she has mastitis as this can lead to abscess formation.If she still wishes to wean after her mastitis has resolved, she should wean as slowly as possible to prevent a recurrence.

6.5 - Physiotherapy Management of Blocked Ducts and Lactational MastitisReferral Referrals are accepted directly from:

o self-referring patientso health professionals involved in their care including:

GPs physiotherapists specialists, and MACH nurses

women referred with blocked ducts or mastitis are triaged as a Category 1 referral and are seen as a priority on day of referral wherever possible

women less than 3 months postpartum should be referred to the physiotherapy department of the hospital where they birthed for treatment i.e. Canberra Hospital and Health Services HWC or Calvary Health Care ACT. Women who birthed at Calvary John James Hospital may be referred to Women, Youth and Children Community Health Program (WYC&CCHP) physiotherapist

women more than 3 months postpartum residing in the ACT or accessing ACT MACH services should be referred to the WY&CCHP physiotherapist

Physiotherapy provides a Monday to Friday service. Women should be advised to contact a private physiotherapist in the ACT if:o treatment is required over the weekendo an appointment is not available within the appropriate serviceo they have private health insurance with ancillary cover.

Initial Assessment Gain informed consent from patient for examination of the breast as per ‘Intimate Body

Care and Examinations by Health care Workers’ SOP complete subjective and objective assessment of patient as per ‘Physiotherapy

Assessment – Breast Postpartum’ form found on the Clinical forms register determine from assessment if the woman has blocked ducts or inflammatory mastitis

and the condition is appropriate for physiotherapy intervention.



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Physiotherapy ManagementPhysiotherapy intervention is primarily indicated in the treatment of blocked ducts and inflammatory mastitis. Treatment options include therapeutic ultrasound (US), lymphatic drainage massage, kinesiotaping and education.

Therapeutic Ultrasound Therapeutic ultrasound (US) should be considered to treat areas of the breast that are

inflamed and/or have palpable lumps on assessment. Commencement of US is most effective in the early inflammatory phase, ideally within the first 24-48 hours of onset of symptoms.

Interventiono determine whether there are any contraindications or precautions. These include,

breast cancer, breast implants, an inability to distinguish between hot and cold sensations, a haemorrhagic condition or vascular abnormalities, metal implants or inbuilt stimulator in the area, tissues previously treated with radiation therapy within the last 6 month, an inability to comprehend the nature of the treatment and the potential dangers and an inability to communicate. Precautions include: reduced hot/cold discrimination, and over broken skin.

o assess thermal sensitivity of skin in area of breast to be treated using appropriately heated or cooled dry test tubes or metal spoons. Document the woman’s ability to reliably discriminate hot from cold in the medical record

o obtain informed consent to perform US therapy. Document informed verbal consent and warnings given in medical record

o ask the woman to remove clothing from the top half of her body and provide her with a gown to wear or drape with towel as appropriate

o position the woman so that she is comfortable and the affected area of the breast is easily accessible

o apply US gel generously to treatment area and soundheado use the following US settings:

frequency: 1 MHz for a tissue depth of 3-5 cm intensity: use the lowest intensity that produces the required therapeutic

effect. Thermal effect is gained at intensities over 0.5 W/cm2. Increase intensity to give a comfortable warmth up to maximum of 2.0 W/cm2

mode: continuous duration: 5 minutes per soundhead area

o treatment should be performed once a day until pain and swelling have resolved, usually requires 2-3 treatments

o following treatment: assess immediate effect of intervention including any abnormal reactions advise the woman to drain affected breast by breastfeeding or expressing,

ideally within 30 minutes of treatmento subsequent treatments

re-evaluate effect of treatment on pain levels, size of the lump(s), redness and temperature differences between breasts



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if symptoms are escalating, or there is no improvement after 2-3 treatments, refer the woman to see her GP for a medical review

o infection control milk is considered a low risk body fluid ultrasound treatment head must be cleaned with warm soapy water and dried

thoroughly post treatment.

Lymphatic drainage massage may be helpful to decrease oedema of the breast resulting from inflammation of the

parenchyma, thereby relieving pressure on milk ducts women should be advised not to massage forcefully towards the nipple to unblock the

duct as this can be painful and cause more breast tissue trauma massage should be performed with a flat, open palm, with slow, gentle, light strokes,

clearing towards the axilla the following self massage sequence may be performed in lying 2-3 times daily during

the inflammatory phase:o diaphragmatic breathing x 5 breaths, utilising the respiratory pump and

encouraging relaxationo kneading to entire axilla for 1 minute to activate axillary lymph nodeso slow effleurage strokes x 10-12 over the breast clearing towards the axillao static pectoral muscle exercise pressing hands together x 10 repetitions, rest time

greater than work time to maximise lymphatic flow (e.g. 2 seconds on / 5 seconds off)

o diaphragmatic breathing x 5 breaths.

Kinesiotaping kinesiotape may be applied to the breast to reduce oedema by directing fluid to the

axillary lymph nodes prior to using kinesiotape check that the skin is in good condition and if the woman has

any known allergies or skin conditions. A small patch test of tape may be applied to skin of the arm for 24 hours to monitor for any reaction prior to full use. Tape should be removed immediately if there is any sign of irritation.

applicationo cut length of tape into 4-5 strips leaving approximately 2-3cm uncut at base of tape

to use as an anchor. Round edges of tape to prevent edges catching and liftingo have the woman positioned with shoulder flexed and abducted overhead to put

breast tissue on stretcho place base of fan (anchor) into axilla on affected side, and fan strips out around

breast particularly targeting areas of oedema. For lymphatic drainage the tape should be applied to the skin with very little tension (0-15% of available tension)

o if there is no reaction to the tape, it may remain on the skin for 3-4 days. Care should be taken when removing tape to minimise pain and irritation of skin.



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6.6 - Breast abscess A breast abscess is a collection of pus within the breast tissue. It is a complication of infective mastitis and is caused by delayed, inadequate or incorrect treatment of mastitis. The woman may present with a localised mass and fever. Diagnostic ultrasound may be required to confirm the presence of an abscess. Needle aspiration or surgical drainage may be required. Studies suggest approximately 3% of lactating women will develop an abscess. The drained fluid should be cultured to ensure antibiotic sensitivity.

Signs and Symptoms hard, red, painful lump on breast fever ‘flu like’ symptoms fever dizziness nausea extreme fatigue and aching muscles.

Classification of breast abscess subareolar 23% - superficial and near the nipple. These usually ripen like a boil and are

easier to excise and have better prognosis intramammary-uniocular 12% - a single area of pus deep in the breast away from the

nipple intramammary-multilocular 65% - multiple sites of pus within the abscess, these have a

high rate of recurrence.

Management of breast abscess women with a breast abscess need to be referred to a surgeon/radiologist for

management for proven breast abscess, needle aspiration under ultrasound or surgical drainage is

the standard management IV antibiotic therapy (drainage should be cultured to ensure correct antibiotic) breastfeeding can resume immediately after drainage/surgery, unless the wound or

drain is in a position which prevents the baby attaching; continued breastfeeding is not harmful to the baby

if the affected breast is extremely painful it may be helpful to offer the baby the unaffected breast first until let-down occurs and then to switch to the affected breast

if indicated, temporary weaning may be necessary for up to 4 days to allow for sufficient healing and removal of drain

milk may leak from the wound for some weeks until the site has healed (this is to allow growth factor, anti-inflammatory and immune factors to bath the wound)

it is rare that surgical draining of the breast abscess leads to suppression of lactation in the affected breast. If this does occur, milk supply from the unaffected breast will sustain the baby's growth.



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As with mastitis, a breast abscess can be a reason for some women wanting to cease breastfeeding. Provide the woman professional guidance and support, and consider referral to and assessment by a lactation consultant.

6.7 - Blood in the breastmilkAround 15% of lactating women have blood in their early breastmilk when cytologically examined. Increased vascularisation of the breast and rapid cellular proliferation during pregnancy may cause a pinkish or rust-tinged appearance to colostrum and early milk, commonly known as ‘rusty pipe syndrome’. This usually goes unnoticed unless the mother is expressing or her infant vomits blood.Other causes of blood in breastmilk include: nipple or breast trauma intraductal papilloma – a small, benign growth on the lining of a duct which may erode,

causing painless bleeding into the duct fibrocystic disease.

Management Small amounts of ingested blood will be tolerated by most babies and therefore

breastfeeding can usually continue ensure correct positioning and attachment and manage nipple trauma if blood in the breastmilk continues for longer than a few days, diagnostic ultrasound

and cytologic evaluation should be considered moderate vomiting of blood in an infant requires medical review to exclude illness.


Section 7 - Lactation Aids

All feeds that are given via lactation aids must be double checked e.g. midwife : parent, or midwife : midwife, prior to a feed being offered to a baby.

7.1 - Nipple ShieldsA nipple shields must only be introduced by a lactation consultant or experienced midwife after an assessment of the breastfeeding difficulty to determine the suitability and benefit to breastfeeding; and the milk is in (Lactogenisis II), with it flowing well

Indications for use of nipple shield: women with inverted nipples or other nipple variations where the baby cannot attach for preterm babies who are unable to maintain attachment to the breast transitioning baby from artificial teats to the breast baby with micrognathia (e.g. Pierre Robin syndrome) baby with low tone (e.g. Down Syndrome) disorganised sucking oral cavity abnormalities



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use of a nipple shield for sore and damaged nipples is not a first-line treatment. However, if other strategies have not resolved the problem, judicious use may enable the mother who may otherwise stop breastfeeding to continue.

Advantages for use of nipple shield Breastfeeding may continue where it might have been ceased without a nipple shield.

Disadvantages for use of nipple shield lack of stimulation to the breast ineffective milk transfer poor weight gain or weight loss altered suck resulting in breast refusal inconvenience for the woman difficulty weaning from the nipple shield.

Contraindications for use of nipple shield mother’s milk has not yet ‘come-in’.

Management provide the woman with the Nipple Shield information sheet (Attachment 2) and obtain

verbal consent use only after the milk is ‘in’ and flowing choose the correct size; the nipple should not be squashed into the shield. Determine

the base diameter of the shield fits comfortably over the woman’s nipple and areola base. Most women will need a medium to large shield

evaluate the correct fit for the baby ensuring the length of the shield does not exceed the length of the baby’s mouth

observe and evaluate breastfeed to determine effective milk transfer educate the woman in correct use and cleaning of nipple shield as per the

manufacturer’s instructions recommend and educate the woman to express after breast feeds to remove any

residual milk to protect her lactation preventing engorgement, blocked ducts and mastitis

evaluate and document outcome develop a follow-up plan to monitor baby’s weight and weaning from the shield the woman and baby should be referred to the MACH nurse for priority support on

discharge.

Instructions for use express a few drops of milk to start the milk flowing smear breastmilk onto the outside of the shield to encourage the baby to attach hand express a few drops of milk into the shield before offering the breast to the infant to draw the nipple into the shield, first turn the shield almost inside out and fold the

wings outwards, then place the centre of the shield over the nipple and fold the wings back into place and hold the shield with fingers at the outer edges



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touch the baby’s lips with nipple shield, wait for a wide-open mouth then bring the infant quickly onto the shield

ensure a deep latch with the lips around the widest part of the shield, close to the breast. It is important that the infant does not slip back off the shield as this will cause pinching and nipple damage

feed duration may be longer due to possible reduced milk flow. Observe for signs of milk transfer and monitor the infant’s output, weight and wellbeing.

Cleaning instructionsRinse in cold water after use, then wash in hot soapy water and rinse under hot running water. Drain, dry and store in a clean covered container.

Weaning from the nipple shield continue to offer breastfeeds without the shield, drawing the nipple out manually or

with a pump as above if unable to attach, start the feed with the shield then take the shield off during a break

in the feed and try again the time taken to wean from a shield varies considerably seek assistance from the MACH nurse, a lactation consultant or experienced clinician

for ongoing support.

7.2- Cup FeedingDiscuss with the woman that cup feeding may be used as short-term alternative to feed her baby if her baby requires complementary feeding or is not attaching and sucking at the breast. Cup feeding may be used instead of naso-gastric or supply line feeding in a well baby.

Indications for cup feeding: to avoid possible nipple/teat confusion maternal illness and the baby is unable to have access to the breast babies who are unable to attach at the breast.

Advantages of cup feeding: parents are able to feed their baby independently babies are able to pace their intake in time and quantity appropriate tongue and jaw movements are stimulated olfactory and oral sensory receptors are stimulated no foreign objects are placed in the baby’s mouth movements of the tongue and muscles of the mouth are encouraged babies are assisted to develop a good undulating rhythm of their tongue.

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Possible contraindications to cup feeding: the baby has a poor gag reflex the baby is lethargic or excessively sleepy the baby has a poor suck the baby has a marked neurological deficit.

If formula has to be used for a breastfed baby, obtain the woman’s verbal consent and document this in the clinical record.

Explain and demonstrate the following cup feeding method to the parents: offer skin to skin and breast cuddles prior to offering cup feeds explain hand hygiene to the parents ensure the baby is awake and alert wrap the baby securely so the cup will not be knocked place the baby in an upright position on the lap use a small breastmilk cup and half fill with breastmilk or formula place the lip of the cup at the outer corners of the baby’s upper lip, resting gently on

the lower lip with the tongue inside the cup tilt the cup so the milk is just touching the baby’s lips. The baby may lap or sip the milk

from the cup.

Alert:Do not pour milk into the baby’s mouth as this increases the risk of milk aspiration

allow time for the baby to swallow let the baby pace the feedings which should be limited to 30 minutes to minimise

fatigue allow time for the baby to burp supervise the parents technique of cup feeding explain that the baby should be given every opportunity to suck on the breast as often

as the baby demands as preference for the cup may develop document in the baby’s clinical record of care their response to the cup feed and the

amount taken.

Cleaning instructionsThe equipment must be rinsed in cold water immediately after use, washed in warm, soapy water, rinsed again and stored in a clean, sealed container until use.

7.3 - Supply lineA supply line enables the baby to receive additional milk whilst at the breast. A fine tube is attached to the breast, alongside the nipple. The tubing is connected to a bottle or syringe containing milk. The baby attaches to the breast normally, and receives additional milk from the supplemental device as he/she suckles.



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Indications for use of supply lineAny situation where the baby is sucking at the breast but a greater supply of milk is required e.g.: to provide expressed breast milk or medically indicated extra fluids, in the early stages

of lactation delayed lactation compromised lactation e.g. hypoplastic breasts, breast surgery, breast reduction adoptive breastfeeding babies with medical conditions which prevents them from sucking adequately at the

breast e.g. heart anomalies, neurological conditions.

Advantages of a supply line use of a supply line enables breastfeeding to continue.

Disadvantages of a supply line supply lines can be inconvenient to use the equipment is difficult to clean.

Contraindication of use of a supply line supply lines are not to be used where the baby cannot or will not attach and suck at the

breast.

Equipment supply line tube nonallergenic tapeor the Medela supply line (mother’s own) and use according to product information.

Management describe to the woman how a supply line is used if formula is required for a medical indication obtain verbal consent from the mother

after she has read the information sheet on ‘Breastfeeding and Complementary Feeds’ measure correct volume and place in bottle and insert feed tubing into disc or teat

which is secured on top secure tube with nonallergenic tape to the woman’s breast, with the tip of the tubing at

point just beyond the top of the nipple; avoid taping both nipple or areola check baby’s position and attachment to the breast is comfortable for the mother milk flow should be spontaneous as the baby breastfeeds.

Cleaning Instructions:Supply line: show the mother how the tubing should be rinsed in cold water after use and then filled

with warm soapy water and rinsed well and stored in a sealed, dry container discard the tubing when no longer needed as it should be used by one mother and baby

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Discharge seek assistance from the MACH nurse, a lactation consultant or experienced clinician

for ongoing support.

7.4 Syringe drop feeding Equipment disposable food syringes with a soft tip are to used.

Indications for the use of syringe dropper feeding: a baby who is unable to latch onto the breast within the first 24 hours and who has no

risk factors requiring complementary feeding other than EBM, should be offered EBM at least 3- 4 hourly

discuss the reasons for a syringe drop feed with the woman and obtain her consent educate the woman or her partner to:

o offer skin to skin contact; observe for the baby’s readiness to feedo observe for the baby’s rooting reflex and licking behaviourso offer a breastfeed if the baby appears ready to feedo small amounts of EBM in a 1-2 ml syringe should be dropped onto the baby’s

tongue after eliciting the rooting and gape reflex gently dropping the EBM into the baby’s mouth, allowing the baby to swallow each bolus

o DO NOT place the syringe or finger into the baby’s mouth.

7.5 Finger Feeding Consultation with the clinical midwife consultant, lactation consultant or senior postnatal midwife is recommended before introducing finger feeding.

Finger feeding is only to be used as an interim measure and is suitable for babies who are having difficulties attaching at the breast.

Advantages for the use of finger feeding: the support a baby who has attaching and sucking difficulties.

Disadvantages for the use of finger feeding: the introduction of any feeding method other than the breast should always be treated

with caution.

Contraindications for the use of finger feeding: a baby who sucks correctly at the breast and needs a complementary feed should be

offered a supply line, syringe dropper, cup, or spoon.

Management Educate the woman to: offer skin to skin contact; observe for the baby’s readiness to feed



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observe for the baby’s rooting reflex and licking behaviours offer a breastfeed.

Equipment: disposable No. 5 G feeding tube hypoallengic tape latex free gloves disposable 20 ml syringe.

If the baby is unable to latch then offer a finger feed: attachment to the breast should be attempted and assessed at each feed discuss the reasons for a finger feed with the woman and obtain her verbal consent educate the woman how to finger feed independently explain hand hygiene to the parents and ensure short fingernails warm the milk to room temperature attach feeding tube to the side of the mother’s little finger with tape. The tape should

be attached to the finger as far back as possible, so that the tape does not enter the baby's mouth

attach a filled (EBM/complementary feed) 20 ml syringe to the other end of the feeding tube

elicit the baby’s rooting reflex by stroking firmly the cheek or corner of the baby’s mouth in an outward motion waiting for the baby to respond by turning to the side stimulated

elicit the gape reflex by firmly stroking from nose to chin motion and await baby’s wide open mouth with tongue down

allow the baby to draw the finger into his mouth so that the pad side touches the baby's hard palate and the nail side touches the tongue. The finger should be introduced as far as the junction of the hard and soft palate

do not squirt the milk into the baby's mouth. Correct sucking will initiate the milk to flow. One or two drops of milk may be necessary to coax the baby to start sucking

monitor the baby’s progress carefully. If the baby’s suck has improved breastfeeding may be re-introduced

encourage the woman to record the amount of fluid taken and the baby's response to finger feeding

document the feed and feeding plan in the clinical record contact the neonatal registrar to assess the baby’s wellbeing if poor feeding continues.s.


Section 8 - Baby-related breastfeeding issues

8.1 - The sleepy babySleepiness is common in newborn babies. Some babies remain persistently sleepy for a few days or longer, do not wake spontaneously for feeds, or may have difficulty staying awake



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during feeds. The cause of persistent sleepiness in the full term healthy baby is often not known, but may occur in babies affected by labour analgesia or birth interventions.

It is important to exclude possible medical reasons for persistent sleepiness and lethargy, such as jaundice, hypoglycaemia, sepsis, congenital heart disease, neurological conditions, prematurity, congenital abnormalities and failure to thrive.

Management conduct a routine breastfeeding and newborn assessment and refer any anomalies to

the neonatal registrar ensure correct positioning and attachment technique teach parents to recognise and respond to subtle feeding cues wake the baby for breastfeeds, ensuring 8–12 feeds per 24 hours in the early postnatal

period implement strategies to rouse the sleepy baby or the baby who falls asleep easily at the

breast (see below) monitor the lactation response and increase breast activity by hand expressing monitor the baby’s progress i.e. output, feeding activity and weight if the baby ’s hydration or weight gain are of concern, care as per Guideline .

Strategies to rouse a sleepy baby unwrap the baby, change the nappy and allow to self-stimulate for a few minutes undress baby and place in skin-to-skin contact with mother gently massage the baby’s back, front, arms, legs and talk to the baby give the baby a taste of expressed breastmilk either directly from the breast or from a

spoon, cup or dropper stroke the cheek and lips and encourage the baby to suck on a clean finger.

Strategies for the baby who falls asleep during breastfeeds‘Switch’ feeding or ‘double feeding’ - The baby is swapped to the other breast whenever he/she becomes sleepy and nutritive sucking is no longer occurring.

Switch feeding technique utilise rousing techniques as above breastfeed on the first side until nutritive sucking and swallowing changes to non-

nutritive sucking and the baby does not respond to gentle stimulation (this may happen after only a few minutes

gently remove the baby from the breast and use rousing techniques to wake the infant up again; once awake, switch baby to the opposite breast

when the baby becomes sleepy on the second breast, remove from the breast again change the baby’s nappy, and repeat gentle rousing techniques offer the first breast again, and swap sides when the baby becomes sleepy. Each breast

may be offered two to three times per feed and breast compression while the baby is feeding may assist with milk flow

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once the persistent sleepiness is resolving and the baby is feeding more effectively, the mother can allow the baby to continuew the baby to continue sucking to finish the first side first before swapping sides.

8.2 - The unsettled babyMany babies have frequent, unsettled periods which may commonly occur in the evening.

It is important for parents to understand normal infant behaviour, including normal feeding and crying patterns, as well as learning techniques to help them to cope with an unsettled infant. An unsettled, crying and fussy baby is one of the main reasons that parents seek advice from health professionals, including doctors, maternal and child health nurses, and lactation consultants.

Parents are often concerned about milk supply or quality, gastro-oesophageal reflux and colic, and cease breastfeeding prematurely for these reasons.

Some infants cry and fuss excessively. They may be irritable and have feeding difficulties, feeding very frequently or refusing the breast; these babies should be reviewed by a medical officer.

The early postnatal period unsettled behaviour can be normal or may be related to birth intervention, over-

stimulation, environmental factors such as being too hot or too cold, being in an uncomfortable position

before the milk comes in, babies typically feed very frequently, especially on the second day of life. Reassure patents that this is normal behaviour which assists in stimulating lactogenesis and helps to minimise breast engorgement

after the milk comes in, the baby may be unsettled for a few days as she/he adjusts to the larger volumes of milk

crying is a late sign of hunger, advise the mother to offer breastfeeds when her baby is in a quiet alert state to reduce hunger-related crying

teach parents how to recognise and respond to hunger cues.

Management increase skin-to-skin contact and minimise over-stimulation ensure correct positioning and attachment and encourage baby-led feeding reassure the mother that it is okay to use the breast as a source of comfort for an

unsettled baby avoid giving feeds of infant formula or water unless there are medical indications, the

baby should be offered more frequent breastfeeds instead explore strategies to allow the mother to rest by enlisting support of family and friends after the milk is in, a baby receiving large volumes of early milk may not settle for long

and may experience abdominal discomfort, if the breasts are overfull, encourage the mother to feed her baby on the first breast until finished and releases spontaneously before offering the second breast



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assist parents to understand that babies do not always feed on schedule; that individual feeding and sleeping patterns vary and it is normal for babies to breastfeed around 8-12 times in 24 hours in the first weeks of life

assist parents to recognise nutritive sucking patterns and signs of milk transfer parents may need additional support from their doctor, maternal and child health nurse

or other health professionals.

Strategies that may helpIn the absence of medical or feeding-related causes of crying or unsettled behaviour, the following strategies may assist. Parents should be encouraged to experiment with a range of interventions to soothe an unsettled infant: increase skin-to-skin contact and cuddling carry the baby in a baby carrier or sling try swaddling, rocking, singing, stroking, massage, bathing, music, white noise,

movement in a pram or car reduce sensory input – loud noises, television, bright lights, excessive movement or

over-handling ensure the baby is not too hot or too cold .

Parental expectations most parents feel anxious if their baby is unsettled. Health professionals can help by

discussing normal baby behaviour and helping parents to understand their baby’s feeding, satiety and tired cues

8.3 - Excessive cryingA medical assessment may be required to exclude conditions that may be causing excessive crying. . Features which warrant medical assessment include: blood in stool or vomit fever, vomiting, rash ear discharge offensive urine or stools sub-optimal weight gain, or weight loss dysmorphic appearance developmental delay

Other possible causes to consider include: maternal intake of nicotine and caffeine maternal ingestion of dietary allergens.

8.4 - Breast refusal Breast refusal can be distressing for both the woman and her baby. It can occur at any stage during lactation and can occur for various reasons. The woman will need significant support during this event and be given strategies to feed her baby and maintain her milk supply.

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arch their back away from their mother cry when approaching the breast push away from the breast turn head away from the breast.

Possible reasons for breast refusalBaby-related: problems with attachment or positioning at the breast birth intervention overtiredness/overstimulation infectious illness such as respiratory illness, sore throat, blocked nose or ear infection distraction while feeding recent vaccination teething, biting tongue-tie.

Other-related: nipple and breast variations mastitis changes to the smell of the woman – such as perfume, soaps, chlorine unwell mother with decreased milk supply maternal intake of particular foods/medicines hormonal changes (such as ovulation, menstruation, oral contraceptive or pregnancy) delayed let-down reflex fast flow or slow flow low milk supply.

Management reassurance that this is usually a temporary situation assess for cause and correct if possible do not force the baby at the breast increase skin-to-skin contact to facilitate baby-led feeding and attachment offer feeds with an early feeding cue hand express to soften areola express milk into the baby’s mouth assess positioning and attachment technique try feeding in different positions try walking and breastfeeding or breastfeeding in the bath try to feed the baby when they are drowsy monitor baby’s urine and stool output maintain the milk supply with expressing feed the baby using a cup.



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8.5 - Breastfeeding multiple babiesWomen and their families are offered advice from health professionals about breastfeeding multiple babies. Women with a multiple pregnancy may give birth to preterm babies, supportive strategies for establishing breastfeeding in preterm babies will also be required.

During pregnancy it would be appropriate to refer the woman to a lactation consultant.

An antenatal referral will give the woman time to seek local community supports such as the Australian Breastfeeding Association and Australian Multiple Birth Association, access written information and involve her partner or other family members in antenatal classes so they will be able to best support her after the birth.

Establishing and maintaining breastfeeding early breastfeeding after the birth if separated from the babies due to baby/s being preterm or unwell then establish

breastfeeding/expressing as soon as possible after birth. If expressing for twins, it is recommended to express 10–12 times in 24 hours

women often start by breastfeeding multiple infants one at a time so they can focus on correct positioning and attachment. As the woman becomes more familiar with breastfeeding each baby she can then commence breastfeeding two babies at a time

feeding babies simultaneously is more time-efficient for the woman; however, some women prefer to feed each baby one at a time. It remains the woman’s choice

when a woman is breastfeeding triplets or quadruplets then a system of rotation applies for the babies; for example, two babies feed simultaneously (from one breast each) and the third baby is offered both breasts—‘triangular rotation’. As with women with twins, women with higher order multiples will require great support from family and the community in all aspects of parenting, including feeding..

8.6 - Breastfeeding during pregnancy and tandem breastfeeding (feeding a baby and an older child)Where no pregnancy risk factors exist it is the woman’s choice whether to continue breastfeeding or not. Some women will become pregnant while they are breastfeeding. Woman may seek advice about the practicalities of breastfeeding in pregnancy and breastfeeding a newborn baby and a toddler.

Breastfeeding during pregnancy is thought to pose no increased risk to the pregnancy. Risks factors such as a history of miscarriage, previous preterm birth, and current pregnancy complications should be considered, as well as other relevant medical history. The midwife, obstetrician/GP and woman will then determine whether or not breastfeeding should continue.

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decline in milk supply change in milk taste – as described by breastfeeding toddlers uterine contractions while breastfeeding weaning – some toddlers will wean themselves.

When a woman chooses to breastfeed during pregnancy: women should be provided routine maternal nutritional advice women who breastfeed during pregnancy will still have colostrum production in the

early postpartum phase when the baby is born the newborn infant should always breastfeed before the toddler

to ensure the newborn baby gets adequate intake it is not necessary for the mother to reserve one breast for each baby/child, but is an

option if it suits the woman and children. The ABA has breastfeeding information and provides face-to-face, online and telephone

counselling about breastfeeding through pregnancy and tandem feeding for women.


Section 9 – Complementary feeding

9.1 Complementary feedingNo breastfed baby is to be given a breastmilk substitute unless medically indicated. Teats are not to be used for a breastfeeding baby who requires a complementary feed.

The WHO/UNICEF Baby Friendly Health Initiative (BFHI) recommends giving babies additional fluids in addition to, or in place of, breastmilk for: babies whose mother may have a serious illness which precludes breastfeeding babies with inborn errors of metabolism, as outlined below:

o Galactosaemia is an extremely rare disorder affecting 1:40,000 babies caused by the accumulation of galactose in the blood. A special galactose-free formula is needed

o Maple syrup urine disease a special formula free of leucine, isolecine and valine is needed

o Phenylketonuria is a rare condition affecting 1:10,000 babies caused by the babies inability to use phenylalanine (a protein building block which if accumulates in the blood causes brain damage). A special phenylalanine-free formula is needed (some breastfeeding is possible, under careful monitoring)

Alert:These babies will require specialised formula, these include: hydrolysates of casein and whey and amino acids: formulas in which the whey and

casein have been hydrolysed to peptides or amino acid are used in the treatment of allergy or intolerance to cow’s, goat’s or soy protein (Nutramigen)

lactose modified: lactose free formulas are used for babies with galactosaemia, these babies have a deficiency of the enzyme galactose-1- phosphate uridyltransferase, they cannot metabolose galactose and need to weaned from the breast (this is tested for in



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the Neonatal Screening test NNS) phenylalanine free formula: used for babies with PKU, can be given in combination with

partial breastfeeding (Lofenalac). These formulas are available only on a doctor’s prescription.

critically dehydrated babies who do not improved with increased breastfeeding or breast milk feeding

babies whose mothers are taking medication which is contraindicated when breastfeeding and for which there is no safe alternative.

Breastfeeding babies who may need other food in addition to breastmilk for a limited period: hypoglycaemic risk in newborn babies if their blood sugar fails to respond to increased

breastfeeding or breast milk feeding low birth weight babies less than 1500gm very preterm babies born less than 32 weeks gestation

Prior to proceeding to give a baby a complementary feed, determine medical reasons, indicating the need for a complementary feed.

Determine if the woman has a history of allergies and discuss with the woman the information sheet ‘Breastfeeding and Complementary Feeds’ (available in the Maternity Unit) and obtain her verbal consent before giving a complementary feed of artificial baby formula.

Discuss with the woman: if the baby is able to have breastmilk, this will always be prioritised and the woman

supported to express her milk give the expressed breastmilk (EBM) or formula – (See ‘Lactation Aids’ section in this

guideline-Cup Feeding and Supply Lines) as normal suckling on the breast involves different sucking patterns from those observed in babies sucking on teats and pacifiers

complementary feeds may interfere with the establishment and duration of breastfeeding

review the baby’s feeding behaviour and the woman’s supply, the woman may become engorged or need additional lactation stimulation, discuss hand expressing or the electric breast pump.

Document in the clinical record: the reason the complementary feed was given the method by which the complementary feed was given measures taken to maintain the woman's milk supply the baby’s condition and behaviour at each feed.




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Section 10 - Artificial Feeding/Infant formula

10.1 - Artificial FeedingHealth care professionals have an important role in protecting, promoting and supporting breastfeeding as the optimal way of feeding a baby. It is the responsibility of health workers to promote breastfeeding first for a well baby and that all pregnant women are informed of the benefits and management of breastfeeding. Particular attention should be given to families from a non-English speaking background.

A woman who has made an informed decision to not breastfeed her baby should receive the same respect, support and guidance from health care professionals as those that breastfeed. Babies who are not breastfed should only receive infant formula to meet their nutritional requirements. Feeding a baby with formula should be demonstrated by health care professionals only, and only to mothers and families who need to use it. Do not give group instruction on formula preparation.

Powdered infant formula has been associated with serious illness and death in babies due to infections with Enterobacter sakazakii. During production,pPowdered infant formula can become contaminated with harmful bacteria, such as Enterobacter sakazakii and Salmonella enterica. This is because, using current manufacturing technology, it is not feasible to produce sterile powdered infant formula. During the preparation of powdered infant formula, inappropriate handling practices can exacerbate the problem.

This document is based on the NHMRC infant feeding guidelines

Formula FeedingDiscuss with the woman: the nutrient composition of human milk is used as a guide in establishing minimum and

maximum nutrient levels in formula her choice of formula and sterilising method that she will need to provide the formula and feeding equipment for her baby during

her hospital stay equipment required for bottle feeding:

o bottles: at least six plastic (BPA free) or glass infant feeding bottleso several teatso a knife for levelling off the formulao a bottle brush to clean the bottleso sterilising equipment (steam, boiling).

Practise Points-Some types of milk are not suitable for babies in the first year of life. These milks do not contain the right combination of proteins, fats and minerals necessary for a baby’s normal growth and development. These include: cow’s milk (whole, skimmed, powdered, watered down)Doc Number Version Issued Review Date Area Responsible PageCHHS16/042 1.1 02/03/2016 01/03/2019 WY&C 65 of 85


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evaporated milk sweetened condensed milk goat’s milk.

Soy formula:Soy formula is not recommended as it has no specific advantage over cow’s milk formula. The use of soy will not prevent allergy nor will it prevent or be useful in the management of infant colic. Soy formulas have a higher content of phyto-oestrogens than cow’s milk formula (Infant Feeding Guidelines, NHMRC, 2012)

Teach the woman how to prepare formula with one to one instruction. Before starting, discuss: the importance of cleanliness such as:

o washing hands o cleaning the bench area where the formula is to be madeo cleaning the lid and the top of the tin with warm soapy water, before opening the

tino ensuring all feeding equipment has been sterilised using a recommended home

sterilising method mark on lid the date of opening the tin. The formula must be used within one month of

opening use cooled, boiled water ( Australia, NHMRC recommendations) it is recommended to make bottles as they are needed (World Health Organisation) follow the manufacturer’s directions for amount of water and number of scoops into

sterile bottle, as water is always added to the bottle first follow the manufacturer’s directions exactly when measuring powder mix the formula by capping and shaking the bottle rapidly when warming formula advise to stand bottle in a jug of hot water for a few minutes

check the temperature of the formula by dropping onto the inner side of the wrist. NEVER use a microwave for heating formula

discard any leftover formula feed quotas are a guide only. Allow the baby to regulate the amount of feed taken, the

baby may demand more or less.

Alert:If the woman is planning travel overseas it is important she is aware of the World Health Organisation’s recommendations for formula preparation and storage. She should also enquire about access to formula in the countries she plans to visit.

When bottle feeding the baby the following should be emphasised to the woman: offer feeds in response to baby’s hunger cues after checking milk temperature milk should drip from the teat at approximately 1

drop/second hold the baby closely, in crook of the arm, facing towards the person feeding baby



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hold bottle at an angle to keep teat and neck of bottle full of milk give half of the required feed sit the baby up and gently allow to 'burp' continue with the second half of the feed any feed remaining should be discarded, not stored and reheated never ‘PROP FEED’ or leave the baby unattended with a bottle.

Discuss the following points to the woman regarding storage and use of the formula: keep prepared formula refrigerated until ready for use store prepared formula in the body of the fridge where the temperature is coldest discard prepared formula after 24 hours discard any unused prepared formula after the baby’s feed discuss and provide the woman with the ACT Health formula feeding pamphlet if formula is required to be transported, this should be prepared at the destination

rather than transporting bottles of prepared formula; if this is not possible, the prepared formula should be cooled to refrigerated temperature, transported in a cool bag with ice packs and re-warmed at the destination.

First week daily infant formula quotas for well term babies:DAY 0/1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 630mls/kg/day

60mls/kg/day

90mls/kg/day

120mls/kg/day

150mls/kg/day

180mls/kg/day

Quota Calculation: Birth weight multiply by number of mls/day = Total Daily Volume (TDV) Divide TDV by either 6 or 8 feeds = Quota per feed.

Example: Day 1, baby weighs 3.6 kgCalculation: 3.6x30=108 (TDV) ÷8 (feeds per day)=13.5mls per feed

Quotas beyond this week should be as per the recommendations on the chosen formula and in consultation with the MACH nurse or GP.

10.2- Cleaning and sterilising of feeding equipmentIn HospitalAny equipment used for formula is to be one use only and then disposal must occur.

At homeAny equipment used with infant formula must be washed and sterilised after each use.

Inform the woman of the importance of washing hands prior to handling any equipment.

Discuss with the woman the various methods available for cleaning and sterilising equipment and provide education on their preferred method.

Available Sterilising Methods:



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Boiling place bottles, teats, other utensils used for formula preparation in a large saucepan and

completely immerse and cover with water. Put the lid on, bring to the boil and boil for 5 minutes. Leave to cool and dry then store in sealed, dry container until ready for use.

Steam Sterilising steam sterilisation is done in commercially available kits, some are electric others are

used in the microwave. Follow the instructions on the kit then store equipment in a sealed, dry container until ready for use.

Chemical discuss with the woman that chemical sterilisation solutions whilst available in the

community are not the method of choice and that all equipment will also need to be boiled once in 24 hours (to kill spores) if this method is chosen

some specialised feeding equipment e.g. cleft palate teats and bottles can only be sterilised in chemical solution

make up the solution in large glass or plastic container, as per manufacturer’s directions. The solution needs to be discarded after 24 hours, the container must be thoroughly washed in hot soapy water and fresh solution prepared. The manufacturer’s instructions will state how long the equipment must be soaked for disinfection and equipment is usually stored in the solution until used. The woman needs to wash her hands with soap before removing equipment, and shake them to remove excess solution but do not rinse.

How to clean and sterilise feeding and lactation aidsAll equipment needs to be rinsed in cold water, washed in hot soapy water and rinsed again before being sterilized irrespective of the method used.

If the woman is feeding breastmilk to the baby then the equipment must be rinsed in cold water immediately after use, washed in warm, soapy water, rinsed again and stored in a clean, sealed container until use. If a woman has her own designated expressing equipment or lactation aid while in hospital then this needs to be kept in her room in a sealed dry container.

Alert: Cleft palate teats and bottles must not be boiled or steam sterilised they must be sterilised in a cold sterilising solution.

10.3 - Suppression of LactationWoman who have never breastfedAdvise the woman to avoid breast stimulation and explain to her that after the birth of her baby the hormone prolactin, which produces milk, (endocrine control) is released. To decrease this supply it is important that milk is not removed from the breast as a special



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inhibitory peptide will be released that ceases further production of milk (autocrine control): some women will produce enough milk to make them uncomfortable and this may lead

to engorgement offer analgesia and cold packs for relief suggest wearing a firm bra for support teach the woman how to hand express for comfort if she needs some relief teach the woman the signs and symptoms of mastitis and give her the unit leaflet on

mastitis before discharge. Discuss with her the community support that she may like to access.

Alert:If weaning is due to nipple pain, mastitis, a sick baby or a crisis situation, refer the woman to a senior midwife or lactation consultant for assessment, support and appropriate follow up.

If lactation is established and a mother decides to wean: gradual weaning is recommended inform the woman of an increased risk of mastitis advise her that the longer the process takes the better for her baby and for her. If the

weaning process is allowed to take place over a period of time the concentrations of antibodies increase in the milk which gives the baby protection and also protects her breast from mastitis. The usual recommended advice is to wean over a period of weeks by replacing one breastfeed per day. The mother should wait until her breasts are comfortable between feeds (which may take a few days) before replacing another breastfeed. She should wait again until her breasts are comfortable; replacing another feed and continuing this process until complete weaning is achieved

many women are anxious to wean quickly once the decision to wean has been made and do not wish to put their baby back on their breast. These women should be taught how to hand express or taught how to use a hand or electric pump. The woman can gradually express less frequently and remove less milk at each expression. If her breasts are particularly full and uncomfortable she may need to express more frequently to start with, gradually decreasing the number of expressions in a 24 hour period and also decreasing the amount expressed. Weaning breastmilk is especially high in antibodies and should be given to the baby

offer ice packs, pain relief and advice about using a firm bra advise the woman that medications are no longer recommended to suppress lactation

because of side effects of nausea, vomiting, dizziness headache, nasal congestion, fatigue, postural hypotension, hallucination, confusion, behavioural disturbances and possible rebound milk production

support the woman in the weaning process. Some women may experience relief, regret, anger, guilt and depression if they decide to wean because of breastfeeding difficulties

inform the woman that she is able to reverse the weaning process up till one month after she weans. If she changes her mind and wishes to re-establish lactation this will



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take commitment, time and need guidance from a health professional skilled in lactation management

discuss support for the future. Reassure the woman if she has another child and decides to breastfeed that she may not experience the same problems

teach the woman about the signs and symptoms of Mastitis and give her a leaflet on Mastitis before discharge and discuss breast engorgement and breast abscess

discuss with her community support of ABA, MACH and GP.


Section 11 – Dummies and Pacifiers

Inform women in the antenatal period why the Maternity Unit does not recommend dummies/teats in the early postnatal period, and why dummies and teats are not provided. Babies who use a dummy frequently are more likely to be weaned earlier than babies who do not use a dummy or pacifier.

Dummy use may be more of a marker than a cause of breastfeeding difficulties and midwives need to focus on underlying concerns and inappropriate breastfeeding practices rather than just discourage dummy use: discuss with the women who request a dummy/teat or bring in a dummy/teat to be

used, why it is not recommended that they be used before breastfeeding and lactation is fully established

educate the woman on the normal behaviour of newborn babies and frequency of feeds, as per the Breastfeeding Guideline.

If the woman makes an informed choice to use a dummy: discuss the safe use of dummies/teats and the importance of regular inspections to

check whether they are perishing discuss the importance of proper cleaning and sanitisation document in the clinical pathway when a woman makes an informed choice to use a

dummy/teat.

Dummy Hygiene advise the mother never to put the dummy in her own mouth before giving to the baby dummies can be cleaned between uses with warm soapy water, stored in sealed

container when not in use and must be provided by the woman for her own baby at home at least two dummies are recommended so that there is always one clean

dummy for use when required.


Section 12 – Contraception and breastfeeding



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The Academy of Breastfeeding Medicine presents the following advice on choosing contraceptives in order to minimise the physiologic impact on breastfeeding:First choice: lactational amenorrhea method (LAM), ‘natural’ family planning, barriers, non-hormonal intrauterine device (IUD)Second choice: progesterone only methodsThird choice: oestrogen containing contraceptives.

12.1 Lactational amenorrhea methodBreastfeeding is used as a contraceptive method by many women who are amenorrhoeic and not feeding supplements to the baby for up to six months after birth. The Lactational Amenorrhoea Method (LAM) of contraception provides 98% protection from pregnancy if the following three conditions are strictly met: full breastfeeding (no breast milk substitutes – water, glucose water, formula, juices,

solids) the woman is amenorrhoeic the baby is under six months of age.

When the baby starts on solids or fluids, the woman’s menses return, or the baby reaches six months of age, the risk of pregnancy increases and other methods of contraception need to be considered. The reliability of fertility control offered by prolonged breastfeeding is uncertain.

12.2 Hormonal methodsProgestogen-only contraceptives (‘minipill’, intra-uterine device or implant) are compatible with lactation but should not be initiated before six weeks postpartum. Anecdotally, some women report a noticeable reduction in milk supply after starting the minipill. This may be overcome by increasing feeding frequency for a time.The combined oral contraceptive pill should not be used in the first six months postpartum, but can be offered to women with well-established lactation (> six months).


Implementation

This Clinical Guideline will be referred to in existing delivery of education. Sent to staff via email and displayed in workrooms.


Definitions

Colostrum: is the fluid produced by the breast at the end of pregnancy and in the early postpartum period. It is thicker and more yellow in colour than mature breastmilk, reflecting a higher content of proteins, immunoglobulins, fat soluble vitamins and some minerals (Ballarat Health Service).



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Related Policies, Procedures, Guidelines and Legislation

Further information relating to the support and facilitation of breastfeeding across the care continuum can be accessed from the following resources:

http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/ n56_infant_feeding_guidelines.pdf

http://health.act.gov.au/breastfeeding/ebook/ http://health.act.gov.au/c/health?a=dlpubpoldoc&document=2777 https://www.breastfeeding.asn.au/ http://www.who.int/nutrition/publications/infantfeeding/9241561300/en/ http://www.who.int/nutrition/publications/code_english.pdf

PoliciesAustralian Capital Territory Government. (2010). The ACT Breastfeeding Strategic Framework. 2010-2015. Canberra: Australian Capital Territory Government.

Commonwealth of Australia. (2009). Australian National Breastfeeding Strategy. 2010-2015. Canberra: Australian Government Department of Health and Ageing.

ProcedureHypoglycaemia in the newborn-SOP


References

Academy of Breastfeeding Medicine. (2014). ABM clinical protocol #4: mastitis. Breastfeeding Medicine 9(5). DOI: 10.1089/bfm.2014.9984

Academy of Breastfeeding Medicine. (2009). ABM clinical protocol #20: engorgement. Breastfeeding Medicine 4(2). Doi:10:1089/bfm.2009.9997

Australian Breastfeeding Association. (2013). Expressing and storing breastmilk. Accessed at hppt://www.breastfeeding.asn.au/bf-info/breastfeeding-and-work

Australian Breastfeeding Association. (2012). Engorgement. Accessed at hppt://www.breastfeeding.asn.au/bf-info/commonconcerns

Fetherstone C. (2001). Mastitis in lactating women: Physiology or pathology? Breastfeeding Review, 9(1):5-12.



http://www.who.int/nutrition/publications/code_english.pdf

http://www.who.int/nutrition/publications/infantfeeding/9241561300/en/

https://www.breastfeeding.asn.au/

http://health.act.gov.au/c/health?a=dlpubpoldoc&document=2777

http://health.act.gov.au/breastfeeding/ebook/

http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/n56_infant_feeding_guidelines.pdf

http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/n56_infant_feeding_guidelines.pdf

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Geddes DT, Kent JC, Mitoulas LR & Hartmann PE, (2008).Tongue movement and intra-oral vacuum in breastfeeding infants. Early Hum Dev, 84(7):471-477.

Joanna Briggs Institute. (2005). Early childhood pacifier use in relation to breastfeeding, SIDS, infection and dental malocclusions: a systematic review. Best Practice Information Sheet, 9 (3).

Kase K, Wallis J & Kase T. (2003). Clinical therapeutic applications of the Kinesio Taping method. 2nd Ed. Kinesio Taping. Accessed at: http://www.scribd.com/doc/42827982/Clinical-Therapeutic-Applications-of-the-Kinesio-Taping-Method on 16th October 2012.

Kent JC, Mitoulas LR, Cregan MD, Ramsay DT, Doherty DA & Hartmann PE., (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics, 17(3):387-395.

King Edward Memorial Hospital. (2012). Feeding according to need. Perth: King Edward Memorial Hospital.

Mangesi L & Dowsell T. (2010). Treatment for breast engorgement during lactation. Cochrane Database Systematic Review 9. Doi:10.1002/14651858.CD006946.pub2.

National Health and Medical Research Council. (2012). Eat for health. Infant feeding guidelines. Information for health workers. Canberra: Commonwealth of Australia.

New South Wales Kids and Families. (2011). Breastfeeding in NSW: promotion, protection and support. Sydney: NSW Ministry of Health.

Pinelli J & Symington A. (2005). Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants. Cochrane Database of Systematic Review .

Riordan J & Wambach K. (2009). Breastfeeding and human lactation. 4th Ed. Massachusetts: Jones and Bartlett Publishers.

Robertson VJ, Chipchase LS, Laakso EL, Whelan KM & McKenna LJ. (2001). Guidelines for the clinical use of electrophysical agents. Victoria: Australian Physiotherapy Association.

Woolridge MW. (1986) The ‘anatomy’ of infant sucking. Midwifery, 2(4):164-171.

World Health Organization. (2001).Global strategy for infant and young child feedingThe optimal duration of exclusive breastfeeding. Accessed at:http://www.who.int/nutrition/topics/infantfeeding_recommendation/en/



http://www.who.int/nutrition/topics/infantfeeding_recommendation/en/

http://www.scribd.com/doc/42827982/Clinical-Therapeutic-Applications-of-the-Kinesio-Taping-Method

http://www.scribd.com/doc/42827982/Clinical-Therapeutic-Applications-of-the-Kinesio-Taping-Method

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World Health Organization. (2008). Indicators for assessing infant and young child feeding practices. Geneva: World Health Organization. Accessed at: http://whqlibdoc.who.int/publications/2008/9789241596664_eng.pdf?ua=1

World Health Organization. (1989). Protecting, promoting and supporting breast-feeding. The special role of maternity services. Geneva: World Health Organization. Accessed at: http://www.who.int/nutrition/publications/infantfeeding/9241561300/en/

World Health Organization. (1981). International code of marketing of breast milk substitutes. Geneva: World Health Organization. Accessed at: http://www.who.int/nutrition/publications/code_english.pdf

Young S. (2002) Ultrasound therapy. In S. Kitchen (ed.) Electrotherapy : Evidence –based Practice. 11th Ed. Edinburgh: Elsevier Churchill Livingstone: pp. 211-230.




http://www.who.int/nutrition/publications/code_english.pdf

http://www.who.int/nutrition/publications/infantfeeding/9241561300/en/

http://whqlibdoc.who.int/publications/2008/9789241596664_eng.pdf?ua=1

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Search Terms

Breastfeeding, Breatmilk, 10 Steps, WHO Code, Expressing, Breast pump, First Feed, Breastfeeding after caesarean, Damaged nipples, Sore nipples, Hepes simplex, Bacterial infection of the nipple, Nipple shields, Supply line, Cup feeding, Syringe droplet feeding, Finger feeding, Storage of breastmilk, Complementary feeding, Artificial feeding, Cleaning and sterilising feeding equipment, Dummies and teats, Blocked ducts, Mastitis, Breast abscess, white bleb


Attachments

Attachment 1: Breastfeeding Policy SummaryAttachment 2: Parent Information Sheet Antenatal Expressing Attachment 3: Parent Information Sheet Nipple ShieldsAttachment 4: Referral Flowchart

Disclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

(to be completed by the HCID Policy Team)

Date Amended Section Amended Approved By24/03/2016 Sentence added to the introduction HCID Policy Team, CHHS05/03/2018 Information pertaining to storage

and labelling of EBM added to Section 5.5

Karen Faichney A/g ED, WY&C



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Attachment 1: Breastfeeding Policy Summary

The division of Women, Youth and Children recognise that breastfeeding is the healthiest way for a woman to feed her baby. Important health benefits exist for both the mother and her child. Our staff will promote, protect, and support breastfeeding by implementing “UNICEF/WHO Ten Steps to Successful Breastfeeding". The health benefits of breastfeeding and the potential health risks of formula feeding are discussed with all women so that they can make an informed choice about how to feed their babies.

The staff at Women, Youth and Children will follow the WHO 10 Steps to Successful Breastfeeding.

The breastfeeding policy is available in all areas of the hospital where breastfeeding women and babies are admitted

The policy is displayed in areas of the hospital which serve mothers and babies. Where a summary of the policy is displayed, a full version will be available on request from staff

The benefits of breastfeeding are clearly and simply explained to all pregnant women, together with good breastfeeding management practices

A written curriculum of the breastfeeding education is available for pregnant women using our services

All women are encouraged to hold their babies in skin-to-skin contact as soon as possible after birth, whether they plan to breastfeed or not

All women are encouraged to offer the first breastfeed when the baby is showing signs of readiness. A midwife is available to help women recognise readiness to feed signs and ensure the baby is given time to self attach. Assistance from the midwife is available if required

Midwives ensure that women are offered the support necessary to acquire the skills of positioning and attachment. Midwives will explain positioning and attachment techniques.

All breastfeeding women are shown how to hand express their milk When a woman and her baby are separated for medical reasons, it is the responsibility

of the all health professionals to ensure that the mother is given help and encouragement to express her milk and initiate /maintain her lactation. Women are encouraged to begin expressing as soon as possible after birth (usually before leaving the birth room)

No water or artificial feed should be given to a breastfed baby except in cases of medical indication or fully informed parental choice

Prior to offering artificial milk to breastfed babies every effort should be made to encourage the woman to express breastmilk to be given to the baby via cup or syringe

Encourage and support the woman to have her baby remain with her 24 hours per day Demand (baby-led) feeding is encouraged for all babies unless clinically indicated. No

restrictions are placed on breastfeeding. Encourage women to feed their babies whenever the baby shows signs of wanting to feed



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Women wishing to use dummies/teats should be advised of the potential detrimental effects such use may have on breastfeeding to enable them to make an informed choice. A record of the discussion and woman’s decision should be made in the baby’s clinical record

Health care staff should not recommend the use of dummies/teats during the establishment of breastfeeding

All women will be provided with information on where they may obtain advice and support with breastfeeding after discharge

All women will be referred to community agencies such as the Australian Breastfeeding Association and MACH nurses on discharge



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Attachment 2: Parent Information Sheet - Antenatal Expressing

Colostrum is the first milk available for your baby and it is recommended because it is rich in protein, immune factors and other important nutrients.Expressing of colostrum from 36 weeks gestation is recommended for a pregnant woman who has an increased risk of giving birth to a baby with low blood sugars (hypoglycaemia); or where feeding in the first hours after birth may be affected.

If you have a high risk pregnancy for threatened preterm labour or shortened cervix you should not participate in antenatal expressing. If you are unsure, please discuss this with your midwife or doctor.

Who is at Risk? Women with diabetes Women whose babies will be born by caesarean section Women whose babies have been diagnosed with a congenital condition, such as cleft

lip or palate, Down syndrome or cardiac disorders Families with a strong family history of dairy intolerance.

How to express milk by handA midwife will provide you with written information about the expression of colostrum and undertake a demonstration. 1. You will be given a start - up expression kit: 4 oral syringes, 2 small plastic pouches and

blank labels. 2. You will be instructed to express each breast 2 times a day for 5 minutes, or until the

flow of colostrum slows, repeat the cycle once (Change syringes daily and store any expressed colostrum in the fridge between expressing - freeze the colostrum 24 hours after the first expression).

3. Attach a label with your name, date and time of first expression onto each syringe, place the syringes into the plastic bags provided.

4. Place the plastic bags into the freezer; bring the frozen colostrum to hospital when you are admitted for the birth of your baby. The milk will be stored until needed.

Every woman will express different amounts of colostrum - and any amount expressed is valuable to your baby.You may experience Braxton - Hicks contractions whilst expressing and this is normal.

If you experience symptoms of preterm labour (painful contractions) you should cease expressing and contact Birthing on (02) 6174 7444, or your midwife or doctor.



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Breastmilk status Room temperature(26°C or lower)

Refrigerator(4°C or lower)

Freezer

Freshly expressed into container

6-8 hours If refrigerator is available store milk there

3 days Store at the back where it is coldest

2 weeks in freezer compartment inside refrigerator3 months in freezer section of refrigerator with separate door6-12 months in deep freeze(-18°C or lower)

Previously frozen thawed in refrigerator but not warmed

4 hours or less - that is, the next feeding

24 hours Do not re-freeze

Thawed outside refrigerator in warm water

For completion of feeding

4 hours or until the next feeding

Do not re-freeze

Infant has begun feeding Only for completion of feeding

Discard Discard

Australian Breastfeeding Association reproduced from NHMRC Infant Feeding Guidelines 2012

AccessibilityThe ACT Government is committed to making its information, services, events and venues as accessible as possible.If you have difficulty reading a standard printed document and would like to receive this publication in an alternative format such as large print, please phone 13 22 81 or email [email protected] you are Deaf, or have a speech or hearing impairment and need the teletypewriter service, please phone 13 36 77 and ask for 13 22 81.For speak and listen users, please phone 1300 555 727 and ask for 13 22 81. For more information on these services visit http://www.relayservice.com.au If English is not your first language and you require the Translating and Interpreting Service (TIS), please call 13 14 50.

© Australian Capital Territory, Canberra, February 2016

This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without written permission from the Territory Records Office, Community and Infrastructure Services, Territory and Municipal Services, ACT Government, GPO Box 158, Canberra City ACT 2601.

Enquiries about this publication should be directed to ACT Government Health Directorate, Communications and Marketing Unit, GPO Box 825 Canberra City ACT 2601 or email: [email protected]

www.health.act.gov.au | www.act.gov.au

Enquiries: Canberra 13ACT1 or 132281 | Publication No XXXXX



http://www.act.gov.au/

http://www.health.act.gov.au/

http://www.relayservice.com.au/

mailto:[email protected]

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Attachment 3: Parent Information Sheet - Nipple shields

What are nipple shields? nipple shields are thin flexible, silicone covers that can be placed over the nipple to

assist with breastfeeding. Because they are shaped they make it easier for a baby to grasp with a similar latch to

breastfeeding, making attachment easier.

When to use: for inverted or flat nipples after all other attempts to attach baby have been

unsuccessful.

Nipple Shields should not be used: until the milk is in and flowing well when nipples are damaged from poor attachment to the breast if the breastfeeding problem has not been fully assessed by the lactation consultant or

experienced midwife to determine whether it is a safe and appropriate option for you and your baby.

Important Information: the size of the nipple shield should be comfortable for both mother and baby your milk supply may slowly decline over time if your baby is not well attached or

feeding effectively your milk can take longer to flow from the breast when a nipple shield is used so feeds

may take longer to finish always ensure your breasts are comfortable after feeds, it may be necessary to express

for a few minutes after feeds to make your breasts are comfortable. while you are feeding with a nipple shield, it is recommended to have your baby

weighed weekly or at least fortnightly to ensure adequate growth Ensure your nipples air dry after using a shield to avoid them remaining too moist.

How to Use: Ensure your hands are clean express a few drops of milk to start your milk flowing turn nipple shield inside out smear breast milk onto both sides of the shield to encourage your baby to attach and

assist the shield to adhere to your skin gently place nipple shield centrally over your nipple and holding the top and bottom

sides to your breast to allow nipple to fill into the funnel. the baby’s nose and chin should be free of the silicone.

How to Clean the Nipple Shield generally there is no need to sterilise the nipple shield wash well in hot soapy water and rinse and drain dry. store in a clean, dry, covered container.Doc Number Version Issued Review Date Area Responsible PageCHHS16/042 1.1 02/03/2016 01/03/2019 WY&C 80 of 85


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Community Follow-upIf you are going home using a nipple shield it is important that you see a Maternal and Child Health Nurse (MACH) or lactation consultant for advice about: continuing its use checking your baby’s weight and your breast milk supply when to stop using the shield.

Weaning from the Nipple Shield:It is recommended that your baby eventually feed directly from your breast and attempts to do this should be made within a few days. The transition from the nipple shield to the breast can sometimes be difficult but is achievable with patience and gentle persistence. Removing the shield part way through the feed when the nipple is drawn out may make direct attachment easier. Support can be a great help during this transition, and assistance can be obtained from your midwife, a lactation consultant, MACH nurse or Australian Breastfeeding Association (ABA) Counsellor.

For your information: Australian Breastfeeding Association:

24 hour help line 1800 686 268 (services all of Australia) www.breastfeeding.asn.au ACT Maternal and Child Health Nurse

Community Health Intake on (02) 6207 9977 between 8am and 5pm weekdays Queanbeyan Maternal and Child Health Nurse: 61243700

AccessibilityThe ACT Government is committed to making its information, services, events and venues as accessible as possible.If you have difficulty reading a standard printed document and would like to receive this publication in an alternative format such as large print, please phone 13 22 81 or email [email protected] you are Deaf, or have a speech or hearing impairment and need the teletypewriter service, please phone 13 36 77 and ask for 13 22 81.For speak and listen users, please phone 1300 555 727 and ask for 13 22 81. For more information on these services visit http://www.relayservice.com.au If English is not your first language and you require the Translating and Interpreting Service (TIS), please call 13 14 50.

© Australian Capital Territory, Canberra, February 2016

This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without written permission from the Territory Records Office, Community and Infrastructure Services, Territory and Municipal Services, ACT Government, GPO Box 158, Canberra City ACT 2601.

Enquiries about this publication should be directed to ACT Government Health Directorate, Communications and Marketing Unit, GPO Box 825 Canberra City ACT 2601 or email: [email protected]

www.health.act.gov.au | www.act.gov.au

Enquiries: Canberra 13ACT1 or 132281 | Publication No XXXXX



http://www.act.gov.au/

http://www.health.act.gov.au/

http://www.relayservice.com.au/

mailto:[email protected]

http://www.breastfeeding.asn.au/

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Attachment 4: ACT Breastfeeding Referral Flowchart



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ACT Health website provides information on breastfeeding services in the ACT. Visit www.health.act.gov.au/breastfeeding. The lactation consultants at the Centenary and Calvary public hospitals are available to clients of these hospitals by referral from your midwife or ACT Health professional. Breastfeeding classes are available.

Midcall offers home visits to clients of Centenary or Calvary public hospitals for the first few days after birth by referral from their midwife, which must be organised before discharge from hospital. After about a week of care, the midwife will discharge you to a Maternal and Child Health (MACH) Nurse.

Community Health Intake (CHI) provides a single point of entry to ACT Health services for clients, health professionals, and community health services. It is the main contact number for MACH Nurses. Contact CHI on 6207 9977 between 8am to 5pm for information or to make an appointment.

Maternal and Child Health (MACH) Nursing Clinics provide information on baby and child health and development, breastfeeding, nutrition and feeding, sleep issues, parenting, child safety, behavioural issues, and perinatal mental health. Appointments can be made through CHI on 6207 9977 between 8am to 5pm.

Early Days Groups (no appointment required) are a MACH Nurse facilitated session for parents of infants up to 3 months of age who are experiencing difficulties with feeding and settling their infants. Groups run every day of the week at various locations across the ACT. Times and locations are online: www.health.act.gov.au/MACH

Drop-In Clinics (no appointment required) are available for short consultations and referrals with a Maternal and Child Health (MACH) nurse. Information on times and locations is online at: www.health.act.gov.au/MACH

MACH Liaison enables telephone contact with a MACH nurse for both clients and staff (call CHI on 6207 9977 between 8am to 5pm and ask for ‘MACH Liaison’).

Women Youth and Children - Community Nutrition provides advice on a range of dietary issues including general nutrition for the mother while breastfeeding (e.g. multivitamins, iodine, vitamin D, fish/mercury) and baby weaning.

ACT Health Walk in Centres (Belconnen and Tuggeranong) are now able to treat women who present with symptoms of lactation related mastitis (inflammation of the breast due to a blocked milk duct whilst breastfeeding) between 7:30am to 10pm. This offers women an option Doc Number Version Issued Review Date Area Responsible PageCHHS16/042 1.1 02/03/2016 01/03/2019 WY&C 84 of 85


http://www.health.act.gov.au/MACH

http://www.health.act.gov.au/MACH

http://www.health.act.gov.au/breastfeeding

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out of hours, including weekends, or when they cannot get an appointment to see a GP. Centres cannot see babies aged 0-2 years; this is only a service for the breastfeeding mother.

The QEII Family Centre provides a residential tertiary service for families with young children (0-3 yrs). The QEII provides care for families experiencing complex lactation and other feeding problems, unsettled babies, postnatal depression, children with special needs, parenting support and behavioural problems in children/families. Referral by a health professional is essential. For breastfeeding issues, it is recommended clients attend a MACH Early Days group in the first instance.

Australian Breastfeeding Association (ABA) aims to support and encourage women who want to breastfeed their babies, and to raise community awareness of the importance of breastfeeding and human milk to both child and maternal health. The 1800 mum 2 mum 24 hour, toll free service is run by the ABA, and offers trained volunteer counsellors, who are mothers, to assist other mums with issues including the early days with a new baby, expressing and storing milk and weaning.

Raising Children Network is an Australian Government initiative, and is the complete Australian resource for parenting newborns to teens. Parents and carers can learn and access tools, support and resources as their children grow and develop.

healthdirect provides free, 24 hour telephone advice by a Registered Nurse. Contact 1800 022 222. They also offer an After Hours Information telephone service provided by GPs.

Pregnancy, Birth and Baby is an Australian Government initiative linked to healthdirect that offers free and confidential information, advice and counselling to women, their partners, friends and relatives about pregnancy, childbirth and your baby’s first year. It’s available 24 hours a day, 7 days a week online (www.pregnancybirthbaby.org.au) and over the phone (1800 882 436). Video calls with qualified counsellors are also now available; accessed on their website www.pregnancybirth baby.org.au (click on ‘video call’).

Tresillian Parent Helpline offers advice from Child and Family Health Nurses on feeding and parenting children aged 0-5 years. Call for free on 1800 637 337 (7am -11pm) or chat live online (5pm-11pm) https://tresillianchat.com.au/



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