Breastfeeding Clinical Guideline - | Health



Canberra Hospital and Health ServicesClinical GuidelineBreastfeedingContents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc508019946 \h 1Introduction PAGEREF _Toc508019947 \h 5Background PAGEREF _Toc508019948 \h 5Key Objectives PAGEREF _Toc508019949 \h 6Section 1 - The WHO Code PAGEREF _Toc508019950 \h 6Section 2 - The Ten Steps PAGEREF _Toc508019951 \h 8Step 1 – Have a written breastfeeding policy that is routinely communicated to all health care staff PAGEREF _Toc508019952 \h 9Step 2 – Train all health care staff in skills necessary to implement this policy PAGEREF _Toc508019953 \h 9Step 3 – Inform all pregnant women about the benefits and management of breastfeeding PAGEREF _Toc508019954 \h 9Step 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 PAGEREF _Toc508019955 \h 10Step 5 – Show mothers how to breastfeed and maintain lactation even if they should be separated from their infants PAGEREF _Toc508019956 \h 10Step 6 – Give newborn infants no food or drink other than breastmilk unless medically indicated PAGEREF _Toc508019957 \h 11Step 7 – Practise rooming in- allow mothers and infants to remain together 24 hours a day PAGEREF _Toc508019958 \h 11Step 8 – Encourage breastfeeding on demand PAGEREF _Toc508019959 \h 12Step 9 – Give no artificial teats or pacifiers (dummies) to breastfeeding infants PAGEREF _Toc508019960 \h 12Step 10 – Foster the establishment of breastfeeding support groups and refer mothers to them PAGEREF _Toc508019961 \h 12Section 3 - Breastfeeding Management PAGEREF _Toc508019962 \h 123.1 - The natural pattern of breastfeeding PAGEREF _Toc508019963 \h 133.2 - Exclusive breastfeeding PAGEREF _Toc508019964 \h 173.3 - Positioning and attachment at the breast PAGEREF _Toc508019965 \h 173.4 - Assessing milk transfer at a breastfeed PAGEREF _Toc508019966 \h 193.5 - First Feed PAGEREF _Toc508019967 \h 193.6 - Baby-led or demand feeding PAGEREF _Toc508019968 \h 213.7 - Rooming-in PAGEREF _Toc508019969 \h 223.8 - Breastfeeding after Caesarean Section PAGEREF _Toc508019970 \h 23Section 4 - Breastfeeding challenges in the immediate and longer postnatal period PAGEREF _Toc508019971 \h 244.1 - Inverted nipples PAGEREF _Toc508019972 \h 244.2 - Nipple pain and trauma PAGEREF _Toc508019973 \h 264.3 - Bacterial infection of the nipple PAGEREF _Toc508019974 \h 294.4 - Nipple vasospasm PAGEREF _Toc508019975 \h 294.5 - Breast and nipple thrush PAGEREF _Toc508019976 \h 294.6 - Herpes simplex virus PAGEREF _Toc508019977 \h 314.7 - Lactation Consultant Referrals PAGEREF _Toc508019978 \h 314.8 - Speech Pathology Referrals PAGEREF _Toc508019979 \h 324.9 - Delay in Lactation or Low supply PAGEREF _Toc508019980 \h 324.10 - Breast surgery and breastfeeding PAGEREF _Toc508019981 \h 354.11 - Breastfeeding a preterm or unwell baby PAGEREF _Toc508019982 \h 36Section 5 - Breastmilk expression PAGEREF _Toc508019983 \h 375.1 - General principles of expressing in all settings via any method PAGEREF _Toc508019984 \h 385.2 - Expressing by hand PAGEREF _Toc508019985 \h 385.3 - Expressing by electric pump PAGEREF _Toc508019986 \h 385.4 - Antenatal Expressing PAGEREF _Toc508019987 \h 395.5 - Storage of Breastmilk PAGEREF _Toc508019988 \h 40Section 6 - Breast related issues PAGEREF _Toc508019989 \h 426.1 - Blocked lactiferous ducts PAGEREF _Toc508019990 \h 426.2 - White spot/nipple bleb PAGEREF _Toc508019991 \h 436.3 - Full breasts and engorgement PAGEREF _Toc508019992 \h 436.4 – Mastitis PAGEREF _Toc508019993 \h 456.5 - Physiotherapy Management of Blocked Ducts and Lactational Mastitis PAGEREF _Toc508019994 \h 47Referral PAGEREF _Toc508019995 \h 47Initial Assessment PAGEREF _Toc508019996 \h 47Physiotherapy Management PAGEREF _Toc508019997 \h 486.6 - Breast abscess PAGEREF _Toc508019998 \h 506.7 - Blood in the breastmilk PAGEREF _Toc508019999 \h 51Section 7 - Lactation Aids PAGEREF _Toc508020000 \h 517.2- Cup Feeding PAGEREF _Toc508020001 \h 537.3 - Supply line PAGEREF _Toc508020002 \h 557.4 Syringe drop feeding PAGEREF _Toc508020003 \h 567.5 Finger Feeding PAGEREF _Toc508020004 \h 56Section 8 - Baby-related breastfeeding issues PAGEREF _Toc508020005 \h 588.1 - The sleepy baby PAGEREF _Toc508020006 \h 588.2 - The unsettled baby PAGEREF _Toc508020007 \h 598.3 - Excessive crying PAGEREF _Toc508020008 \h 608.4 - Breast refusal PAGEREF _Toc508020009 \h 618.5 - Breastfeeding multiple babies PAGEREF _Toc508020010 \h 628.6 - Breastfeeding during pregnancy and tandem breastfeeding (feeding a baby and an older child) PAGEREF _Toc508020011 \h 63Section 9 – Complementary feeding PAGEREF _Toc508020012 \h 639.1 Complementary feeding PAGEREF _Toc508020013 \h 63Section 10 - Artificial Feeding/Infant formula PAGEREF _Toc508020014 \h 6510.1 - Artificial Feeding PAGEREF _Toc508020015 \h 6510.2- Cleaning and sterilising of feeding equipment PAGEREF _Toc508020016 \h 68Boiling PAGEREF _Toc508020017 \h 68Steam Sterilising PAGEREF _Toc508020018 \h 6810.3 - Suppression of Lactation PAGEREF _Toc508020019 \h 69Section 11 – Dummies and Pacifiers PAGEREF _Toc508020020 \h 70Section 12 – Contraception and breastfeeding PAGEREF _Toc508020021 \h 7112.1 Lactational amenorrhea method PAGEREF _Toc508020022 \h 7112.2 Hormonal methods PAGEREF _Toc508020023 \h 72Implementation PAGEREF _Toc508020024 \h 72Definitions PAGEREF _Toc508020025 \h 72Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc508020026 \h 72References PAGEREF _Toc508020027 \h 73Search Terms PAGEREF _Toc508020028 \h 75Attachments PAGEREF _Toc508020029 \h 75Attachment 1: Breastfeeding Policy Summary PAGEREF _Toc508020030 \h 76Attachment 2: Parent Information Sheet - Antenatal Expressing PAGEREF _Toc508020031 \h 78Attachment 3: Parent Information Sheet - Nipple shields PAGEREF _Toc508020032 \h 80Attachment 4: ACT Breastfeeding Referral Flowchart PAGEREF _Toc508020033 \h 83IntroductionThe 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 ContentsBackgroundThis 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.Back to Table of ContentsKey ObjectivesCommunication of a clear and consistent set of principles that protect, promote and support breastfeeding.Back to Table of ContentsSection 1 - The WHO CodeThe 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.Products covered under the WHO Code: Infant formulaOther milk productsCerealsJuices and baby teasFollow-on milksFeeding bottles and teats.The ten (10) main provisions of the Code are:No advertising of breastmilk substitutes to the publicNo products including formula, bottles and teats should be advertised or promoted.No free samples or supplies to mothersNo 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.No promotion of products through health care facilitiesCare 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.Magazines with advertising of products covered by the code (including bottles and teats) should not be distributed to women.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.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.No contact between company marketing personnel and womenNo representatives from companies which manufacture, market or distribute infant formula should seek to contact pregnant women, or mothers of babies or young children.No gifts or personal samples to health workersGifts from formula companies should not be offered to or accepted by health professionals. 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.Samples may be used for research at the institutional level or for professional evaluation.Any grants for research, study or travel made to health professionals by the formula companies should be declined.No words or pictures idealising artificial feeding, including pictures of infants on the labels of products Health professionals should be aware of the formula companies and manufacturers of bottles and teats who violate the Code in this rmation to health workers should be scientific and factualHealth 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.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.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 breastmilkthe negative effect on breastfeeding of introducing partial bottle feedingmaternal nutrition and the preparation for and maintenance of breastfeedingthe difficulty of reversing the decision not to breastfeedif needed, the proper use of infant formula.Unsuitable products, such as sweetened condensed milk should not be promoted for babies.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.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 CodeReaffirm 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.Back to Table of ContentsSection 2 - The Ten StepsStep 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 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 rmation 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 feedingwomen 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 importantthe risks associated with not breastfeedingthe importance of early uninterrupted skin-to-skin contact and the first feedwhy 24-hour rooming-in is importantwhy bottle teats and dummies are discouraged while breastfeeding is being establishedexclusive breastfeeding for the first six months and that breastfeeding continues to be important after six months when other foods are introducedbasic breastfeeding and lactation management, including positioning and attachment, feeding cues and frequency of feedingindications that a baby is getting enough milkmaintaining and increasing breastmilk supplybreastfeeding support groups and services in the community. 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 requiredstaff will educate women on correct positioning and attachmentwomen can recognise whether the baby is well attached on the breast and breastfeeding effectivelywomen 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. 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.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. Back to Table of ContentsSection 3 - Breastfeeding ManagementAll 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. 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 StateFeeding CuesReadiness to FeedDeep sleep – not easily rousedNone NoLight sleep – rousable but likely to fall back to sleepNone NoDrowsy – yawning, eyes opening intermittentlyEarly – wiggling, moving arms and legs, rooting, fingers to mouth, lickingEarly – yesQuiet alert – looking around, regular breathing, body stillEarly – wiggling, moving arms and legs, licking, searchingEarly – yesActive alert – moving arms and legs, sensitive to environmentMid – fussing , squeaky noises,restless, hand to mouth, stretchingMid – yesCrying – agitated, disorganised, needs comfortingLate – full cry, colour turns red Late – noFeeding 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.Reasons for feeding according to need Mother InfantMotherBabyIncreases the rate of successfully establishing lactationIncreases breastfeeding durationReduces the incidence of breast engorgementDecreases the incidence and severity of physiological jaundiceBaby will be more contentEstablishes a supply and demand patternWhen a healthy baby born at term is feeding effectively there should be no restrictions on:frequency of feedingduration of feedsnight 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 spontaneouslybaby appears to have finished the first breastmother feels the first breast is softerbaby 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 SuckingNutritive Suckingrapid and shallow2 sucks per second infrequent swallowsoccurs with periods of slow milk flow:at the beginning of a feedprior to a milk ejectiondeeper and slowerapproximately 1 suck per second swallows after every 1 or 2 sucksoccurs with periods of rapid milk flow:after a milk ejectionLet-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 feedmost women will only be aware of the initial MER and may not be able to sense subsequent milk ejectionsmany women experience a sensation of warmth or tingling in their breastssome women experience ‘afterbirth’/abdominal pain or discomfort during MERsome women are unaware of the MERchanges 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 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’ soundwith a new milk ejection, swallowing may become slightly louder and more frequentspeech pathologist can be consulted for assessment of any swallowing concerns3.2 - 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 monthsnutritionally 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 painprivacybaby’s position. Baby is held close to the mother’s body at the same level of the breast with:whole body turned towards the mothertrunk and head alignedmouth at nipple levelhead 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:mouth open wide against the breast with the nipple and surrounding breast tissue included in the gapechin against the breastobserved deep jaw movementscheeks not sucked inswallowing that can be seen/heard once the milk ejection reflex (MER) occursafter 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 breastenable 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.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 headthe mother can use her upper arm to shape and guide the breast as her baby gapes open the mouth to attachwhen 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 securelythe baby’s chest is touching mother’s chest and breastthe baby’s chin is touching mum’s breast/lower areolathe 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 agequality of breastfeeds - sucking patterns according to stage of lactationlength of time of breastfeed, effectiveness of the milk ejection reflex, swallowing of milk seen or heardweight gainurinary and bowel outputbaby and maternal behaviour during the feed.3.5 - First FeedThe importance of the first breastfeednipple 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 birthfrom 20-60 minutes after birth the baby's sucking reflex is most intense and the baby is most willing to suckthe ‘imprinting process’ starts to take place at the first feed and this is important for future breastfeeds as the baby learns what to dothe mother/baby relationship (attachment and bonding) are positively influencedwomen will usually breastfeed for longer duration if skin-to-skin contact and subsequent breastfeeding is initiated earlythe 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 nippleuncurls fists and makes grasping movements toward nipplemakes small ‘licking’ movementsdemonstrates ‘rooting’ behaviour which may include:opening mouthturning head towards the nipplenuzzling chin into breastattempting to self-attachbabies, 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 breastsletting him/her nuzzle and mouth the nippleallow him/her to suck at the breast once interest is arousedif 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:spontaneously detaching from the nipple without further rooting behaviourfalling asleep at the breast.If the baby does not feed assess the baby for any risk factors and notify the neonatal registrar if appropriatereassure the woman if her baby is unwilling to feed soon after birthencourage her to leave the baby skin-to-skin, close to her breast, allowing the baby to attach when readyexplain that some babies may take more time to attach for their first feedshow 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 positionappropriate and effective analgesiaoffering 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 breasteducate the woman about the benefits of demand feeding including:encouraging early milk production and maintenance of milk production facilitating early passage of meconium and therefore decreasing the likelihood of jaundiceassociation with better weight gain in babiesassociation with longer and more successful lactationflexible 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 independentlydiscuss the feeding behaviour of babies including:in the first 24-72 hours the term healthy baby may demonstrate a variety of feeding patterns some babies demand very frequently while others may feed for a few times only and have long sleep times; both patterns are normal newborn behaviourit 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 hoursonce the milk supply is established the baby should have at a minimum 8-10 feeds in 24 hours 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 availableexplain 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 indicateddiscuss 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: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 offereddiscuss 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 offeredinform 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 breastteach women to allow their babies to detach when satisfied 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 babyunrestricted breastfeeding accessincreased breastfeeding durationincreased opportunity for mothers to become familiar with their baby’s feeding cues, behaviour and feeding patterns prior to dischargepromotion of relaxation and sleep for mother and baby the family has the opportunity for closer contact with the babyreduced risk of SIDS associated with earlier initiation of lactation and successful breastfeeding facilitates frequent suckling and reduces crying and stress for the baby, thereby decreasing energy consumption and contributing to better weight gainthe 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 delayenhances maternal rest and sleepminimises 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 timesprovide 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 settlinga baby who is continually unsettled should be investigated.3.8 - Breastfeeding after Caesarean Section Antenatallydiscuss 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 babyexplain 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 PACUdocument 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 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 onwoman assisted to sit upcot sides upwoman offered a cold drinka 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.Back to Table of ContentsSection 4 - Breastfeeding challenges in the immediate and longer postnatal period4.1 - 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.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 changeswhen breastfeeding the baby attaches to the breast rather than the nipple therefore the actual shape of the nipple may not be a problemnipple protraction improves with each pregnancy and lactation experiencethat there is evidence to support the use of breast shields/shells or Hoffman’s exercises antenatally encourage the woman to contact her local ABA groupwomen may benefit from a Lactation Consultant Clinic appointment during pregnancy to discuss potential management strategies.Postnatallybe positive about breastfeeding success when caring for and talking to the womanencourage early and frequent skin to skin contact, to allow the baby to learn the woman’s anatomy and facilitate self attachencourage 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 medicationsencourage the woman to breastfeed frequently in the first few days while the breasts are soft and easier to graspteach 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 graspsuggest the woman to try different feeding positions e.g. cradle, twin or side lyingassist 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 ineducate the woman to feed the colostrum to her baby using a cup or syringeavoid giving the baby a teat, dummy, finger feed or nipple shield in the first few daysdocument the breastfeeding plan as a variance on the Clinical Pathwaymaintain close observation of the baby's output and discuss normal urine and stool output with the womanonce 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 shieldrecommend 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 crustplaques or flaky skinshiny skinpustulesblanching.Causes:poor positioning and attachment (the most common)engorgementnipple variations such as flatness, retraction, inversioninappropriate use of breast pumpbreast pump shield too small or incorrectly placedsuction too highcandida infectioneczema/dermatitisbacterial infectionherpes simplexnipple vasospasmwhite spot (blocked nipple pore)anatomical variations in the baby such as:a high arched, flattened or bubble palatedisorganised sucking actiontongue-tie (ankyloglossia)bitinghormonal 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 feedavoiding the use of soaps, shampoos and non-medically prescribed ointmentsavoiding synthetic bras – cotton is preferredavoiding plastic-backed breast padschanging breast pads frequentlyif 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 mouthtopical 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 firstsoften the areola if engorged prior to attachmentstimulate let-down before attaching the baby to the breastcorrect positioning and attachment; try different positionstry 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 spontaneouslytreat any associated engorgementconsider hydrogel dressings, to relieve pain; take care with hydrogel dressings if nipples are damaged as the risk of infection may be increaseduse 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 vitalreview the woman for possible causes of ongoing pain, if the pain is not resolvingdiscuss the importance of not limiting feeding times as repeated detachment of baby can contribute to nipple trauma and subsequent ineffective milk transferdiscuss 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 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 suctionrecommend she air her breasts after feedingsuggest rinsing nipple/areola with clean water and bathing the crack with fresh expressed breast milk to aid healing and prevent bacterial infectionrecommend that dummy/pacifier/teat be discontinuedoffer 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 Consultantthe 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 breastsif 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 mastitisfeed 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.Managementreview 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 symptomsnipple pain immediately after or between feeds, or pain precipitated by cold, such as when getting out of the showerpain may range from mild to intense and last for a few minutes or longerpain may radiate into breastmaybe associated with triphasic colour changes of the nipple – from white, to blue, to red.Managementavoid exposure to cold; wear warm clothing and breastfeed in a warm environmentavoid airing the nipples after feedsuse warm packs and nipple warmers after and between breastfeedsavoid caffeine and nicotinerefer for review by doctor who may consider:elemental magnesium supplements which may assist in vasodilation 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/areolawomen may describe burning, stinging nipple pain that continues during and after the feedthe nipples are often very tender to touch and even light clothing can cause painnipples may appear pink and/or shiny and areola may be reddened, dry or slightly flaky.Breastwomen may describe shooting, stabbing, or deep aching breast pain; pain may also be felt radiating into the back or down the armthe breast pain typically occurs after feeding or expressing; the let-down reflex may be more painful than normalthe pain may be localised to one nipple or breast or may be bilateralbreasts 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 diagnosesbacterial infection: if nipple damage is presentnipple vasospasm: if nipple pain is exacerbated by cold and/or nipples blanchnipple eczema/dermatitis: if significant itching and/or rash are presenttrauma 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.BabyOralBaby’s mouth: use anti-fungal gel as prescribed by medical officer or other health care prescriber. TopicalApply anti-fungal cream as prescribed by medical officer or other health care prescriber to nappy area.MotherTopicalNipple 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. OralAnti-fungal capsules as prescribed by medical officer or other health care prescriber.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.Managementin the neonatal period avoid direct contact between the baby and the lesions; the woman should not breastfeed or offer skin-to-skin contactthe affected breast must be regularly drained through expressing to maintain the milk supplyexpressed breastmilk from the affected breast must NOT be fed to the infant and should be discardedthe infant may be fed from the unaffected breastthe woman may be prescribed acyclovir; this is considered compatible with lactationeducate 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 surgerybabies born with anatomical anomalies which will impact on breastfeeding e.g. cleft palateminor problems which persist despite midwifery intervention e.g. damaged nipples unimproved by correcting positioning and attachmentbabies with tongue-tie which may require frenotomybabies brought to the emergency department or admitted to paediatrics with breastfeeding problems.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 attachmentinsufficient breastfeedingrestricting breastfeedssleepy babymother-infant separationunresolved engorgementuse of artificial infant formula, teats and pacifiersankyloglossia (tongue-tie) and other oral cavity abnormalities.Other reported causes of low milk supply may include:maternal smoking, overuse of caffeine and other substance usematernal alcohol consumption may slow the milk ejection reflex, thus reducing breast drainage and milk productionmaternal 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 nipplesmenstruation and/or subsequent pregnancy; some women perceive a reduction in milk supply during menstruation or early pregnancyuse of combined oral contraceptive medicationsexcessive exercisebaby medical problems interfering with breastfeeding; for example, congenital abnormalities, cardiac problems, prematurity, illness, oromotor dysfunctionearly introduction of solidsinsufficient glandular tissue, which may be:primary; for example, hypoplastic breastssecondary; 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 3fewer than 5–6 heavy wet nappies/24 hours after day 5concentrated urineno change to normal breastmilk stools by day 3–4 and scant stools thereafterdry mucous membranesweight loss greater than 10% birth weightfurther weight loss after day 3–4less than 20gm weight gain/day after day 3–4failure to regain birth weight by 2 weeks of agelimited evidence of milk transfer during feedsprolonged or continuous feeding with little evidence of satietypersistent jaundicepersistently sleepy or lethargic infantexcessive crying, weak crybaby appears unwellinadequate number of feeds per day <6-8 feeds/24 hourssleepy babysub optimal positioning and attachment during breastfeedingincorrect sucking technique (sucking disorganisation or dysfunction) sleepy babybaby mouth, tongue or palate structural concernsbaby affected by medication that the mother received in labourusing a dummy/pacifier (see Section 11 in this document ‘Dummies and Pacifiers’)use of medically indicated breastmilk substitutes in the first few daysuse 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)nipple traumaretained products previous breast surgeryinsufficient glandular development of the breastuse of a nipple shield insulin dependent diabetes mellitus traumatic labour and/or birthpostpartum haemorrhage (PPH) hypothyroidismpolycystic 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 supplyassess for correct positioning and attachment and encourage to feed frequently according to the cues of her babyrecommend frequent emptying of the breast by adequate feeding or/and expressing by hand and transitioning to pumpingthe baby should be assessed for signs of wellness or wellbeing offering top-up feeds at the breastoffering comfort feeds at the breastdiscuss 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 Linethe woman can articulate signs of adequate milk transfer in her babythe 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 occurredreason for the surgerytype 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 rupturenerve injury – loss of nipple sensation (~10%); can interfere with milk ejection reflexductal injury – milk production will not continue in glandular tissue without intact drainageimplant 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 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 outcomeit is possible to breastfeed – most women can produce some amount of milkduring establishment of lactation it will be important to monitor the baby for signs of adequate milk intake and growthbreast 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. 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.Back to Table of ContentsSection 5 - Breastmilk expressionExpression of breastmilk is enhanced when both physical and psychological factors are met to elicit the milk ejection reflex.Physicalstimulation of the very sensitive nipple/areola.Psychologicalhearing a baby crythinking about her babysmelling her baby – maybe the baby’s nightgown or blanketseeing her baby or a phototouching 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 useit may help to have a picture of her baby close bythe woman should have a glass of water nearbysome women may prefer to use combined methods of expressing alternating hand and pump to maximise yielddiscuss the use of breast compression during expression to increase milk yielddisposable breast pump kits may be used for 24 hours or 8 expressionsthe 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. 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 areolainstructing the woman to gently push her hand into her chest wall and gently roll her thumb and finger towards each other in a rhythmical motionusing the other hand, a clean plastic container should be positioned to collect the milkmoving the fingers to another position once the flow has stopped, ensuring all lobes of the breast are emptiedrepeating the process on the other breastchanging from breast to breast until the required amount is collected, or waiting and trying again later.5.3 - Expressing by electric pumpthe woman will be shown how to assemble the pump according to manufacturer’s instructionsthe woman should be encouraged to gently massage the breast prior to pumpingit may help for the woman to hand express prior to pumpingthe suction strength of an electric pump should be started on low and increased as long as there is no discomfortexpressing should continue until the breast is softrepeating the process on the other breast, or alternatively the woman can be shown how to double pump, using two pump kits concurrentlychanging 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:Indicationswith diabetes in pregnancywhose baby will be born by elective caesarean sectionwhose babies have been diagnosed antenatally with cleft lip and palatewhere there is as strong family history of dairy intolerancewhose babies have been diagnosed antenatally with congenital conditions which may include Down Syndrome or cardiac disorders. Procedureadvise the woman to commence antenatal expressing at > 36 weeks pregnantthe 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 onceadvise 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 birthcolostrum 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 equipmentthe most appropriate containers to usethe 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 freezerthat 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 expressionwhen at home the milk should be labelled with the date and time so that the woman knows which milk to use first.Refrigerationexpressed 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 babywhile 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 frozenFor further information regarding refrigeration/freezing of EBM see table below.Freezingfrozen 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 cyclefrozen 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 milkeach container should be labelled and dated.Thawinguse the oldest milk firstideally breastmilk should be thawed in the fridge otherwise place the container in a pan or jug of tepid waterthawed milk should be refrigerated if not used immediatelyshake the container to evenly distribute the fatdiscard any thawed milk not used within 24 hours.Storage and Use of Breastmilk in HospitalAll 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.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.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.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 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 MilkBreastmilkRoom TemperatureRefrigeratorFreezerFreshly expressed into a closed container6–8 hrs (26?C or lower). If refrigeration is available store milk there3–5 days (4?C or lower) Store in back of refrigerator where it is coldest2 weeks in freezer compartment inside refrigerator. 3 months in freezer section of refrigerator with separate door.6–12 months in deep freeze(-18?C or lower).Previously frozen -thawed in refrigerator but not warmed4 hours or less(i.e. the next feeding)Store in refrigerator 24 hoursDo not refreezeThawed outside refrigerator in warm waterFor completion of feedingHold for 4 hours or until next feedingDo not refreezeBaby has begun feedingOnly for completion of feeding, then discardDiscardDiscard(Australian Breastfeeding Association, 2012) HeatingHeating breastmilk:place the breastmilk in a container of warm to very warm waterdo not use the microwave oven to heat the breastmilk due to uneven heating of the breastmilk, which may lead to scolding the babydiscard 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 informationif 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’ pamphletrefer the woman to the ACT Health Breastfeeding e-resource ‘Expressing and storing breastmilk’ section: to Table of ContentsSection 6 - Breast related issues6.1 - Blocked lactiferous ductsA 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 rigoursblocked ducts are usually seen after 7 days postpartum but very occasionally occur in the early postpartum period.Predisposing Factorsblocked ducts may occur in women who have an abundant milk supply and who are unable to drain each breastpoor attachment or incorrect sucklingconstriction 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 constrictionrepeated blocked ducts occurring after discharge from hospital may be due to a poor diet, or fatigue.Management of a blocked ductexplain to the woman the importance of treating the blocked duct immediatelycheck the attachment of the baby to the breast and how many breastfeeds her baby is having per dayposition the baby on the breast so that the bottom jaw is on the affected side of the breast and feed from the affected side firstexplain to the woman that she may like to vary the feeding positions to help empty the breastsuggest to the woman that she gently massages the lump towards the nipple during (and after) feeding her babyapplication 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)Alert Advise 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.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.Managementsoftening 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 resolvesthe 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. 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 hourscorrect positioning and attachmentavoid the use of dummies, artificial teats and supplementary feeds.Management continue to offer frequent and unrestricted breastfeedssoften 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 comfortablealternate feeding positions to facilitate drainage of all breast segmentsallow milk to drip from one side while feeding from the otherexpress 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 feedapply cold packs after feedsgently massage the breasts whilst under the shower, allowing milk to flow spontaneouslyrecommend analgesia such as paracetamol or ibuprofenmaintain good drainage and comfort until breast fullness resolves, usually within a few daysteach woman how to check for lumps and follow guidelines for blocked ducts if requiredteach 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. 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 reflexcheck positioning and attachment of the baby at the breastrecommending frequent baby-led feedingif 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 discomfortuse cold packs to alleviate pain between feeds for the next 12-24 hoursempty at least one breast at each feed . Full breasts and engorgement Full Breasts EngorgementBreastswarm, heavy, tenderhot, oedematous, painfulSkinnormal appearance, possible marblingshiny, streaky or diffuse red areasAreolafirmmay be stretched flat and oedematousMilk flowmilk flows well, infant can still suckle and remove milk easilypoor or no milk flow, difficult for the baby to attachFeverusually absentmay have a mild feverExpressing 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)lethargyheadachenauseaanxiety‘flu like’ symptoms such as aching joints.Risk Factorsprevious history of mastitistight restrictive clothing such as a tight/poor fitting bra, underwire bramissing feeds and abrupt weaningwhite spot on nipple or blocked ductincomplete emptying of the breastincorrect positioning of the baby at the breast which may lead to poor drainage and trauma of the nipplesrough handling of the breastspoor hygiene such as not washing hands before breastfeeding, application of nipple creamspoor diet and anaemiastress 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 removaloffer affected side first apply heat on the affected area or a warm shower prior to feeds, and cold pack between feeds to reduce inflammationsimple analgesia avoid pressure on breast tissue from bras, tight clothing or baby carrierssupportive 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 breastthe electric breast-pump may be used to empty the affected breasttry 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 hoursa medical review is needed as antibiotic therapy may be requiredcontinue to maintain breastfeeding or effective milk removal by expressing.Antibiotic regime as per the Therapeutic Guidelinesadvise the woman to complete the entire course of antibioticsprovide 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 MastitisReferralReferrals are accepted directly from:self-referring patientshealth professionals involved in their care including:GPs physiotherapistsspecialists, and MACH nurseswomen referred with blocked ducts or mastitis are triaged as a Category 1 referral and are seen as a priority on day of referral wherever possiblewomen 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) physiotherapistwomen more than 3 months postpartum residing in the ACT or accessing ACT MACH services should be referred to the WY&CCHP physiotherapistPhysiotherapy provides a Monday to Friday service. Women should be advised to contact a private physiotherapist in the ACT if:treatment is required over the weekendan appointment is not available within the appropriate servicethey have private health insurance with ancillary cover.Initial AssessmentGain informed consent from patient for examination of the breast as per ‘Intimate Body Care and Examinations by Health care Workers’ SOPcomplete subjective and objective assessment of patient as per ‘Physiotherapy Assessment – Breast Postpartum’ form found on the Clinical forms registerdetermine from assessment if the woman has blocked ducts or inflammatory mastitis and the condition is appropriate for physiotherapy intervention. 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 UltrasoundTherapeutic 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.Interventiondetermine 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.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 obtain informed consent to perform US therapy. Document informed verbal consent and warnings given in medical recordask 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 position the woman so that she is comfortable and the affected area of the breast is easily accessibleapply US gel generously to treatment area and soundheaduse the following US settings:frequency: 1 MHz for a tissue depth of 3-5 cmintensity: 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/cm2mode: continuousduration: 5 minutes per soundhead areatreatment should be performed once a day until pain and swelling have resolved, usually requires 2-3 treatmentsfollowing treatment:assess immediate effect of intervention including any abnormal reactionsadvise the woman to drain affected breast by breastfeeding or expressing, ideally within 30 minutes of treatmentsubsequent treatmentsre-evaluate effect of treatment on pain levels, size of the lump(s), redness and temperature differences between breastsif symptoms are escalating, or there is no improvement after 2-3 treatments, refer the woman to see her GP for a medical reviewinfection controlmilk is considered a low risk body fluidultrasound treatment head must be cleaned with warm soapy water and dried thoroughly post treatment.Lymphatic drainage massagemay be helpful to decrease oedema of the breast resulting from inflammation of the parenchyma, thereby relieving pressure on milk ductswomen should be advised not to massage forcefully towards the nipple to unblock the duct as this can be painful and cause more breast tissue traumamassage should be performed with a flat, open palm, with slow, gentle, light strokes, clearing towards the axillathe following self massage sequence may be performed in lying 2-3 times daily during the inflammatory phase:diaphragmatic breathing x 5 breaths, utilising the respiratory pump and encouraging relaxationkneading to entire axilla for 1 minute to activate axillary lymph nodesslow effleurage strokes x 10-12 over the breast clearing towards the axillastatic 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)diaphragmatic breathing x 5 breaths.Kinesiotapingkinesiotape may be applied to the breast to reduce oedema by directing fluid to the axillary lymph nodesprior 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.applicationcut 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 liftinghave the woman positioned with shoulder flexed and abducted overhead to put breast tissue on stretchplace 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)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.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 Symptomshard, red, painful lump on breastfever ‘flu like’ symptoms feverdizziness nausea extreme fatigue and aching muscles.Classification of breast abscesssubareolar 23% - superficial and near the nipple. These usually ripen like a boil and are easier to excise and have better prognosisintramammary-uniocular 12% - a single area of pus deep in the breast away from the nippleintramammary-multilocular 65% - multiple sites of pus within the abscess, these have a high rate of recurrence. Management of breast abscesswomen with a breast abscess need to be referred to a surgeon/radiologist for managementfor proven breast abscess, needle aspiration under ultrasound or surgical drainage is the standard managementIV 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 babyif 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 breastif indicated, temporary weaning may be necessary for up to 4 days to allow for sufficient healing and removal of drainmilk 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.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 traumaintraductal papilloma – a small, benign growth on the lining of a duct which may erode, causing painless bleeding into the ductfibrocystic disease.ManagementSmall amounts of ingested blood will be tolerated by most babies and therefore breastfeeding can usually continueensure correct positioning and attachment and manage nipple traumaif blood in the breastmilk continues for longer than a few days, diagnostic ultrasound and cytologic evaluation should be consideredmoderate vomiting of blood in an infant requires medical review to exclude illness.Back to Table of ContentsSection 7 - Lactation AidsAll 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 wellIndications for use of nipple shield:women with inverted nipples or other nipple variations where the baby cannot attachfor preterm babies who are unable to maintain attachment to the breast transitioning baby from artificial teats to the breastbaby with micrognathia (e.g. Pierre Robin syndrome)baby with low tone (e.g. Down Syndrome)disorganised sucking oral cavity abnormalitiesuse 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 shieldBreastfeeding may continue where it might have been ceased without a nipple shield.Disadvantages for use of nipple shieldlack of stimulation to the breast ineffective milk transfer poor weight gain or weight lossaltered suck resulting in breast refusal inconvenience for the woman difficulty weaning from the nipple shield. Contraindications for use of nipple shieldmother’s milk has not yet ‘come-in’.Managementprovide the woman with the Nipple Shield information sheet (Attachment 2) and obtain verbal consentuse only after the milk is ‘in’ and flowingchoose 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 shieldevaluate the correct fit for the baby ensuring the length of the shield does not exceed the length of the baby’s mouthobserve 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 mastitisevaluate and document outcomedevelop a follow-up plan to monitor baby’s weight and weaning from the shieldthe woman and baby should be referred to the MACH nurse for priority support on discharge.Instructions for useexpress a few drops of milk to start the milk flowingsmear breastmilk onto the outside of the shield to encourage the baby to attachhand express a few drops of milk into the shield before offering the breast to the infantto 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 edgestouch the baby’s lips with nipple shield, wait for a wide-open mouth then bring the infant quickly onto the shieldensure 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 damagefeed 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 shieldcontinue to offer breastfeeds without the shield, drawing the nipple out manually or with a pump as aboveif unable to attach, start the feed with the shield then take the shield off during a break in the feed and try againthe time taken to wean from a shield varies considerablyseek 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 breastbabies who are unable to attach at the breast.Advantages of cup feeding:parents are able to feed their baby independentlybabies are able to pace their intake in time and quantityappropriate tongue and jaw movements are stimulatedolfactory and oral sensory receptors are stimulatedno foreign objects are placed in the baby’s mouthmovements of the tongue and muscles of the mouth are encouragedbabies are assisted to develop a good undulating rhythm of their tongue.Disadvantages of cup feeding:the baby’s need to suck will not be fulfilledthe baby may become accustomed to feeding from the cupthe baby may tend to dribble the milkPossible contraindications to cup feeding:the baby has a poor gag reflexthe baby is lethargic or excessively sleepythe 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 parentsensure the baby is awake and alertwrap the baby securely so the cup will not be knocked place the baby in an upright position on the lapuse a small breastmilk cup and half fill with breastmilk or formulaplace 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 cuptilt 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 aspirationallow time for the baby to swallowlet the baby pace the feedings which should be limited to 30 minutes to minimise fatigueallow time for the baby to burpsupervise the parents technique of cup feedingexplain 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.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 lactationdelayed lactationcompromised lactation e.g. hypoplastic breasts, breast surgery, breast reductionadoptive breastfeeding babies with medical conditions which prevents them from sucking adequately at the breast e.g. heart anomalies, neurological conditions.Advantages of a supply lineuse of a supply line enables breastfeeding to continue.Disadvantages of a supply linesupply lines can be inconvenient to usethe 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.Equipmentsupply line tubenonallergenic tapeor the Medela supply line (mother’s own) and use according to product information.Managementdescribe to the woman how a supply line is usedif 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 topsecure 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 areolacheck baby’s position and attachment to the breast is comfortable for the mothermilk 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 containerdiscard the tubing when no longer needed as it should be used by one mother and baby dyad only.Dischargeseek assistance from the MACH nurse, a lactation consultant or experienced clinician for ongoing support.7.4 Syringe drop feeding Equipmentdisposable 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 hourlydiscuss the reasons for a syringe drop feed with the woman and obtain her consenteducate the woman or her partner to:offer skin to skin contact; observe for the baby’s readiness to feedobserve for the baby’s rooting reflex and licking behavioursoffer a breastfeed if the baby appears ready to feedsmall 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 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 feedobserve for the baby’s rooting reflex and licking behavioursoffer a breastfeed.Equipment:disposable No. 5 G feeding tubehypoallengic tapelatex free glovesdisposable 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 independentlyexplain 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 mouthattach a filled (EBM/complementary feed) 20 ml syringe to the other end of the feeding tubeelicit 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 stimulatedelicit the gape reflex by firmly stroking from nose to chin motion and await baby’s wide open mouth with tongue downallow 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-introducedencourage the woman to record the amount of fluid taken and the baby's response to finger feedingdocument the feed and feeding plan in the clinical recordcontact the neonatal registrar to assess the baby’s wellbeing if poor feeding continues.Back to Table of ContentsSection 8 - Baby-related breastfeeding issues8.1 - 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 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.Managementconduct a routine breastfeeding and newborn assessment and refer any anomalies to the neonatal registrarensure correct positioning and attachment techniqueteach parents to recognise and respond to subtle feeding cueswake the baby for breastfeeds, ensuring 8–12 feeds per 24 hours in the early postnatal periodimplement 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 expressingmonitor the baby’s progress i.e. output, feeding activity and weightif the baby ’s hydration or weight gain are of concern, care as per Guideline .Strategies to rouse a sleepy babyunwrap the baby, change the nappy and allow to self-stimulate for a few minutesundress baby and place in skin-to-skin contact with mothergently massage the baby’s back, front, arms, legs and talk to the babygive the baby a taste of expressed breastmilk either directly from the breast or from a spoon, cup or dropperstroke 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 techniqueutilise rousing techniques as abovebreastfeed 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 minutesgently remove the baby from the breast and use rousing techniques to wake the infant up again; once awake, switch baby to the opposite breastwhen the baby becomes sleepy on the second breast, remove from the breast againchange the baby’s nappy, and repeat gentle rousing techniquesoffer 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 flowat the end of the feed, the baby may have a period of comfort, non-nutritive suckingonce the persistent sleepiness is resolving and the baby is feeding more effectively, the mother can allow 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 periodunsettled 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 positionbefore 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 engorgementafter the milk comes in, the baby may be unsettled for a few days as she/he adjusts to the larger volumes of milkcrying 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 cryingteach parents how to recognise and respond to hunger cues.Managementincrease skin-to-skin contact and minimise over-stimulationensure correct positioning and attachment and encourage baby-led feedingreassure the mother that it is okay to use the breast as a source of comfort for an unsettled babyavoid giving feeds of infant formula or water unless there are medical indications, the baby should be offered more frequent breastfeeds insteadexplore strategies to allow the mother to rest by enlisting support of family and friendsafter 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 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 lifeassist parents to recognise nutritive sucking patterns and signs of milk transferparents 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 cuddlingcarry the baby in a baby carrier or slingtry swaddling, rocking, singing, stroking, massage, bathing, music, white noise, movement in a pram or carreduce sensory input – loud noises, television, bright lights, excessive movement or over-handlingensure the baby is not too hot or too cold .Parental expectationsmost 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 cues8.3 - 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 vomitfever, vomiting, rashear dischargeoffensive urine or stoolssub-optimal weight gain, or weight lossdysmorphic appearancedevelopmental delayOther possible causes to consider include:maternal intake of nicotine and caffeinematernal 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.Babies who refuse the breast may:arch their back away from their mothercry when approaching the breastpush away from the breastturn head away from the breast.Possible reasons for breast refusalBaby-related:problems with attachment or positioning at the breastbirth interventionovertiredness/overstimulationinfectious illness such as respiratory illness, sore throat, blocked nose or ear infectiondistraction while feedingrecent vaccinationteething, bitingtongue-tie.Other-related:nipple and breast variationsmastitischanges to the smell of the woman – such as perfume, soaps, chlorineunwell mother with decreased milk supplymaternal intake of particular foods/medicineshormonal changes (such as ovulation, menstruation, oral contraceptive or pregnancy)delayed let-down reflexfast flow or slow flowlow milk supply.Managementreassurance that this is usually a temporary situationassess for cause and correct if possibledo not force the baby at the breastincrease skin-to-skin contact to facilitate baby-led feeding and attachmentoffer feeds with an early feeding cuehand express to soften areolaexpress milk into the baby’s mouthassess positioning and attachment techniquetry feeding in different positionstry walking and breastfeeding or breastfeeding in the bathtry to feed the baby when they are drowsy monitor baby’s urine and stool outputmaintain the milk supply with expressingfeed the baby using a cup.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 breastfeedingearly breastfeeding after the birthif 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 hourswomen 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 timefeeding 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 choicewhen 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. Women who do continue to breastfeed in pregnancy will cite breast and nipple pain as the most common reason for stopping breastfeeding while pregnant. Women who breastfeed during pregnancy may experience:nipple and/or breast tendernessdecline in milk supplychange in milk taste – as described by breastfeeding toddlersuterine contractions while breastfeedingweaning – 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.Back to Table of ContentsSection 9 – Complementary feeding9.1 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: 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 neededMaple syrup urine disease a special formula free of leucine, isolecine and valine is neededPhenylketonuria 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 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 feedingbabies 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 feedinglow birth weight babies less than 1500gmvery preterm babies born less than 32 weeks gestationPrior 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 milkgive 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 pacifierscomplementary 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 giventhe method by which the complementary feed was givenmeasures taken to maintain the woman's milk supplythe baby’s condition and behaviour at each feed.Back to Table of ContentsSection 10 - Artificial Feeding/Infant formula10.1 - 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 formulaher choice of formula and sterilising methodthat she will need to provide the formula and feeding equipment for her baby during her hospital stayequipment required for bottle feeding:bottles: at least six plastic (BPA free) or glass infant feeding bottlesseveral teatsa knife for levelling off the formulaa bottle brush to clean the bottlessterilising 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)evaporated milksweetened condensed milkgoat’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:washing hands cleaning the bench area where the formula is to be madecleaning the lid and the top of the tin with warm soapy water, before opening the tinensuring all feeding equipment has been sterilised using a recommended home sterilising methodmark 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 firstfollow the manufacturer’s directions exactly when measuring powdermix 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 formuladiscard any leftover formulafeed 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 hold bottle at an angle to keep teat and neck of bottle full of milkgive half of the required feedsit the baby up and gently allow to 'burp'continue with the second half of the feedany feed remaining should be discarded, not stored and reheatednever ‘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 usestore 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 feeddiscuss and provide the woman with the ACT Health formula feeding pamphletif 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 0/1DAY 2DAY 3DAY 4DAY 5DAY 630mls/kg/day60mls/kg/day90mls/kg/day120mls/kg/day150mls/kg/day180mls/kg/dayQuota 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 feedQuotas 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 rm 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:Boilingplace 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 Sterilisingsteam 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.Chemicaldiscuss 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 chosensome specialised feeding equipment e.g. cleft palate teats and bottles can only be sterilised in chemical solutionmake 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 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 reliefsuggest wearing a firm bra for supportteach the woman how to hand express for comfort if she needs some reliefteach 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 babyoffer 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 productionsupport 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 take commitment, time and need guidance from a health professional skilled in lactation managementdiscuss support for the future.? Reassure the woman if she has another child and decides to breastfeed that she may not experience the same problemsteach the woman about the signs and symptoms of Mastitis and give her a leaflet on Mastitis before discharge and discuss breast engorgement and breast abscessdiscuss with her community support of ABA, MACH and GP. Back to Table of ContentsSection 11 – Dummies and PacifiersInform 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 establishededucate 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 sanitisationdocument in the clinical pathway when a woman makes an informed choice to use a dummy/teat. Dummy Hygieneadvise the mother never to put the dummy in her own mouth before giving to the babydummies 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 babyat home at least two dummies are recommended so that there is always one clean dummy for use when required.Back to Table of ContentsSection 12 – Contraception and breastfeedingThe 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 amenorrhoeicthe 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).Back to Table of ContentsImplementation This Clinical Guideline will be referred to in existing delivery of education. Sent to staff via email and displayed in workrooms.Back to Table of ContentsDefinitionsColostrum: 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).Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationFurther information relating to the support and facilitation of breastfeeding across the care continuum can be accessed from the following resources: Capital Territory Government. (2010). The ACT Breastfeeding Strategic Framework. 2010-2015. Canberra: Australian Capital Territory monwealth of Australia. (2009). Australian National Breastfeeding Strategy. 2010-2015. Canberra: Australian Government Department of Health and Ageing.ProcedureHypoglycaemia in the newborn-SOPBack to Table of ContentsReferencesAcademy of Breastfeeding Medicine. (2014). ABM clinical protocol #4: mastitis. Breastfeeding Medicine 9(5). DOI: 10.1089/bfm.2014.9984Academy of Breastfeeding Medicine. (2009). ABM clinical protocol #20: engorgement. Breastfeeding Medicine 4(2). Doi:10:1089/bfm.2009.9997Australian Breastfeeding Association. (2013). Expressing and storing breastmilk. Accessed at hppt://breastfeeding.asn.au/bf-info/breastfeeding-and-workAustralian Breastfeeding Association. (2012). Engorgement. Accessed at hppt://breastfeeding.asn.au/bf-info/commonconcernsFetherstone C. (2001). Mastitis in lactating women: Physiology or pathology? Breastfeeding Review, 9(1):5-12.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: 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: World Health Organization. (2008). Indicators for assessing infant and young child feeding practices. Geneva: World Health Organization. Accessed at: Health Organization. (1989). Protecting, promoting and supporting breast-feeding. The special role of maternity services. Geneva: World Health Organization. Accessed at: Health Organization. (1981). International code of marketing of breast milk substitutes. Geneva: World Health Organization. Accessed at: S. (2002) Ultrasound therapy. In S. Kitchen (ed.) Electrotherapy : Evidence –based Practice. 11th Ed. Edinburgh: Elsevier Churchill Livingstone: pp. 211-230.Back to Table of ContentsSearch TermsBreastfeeding, 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 blebBack to Table of ContentsAttachmentsAttachment 1: Breastfeeding Policy SummaryAttachment 2: Parent Information Sheet Antenatal Expressing Attachment 3: Parent Information Sheet Nipple ShieldsAttachment 4: Referral FlowchartDisclaimer: 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 AmendedSection AmendedApproved By24/03/2016Sentence added to the introductionHCID Policy Team, CHHS05/03/2018Information pertaining to storage and labelling of EBM added to Section 5.5Karen Faichney A/g ED, WY&CAttachment 1: Breastfeeding Policy SummaryThe 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 staffThe benefits of breastfeeding are clearly and simply explained to all pregnant women, together with good breastfeeding management practicesA written curriculum of the breastfeeding education is available for pregnant women using our servicesAll 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 requiredMidwives 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 milkWhen 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 syringeEncourage and support the woman to have her baby remain with her 24 hours per dayDemand (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 feedWomen 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 recordHealth care staff should not recommend the use of dummies/teats during the establishment of breastfeedingAll women will be provided with information on where they may obtain advice and support with breastfeeding after dischargeAll women will be referred to community agencies such as the Australian Breastfeeding Association and MACH nurses on dischargeAttachment 2: Parent Information Sheet - Antenatal ExpressingColostrum 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 sectionWomen whose babies have been diagnosed with a congenital condition, such as cleft lip or palate, Down syndrome or cardiac disordersFamilies 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. You will be given a start - up expression kit: 4 oral syringes, 2 small plastic pouches and blank labels. 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). Attach a label with your name, date and time of first expression onto each syringe, place the syringes into the plastic bags provided.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.Breastmilk statusRoom temperature(26°C or lower)Refrigerator(4°C or lower)FreezerFreshly expressed into container6-8 hours If refrigerator is available store milk there3 days Store at the back where it is coldest2 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 warmed4 hours or less - that is, the next feeding24 hoursDo not re-freezeThawed outside refrigerator in warm waterFor completion of feeding4 hours or until the next feedingDo not re-freezeInfant has begun feedingOnly for completion of feedingDiscardDiscardAustralian Breastfeeding Association reproduced from NHMRC Infant Feeding Guidelines 2012AccessibilityThe 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 HealthACT@.auIf 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 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 2016This 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: HealthACT@.auhealth..au | .auEnquiries: Canberra 13ACT1 or 132281 | Publication No XXXXXAttachment 3: Parent Information Sheet - Nipple shieldsWhat 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 wellwhen nipples are damaged from poor attachment to the breastif 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 babyyour milk supply may slowly decline over time if your baby is not well attached or feeding effectivelyyour milk can take longer to flow from the breast when a nipple shield is used so feeds may take longer to finishalways 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 growthEnsure your nipples air dry after using a shield to avoid them remaining too moist.How to Use:Ensure your hands are cleanexpress a few drops of milk to start your milk flowingturn nipple shield inside outsmear breast milk onto both sides of the shield to encourage your baby to attach and assist the shield to adhere to your skingently 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 Shieldgenerally there is no need to sterilise the nipple shieldwash well in hot soapy water and rinse and drain dry.store in a clean, dry, covered munity 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 usechecking your baby’s weight and your breast milk supplywhen 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) breastfeeding.asn.auACT Maternal and Child Health NurseCommunity Health Intake on (02) 6207 9977 between 8am and 5pm weekdaysQueanbeyan 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 HealthACT@.auIf 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 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 2016This 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: HealthACT@.auhealth..au | .auEnquiries: Canberra 13ACT1 or 132281 | Publication No XXXXXAttachment 4: ACT Breastfeeding Referral FlowchartACT Health website provides information on breastfeeding services in the ACT. Visit health..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) munity 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: health..au/MACHDrop-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: health..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 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 (.au) and over the phone (1800 882 436). Video calls with qualified counsellors are also now available; accessed on their website pregnancybirth .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) ................
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