Breast feeding: Guidance for staff assisting the mother

NOTE: We review our guidelines regularly and this guideline is now past its review date. The content of the guideline below may not reflect the most recent evidence-based practice. Please use with caution.

Introduction

Advantages of Breast-Feeding for the Baby

Advantages of Breast-Feeding for the Mother

The UNICEF/World Health Organisation (WHO) Baby Friendly Initiative was launched in 1994 with the publication of a ‘Mothers Charter’, ‘Protecting Breast-Feeding Rights’. (UNICEF, 1994)
Resident mothers who are breast-feeding should be offered literature about the facilities for breast-feeding and expressing milk at GOSH:

Background

Physiology of lactation

Milk production begins when the placental steroid hormones, (progesterone and the oestrogens) have declined, and prolactin secretion rises. (RCM, 2002)
Colostrum (which is secreted from the breasts shortly after birth) is high in protein, immunoglobulin A (IgA), the Vitamins A and E, and contains less fat and lactose than mature human milk. (Lang, 2002; RCM, 2002; Henschel and Lynch, 1996) It also acts as a mild laxative, so assists with the passage of meconium. (Lang, 2002)
The two main hormones involved with milk production are:

  • Prolactin (produced in the anterior pituitary gland) which stimulates milk secretion in the milk ducts. 
  • Oxytocin (from the posterior pituitary gland) which is responsible for the propulsion of the milk from the ducts to the nipple (known as the ‘let down’ reflex).

The composition of the breast milk changes during feeds. Initially the milk is ‘watery’, (foremilk) but as the baby settles into a regular sucking rhythm, the fat and calorie content increase (hindmilk). Adequate emptying of the breast is necessary for the maintenance of effective lactation.
Milk is produced while the baby is suckling, so to establish lactation the nipple area (areola) needs to be stimulated regularly. If the baby is unable to suck the breast, milk should be expressed at least 8 times a day when establishing lactation. Once lactation is established the frequency of expressing may be reviewed.
As the baby gets older, the composition of the milk will change. It will appear thinner and whiter and is known as mature milk.
Normal babies will experience ‘growth spurts’ when they will feed more frequently. This may occur at around six weeks.

Advice about supporting the mother who is establishing lactation

Psychological support

Give the mother much encouragement to breastfeed, supplying her with information about its advantages. (Lang, 2002; RCM, 2002; Henschel and Lynch, 1996)
See:

Physiological support

  • Encourage the mother to drink regularly (at least 8-10 glasses of fluid daily), and eat a good balanced and nutritious diet.
  • Offer breast-feeding vouchers towards the cost of food (babies under 6 months).
  • Try to encourage the mother to rest and take some regular exercise (Rationale 3). 

Environmental support

  • Privacy is usually appreciated while feeding, so provide a single room and/or curtains (Rationale 4). 
  • Supply a comfortable chair and provide pillows to assist the mother to position the baby well (UNICEF Enterprises Ltd, 2004). 
  • When necessary, obtain a breast pump and equipment for expressing milk. (Rationale 5). 
  • N.B. Mothers must be taught correct use of the breast pump and shown how to safely handle their expressed breast milk (Rationale 6, Rationale 7).

Community Midwifery Services

  • Mothers who remain under the care of a midwife at home (ordinarily for ten days following the birth of their baby), who are resident with their baby at GOSH, receive their post-natal care from the community midwives at University College London Hospital (UCLH) (Rationale 8). 
  • A post-natal clinic is held three days each week at GOSH.

Midwifery clinics are held on Monday, Wednesday and Friday afternoons, 14:00-15:30.
Mother’s Accommodation, Weston House Level 4 (Rationale 9).
If further support is required the UCLH midwives can be contacted by telephone:
( 020 ) 7380 9564 Or ( 020 ) 7388 9563
Further details of this service are available from the Family Services Department, on extension 8151 (Rationale 10).

Advice about establishing breast feeding

  • Provide a comfortable environment for the mother (UNICEF Enterprises Ltd, 2004). 
  • Assist the mother to position the baby well (UNICEF ENterprises Ltd, 2004)(See Appendix 1) (Word document, 169 KB)(Rationale 11).
  • Encourage the mother to give breast feeds on demand when medically possible (Lang, 2002; RCM, 2002; Henschel and Lynch, 1996)(Rationale 12).
  • If the breasts are very full, express a small amount of milk before starting the feed, to enable the baby to latch on well (Rationale 13). 
  • Lots of encouragement will be required until the baby has established this. In some instances, this may take some time.
  • Breast pads are available from chemists, and most mothers will find them useful to prevent leakage onto their clothes (Rationale 14). 
  • A list of agencies and support groups that can advise the breast-feeding mother is provided (See Appendix 2)(Word document, 933 KB)

Practical advice for staff when a mother needs to express her milk

  • There are two main types of breast pump:
    • Hand pumps: These can usually be bought in the local chemist or supermarket, e.g. Avent ‘Isis’™ pump and Medela ‘Harmony’™ hand pumps (Rationale 15). 
    • Electric pumps: These can be hired from the manufacturers or the National Childbirth Trust (NCT), e.g. Medela ‘Lactina’™ and Egnell ‘Ameda’™ pumps (Rationale 16). 
  • Mini electric/battery pumps are also available from the above manufacturers and from chemists and department stores.
  • At GOSH, Medela 'Symphony' (yellow) and ‘Lactina’™ (blue) pumps are available on the wards, and can be taken to parents’ hospital accommodation. Pumps can be requested from HSDU via the CARPS system. Please make sure that parents are aware that these pumps are on loan and should be returned to the ward when parents are no longer in hospital accommodation or stop expressing (Rationale 17, Rationale 18). 
  • Mothers can also rent the symphony pumps directly from Medela Phone: 0161 776 0400 using the code 'NICU 30' for a discount.

Common problems that occur when a mother is breast-feeding and how to assist and support her

Problem: The Baby Who Has Difficulty in Establishing Breast-Feeding

  • Ensure that the mother is feeling secure and has privacy (Rationale 19). 
  • Put up a ‘Breast-Feeding in Progress’ notice and ask non-essential staff to leave the room and stay out if possible.
  • Try to prevent disturbance during the feeding time, so aim to coordinate the baby’s care.
  • Provide a comfortable chair, and pillows for the mother’s lap.
  • Give the mother assistance with positioning the baby when needed (See Appendix 1)(Word document, 169 KB)(Rationale 20). 
  • Provide lots of encouragement. It will get easier!
  • Seek further advice from a colleague (see the ward list of GOSH staff with experience in breast feeding). Give the mother details of national support groups (See Appendix 2)(Word document, 933 KB).
  • If the breasts are engorged with milk and the baby has difficulty latching on, suggest that the mother expresses a little milk from the breast using the breast pump (Nikodem et al, 1993). This will make the breasts feel more comfortable and supple and will help the nipple to protrude, so making it easier for the baby to latch onto the breast (Rationale 21).
  • Nipple shields may assist the mother if she has flat or inverted nipples. 
  • Use a Nasogastric (NG) or Orogastric (OG) tube, syringe, or cup to supplement feeds where necessary, and try not to introduce a bottle for feeding (Rationale 22, Rationale 23).

Problem: A Sick Baby Who is Unable to Have Feeds by Mouth or is Unable to Absorb Them

  • Provide facilities for the mother to express her milk (Rationale 24).
  • If the mother is establishing lactation encourage her to express milk at least 8 times a day, including overnight. When lactation is established, this may be reviewed.
  • If the mother is resident away from the baby, ensure that she has access to the use of a breast pump.
  • Remind the mother that to maintain her lactation, she will need to express regularly until the baby can start to feed again (UNICEF Enterprises LTD, 2004).
  • Label the milk with the baby’s name and the date and time of expressing, and place it in a refrigerator as soon as possible after expressing. Milk not required within 24 hours should be placed in the freezer (Rationale 25). 
  • The main freezer at GOSH is located in the special feeds milk room, on Level 1 VCB. Some ward areas also have additional small freezers are available for the storage of EBM.
  • Frozen milk can be safely stored for up to 3 months (Rationale 26).

Problem: The Baby is Unsettled Following Breast-Feeds

  • Check that the baby is well positioned on the breast during feeds (SeeAppendix 1) (Word document, 169 KB).
  • Check that the baby is winded adequately.
  • Give demand breast feeds providing this is medically allowed.
  • Complement feeds (top-ups) or supplement (replacement) feeds may be required if the baby is not gaining weight. Parents’ consent should be sought for the use of infant formula.
  • Try not to give feeds by bottle, but if extra feeds are required, use a NG or OG tube, syringe or cup (Lang, 2002)(Rationale 27).

Problem: The Mother Has an Inadequate Supply of Breast-Milk

  • Encourage the mother to have a nutritious diet and good fluid intake.
  • Encourage the mother to take rest while the baby is asleep.
  • Put the baby to the breast frequently, and/or express 3 hourly, or more frequently (Rationale 28). 
  • Provide lots of encouragement (Rationale 29). 

Problem: The Baby Has Difficulty Fixing at the Breast

  • Give much encouragement, as in most cases the baby will gradually learn to feed well (Rationale 30). 
  • Ensure that the environment is calm and quiet, and that the mother and baby have privacy and are undisturbed during feeding (Rationale 31). 
  • Check positioning and correct if necessary (Rationale 32). 
  • Make sure that the mother and baby are both comfortable and not to warm or too cold. Change the baby’s nappy if necessary (Rationale 33). 
  • Put the baby to the breast before he gets too ravenous and fractious, and do not attempt to put a screaming baby to the breast in the early stages of establishing breastfeeding. Settle the baby if possible first (Rationale 34). 
  • Check whether the mother has flat or inverted nipples (Rationale 35). 
  • See Appendix 1 (Word document, 169 KB) for diagrams and advice. Suggest using the UNICEF booklet: Breastfeeding Your Baby: Important Information for New Mothers (p 2-6). (Reference 5).

Problem: The Mother’s Breasts Become Engorged

Fullness of the breast is common in the early stages of lactation and is due to venous congestion and the accumulation of milk. This normally resolves within 24 hours and the breast remains soft enough for the baby to feed. Engorged breasts may become hard, painful, warm and shiny and it may be difficult for the baby to latch on effectively (RCM, 2002; Henschel and Lynch, 1996).

  • Use hot and cold flannels on the breast alternately (RCM, 2002; Henschel and Lynch, 1996)(Rationale 36). 
  • Suggest that the mother uses the showerhead to sprinkle her breasts when showering (Rationale 37). 
  • Have a deep bath and massage the breasts very gently while in the bath.
  • Cold cabbage leaves placed inside the bra may help to give relief (UNICEF Enterprises Ltd, 2004)(Rationale 38).
  • Encourage the mother to express her milk by hand (with great care to prevent bruising), or use the breast pump (on low pressure) regularly until the baby is able to suck the breast (Rationale 39 and 40). 
  • Regular analgesia will be required until the engorgement settles (Rationale 41). 
  • Remember that the more the mother expresses the milk, the more she will lactate, so take care that she does not over stimulate the breasts.

Problem: The Mother Develops Mastitis

This becomes evident when the mother has a painful area of redness on her breast, is pyrexia, and feels generally unwell.

  • Continue breast-feeding (or expressing milk)(RCM, 2002; Henschel and Lynch, 1996).
  • Ensure that the mother is using a proper breastfeeding brassiere, and that there is no pressure n the breast during feeding. Mothers wearing non nursing brassieres should remove these during feeding (Rationale 42). 
  • Antibiotics may be required, so arrange for the mother to visit the General Practitioner.
  • Analgesics may be required until the infection resolves.
  • Provide lots of encouragement to the mother. This condition usually resolves within 2-3 days.

Problem: The Mother Develops Sore Nipples

  • Assess the baby’s position while breastfeeding and if necessary help the mother to position the baby correctly (See Appendix 1)(Word document, 169 KB). It may help if she uses a different hold during feeds e.g. under the arm, or lying down to feed (Rationale 43). 
  • Suggest that she rubs some of her milk over the nipple at the completion of the feed (Rationale 44). 
  • Commercially available nipple creams may also be of assistance.
  • Sometimes the mother may develop thrush causing the nipples to be red and very sore (Rationale 45). 
  • Antifungal cream on the nipples will be required. Dactarin Oral Gel is the one most usually used (Rationale 46). 
  • In very severe cases, the breast may need to be rested and the mother encouraged to do some gentle hand expression (See UNICEF booklet: Breastfeeding Your Baby: Important Information for New Mothers (p 7)(UNICEF Enterprises Ltd, 2004).
  • The mother may find it helpful to remove her brassiere so that the nipples are exposed to air between feeds.

Problem: The Mother Has Flat or Inverted Nipples

  • Suggest that the mother expresses a small amount of milk by hand or pump immediately before the feed (Rationale 47).
  • Encourage the mother to keep her breasts as supple as possible by expressing them regularly until the baby has established feeding (Rationale 48). 
  • Use a nipple shield to assist the baby to latch onto the breast. The thin silicone shield fits over the nipple so making it easier for the baby to latch onto it. The nipple shape will gradually improve, as it will be pulled into the shield as the baby suckles (Rationale 49). 
  • Nipple shields are available in most chemists.
  • Suggest that the mother seeks professional advice from her local midwife, or contact a national supporting agency (See Appendix 2)(Word document, 933 KB).

Advice to Give to a Mother With Established Lactation Who Needs to Stop Breast-Feeding

  • This may be medically indicated when:
    • A baby is diagnosed with certain metabolic diseases, e.g. long chain fatty acid oxidation defects and galactosaemia.
    • The baby dies.
  • As the mother has established lactation, suggest that she reduces the frequency and duration of expressing so that her breasts do not become overly engorged. Aim to discontinue expressing within 2-3 days (Rationale 50). 
  • Much practical and psychological support will be required (Rationale 51). 
  • Encourage the mother to wear a firm, supportive brassiere (Rationale 52). 
  • Encourage the mother to take adequate analgesia (Rationale 53). 
  • Suppression with hormones is no longer recommended.

Rationale

Rationale 1: Breast milk is the optimum form of nutrition for babies unless this is medically contraindicated.
Rationale 2: Mothers who have a sick baby, may lack knowledge regarding the process of breastfeeding and confidence in their ability to breastfeed.
Rationale 3: Sufficient rest, fluid and a balanced diet create the optimum conditions for the initiation and maintenance of lactation.
Rationale 4: Comfort, privacy and a calm, supportive environment facilitate the let down reflex.
Rationale 5: To initiate and maintain lactation if the baby is unable to suckle.
Rationale 6: Incorrect use of the breast pump may result in breast and nipple trauma.
Rationale 7: Correct handling and storage of breast milk prevents contamination and wastage.
Rationale 8: To enable assessment of the mother’s post natal health and progress.
Rationale 9: To enable the mother to have care from the midwife at regular times.
Rationale 10: If the mother is acutely unwell, arrangements must be made for her transfer to UCLH.
Rationale 11: Correct positioning is essential for effective stimulation and emptying of the breast.
Rationale 12: Demand Feeding enhances breast milk supply and helps to ensure that the mother’s milk supply meets the baby’s needs.
Rationale 13: Babies may find it difficult to latch on to a very engorged breast.
Rationale 14: The ‘let down’ often reflex occurs when the mother is near her baby and/or hears him cry.
Rationale 15: Hand pumps can be a very useful and effective way to maintain lactation.
Rationale 16: Electric pumps are more suitable for longer-term use.
Rationale 17: Electric breast pumps are available for the mothers who are resident in hospital accommodation to prevent them having to walk to the hospital in the middle of the night.
Rationale 18: Expression during the night is important for the maintenance of a healthy lactation.
Rationale 19: Difficulties in establishing breastfeeding may stem from a lack of confidence, anxiety or physical discomfort.
Rationale 20: Ineffective positioning will lead to a poor latch and ineffective breast feeding. Poor positioning is a common predisposing factor for sore nipples.
Rationale 21: Engorged breasts are very painful and they feel hard and heavy. This makes it difficult for the baby to latch onto them. (For more information, see later section on engorgement).
Rationale 22: Offering the baby a rubber teat may make it more difficult to establish full breast-feeding and reduce the duration of exclusive breast-feeding.
Rationale 23: The use of bottle-feeding can negatively affect the success of breast-feeding because bottles provide an immediate and consistent supply of milk. (Collins et al, 2004)
Rationale 24: Expressing milk mechanically is an effective means of establishing and maintaining lactation.
Rationale 25: EBM must be labelled correctly and should include the baby’s name sticker to ensure easy identification. It should be refrigerated or frozen as soon as possible to prevent contamination.
Rationale 26: Royal College of Midwives (RCM) and milk banking guidelines.
Rationale 27: Offering the baby a rubber teat may make it more difficult to establish full breastfeeding and reduce the duration of full breastfeeding.
Rationale 28: Regular stimulation of the areola is essential for lactation
Rationale 29: This can be an anxious time for the mother, so support is essential.
Rationale 30: This is a very stressful time for the mother, and they will need a lot of support.
Rationale 31: A peaceful and calm environment is more conducive to successful breastfeeding.
Rationale 32: Incorrect positioning prevents effective milking of the breast, may result in the baby becoming frustrated and predisposes the mother to developing sore nipples.
Rationale 33: Babies who are too warm may be sleepy. Babies should not however be over exposed.
Rationale 34: Very hungry and unsettled babies often find it difficult to attach effectively to the breast.
Rationale 35: This may make successful latching difficult.
Rationale 36: This will provide comfort and help to relieve the congestion.
Rationale 37: This also provides an effective way to give relief.
Rationale 38: This treatment does no harm, but whether it is helpful remains to be established. (RCM, 2002; Henschel and Lynch, 1996)
Rationale 39: Gentle hand expression is often very effective.
Rationale 40: Using the pump on low pressure may also be effective.
Rationale 41: Engorged breasts are very painful. (Henschel and Lynch, 1996)
Rationale 42: To prevent pressure on the milk ducts and the risk of milk stasis and blockage of the milk ducts.
Rationale 43: Good positioning ensures that the baby’s jaws compress the nipple and areola correctly and promotes effective emptying of the breast.
Rationale 44: This may help to promote healing.
Rationale 45: This usually occurs when the baby develops oral thrush.
Rationale 46: Remember that the baby will need to be examined and also start treatment.
Rationale 47: This will help to draw out the nipples so making it easier for the baby to latch onto them.
Rationale 48: When the breasts are soft, the baby can latch onto the nipple more readily.
Rationale 49: If a shield is used, it should be for as short a time as possible as longer-term use may hinder milk supply. They should be used only when lactation has been established. (RCM, 2002; Henschel and Lynch, 1996)
Rationale 50: To reduce the stimulus for lactation.
Rationale 51: This can be a painful and distressing experience for mothers who want to breastfeed, and who may also be grieving for their baby.
Rationale 52: To promote comfort.
Rationale 53: To provide effective pain relief. The subsequent engorgement may be painful.

References

References/Bibliography

Reference 1:
Lang S (2002) Breastfeeding special care babies (Second Edition). Edinburgh, Balliere Tindall

Reference 2:
Royal College of Midwives (2002) Successful Breastfeeding (Third edition). Edinburgh, Churchill Livingstone

Reference 3:
Henschel D, Lynch S (1996) Breastfeeding, a guide for midwives. Cheshire, Books for Midwives Press

Reference 4:
UNICEF (1994) The Ten Steps for Successful Breastfeeding. . The UNICEF UK Baby Friendly Initiative (e-pub) (www.unicef.org/programme/breastfeeding/baby.htm).

Reference 5:
UNICEF Enterprises Ltd, Baby Welcome Programme (01/11/2004) Breastfeeding Your Baby: Important information for new mothers. . UNICEF Baby Friendly Initiative (e-pub) www.babyfriendly.org.uk/parents/byb.asp.

Reference 6:
Nikodem VC, Danziger D, Gebka N, Gulmezoglu AM, Hofmeyr GJ (1993) Do cabbage leaves prevent breast engorgement? A randomized, controlled studyBirth: Issues in Perinatal Care and Education 20(2): 61-64.

Reference 7:
Collins C, Ryan P, Crowther C, McPhee A, Paterson S, Hiller J (2004) Effect of bottles, cups and dummies on breast-feeding in preterm infants: a randomised controlled trialBritish Medical Journal 329: 193-198.

Document control information

Lead Author(s)

Mary Wallis, Neonatal Nurse Advisor, GOSH

Additional Author(s)

Margaret Harper, Senior Lecturer, London South Bank University

Document owner(s)

Annette Rathwell, Neonatal Nurse Advisor, GOSH

Approved by

Clinical Practice Committee

Reviewing and Versioning

First introduced: 
25 July 2008
Date approved: 
04 November 2009
Review schedule: 
Two years
Next review: 
04 November 2011
Document version: 
1.0