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## Complete Summary

#### GUIDELINE TITLE

Model breastfeeding policy.

#### BIBLIOGRAPHIC SOURCE(S)

Academy of Breastfeeding Medicine Protocol Committee. ABM clinical
protocol #7: model breastfeeding policy. Breastfeed Med 2007
Mar;2(1):50-5. \[22 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17661620)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Infant health/nutrition

#### GUIDELINE CATEGORY

Counseling\
Evaluation\
Management\
Prevention\
Risk Assessment

#### CLINICAL SPECIALTY

Family Practice\
Nutrition\
Obstetrics and Gynecology\
Pediatrics\
Preventive Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To facilitate optimal breastfeeding practices

-   To promote a philosophy of maternal infant care that advocates
    breastfeeding and supports the normal physiological functions
    involved in the establishment of this maternal infant process

-   To assist families choosing to breastfeed with initiating and
    developing a successful and satisfying experience

#### TARGET POPULATION

All pregnant women and their support people, new mothers and their
healthy, term infants

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Active support of breastfeeding as the preferred method of providing
    nutrition to infants, including establishment of multidisciplinary
    team to identify and eliminate institutional barriers to
    breastfeeding

2.  Establishment of a written breastfeeding policy

3.  Education and counseling of all pregnant women, including
    information on latch and positioning, nutritive suckling, milk
    production, frequency of feedings and feeding cues, expression of
    milk, assessment of infant nourishment, and reasons to contact the
    clinician

4.  Documentation of breastfeeding

5.  Skin-to-skin contact and initiation of breastfeeding soon after
    birth

6.  Encouragement of rooming in

7.  Assessment of feeding at each shift

8.  Referral to a lactation consultant or specialist, if necessary

9.  Use of supplemental feedings only if specifically ordered or
    requested

10. Alternative feeding methods (syringe or spoon feeding), when
    necessary

11. Avoidance of pacifier use (unless as a method of pain management)

12. Assessment of infant for hypoglycemia and dehydration

13. Use of nipple shields (in conjunction with a lactation consultant)

14. Breast massage and hand expression of colostrums or milk, if no
    adequate latch within hours

15. Provision of discharge instructions

16. Post-discharge follow-up appointment schedule

17. Provision of information on community breastfeeding resources

18. Management of mothers who are separated from their sick or premature
    infants

19. Staff development

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

#### MAJOR OUTCOMES CONSIDERED

-   Breastfeeding initiated within one hour of birth

-   Rate of exclusive breast feeding

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

An initial search of relevant published articles written in English in
the past 20 years in the fields of medicine, psychiatry, psychology, and
basic biological science is undertaken for a particular topic. Once the
articles are gathered, the papers are evaluated for scientific accuracy
and significance.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus (Committee)\
Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

I Evidence obtained from at least one properly randomized controlled
trial

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

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

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

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

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

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

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

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

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

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

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

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

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

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Policy Statements**

1.  *\"Name of institution\"* staff will actively support breastfeeding
    as the preferred method of providing nutrition to infants. A
    multidisciplinary, culturally appropriate team comprising hospital
    administrators, physician and nursing staff, lactation consultants
    and specialists, nutrition staff, parents, and other appropriate
    staff shall be established and maintained to identify and eliminate
    institutional barriers to breastfeeding. On a yearly basis, this
    group will compile and evaluate data relevant to breastfeeding
    support services and formulate a plan of action to implement needed
    changes.

2.  A written breastfeeding policy will be developed and communicated to
    all health care staff. The *\"name of institution\"* breastfeeding
    policy will be reviewed and updated routinely (biannually) using
    current research as an evidence-based guide.

3.  All pregnant women and their support people as appropriate will be
    provided with information on breastfeeding and counseled on the
    benefits of breastfeeding, contraindications to breastfeeding, and
    risk of formula feeding.

4.  The woman\'s desire to breastfeed will be documented in her medical
    record.

5.  Mothers will be encouraged to exclusively breastfeed unless
    medically contraindicated. The method of feeding will be documented
    in the medical record of every infant.

    -   Exclusive breastfeeding is defined as providing breast milk as
        the sole source of nutrition. Exclusively breastfed babies
        receive no other liquids or solids.

6.  At birth or soon thereafter all newborns, if baby and mother are
    stable, will be placed skin-to-skin with the mother. Skin-to-skin
    contact involves placing the naked baby prone on the mother\'s bare
    chest. Mother-infant couples will be given the opportunity to
    initiate breastfeeding within 1 hour of birth. Post-Cesarean-birth
    babies will be encouraged to breastfeed as soon as possible. The
    administration of vitamin K and prophylactic antibiotics to prevent
    ophthalmia neonatorum should be delayed for the first hour after
    birth to allow uninterrupted mother infant contact and breastfeeding
    (Protocol Committee Academy of Breastfeeding Medicine, \"Clinical
    Protocol #3,\" 2002).

7.  Breastfeeding mother-infant couples will be encouraged to remain
    together throughout their hospital stay, including at night
    (rooming-in). Skin-to-skin contact will be encouraged as much as
    possible.

8.  Breastfeeding assessment, teaching, and documentation will be done
    on each shift and whenever possible with each staff contact with the
    mother. After each feeding, staff will document information about
    the feeding in the infant\'s medical record. This documentation may
    include the latch, position, and any problems encountered. For
    feedings not directly observed, maternal report may be used. Every
    shift, a direct observation of the baby\'s position and latch-on
    during feeding will be performed and documented.

9.  Mothers will be encouraged to utilize available breastfeeding
    resources including classes, written materials, and video
    presentations, as appropriate. If clinically indicated, the
    clinician or nurse will make a referral to a lactation consultant or
    specialist.

10. Breastfeeding mothers will be instructed about:

    -   Proper positioning and latch on

    -   Nutritive suckling and swallowing

    -   Milk production and release

    -   Frequency of feeding/feeding cues

    -   Expression of breast milk and use of a pump if indicated

    -   How to assess if infant is adequately nourished

    -   Reasons for contacting the clinician

> These skills will be taught to primiparous and multiparous women and
> reviewed before the mother goes home.

11. Parents will be taught that breastfeeding infants, including
    cesarean-birth babies, should be put to breast at least 8 to 12
    times each 24 hours. Infant feeding cues (such as increased
    alertness or activity, mouthing, or rooting,) will be used as
    indicators of the baby\'s readiness for feeding. Breastfeeding
    babies will be breastfed at night.

12. Time limits for breastfeeding on each side will be avoided. Infants
    can be offered both breasts at each feeding but may be interested in
    feeding only on one side at a feeding during the early days.

13. No supplemental water, glucose water, or formula will be given
    unless specifically ordered by a physician or nurse practitioner or
    by the mother\'s documented and informed request. Prior to
    nonmedically indicated supplementation, mothers will be informed of
    the risks of supplementing. The supplement should be fed to the baby
    by cup if possible and will be no more than 10 to 15 mL in a term
    baby (Howard et al., 2003; Howard et al., 1999; Marinelli, Burke, &
    Dodd, 2001). Alternative feeding methods such as syringe or spoon
    feeding may also be used; however, these methods have not been shown
    to be effective in preserving breastfeeding. Bottles will not be
    placed in a breastfeeding infant\'s bassinet.

14. This institution does not give group instruction in the use of
    formula. Those parents who, after appropriate counseling, choose to
    formula feed their infants will be provided individual instruction.

15. Pacifiers will not be given to normal full-term breastfeeding
    infants. The pacifier guidelines at *\"name of institution\"* state
    that preterm infants in the Neonatal Intensive Care or Special Care
    Unit or infants with specific medical conditions may be given
    pacifiers for non-nutritive sucking. Newborns undergoing painful
    procedures (circumcision, for example) may be given a pacifier as a
    method of pain management during the procedure. The infant will not
    return to the mother with the pacifier. *\"Name of institution\"*
    encourages \"pain-free newborn care,\" which may include
    breastfeeding during the heel stick procedure for the newborn
    metabolic screening tests.

16. Routine blood glucose monitoring of full-term healthy appropriate
    for gestational age (AGA) infants is not indicated. Assessment for
    clinical signs of hypoglycemia and dehydration will be ongoing
    (Protocol Committee Academy of Breastfeeding Medicine, \"Protocol
    #1,\" 1999).

17. Antilactation drugs will not be given to any postpartum mother.

18. Routine use of nipple creams, ointments, or other topical
    preparations will be avoided unless such therapy has been indicated
    for a dermatological problem. Mothers with sore nipples will be
    observed for latch-on techniques and will be instructed to apply
    expressed colostrum or breast milk to the areola after each feeding.

19. Nipple shields or bottle nipples will not be routinely used to cover
    a mother\'s nipple to treat latch-on problems or prevent or manage
    sore or cracked nipples or when a mother has flat or inverted
    nipples. Nipple shields will be used only in conjunction with a
    lactation consultation.

20. After 24 hours of life, if the infant has not latched on or fed
    effectively, the mother will be instructed to begin breast massage
    and hand expression of colostrum into the baby\'s mouth during
    feeding attempts. Skin-to-skin contact will be encouraged. (Parents
    will be instructed to watch closely for feeding cues and whenever
    these are observed to awaken and feed the infant.) If the baby
    continues to feed poorly, pumping with skilled hand expression or a
    double set-up electric breast pump will be initiated and maintained
    approximately every 3 hours or a minimum of eight times per day. Any
    expressed colostrum or mother\'s milk will be fed to the baby by an
    alternative method. The mother will be reminded that she may not
    obtain much milk or even any milk the first few times she pumps her
    breasts. Until the mother\'s milk is available, a collaborative
    decision should be made among the mother, nurse, and clinician
    regarding the need to supplement the baby. Each day clinicians will
    be consulted regarding the volume and type of the supplement.
    Pacifiers will be avoided. In cases of problem feeding, the
    lactation consultant or specialist will be consulted (Protocol
    Committee Academy of Breastfeeding Medicine, \"Clinical Protocol
    #3,\" 2002).

21. If the baby is still not latching on well or feeding well when going
    home, the feeding/pumping/supplementing plan will be reviewed in
    addition to routine breastfeeding instructions. A follow-up visit or
    contact will be scheduled within 24 hours. Depending on the clinical
    situation it may be appropriate to delay discharge of the couplet to
    provide further breastfeeding intervention, support, and education.

22. All babies should be seen for follow-up within the first few days
    postpartum. This visit should be with a pediatrician or other
    qualified health care practitioner for a formal evaluation of
    breastfeeding performance, a weight check, assessment of jaundice
    and age appropriate elimination:

    -   For infants discharged at less than 2 days of age (\<48 hours):
        Follow-up at 2 to 4 days of age

    -   For infants discharged at more than 2 days of age (\>48 hours):
        Follow-up at 4 to 5 days of age

    -   All newborns should be seen by 1 month of age.

23. Mothers who are separated from their sick or premature infants will
    be

    -   Instructed on how to use skilled hand expression or the double
        set up electric breast pump---instructions will include
        expression at least eight times per day or approximately every 3
        hours for 15 minutes (or until milk flow stops, whichever is
        greater) around the clock and the importance of not missing a
        pumping session during the night

    -   Encouraged to breastfeed on demand as soon as the infant\'s
        condition permits

    -   Taught proper storage and labeling of human milk

    -   Assisted in learning skilled hand expression or obtaining a
        double set up electric breast pump prior to going home

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24. Before leaving the hospital, (Protocol Committee Academy of
    Breastfeeding Medicine, \"Clinical Protocol #2,\" 2002)
    breastfeeding mothers should be able to:

    -   Position the baby correctly at the breast with no pain during
        the feeding

    -   Latch the baby to breast properly

    -   State when the baby is swallowing milk

    -   State that the baby should be nursed approximately 8 to 12 times
        every 24 hours until satiety

    -   State age-appropriate elimination patterns (at least six
        urinations per day and three to four stools per day by the
        fourth day of life)

    -   List indications for calling a clinician

    -   Manually express milk from their breasts

25. Prior to going home, mothers will be given the names and telephone
    numbers of community resources to contact for help with
    breastfeeding, including (the support group or resource recommended
    by *\"name of institution\"*).

26. *\"Name of institution\"* does not accept free formula or free
    breast milk substitutes. Nursery or neonatal intensive care unit
    (NICU) discharge bags offered to all mothers will not contain infant
    formula, coupons for formula, logos of formula companies, or
    literature with formula company logos.

27. *\"Name of institution\"* health professionals will attend
    educational sessions on lactation management and breastfeeding
    promotion to ensure that correct, current, and consistent
    information is provided to all mothers wishing to breastfeed.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=11224)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

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

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

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

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Improved breastfeeding outcomes for mothers and infants

#### POTENTIAL HARMS

Not stated

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

Breastfeeding is contraindicated in the following situations:

-   Human immunodeficiency virus (HIV)-positive mother in developed
    countries (e.g., United States, Europe)

-   Mother using illicit drugs (for example, cocaine, heroin) unless
    specifically approved by the infant\'s health care provider on a
    case by case basis

-   A mother taking certain medications. Although most prescribed and
    over-the-counter drugs are safe for the breastfeeding infant, some
    medications may make it necessary to interrupt breastfeeding. These
    include radioactive isotopes, antimetabolites, cancer chemotherapy,
    and a small number of other medications.

-   Mother has active, untreated tuberculosis

-   Infant has galactosemia

-   Mother has active herpetic lesions on her breast(s)---breastfeeding
    can be recommended on the unaffected breast (the Infectious Disease
    Service will be consulted for problematic infectious disease
    issues.)

-   Mother with varicella that is determined to be infectious to the
    infant

-   Mother has human T-cell leukemia virus type 1 (HTLV1)

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

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

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Academy of Breastfeeding Medicine Protocol Committee. ABM clinical
protocol #7: model breastfeeding policy. Breastfeed Med 2007
Mar;2(1):50-5. \[22 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17661620)

#### ADAPTATION

This guideline was partially adapted from the following sources:

-   U.S. Department of Health and Human Services. HHS Blueprint for
    Action on Breastfeeding. U.S. Department of Health and Human
    Services, Office on Women\'s Health, Washington, DC, 2000.

-   The American Academy of Pediatrics, Work Group on Breastfeeding.
    Breastfeeding and the use of human milk. Pediatrics
    1997;100:1035--1039.

-   American College of Obstetricians and Gynecologists and Committees
    on Health Care for Underserved Women and Obstetric Practice, Queenan
    JT (ed). Breastfeeding: Maternal and Infant Aspects. ACOG
    Educational Bulletin. The American College of Obstetricians and
    Gynecologists, Washington, DC, 2000.

-   The American Academy of Family Physicians. Family Physicians
    Supporting Breastfeeding: Breastfeeding Position Paper 2002. The
    American Academy of Family Physicians. Compendium of AAFP positions
    on selected health issues. The American Academy of Family
    Physicians, Kansas City, MO, 2002. Available at:
    <http://www.aafp.org/online/en/home/policy/policies/b/breastfeedingpositionpaper.html>.

-   World Health Organization, United Nations Children\'s Fund.
    Protecting, promoting and supporting breastfeeding: The special role
    of maternity services (A joint WHO/UNICEF statement). Int J Gynecol
    Obstet 1990;31:171--183.

-   Position of the American Dietetic Association. Breaking the barriers
    to breastfeeding. J Am Diet Assoc 2001;01:1213--1220.

-   Academy of Breastfeeding Medicine Board of Directors. ABM Mission
    Statement, 2003. Available at: www.bfmed.org.

-   WHO/UNICEF Joint Statement. Meeting on Infant and Young Child
    Feeding. J Nurse-Midwifery 1980;25: 31--38.

-   World Health Organization and United Nations Children\'s Fund.
    Innocenti Declaration on the Protection, Promotion and Support of
    Breastfeeding. UNICEF, New York, 1990.

#### DATE RELEASED

2004 (published 2007)

#### GUIDELINE DEVELOPER(S)

Academy of Breastfeeding Medicine - Professional Association

#### SOURCE(S) OF FUNDING

Academy of Breastfeeding Medicine

A grant from the Maternal and Child Health Bureau, US Department of
Health and Human Services

#### GUIDELINE COMMITTEE

Academy of Breastfeeding Medicine Protocol Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Committee Members*: Caroline J. Chantry, MD, FABM (Co-Chairperson);
Cynthia R. Howard, MD, MPH, FABM (Co-Chairperson); \*Barbara L. Philipp
MD, IBCLC, FABM

\**Lead author(s)*

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

None to report

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[Academy of Breastfeeding Medicine Web
site](http://www.bfmed.org/ace-files/protocol/mhpolicy_ABM.pdf).

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

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

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

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

#### PATIENT RESOURCES

None available

#### NGC STATUS

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

#### COPYRIGHT STATEMENT

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

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

### DISCLAIMER

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Date Modified: 12/8/2008