These guidelines, based on current evidence, are for health care providers in BC who care for women and infants. Areas addressed are: guiding principles, prenatal, intrapartum and postpartum care which is further delineated into three periods: 2 -24 hours, 24 -72 hours, and 72 hours to 7 days and beyond.

# Guiding Principles for Health Care Providers
In this guideline the recommendations for health care professionals working in both hospital and community health settings are considered best practices for breastfeeding care throughout the pre-conception, prenatal, intrapartum, and immediate and extended postpartum periods. A strategy for promoting best practice is the Baby-Friendly Initiative (BFI) (see Appendix A). 6,8.9,10 Guiding principles:
- Promote exclusive breastfeeding for the first six months of an infant's life with continued breastfeeding for two years and beyond  - Support the breastfeeding mother across the continuum of care to breastfeed according to her goals and provide care based on best evidence, assessment of needs, analysis of the data obtained, and a plan of action developed with the mother
- Use principles of adult education when working with parents:
Recognize the postpartum period is a continuation of the total childbirth experience Determine what parents know then build on their knowledge and skills Focus assistance on the mothers' and families' needs, their readiness to learn, and information required for them to make informed decisions
- Respect parent's decision making when it is based on accurate knowledge (this is professionally ethical and facilitates respectful discussion leading to informed decision making) Initiate breastfeeding education in the first prenatal visits providing the parents with information that builds on their knowledge and needs. (A)
- The decision to breastfeed is influenced by the woman's life experiences, beliefs, culture, and the attitudes and views of family and friends. In particular her decision, initiation, and the duration of breastfeeding is strongly influenced by her partner,  and her mother 32,35 - Evidence shows that the attitudes and behaviours of health care professionals regarding breastfeeding influence women's initiation, success, and duration of breastfeeding therefore health care providers should show a positive attitude and commitment to breastfeeding rather than assuming a neutral position 36,37 - Initiate breastfeeding education in the first visit(s). Provide parents with accurate, evidence-based information that builds on their knowledge, individual needs, and concerns and that assist them to make informed decisions early and realistically prepare for their postpartum experience
- Show sensitivity to cultural influences and views but address cultural perceptions which may be incorrect
- Inquire about the mother's support systems
- Assess breasts and nipples: a responsibility of the primary health care provider during an early prenatal visit.
Conditions that MAY affect breastfeeding are: lack of breast enlargement during pregnancy breast traumas and malformations breast augmentation breast reduction surgery: the woman's ability to sustain the nutritional needs of her infant following breast reduction is individual and variable For these mothers:
- counsel the mother about this possibility
- monitor breastfeeding and infant behaviours in the first postpartum month
- discuss strategies such as the eventual use of a supplemental nursing system if the mother's milk supply does not increase to meet the infant's nutritional needs
- Discuss prenatal preparation of nipples: use of creams and lotions; and that Hoffman's exercise and nipple "conditioning" is ineffective and not recommended: stimulation may cause uterine contractions, leading to premature labor 38,39 - Encourage parents to attend support groups and prenatal breastfeeding education sessions
- Prenatal education includes:

# Exploration of attitudes and feelings

# Review maternal and family beliefs and values about breastfeeding and infant feeding
Appraise maternal views about breasts, body image, exposing breasts, and others touching her breasts and nipple area Assess maternal self-confidence and perceived competence related to breastfeeding as greater confidence is associated with breastfeeding success Acknowledge maternal perceptions of infant feeding experiences of self and others and related feelings 3.0 Breastfeeding Guidelines for Health Care Providers for Healthy Infants: Birth to Six Months and Beyond, cont.
Breastfeeding encompasses nutritional, immunological, psychological, developmental, and emotional components that contribute to normal growth and development of infants and children, facilitates a positive maternal-child relationship, 13 and provides short and long-term healthcare outcomes for mothers and infants.  (see Appendix C) Impact of lifestyle habits on pregnancy, breastfeeding, and the infant's health, e.g., smoking, alcohol, and substance abuse. (see PSBC Guidelines 40,42 and SOGC Guidelines 43,44 Responses to basic queries, e.g., why do my breasts and nipples tingle; what is colostrum; how is milk produced; how often will I breastfeed each day; how long does each breastfeeding take; how do I know I have enough milk; should breastfeeding be painful or sore; and can I return to work and still breastfeed?
Potential effects of anesthetics during labor and birth on the infant's alertness and behaviours that may delay early initiation of breastfeeding and decrease the length of time the infant is breastfed. 44 This may lead to discussion of pain during labor and knowledge of nonpharmacological pain-relief strategies Breastfeeding after birth and best practices in hospital:
- skin-to-skin following vaginal and caesarean births - infant's ability to find mother's nipple and suckle effectively
- offer only breastmilk or human donor milk
- early and frequent feedings to stimulate milk production and for maternal comfort
- keep infant at the bedside 24 hours a day
- observe and educate about infant's behaviors and feeding cues - Mothers habitually ingesting more than a moderate amount of alcohol (.0.5g/kg/day, equivalent to 2 drinks) 2,45 - Mothers who are using illicit drugs 2,26 3.0 Breastfeeding Guidelines for Health Care Providers for Healthy Infants: Birth to Six Months and Beyond, cont.
- Mothers in Canada who are known to be HIV antibody positive are currently advised not to breastfeed. 2,13,45 Counsel and emotional support for the mother is often required if pasteurized donor milk is not accessible. 45 For BC mothers in receipt of Income Assistance, who use breastmilk substitutes due to HIV status, financial help is available
- Mothers with human T-lymphotropic virus type 1 or 2 infection 13,26,45 Temporary conditions: If breastfeeding is temporarily contraindicated mothers are encouraged to express their milk until breastfeeding is resumed
- Mothers with active herpes simplex lesions on or near the nipple should interrupt breastfeeding on the breast and nipple affected until lesions are crusted or resolved 2,26,45 - Mothers receiving a high-dose of the antibiotic Metroridazole: discontinue breastfeeding for 12 -24 hours to allow excretion of the dose 45 - Mothers with active tuberculosis who are not receiving adequate therapy are considered infectious. 2 Following 2-weeks of appropriate TB drug therapy breastfeeding is recommended as the drugs used are considered safe during breastfeeding. 2,3,45 TB prophylaxis should also be provided to the infant 13 - Mothers receiving diagnostic or therapeutic radioactive isotopes or are exposed to radioactive materials 26 until the milk is clear of radioactivity
- Mothers receiving long-term chemotherapy should temporarily stop breastfeeding for 1 day to 2 weeks depending on the type of isotope used 2,26,45 - Encourage labor support from professionals, family and/or friends based on nonpharmacological strategies to minimize use of pharmacologic anesthetics and analgesics. 38 Associations have shown that the effect of epidural anesthesia on breastfeeding are: 1) increased difficulty initiating full breastfeeding during the first few days after birth 44 and 2) earlier termination of breastfeeding 13,47,48 The higher the dose of fentanyl in epidural anesthesia the greater the negative effect on breastfeeding 48 - Following birth place skin-to-skin on the mother so the infant has full access to mother's breast and nipple. Skin-to-skin contact at birth is associated with improved breastfeeding outcomes, early motherinfant attachment, enhanced mother-baby interaction, less infant crying and greater cardio-respiratory and temperature stability for the infant 49,50 - Place a warmed blanket over both mother and infant to maintain and stabilize the infant's temperature 51,52 3.0 Breastfeeding Guidelines for Health Care Providers for Healthy Infants: Birth to Six Months and Beyond, cont.
- Facilitate mother-infant introduction to breastfeeding; keep them together, skin-to-skin allowing the infant to lick, suckle, and touch the nipple with his/her hand. 53 In the first hour after birth the infant's suckling reflex is generally intense, infants are alert and awake, and mothers have a surge of oxytocin which is associated with milk-ejection, increasing uterine contractions, and enhancing mother-infant attachment 38,53 - Promote mother-infant togetherness: assess the infant and administer Vitamin K on the mother; delay eye prophylaxis up to one hour 54,55 and postpone infant weight and measurements until completion of the first feeding
- Continue skin-to-skin contact in a position that facilitates the infant to touch the breast if labor has been long or stressful. Place infant skin-to-skin on father or another designate if maternal skin-to-skin is not feasible 56 - Assist mother with breastfeeding as soon as possible or within 1 to 2 hours
- Maintain a quiet and tranquil environment and use an unhurried and encouraging approach when assisting with breastfeeding. 38 If transport to a postpartum unit is required, keep mother and infant skin-to-skin

# Key Points for Caesarean Births
- Follow as many of the recommendations for vaginal birth as the situation allows
- Place the infant skin-to-skin on the father's or other designee's chest, and cover with a warm blanket if maternal skin-to-skin is not feasible 56 - Encourage the mother to breastfeed as soon as possible. Caesarean birth is associated with delayed initiation of the first breastfeeding and delayed lactogenesis  - Overcoming obstacles to skin-to-skin contact and early initiation of breastfeeding in the OR/PAR are important to breastfeeding success C. Postpartum Care - Skin-to-skin contact is encouraged to enhance effects; longer breastfeeding duration, early mother-infant attachment, less infant crying, and greater infant cardio-respiratory stability 49 - Artificial nipples, pacifiers, nipple shields, and breast pumps are avoided unless clinically indicated or until breastfeeding is established
- Recognition of signs of adequate breastmilk intake, by parents, is essential 60 (see Table 1)
- Hand expression of colostrum/breastmilk is taught to all mothers 2 to 24 hours
- Use Guidelines to Assist Mother to Breastfeed (see following)
Assist mother to breastfeed within 1 -2 hours after birth and until mother and infant are feeding satisfactorily Feed frequently, a minimum of 5 times in the first 24 hours 38 to prevent infant hypoglycemia, accelerate breastmilk production, ensure breastmilk drainage, prevent breast distension and engorgement, 61 and stimulate infant digestive peristalsis and elimination. 38 Encourage breastfeeds throughout the night
- Keep mothers and infants together at all times; perform infant assessments and procedures in the mother's presence
- Encourage mothers to recognize early infant feeding cues such as wiggling, moving arms and legs, mouthing, rooting, fingers or hands to mouth 38 and to breastfeed immediately when cues exhibited
Infants that are aroused from a deep sleep will not feed and this leads to a frustrated mother, infant, and health care professional Infants will not breastfeed when they are fully crying and must be consoled and quieted before offering the breast
- Cluster feedings (several feeds close together) are common in the first 24 to 36 hours and help to establish breastmilk production. Assure mother that these frequent feedings are normal; a sign that baby is recovering from birth, and will assist in stimulating milk production. This is not a sign of insufficient breastmilk nor is supplementation required
- Feeding duration varies depending on the infant's gestational age, state of consciousness, efficiency of breast attachment and suckle, how quickly breastmilk lets down and maternal comfort - Infant's stomach volume in the first three days is small and variable; 62,63 an average total feeding amount on day 1 is reported as about 6.1 ml 64
- Few healthy term infants require supplementation. Acceptable medical reasons for supplementation are described in Appendix D
- Observe and monitor maternal transition from lactogenesis I to lactogenesis II i which generally occurs within 72 hours (indicated by breast fullness); this may take longer if the mother is a primipara, has never previously breastfed, has been separated from her baby, or had a Caesarean birth 38,65,66 - Avoid use of drugs with Codeine e.g., Tylenol 3 (codeine 30 mg and acetaminophen 500 mg) for maternal postpartum pain or if used closely monitor and educate the mother how to monitor herself and the infant for opioid toxicity 67 - Encourage and support a family member to stay with the mother 24 hours a day particularly if she had a Caesarean birth i Other conditions that may contribute to delayed lactogenesis are: type 1 diabetes, labor analgesia, obesity, high levels of stress to mother and infant during birth 52 flat or inverted nipples and infants with suboptimal breastfeeding behaviour. 62 3.0 Breastfeeding Guidelines for Health Care Providers for Healthy Infants: Birth to Six Months and Beyond, cont.

# Guidelines to Assist Mothers to Breastfeed
- Breastfeeding Positions and Preparation for Feeding (refer to diagrams in Baby's Best Chance) 60 - Encourage use of non-restrictive clothing that allows easy access to the breast - Advise importance of comfort and body support throughout each session
- Unwrap the infant and ensure infant is awake and alert
- Promote skin-to-skin contact during breastfeeding
- Hold the infant close; infant's ventral surface faces the mother's ventral surface (i.e. tummy to tummy)
- The infant's head and shoulders are supported and level with the mother's breast and the infant's nose is level with the mother's nipple. The head may be tilted slightly back but not hyper-extended; avoid pressure on the back of the head
- One of mother's hands may support her breast from below during feeding, particularly if the breast is large. The hand or fingers should be back from the areola and not interfere with the infant latching on the breast
- Sitting positions: cradle, modified cradle, or football hold Mother sits upright with back supported, bring infant to the breast rather than leaning towards the infant. Use pillows and foot rest for comfort and to elevate the infant to the level of the mother's breast
Mother's arm or hand holds and supports the infant's upper back and shoulders, cradling the neck/ base of the skull 13 - Lying position On the bed, mother and infant side-lie, facing each other; use pillows under mother's head, behind her back, and as necessary between her legs Hold infant close; infant head and neck positions as described above
Following the breastfeeding session the baby is placed on his/her back in close proximity (on a separate safe sleep surface) for sleeping.
-Some parents may choose to share a bed with their baby, for example the mother may fall asleep while breastfeeding or when trying to settle a fussy baby. Parents need to have information to reduce the risk of sharing a sleep surface with their infant. Refer to PSBC Safe Sleep Environment Guideline for Infants 0 -12 Months of Age 68

# Infant Attachment on the Breast (Latch)
- PATIENCE is essential, particularly with early breastfeedings
- Infant may lick or mouth the nipple before grasping the nipple to suck - Optimum attachment: the infant's mouth is open wide, lips flanged, and the mouth covers much the areola (variable depending on areola size); infant's chin is on the breast and the nostrils are clear to breathe. If lips are only parted 45 degrees the infant is likely sucking more on the nipple than the breast tissue and this will contribute to pain during breastfeeding and potentially sore nipples
- During the first week a mother may experience nipple sensitivity or soreness for a few seconds when the infant grasps the breast. 38 If pain continues more than 30 seconds, remove the infant from the breast and start again. Persistent or prolonged pain requires further assessment and intervention to correct the problem. Observe nipples when the infant releases the breast -nipple distortion is usually associated with poor attachment (latch) that may cause nipple damage
- To remove infant from the breast place a clean finger in the corner of the infant's mouth to break the suction
- If a healthy infant does not attach (latch) after several attempts keep mother and infant skin-to-skin and have her watch for feeding arousal behaviours. Sleepy behaviours may be due to birth exhaustion or maternal analgesics or anesthetics
- Sleepy infants can be aroused from a light sleep or drowsy state if they have not fed for 2 12 or 3 hours.
If they are left to re-enter a deep sleep the opportunity to feed the infant is lost and feedings may be insufficient

# Attachment and Suckling Pattern
- The nipple and breast are drawn into the infant's oral cavity and the infant's cheeks are full, round, and not withdrawn. The tongue is forward extending over the lower gum and lips are widely flanged around the breast when suckling
- Initially the infant has a few rapid sucks and as breastmilk is released, the infant's sucks are slower and deeper with pauses throughout the feeding period. Listen for swallowing sounds as this indicates the transfer of colostrum or breastmilk. 38,69 (Swallowing sounds may be minimal in the first 48 hours)
- If attachment is uncomfortable or shallow, with the infant's mouth slipping towards the nipple tip, detach and reattach the infant
- Infant remains at breast until satiety cues are observed, i.e., suckling ceases, muscles relax, and infant sleeps or removes self from the breast - If infant detaches within the first 5 minutes, arouse infant and return to the same breast. If longer, arouse infant and breastfeed from the second breast
- Feeding frequency and duration are dependent on how the infant suckles and varies in each motherinfant dyad
- Discourage watching feeding time duration but assist mothers to recognize the signs of milk transfer and their infant's satiety 24 to 72 hours
- Help mothers to recognize later infant feeding cues, i.e., fussing, squeaky noises, restlessness, progressing to soft intermittent crying 60 - Increase breastfeeding frequency to 8 or more times in 24 hours and offer both breasts per feeding to stimulate breastmilk production; breastfeed infant until satiated (may be 20 to 50 minutes) 38 - Assess a breastfeeding session until mother and infant are feeding satisfactorily then every 8 hours until hospital discharge using the Guidelines to Assess Breastfeeding (see following section)
- 0 Breastfeeding Guidelines for Health Care Providers for Healthy Infants: Birth to Six Months and Beyond, cont.

# Guidelines to Assess Breastfeeding Recommendation 6 :
A Breastfeeding assessment of mother and infant should be carried out at key timeframes through discussion and observation (A)
Assessment is complex as it includes mother, infant, and how they "fit" together to enable the breastfeeding process: data is obtained by interview and observation of a breastfeeding session

# Breastfeeding Process
- Mother positions infant to facilitate optimal latch and comfort throughout the breastfeeding session
- Infant suckling pattern indicates audible swallowing and milk transfer 38,69 - Breastfeedings include both breasts until breastfeeding well established
- Infant shows satiated behaviours
- Mother and infant interact positively during and after breastfeeding

# Maternal Assessment
- Maternal transition from lactogenesis I to lactogenesis II, indicated by breast fullness; generally occurs within 72 hours but may take longer if the mother is a primipara, has never previously breastfed, has been separated from her baby, or had a Caesarean birth 38,65,66 - Evidence of breast engorgement
- Sore nipples and nipple variances/anomalies that may interfere with breastfeeding and/or milk transfer. Nipple distortion when the infant releases the breast usually indicates a poor latch
- Feelings and concerns: her self-confidence, perception of milk production, the breastfeeding process, her infant, and support provided from family and friends
- Knowledge about infant feeding cues; feeding frequency, length, and variances; and signs of adequate infant hydration

# Infant Assessment
- Wakes spontaneously every 212 to 3 hours, 24 hours a day, for feeding
- Exhibits cues that show readiness to feed (feeding cues) at least 8 or more times per day
- Alert at the beginning of feeding; contented, relaxed, and sleepy at feeding end  Note: 3 or fewer stools on day 4 after birth in combination with delayed lactogenesis is an indicator for further assessment and continued monitoring 70

# Infant weight loss and gain
- Weight loss is variable in the first week. Loss of greater than 7% 26 or 10% 71,72 in the first 4 days postpartum for infants born vaginally or within 5 days if born by Caesarean 66 indicates continued assessment of the breastfeeding process is required and possible correction of breastfeeding techniques until weight gain is satisfactory 72,73 - Parameters of infant weight loss after birth and when it should start to be regained are not evidencebased,  however, a general consensus is that birthweight should be regained in approximately 2 weeks 38,39,73 - Referral to a lactation health care professional and/or physician is indicated for the following situations 65 delayed lactogenesis + continued infant weight loss delayed lactogenesis + inadequate infant output inadequate infant output + continued infant weight loss
- Breastfeeding assessment tools have been developed although reliability and validity for all tools vary and require further testing (see Appendix E for use and characteristics of the following tools: BAPT, MBFES, BSES, LATCH and the IBFAT)
Hand expression of colostrum or breastmilk. 38,39,76 - Initiate hand expression of colostrum if the infant does not latch on the breast within the first 6 hours after birth or after 2 breastfeeding attempts
- Prior to expression, when initially learning, skin-to-skin or feed baby, gently massage breast, or apply a warm, moist compress to enhance milk ejection
- Teach mother to:
Express colostrum/breastmilk by placing thumb and forefinger behind the areola and gently pressing back into the chest wall then bring finger and thumb together compressing and releasing the breast tissue in a rhythmical and rolling motion while keeping the finger and thumb in a stationary position Continue to rhythmically compress the breast until droplets of colostrum/breastmilk appear, as volume increases milk may spray When no further colostrum or breastmilk is ejected move fingers to another section of the breast to compress another area, gradually working around the areola in a circular pattern
- Collect colostrum droplets/breastmilk on a spoon or small medicine cup to feed to the infant via a spoon, syringe or medicine cup (see Appendix F). A spoon is most efficient for collection and feeding colostrum.

# Breastfeeding Guidelines for Health Care Providers for
Healthy Infants: Birth to Six Months and Beyond, cont.
- Mothers may become discouraged if few droplets are produced: assure her that as her milk supply is established and as the technique is practiced, it becomes easier, the amount increases, and it is a convenient and an efficient method of milk expression
- Avoiding the use of pacifiers until breastfeeding is established is frequently recommended 26,38,39 but support for this is inconsistent: e.g., one review shows that breastfeeding duration is not affected in the first 4 months among mothers motivated to breastfeed their infants 77 whereas other studies reveal:
Use in the first 4 weeks is associated with less exclusive breastfeeding at 1 month and decreased breastfeeding duration among infants followed for 1 year 78 Use could indicate a breastfeeding problem that may need intervention 79 e.g., postponement of and fewer feedings per 24 hours; dental and orthodontic problems; accidents and injuries (choking); candidiasis; speech development; infant attachment; 38 and acute otitis media 80 - Used therapeutically at times to encourage suckling among preterm infants that are gavage fed; to repattern specific sucking disorders; and to soothe infants of mothers who suckle for short periods due to an overabundant maternal milk supply 38,81 Preparation for Hospital Discharge
- Assess maternal and newborn physical, psychological, and social wellbeing 82 - Discharge in less than 48 hours from hospital is considered adequate provided the infant demonstrates effective breastfeeding abilities i.e., at least two successful feedings documented and there is follow-up 83,84 - Contact with families of newborn infants is made by a health care professional within 1 -2 days of hospital discharge to carry out an assessment using the PSBC Postpartum and Newborn Nursing Care Pathways 85
- Assess breastfeeding using Guidelines to Assess Breastfeeding (shown above) during the first contact and each follow-up contact if there are breastfeeding concerns
- Assess knowledge and review or inform as needed: breastfeeding patterns once milk is established; cluster feeding; infant fussiness; need to breastfeed throughout the night; infant hydration; community resources; and breastfeeding challenges
- Evaluate maternal postpartum status and the infant status for hydration, neonatal jaundice, and other abnormalities that may require investigation or referral 84
- Provide anticipatory guidance and resources such as Baby's Best Chance, 60 on possible breastfeeding concerns (e.g. teething, biting, increased feeding frequency during growth spurts)
- Provide information about recommendation of exclusive breastfeeding for first six months with continuation for two years or more combined with nutritious and safe complementary foods 3.0 Breastfeeding Guidelines for Health Care Providers for Healthy Infants: Birth to Six Months and Beyond, cont.
- Newborns who are breastfed or receiving breastmilk should receive a daily vitamin D supplement of 10 g (400 IU) from birth until at least 12 months of age. In individual practice, the decision to discontinue the supplement beyond 12 months of age can be informed by a dietary assessment of other contributors of vitamin D, such as cow milk.
- Encourage attendance at mother-to-mother support groups

# D. Breastfeeding Challenges in the Postpartum Period Recommendation 7:
Provide support for infants identified with specific challenges (A)

# Infant Challenges
- Near-Term Infant, i.e., 34 -38 weeks gestation 38,87 It cannot be assumed that the near-term infant abilities are similar to full term infants Additional time is often needed before these infants breastfeed effectively and breastfeeding is established Assess to determine developmental immaturity related to:
- Neurological organization
- Suck-swallow and breathing pattern abilities
- Muscle tone
- State control which may be disorganized
- Sleep pattern: infant may not wake to feed frequently enough
- Feeding pattern e.g., may suckle for a short period with frequent pauses resulting in limited milk transfer and leading to increase risks of dehydration, hypoglycemia, hyperbilirubinemia, and/or insufficient weight gain
As term gestational age is reached, feeding times become similar to those of term infants Care
- Encourage skin-to-skin contact
- Breastfeed in the football hold or modified cradle
- Ensure infant is warm to assist temperature stability (skin-to-skin contact with light blanket covering mother and infant)
- Use a cue-based feeding approach but allow for differences among infants in time periods between feeds. Observe the infant's sleep pattern for feeding rather than adhering to a strict feeding schedule (e.g. q 3 h feedings)
- Wake the baby from a light sleep or drowsy state for feeding, for example every 2 -3 hours. If allowed to return to a deep sleep the feeding opportunity could be lost
- Where indicated, initiate a hand expression regime for the mother to establish milk production and prevent engorgement. A combination of hand expression and pumping results in increased milk. 88 (see Appendix G) Feed expressed milk to the infant using an alternative feeding method (such as spoon, cup) and avoiding artificial nipples and bottles (see Appendix F)
- 0 Breastfeeding Guidelines for Health Care Providers for Healthy Infants: Birth to Six Months and Beyond, cont.

# - Hypoglycemia
Screen only neonates considered at risk. 89,90 Screening healthy full-term infants is unnecessary 92 and can have a negative impact on successful breastfeeding and the mother-infant relationship 23,90 For screening guidelines and treatment refer to those of the Canadian Paediatric Society (2004, 89 reviewed 91 and reaffirmed in 2012 89. 
Preventative care for all newborns including those at risk for hypoglycemia are:
- Early and ongoing skin-to-skin contact between mother and infant sustains normal infant body temperature and assists normal blood glucose maintenance 90 - Early initiation of exclusive breastfeeding (i.e., within first hour following birth) followed by frequent feedings, 8 or more times in 24 hours 90 Interventions for documented hypoglycemic infants vary depending on individual circumstances. These include: increased breastfeeding frequency, enteral supplementation with expressed breastmilk (the mother's or pasteurized donor milk), or if necessary, breastmilk substitute 89 Infants with symptomatic hypoglycemia, and those with asymptomatic hypoglycemia who fail to respond to enteral supplementation, generally receive dextrose intravenous therapy 89 For infants' diagnosed: support mother and reassure her that nothing is wrong with her breastmilk; initiate and maintain early and frequent breastfeedings; if necessary start interventions to assist establishing mother's milk supply 90

# - Neonatal Jaundice
Refer to PSBC Guidelines for Jaundice in the healthy term newborn 92
Physiologic jaundice is common among all newborns and visible for approximately 50% of healthy term infants. 92 It develops after 24 hours following birth; bilirubin levels peak at approximately 3 days of age for non-Asian infants and may not peak for 5 days for infants of Asian origin. 38 If noted in infants less than 24 hours old it is pathological and clinical evaluation should be immediate 38,39 Early breastfeeding jaundice 38,92 is a prolongation of normal physiologic jaundice 9,38 that is associated with infrequent and ineffective breastfeeding resulting in limited intake and a delay of meconium passage and increased reabsorption of bilirubin from the bowel 13,92,93 More recently it is known as "starvation jaundice" 38,94 and occurs when breastfeeding is not effectively established
- Assess the infant using PSBC Guideline: Jaundice in the healthy term newborn 92 - Prevention and treatment
Early and frequent breastfeedings (8 or more times in 24 hours): ingestion of colostrum will increase stooling Assess infant's position, latch, and milk transfer Encourage mother-infant skin-to-skin contact to promote breastfeeding frequency and stimulate a sleepy or lethargic infant Supplementation is not generally indicated but if necessary supplement with mother's expressed milk or pasteurized donor milk, or breastmilk substitute. Supplementation with glucose water is not recommended 93,95 Late breastmilk jaundice: breastmilk jaundice syndrome
- Affects approximately 2 to 4% of breastfed infants. 13 Onset occurs after day 5 post delivery 38 and bilirubin levels may peak at 7 to 15 days; 92 the condition may last 3 13  For additional information on hyperbilirubinemia refer to PSBC Guideline: Jaundice in the healthy term newborn 92 and the CPS Guideline: Guidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants (35 or more weeks' gestation) 93 - Ankyloglossia (Tongue Tie)
Observed when the infant is unable to adequately extend or elevate tongue due to a short lingual frenulum attached to tip of the tongue that restricts tongue movement 96 as it may contribute to breastfeeding problems such as ineffective milk transfer, low intake of breastmilk resulting in insufficient weight gain, low maternal milk supply, sore or damaged nipples, blocked ducts, and breast infections 38,39,97 Partial ankyloglossia occurs in approximately 3.2% to 4.8% of term infants and in 12.8% of infants with breastfeeding problems 97,98 Complete ankyloglossia (fusion of tongue to the mouth floor) is exceptionally rare 97 Treatment is not necessary if breastfeeding proceeds successfully 96,97 If feeding problems persist refer the infant to a physician for further assessment and possible frenotomy 96 as outlined in the American Academy of Breastfeeding Guideline Protocol #11 97 and in Lawrence and Lawrence, 39 to improve breastfeeding effectiveness 99

# Recommendation 8:
Provide support for mothers identified with specific challenges. (A)

# Maternal Challenges
- Breast Fullness 100,101 a transitory physiologic response that can appear 3 to 6 days post-birth as milk production increases. Breasts are heavy, hot, and firm, and milk flows well, the infant can suckle, and generally it is not painful and resolves in 24 hours 38
- Breast Engorgement can occur 3 to 5 days post-birth; the breast is enlarged, painful, shiny, and edematous with diffuse red areas. The nipple may be effaced, milk often does not flow easily, and the infant can have difficulties latching 38 Contributing factors include delayed breastfeeding initiation, infrequent and/or time restricted feedings, supplementation, inefficient infant latch, breast surgery, or any situation where milk stasis occurs. Milk supply can be compromised by unrelieved engorgement Care 38,39,102 - Warm shower or apply warm compress or breast soaks before breastfeeding to facilitate let down
- Massage breast gently and manually express breastmilk or colostrum to soften the areola before breastfeeding to facilitate infant latch - Breastfeed frequently, using the engorged breast first
- Use anti-inflammatory medications, e.g., ibuprofen (400 mg. every 4 -6 hours) which are compatible with breastfeeding 103 3.0 Breastfeeding Guidelines for Health Care Providers for Healthy Infants: Birth to Six Months and Beyond, cont.
- Additional treatments that some women report as helpful but determined as ineffective in a review of eight RCTs 102 are:
Application of cold treatments e.g., gel packs, cold packs, or cold cabbage leaves; used after breastfeeding Use of oxytocin and ultrasound
- Areolar Engorgement 13 can occur without breast (peripheral) engorgement. Latch is difficult and painful for the mother.
- Manual expression or compression of the areola before breastfeeding 38 - Warm compresses

# - Plugged or Blocked Duct
Characterized by tenderness, heat, local engorgement, and/or a palpable lump if the blockage is in a duct close to the skin. Associated with an abundance of milk, incomplete removal of milk, missed feedings, and pressure or constriction e.g., from clothing, or baby carrier 38 Care 38,39 - Shower or warm compress to breast before feeding to facilitate milk flow
- Breast massage prior to and during feeding starting at the affected area moving toward the nipple
- Breastfeed frequently, start with the affected side and ensure breast is drained
- Position the infant on the breast with chin or nose pointing to the affected area; change the infant's position on the breast frequently
- Avoid missing feedings and wearing tight fitting bras or clothing

# - Milk Blister or Blocked Nipple Pore
A painful white or yellow spot on areola is a blocked nipple-pore preventing drainage from a duct and is painful when breastfeeding. May heal on own in several days or weeks Care
- Apply a warm compress to soften then gently rub area with a damp cloth and/or use hand expression to try to dislodge the obstruction 38 - A treatment could be done by a health professional with skills in treating breasts, by breaking the epithelial skin with a sterile needle to remove the plug 38 - Apply of an ice pack or use an analgesic before breastfeeding to decrease pain 38

# - Overabundance of Breastmilk
May not be problematic until infant is approximately 3 weeks old Breastmilk may eject quickly and forcibly during breastfeeding causing the infant to choke, gag, and remove his/herself from the breast. When this occurs, ensure that the infant's behaviour is due to the rapid flow or ejection of breastmilk, and not an inability of the infant to satisfactorily suckle or coordinate the suckling/ swallowing/ breathing mechanism 38 Mother is more prone to milk stasis and mastitis Typically babies gain well 3.0 Breastfeeding Guidelines for Health Care Providers for Healthy Infants: Birth to Six Months and Beyond, cont.
Care 38 - Offer only one breast per feeding while adjusting to supply and demand
- If letdown is forceful, hand express breastmilk until first letdown occurs or milk flow slows
- If second breast full and uncomfortable hand express only for comfort otherwise do not express milk between feedings as this will increase supply
- Vary nursing positions, e.g. infant in more of an upright position and head higher than the breast or mother leans backwards and infant faces and lies on top of the mother who may need to support the infant's forehead with her hand
- If infant chokes remove from breast and calm infant before reinitiating breastfeeding
- Although it may take a few weeks milk supply should adjust to meet the infant's needs
- Health care professional follow-up is essential for these mother-infant dyads to monitor milk production and support the mother

# - Mastitis
Inflammation of the breast, in which milk stasis is the primary cause that may or may not be accompanied by or progress to infection.101,104 Occurs at anytime during lactation but is most common in the first 2 -6 weeks postpartum 104 Usually only one breast is affected. Breast is hot, swollen, and tender; skin may be reddened; and mothers may complain of malaise, fever of 38.5C or higher, chills, headache, and flu like body aching. 38,39,104 Contributing factors are numerous and can be due to: breast engorgement; delayed breastfeeding initiation; infrequent and/or time restricted breastfeedings; supplementation; breast surgery; any situation where milk stasis occurs; a break in the integrity of the nipple skin (cracked or damaged nipple); inadequate milk removal from the breast; poor latch/attachment; oversupply of milk; pressure on the breast (tight bra or car seatbelt); blocked nipple pore; stress; fatigue; poor maternal nutrition; use of a pacifier; rapid weaning; and ankyloglossia in the infant 100,104 Care - Reassure mother that continuing breastfeeding is advised and that milk from the affected breast is safe for her infant 39,101,102,104,105 - First 12 to 24 hours Shower or warm compresses to breast before feeding may facilitate milk flow Breastfeed frequently ensuring effectual milk removal. Start on the affected breast. If discomfort inhibits let-down then start on the unaffected breast and switch to the affected breast when letdown occurs 104 Position the infant on the breast with chin or nose pointing towards the affected area. During breastfeeding massage the breast starting at the blocked area, moving toward the nipple 104 After breastfeeding, any additional milk may be expressed by hand or pump and applying cold compresses may reduce pain and edema 39,104 Advise bed rest, adequate fluids and nutrition, and support at home Use an analgesic, e.g., ibuprofen (400 mg. every 4 -6 hours) to decrease inflammation and pain 101,103,104 3.0 Breastfeeding Guidelines for Health Care Providers for Healthy Infants: Birth to Six Months and Beyond, cont.

# - Subsequent treatment after 24 hours
Use antibiotics judiciously and only recommended if symptoms have not improved after 12 -24 hours of rest and applying the above recommendations; 101 maternal fever has not subsided and illness remains acute; or if the nipple is cracked/fissured indicating possible infectious mastitis. 107 Most common pathogen is penicillin-resistant Staphylococcus aureus; less common are streptococcus or Escherichia coli 104 Suggested antibiotics are penicillinase resistant penicillins, e.g., dicloxacillin or flucloxacillin 500 mg qid or cephalexin when penicillin allergy is suspected. 104 Although not clinically studied, it is recommended that antibiotic therapy should continue for 10 to 14 days 104,105 Breast Abscess
- Occurs in approximately 3% of women with mastitis 38,104 - Use of ultrasound is advised for diagnosis and to guide aspiration or surgical drainage if necessary 101,104 - Breastfeeding can continue from the unaffected breast and can resume from the affected breast following drainage of the abscess and the initiation of antibiotic treatment if the mother is comfortable and the infant's mouth has no contact with drainage or infected tissue 101,104 - Otherwise, hand express milk from affected breast during this period to maintain supply

# - Inverted or Flat Nipples
Breastfeeding over time can elongate the nipple and lessen an inversion Types 38
- Retractile: the nipple can evert with suckling and/or when the areola is gently pressed between thumb and forefinger. Is the most common
- Invaginated or true inversion: nipple retracts when areola is compressed; rare Care 38,39 - Initiate breastfeeding as soon as possible; the mother's nipple/breast should be the first object introduced into the infant's mouth Apply expressed colostrum/breastmilk or warm water to nipples after feeding then air dry 39 Limiting length of breastfeeding time does not alleviate or prevent sore nipples and is detrimental to establishing breastfeeding 38,39 3.0 Breastfeeding Guidelines for Health Care Providers for Healthy Infants: Birth to Six Months and Beyond, cont.
Prolonged or persistent pain: causes vary and specific diagnosis is difficult

# - Physical/mechanical causes
Characterized by nipple irritation and redness, flattened nipple after feeding, abrasion, cracks, fissures and/or bruised or bleeding nipples.

# - Maternal conditions
Vasospasm: nipple blanched but usually not misshapen after breastfeeding.
Ensure correct position and latch

# Avoid cold
Apply dry heat to nipple immediately after breastfeeding Avoid vasoconstricting drugs, e.g., caffeine and nicotine Reassure mother that this is a time limiting condition and will resolve without treatment Raynaud's phenomenon: a vascular disorder causing vasospasm which is an ongoing maternal condition unrelated to breastfeeding. Presents as a white nipple after feeding that is biphasic or triphasic in colour that change white to blue or white to blue to red. Nipple pain can be excruciating and both nipples are usually affected 106 - Care: Similar to vasospasm (see above).
Health care provider may prescribe medication: Nifedipine 5 -10 mg. 3 times a day or 30 mg. by slow release tablet 38,103,106 and an analgesic for pain relief 3.0 Breastfeeding Guidelines for Health Care Providers for Healthy Infants: Birth to Six Months and Beyond, cont.
Eczema, psoriasis, or herpes simplex: present as painful nipples and/or areola with acute vesicular eruption.
Refer mother to health care provider for diagnoses and medical treatment.
If herpes simplex on or near the areola, temporarily discontinue breastfeeding on the affected side until the lesions are crusted or healed 2,23,38 Encourage mother to express her milk until she can resume breastfeeding
- Candida (fungus infection):
Nipples: exceptionally sore; deep pink or red colour, itchy; and may burn Breasts may have shooting pains or burning sensation during or after feeding that may radiate to the back or arm

# Associated with vaginal yeast infection and or recent use of antibiotics
Infant shows signs of Candida in mouth, or a rash in perineal area that appears red as if scalded, or small red spots or pustules Diagnosis is based on symptoms; cultures frequently inaccurate 119 Care: Rule out other causes of sore nipples -Frequent hand washing and sanitation of all objects in contact with nipples or infant's mouth; keep nipples dry; avoid pacifiers or artificial nipples -Antifungal medications: generally treated but the evidence of effectiveness of the medication is lacking 38 -Treat mother and infant simultaneously
- Mother: apply ointment to nipples (e.g. nystatin or clotrimazole) before and after breastfeeding
- Infant: apply nystatin suspension to oral cavity qid, 103 using dropper or swab and nystatin cream to diaper area as indicated - Reassess if not improved in 5 days and/or if reoccurs,
- Treat partner as well  If condition persists consider using Gentian Violet or Fluconazle (Diflucan).
- Gentian violet should be no stronger than 0.25% to 0.5% diluted with distilled water and used only 1 -2 times daily for not more than 3 -7 days 38,103,104 - Fluconazle use, for ductal candidiasis medication should continue for at least 2 -3 weeks to be effective 106 Additional maternal advice may include: 1acidophilus tablet daily (40 million -1 billion viable units) during and 2 weeks after symptoms disappear and dietary restriction of cheese, bread, wheat products, sugar and honey 38 3.0 Breastfeeding Guidelines for Health Care Providers for Healthy Infants: Birth to Six Months and Beyond, cont.
- Staphylococcus aureus: Occurs most frequently in first month after giving birth Nipples severely sore, inflamed, cracked, or fissured; may exude yellow drainage. Correcting position or latch does not resolve the condition.
-Refer to physician as antibiotics may be needed to promote healing and prevent mastitis of the breast

# Use of Nipple Creams, Gels and Topical Agents
- "No one topical agent shows superior results in the relief of nipple discomfort" 107 - General consensus: if a mother is using a product that she believes is helpful and it is not harmful to her or her infant's health, do not oppose use 38 3.0 Breastfeeding Guidelines for Health Care Providers for Healthy Infants: Birth to Six Months and Beyond, cont.
Recognize maternal feelings of ambivalence, loss, and sadness whenever weaning occurs; counsel the mother

# - Natural or Infant-led Weaning
Occurs when safe complementary foods are introduced (6 months of age) and breastfeeding continues until the child is up to 2 years and beyond Encourage slow, progressive, natural weaning among mothers
- Planned, Mother-led, or Deliberate Weaning
Mother decides and reasons vary: e.g., perception of low milk production; illness; return to employment; or new pregnancy Examine reasons for weaning; provide the mother with information as indicated; and support her "informed decision"
- Wean gradually, discontinue one breastfeeding for several days/week before discontinuing another breastfeeding; evening or early morning feedings often continue the longest
- Mothers returning to work may continue to breastfeed when she is with her infant and express breastmilk for use when she is absent
- Substitute age appropriate family food and liquids from a cup for the discontinued breastfeeding session
- Additional cuddling and/or play interactions will comfort infants who are reacting to the loss of breastfeeding
- During infant illness, breastfeeding frequency may increase
- Consult a public health nurse, nutritionist, or physician regarding introduction of appropriate complementary foods depending on the infant's age
- Infant refusal to breastfeed: "Nursing Strike"
Reassure mother this is temporary, not rejection or initiation of weaning Explore reasons, e.g., return of menses; 39 changes in maternal diet, laundry soap, infant teething or illness Minimize distractions during breastfeeding; e.g., use alternative nursing locations Offer the breast before baby is fully awake Express milk to maintain supply until baby is again fully breastfeeding

# - Accidental Weaning
Mother's milk supply has decreased to the point where baby is no longer interested in breastfeeding Most commonly occurs when baby receiving other foods (formula and/or solid foods) in large amounts Review baby's intake of other foods and pattern of breastfeeding. Discuss options with motherweaning and/or increasing breast milk production

# - Abrupt or emergency weaning
Unanticipated weaning that is abrupt; e.g. maternal illness, unexpected mother-infant separation Short term use of contraindicated drugs is not a reason to wean. Express milk, for the time frame specific for the drug, to maintain supply, and prevent engorgement. Resume breastfeeding as soon as possible Support mother and evaluate infant's feeding pattern and growth until resolved

# Weaning from the Breast 117
Breastmilk includes breastfeeding, expressed breastmilk or pasteurized donor milk and undiluted drops or syrups consisting of vitamins, mineral supplements or medicines.
Exclusive breastmilk no food or liquid other than breastmilk, not even water, is given to the infant from birth by the mother, health care provider, or family member/supporter.
Hoffman's Exercise exercise used for inverted nipples by stretching of the nipples by manual manipulation.
Infant feeding cues include the baby bringing her hands to her mouth, sucking, rooting (turning her head toward the person holding her, often with her mouth open), irritability and crying (a late cue).
Lactogenesis Changes in the breast in the transition from pregnancy to lactation.
Lactogenesis I transition from pregnancy to lactation capacity of the mammary gland to secrete milk from mid-pregnancy to late pregnancy.
Lactogenesis II the onset of copious milk secretion after birth (days 2 or 3 to 8 postpartum).