PURPOSE
The purpose of this policy is to promote a philosophy and practice of maternal infant care that advocates breastfeeding based on the recommendations from the most current evidence. Good Samaritan Hospital (GSH) staff will actively support breastfeeding as the preferred method of providing nutrition to infants.

To provide specific policies that ensure that the hospital promotes the Ten (10) Steps to Successful Breastfeeding and the International Code of Market of Breastmilk Substitutes provided and approved by BabyFriendly USA that are routinely communicated to health care staff. To assure that staff have the knowledge and skill necessary to support infant feeding consistent with evidence and identified patient needs in the inpatient and outpatient settings that service Good Samaritan Hospital.

POLICY/ PROCEDURE:
The decision whether to breastfeed or provide breast milk for her newborn should be an informed choice made by the mother. Exclusive breastfeeding will be recommended as the ideal nutrition for newborns. When appropriate, mothers who plan to combine breastfeeding and formula feeding should be educated about the advantages of beginning with full breastfeeding to establish her milk supply.
The GSH Breastfeeding Task Force is a multidisciplinary team to comprising hospital administration, physician, nursing, lactation consultants, pharmacy, materials management and other appropriate staff, established to identify and eliminate institutional barriers to breastfeeding.
The obstetric, pediatric and neonatal physician staff shall support human milk for all babies for whom breastfeeding is not specifically medically contraindicated and provide parents with complete, up to date information to ensure that their feeding decision is a fully informed one. Mothers who choose not to breastfeed for medical or personal reasons shall be treated with respect and support. Medical contraindications include:

• Maternal HIV infection
• Active herpes on the breast
• Maternal active tuberculosis infections
• Infant galactosemia
• Maternal illicit drug use
• Maternal administration of certain medication (chemotherapy, radioactive iodine, etc.)
• Active, untreated varicella
• Previous breast surgery (if the mother is unable to produce breastmilk)
• Medically unstable mother (admission to the ICU postpartum)

Good Samaritan Hospital will adhere to and promote policies consistent with Baby Friendly USA that will include the Ten (10) Steps to Successful Breastfeeding. The Ten Steps to Successful Breastfeeding delineated below have been demonstrated to increase both initiation and duration of breastfeeding.

A. The Perinatal Management Team (Director, Manager, Department Supervisors, Lactation staff and Educators) is responsible for the development, implementation, evaluation and revision of a written breastfeeding policy. This policy will be communicated to all healthcare staff. The policy will be posted on the intranet and assessable to all staff at Good Samaritan Hospital.

B. This policy will be reviewed annually and revised a minimum of every 3 years by the Director of Perinatal Services and perinatal employees. The Medical Staff (Pediatric Committee, Obstetric Committee, and the Medical Executive Committee) as well as the Board of Directors will approve the policy revisions as presented. The policy will be posted on the intranet to be accessible to all employees.

C. GSH will maintain a Breastfeeding Task Force that will meet a minimum of quarterly to oversee compliance with this policy with house wide membership.

D. New hires will be educated on this infant feeding policy during the mandatory breastfeeding education class that must be completed within 6 months of hire. They will be provided a GSH 15hour course or an online comparable course.

E. This facility upholds the World Health Organization (WHO) International Code of Marketing of Breastmilk Substitutes by offering education and materials that support human milk rather than infant food or drinks and by refusing to accept or distribute free or subsidized supplies of breast milk substitutes, nipples and bottles by October 2015.

a. No employees of manufacturers or distributors of breast milk substitutes, bottles, nipples, or pacifiers have direct or indirect contact with pregnant women or mothers.

b. Vendors will have limited/restricted access to the hospital’s perinatal units.

c. Vendors requesting access to perinatal units are only permitted access by registering with Materials Management and making a scheduled appointment to enter the facility. The Director of Perinatal Services will be contacted directly to discuss any exception to this access.

d. Vendors will not be permitted to provide group instruction in any location where care is provided to mothers and babies (Labor & Delivery, Postpartum/Acute Obstetrics, and NICU).

e. GSH and its staff members may not receive any free gifts, nonscientific literature, materials, equipment, money or support for breastfeeding education or events from manufacturers’ or distributors of breastmilk substitutes, bottles, nipples or pacifiers.

f. Pregnant women, mothers or their families are not given marketing materials or samples/gift packs by Good Samaritan Hospital that include breast milk substitutes (formula), bottles, nipples or other infant feeding equipment or coupons for any of these items.

g. Any educational materials distributed to breastfeeding mothers (discharge education booklet) and the hospitals Newborn Channel are free of messages or logos that promote or advertise infant food or drinks other than breastmilk.

2. Train all health care staff in the skills necessary to implement this policy.

A. The Perinatal Manager(s) and Director in collaboration with the Perinatal and Lactation Educators is responsible for implementing and assuring that all staff in the perinatal units are educated and trained in breastfeeding. The curriculum for this education will cover the 15 sessions identified by BabyFriendly USA.

B. The Perinatal Management Team will plan, implement, evaluate and annually review/revise as needed this competency based training in breastfeeding and parent teaching for formula preparation and feeding for all staff caring for mothers and infants. Training programs will vary in length and substance depending upon the level of competency required by the health care teams function, responsibility and previously acquired training, and will include documentation that essential skills have been completed.

C. The Breastfeeding Task Force will determine the amount of training required by staff in other units and roles based upon their exposure to mothers and babies, current guidelines are:

• Perinatal services Physicians and Allied Health Professionals will be offered a minimum of 3 hours of breastfeeding management education.
• All new clinical employees who will provide direct patient care to pregnant/postpartum mothers and/or infants will be required to receive appropriate lactation/infant feeding education as a part of their orientation (must be completed within 6 months of hire). Education will be provided by a 15hour didactic class or comparable online program, with the addition of 5 hours bedside application training.
• Documented lactation education and training prior to employment will be evaluated and accepted if it adheres to the requirements set forth by Baby Friendly USA and it has been completed within 3 years.

All perinatal nursing staff coming in contact with mothers and infants will be required to participate in a standardized breastfeeding education:

All obstetrics registered nursing staff will receive a total of 20 hours of training which includes 5 hours of supervised clinical training/demonstration at bedside within 6 months of hire. Trained GSH lactation staff (CLE or IBCLC) will validate the clinical bedside demonstration.
All NICU registered nurses must complete a breastfeeding course (at minimum the Wellstart 3 hour breastfeeding curriculum). The Department Supervisors, Relief Charge RN’s and Lactation certified staff in NICU will receive the 15 hours of didactic education.
Supervision/oversight of the breastfeeding training program will be the responsibility of the Perinatal Services Director.
Documentation of lactation education (didactic class and demonstration) will be maintained in the employee files.

D. The annual job performance appraisal of perinatal employees will include lactation skills and compliance with this breastfeeding policy for the obstetric nurses in contact with mothers and infants.

E. The GSH Perinatal Unit skills fair will provide annual updates to support continuing education of breastfeeding (incorporating new evidence and areas of identified opportunity/improvement).

F. The staff and physicians at GSH do not receive free gifts, equipment, money, or support for breastfeeding education or events from manufacturers of breastmilk substitutes, bottles, nipples, or pacifiers.

3. Inform pregnant women about the benefits and the management of breastfeeding.

A. GSH will foster programs that make education about breastfeeding available to pregnant women for whom the facility provides inpatient services. Pregnant women and their support persons (as appropriate) will be educated on the benefits of breastfeeding, the contraindications to breastfeeding and the risk of formula feeding. The OB Liaison to the prenatal clinics will provide education schedules and community resource lists to the clinics.

B. Mothers will be encouraged to exclusively breastfeed unless medically contraindicated. Exclusively breastfed newborns will receive no other liquids or solids with the exception of oral medications prescribed by a medical care provider. C. GSH Community Liaison will promote breastfeeding with the clinics that routinely delivery at GSH in the following ways:

1. Maternity Tours at GSH will include the importance of breastfeeding, skin to skin, and rooming in.
2. The clinics will be educated to avoid product names, images and logos as well as coupons with infant formula.
3. The clinics will be provided the list of educational breastfeeding classes and community resources provided at GSH.
4. The patients will be provided breastfeeding booklets for education (the materials will meet the Baby Friendly materials requirement).
5. The educational materials provided are free of logos, product names or images

D. GSH Childbirth Services at Community Health education staff provide Prenatal Education classes in English, Spanish and Korean and will include breastfeeding basic education to patients from both clinic and private settings. The curriculum includes:

1. The benefits of breastfeeding
2. The importance of exclusive breastfeeding
3. Nonpharmacological pain relief methods for labor
4. Early initiation of breastfeeding
5. Early skin to skin contact
6. Rooming in on a 24hour basis
7. Baby led feeding
8. Frequency of feeding in relation to establishing a milk supply
9. Effective positioning and latch techniques
10. Exclusivity of breastfeeding for the first 6 months
11. Continuation of breastfeeding after introduction of appropriate complimentary foods
12. The focus of these classes is on breastfeeding. Combination (breastfeeding and formula feeding) is not encouraged nor a part of the curriculum in these classes).

E. All prenatal educational media will be free of messages that promote artificial feeding. In-services or group talk that promote the use of formula and bottles for infant feeding is discouraged and flyers are not to be posted in GSH lounges or nursing stations.

F. The patient’s desire to breastfeed or not will be documented in the medical record. Mothers will be encouraged to exclusively breastfeed unless medically contraindicated. If contraindications are identified the physician will be notified and the mother educated.

4. Help mothers initiate breastfeeding, as soon as the mother is responsive and alert.

A. To facilitate mother infant bonding, to ensure best practices for breastfeeding support and to safety transition the infant from intrauterine life to extra uterine life, all mothers and infants will be encouraged to participate in skin to skin care regardless of feeding choice. Staff (nursing, midwives, and physicians) should offer assistance and education during this period to help the parents learn and respond to the infant’s feeding cues. The nursing staff will document the skin to skin contact in the nursing documentation.

B. Skin to skin contact is defined as placement of the naked baby prone on the mother’s bare chest postdelivery. GSH staff responsible for caring for mothers and babies will help mothers initiate breastfeeding as soon as the mother is responsive and alert, unless contraindicated, and assure the early initiation of skin to skin contact and breastfeeding.

C. For vaginal deliveries, the infant is dried and immediately placed skin to skin as soon as feasible usually within 5 minutes when mom is alert and able to hold the baby postdelivery (routine care assessments, Apgar scores) will be done with the baby skin to skin. Routine newborn procedures will be postponed until after the initial skin to skin period and (if required based on the newborn assessment the RN can give on the mother’s chest), whenever feasible.

D. For mothers that choose to formula feed, the initial period of skin to skin for one hour will be encouraged. Procedures that require separation of the baby and mother (bathing, etc.) should be delayed until after the first hour.

E. Post Cesarean birth babies will be encouraged to breastfeed as soon as possible, usually in the recovery area when the mother is able to respond to her baby. Skin to skin will begin as soon as the mother is responsive and alert. The staff will offer assistance with positioning to minimize incision discomfort, and the use of a pillow to protect the incision site.

F. If the mother and/or infant are medically unstable and are separated for medical reasons, the nursing staff will ensure that skin to skin contact will be initiated as soon as the mother and baby are reunited. For NICU /Nursery babies separated for medical reasons, if the babies and mother’s condition allows, the mother will be assisted in initiating skin to skin contact in the Newborn Nursery and or NICU settings.

5. Show mothers how to breastfeed and how to maintain lactation even if they are separated from their infants.

A. Staff caring for the newborn and mother are accountable to assess the mother’s breastfeeding techniques and, if needed provide assistance with breastfeeding within the first six (6) hours after birth and during each shift throughout her stay.

B. GSH staff caring for the mothers will initiate education to the mother and family member upon admission to labor & delivery (triage, antepartum admission or labor admission). An educational packet is given to the mother with written materials to be able to refer to at home in postpartum (a booklet on her care as well as her baby, breastfeeding basics, a resource sheet) and other materials to support her transition to home.

C. Labor & Delivery nurses will begin breastfeeding education and assist mothers with skin to skin post vaginal and cesarean section deliveries and parents will be encouraged to continue skin to skin in the postpartum setting.

D. All staff is responsible to document the education and assessments in the patient care record.

E. Staff will routinely assess mother/baby comfort, and effectiveness of breastfeeding feeding:
a. At the shift assessment, the nurse will educate mothers in correct positioning, latch and the signs of effective feeding in addition to the physiological processes and breastmilk volume.
b. Education will include the importance of breastfeeding, how to maintain breastfeeding for at least 6 months, criteria to assess if the baby is getting enough breastmilk (showing the “belly balls badge illustration) to show the size of the baby’s stomach, and baby feeding readiness (hunger cues, signs of effective feeding).

F. Staff are to also educate the family in how to express, handle and store breastmilk (including manual expression), and how to sustain lactation (even if the mother is separated from her infant or will not be exclusively breastfeeding after discharge):

G. Lactation support will provide individualized assistance to high risk and special needs mothers and infants and to mothers who are having breastfeeding problems and /or those who must be separated from their infants.

H. Best practice when mothers and babies are separated includes:

• Begin milk expression within 6 hours of birth (educate mother to pump 8 or more times in a 24hour time period) with at least one pump session during the night.
• Instruct the mother on how to do hand expression or use the electric breast pump and kits.
• Teach proper storage and labeling of human milk.
• Expressed milk is given to the baby as soon as the baby is medically ready.
• The mother’s expressed milk is used before any supplementation with breastmilk substitutes when medically appropriate.
• Mothers of preterm or sick neonates will be educated about collecting their milk (see the policy” Breast Milk Management and Storage.”

6. Give infants no food or drink other than breastmilk, unless medically indicated.

A. Mothers who have chosen to feed formula will receive both written and verbal information about safe preparation and feeding of infant formula, which includes:

• VLBW infants <1500 grams
• Infants born <32 weeks gestation
• Infants at risk of hypoglycemia – preterm, IDM, SGA, Asphyxiated or ill newborns
• Severe maternal illness
• HSV lesion on the breast
• Phenylketonuria

B. Formula will not be placed in or around the breastfeeding infant’s bassinet or in the mother’s room.

C. Formulas will not be part of the standard orders for newborn care and will only be given to infants per physician’s order and with the mother’s knowledge of the reason why.

D. When supplementation is medically indicated, artificial nipples will be avoided and an alternate feeding method will be utilized first. A lactation educator will provide education regarding options to the mother or a nurse trained in using that method to maintain mother infant breastfeeding skills. Care should be taken not to exceed the physiologic capacity of the newborn stomach at each feeding:

1. On Day #1 of life no more than 15 cc per feeding should be given.
2. On Days 2 and 3, no more than 30 cc per feeding should be given.

E. If a mother requests that her baby be given formula, the healthcare staff will address the mother’s concerns, health of the baby and the success of breastfeeding. If the mother still requests formula, her request should be granted and her informed decision documented.

F. All efforts will be made to supplement with the mother’s milk. If the maternal milk supply is inadequate, formula will be used.

G. Reason for supplementation and education provided will be documented. Supplemental feeding devices used at this facility include spoons, cups, syringes and SNS (supplemental nursing system).

H. GSH will pay fair market value to purchase formula, nipples, bottles and pacifiers.

I. Formula will be stored in a secure location in all perinatal units and distribution will be monitored.

J. Reference books and the pharmacy staff will be used as references to verify medication contraindications. If contraindications are identified, the physician will be notified and the mother educated.

7. Practice rooming in; allow mothers and infants to remain together 24 hours a day.

A. Rooming in (accommodations in a private room for the mother and infant and significant other to remain together 24hours a day), is the standard for normal newborns, regardless of infant feeding choice and assured throughout the hospital stay unless contraindicated.

B. The mother and infant (normal deliveries without complications) will remain together postdelivery as soon as feasible and be transported to the postpartum unit together for both vaginal and cesarean deliveries.

C. The mother infant couplet will be protected from disruption that may impact their ability to bond or interfere with breastfeeding needs. Breastfeeding takes priority over tasks and nurses are advocates for the couplet including asking visitors to wait when the mother is breastfeeding, bonding or during times of needed rest.

D. Procedures will be performed at the mother’s bedside with the focus of keeping the mother and newborn together (whenever possible), and should avoid separations and/or absences of the newborn from the mother for no more than one hour per day.

E. If the maternal or infant conditions preclude rooming in, all efforts will be made to return the infant to the mother for breastfeeding. The infant will return to the newborn nursery for care and be returned to the mother when her condition is stable.

F. If the mother requests that the infant be cared for in the Nursery, the maternity staff will explore the reasons, encourage and educate about the advantages of rooming in 24 hours/day and the availability of staff support. If the mother insists on the infant being cared for in the Nursery, then the education, the processes and decision will be documented in the medical record.

G. Whenever rooming in is interrupted, the reason for the interruption, the location of the infant during the interruption and the time the infant leaves and returns to the mother’s room will be documented in the infant’s medical record.

H. If the infant is separated from the mother for any reason, the infant will be brought to the mother for feedings whenever the infant shows feeding cues.

8. Encourage breastfeeding on demand.

A. Mothers will be encouraged to breastfeed on demand or when the baby exhibits hunger cues or signals. Mothers will be educated as to these feeding readiness cues (increased alertness /activity, mouthing, or rooting) to be used as indicator of the infant’s readiness for feeding.

B. Education will be provided to the mother and includes but is not limited to:

• Milk production and release.
• Frequency of feeding on demand (a minimum of 812 times/day); hunger cues.
• Proper positioning and latch on
• Hand expression of breastmilk and the use of a pump if indicated.
• How to assess if her newborn is adequately nourished
• The importance of physical contact & bonding which are as important as nourishment during breastfeeding.
• When to contact a healthcare professional.

C. Time limits for breastfeeding will be avoided. Infants can be offered both breasts at each feeding but the baby may be interested in feeding only on one side per feeding in the early days. (See #6 – “g” for additional specifics on feeding amounts)

9. Give no pacifiers or artificial nipples to breastfeeding infants

A. Pacifiers will not be given to normal full term breastfeeding infants. The use of pacifiers or other soothers will be delayed in breastfeeding infants until breastfeeding is well established (about one month per American Academy of Pediatrics).

B. All parents will be given education about how the use of bottles and/or pacifiers may interfere with the development of optimal breastfeeding and with babies’ suckling or demonstration of hunger cues and this education will be documented.

C. When a mother requests that her breastfeeding baby be given an artificial nipple or pacifier, the nurse will:

• Inform her of the AAP recommendations to avoid the use of artificial nipples for 1 month.
• Teach alternative methods of pacification and encourage to breastfeed frequently in response to baby’s hunger cues.
• Instruct her regarding the possible negative consequences artificial nipples and pacifiers may have to breastfeeding.
• Document this education and outcomes in the baby’s chart.

D. Infants with certain medical conditions and newborns undergoing procedures may be given a pacifier for comfort or pain management. The infant will not return to the mother with the pacifier.

E. GSH encourages pain free newborn care, which may include breastfeeding during heel stick laboratory procedures.

F. Exceptions to this policy may occur when a mother must feed her newborn expressed breastmilk or a formula and chooses to use a bottle after being educated regarding alternative feeding choices /options.

G. Routine use of nipple creams, ointments, or other topical preparations will be avoided unless such therapy has been indicated per the medical care provider. Mothers with sore nipples will be observed for latch on techniques and be instructed to apply expressed colostrum or breastmilk to the areola/nipple after each feeding.

H. Artificial nipples, pacifiers, other soothers, bottles and breastmilk substitutes will not be included in any gift packs given to pregnant patients or breastfeeding mothers. Marketing materials and coupons for these items will be excluded as well.

10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital.

a. The nursing staff will refer breastfeeding mothers to community lactation support skilled to assist with assessing, intervening and supporting the breastfeeding couplet after discharge.

b. The assigned maternity staff members will assess with the mother, significant other and family members plans for the infant’s feeding after discharge. Discharge planning and teaching will include:

• information on the importance of exclusive breastfeeding up to 6 months and available

c. Any nursing concerns related to the infant’s ability to latch or effective suckle at the breast will be communicated to the infant’s healthcare provider prior to discharge.

d. Discharge planning will include phone numbers for a community resource Pediatric Emergency Room and contact information for their pediatrician office.

e. In the discharge paperwork, the mother will be instructed to contact her healthcare provider/clinic for any concerns or questions about breastfeeding. The GSH maternity unit number is an additional resource that will be provided for lactation specific support.

f. All infants of breastfeeding mothers will be instructed to contact their Primary MD for an appointment to be seen within 4872 hours after discharge. The lactation team from GSH will do follow up phone calls to all exclusively breastfeeding patients within one week post discharge.

g. The GSH staff will collaborate to discover breastfeeding resources to support education to the breastfeeding mother and infant. A list of these resources will be printed and included in a discharge packet to all breastfeeding families in English, Spanish and Korean languages.


CROSS REFERENCE:
1. Policy: Breast Milk Management and Storage
2. Bottle Feeding, Infant (NICU)
3. Breast Pump, Use and Care of Electric Pump
4. Breast Milk: Use of Donor Milk (NICU)
5. Golden Hour

REFERENCES

1. The American Academy of Pediatrics (2005), Policy on Breastfeeding and the Use of Human Milk, 115 (2): 496506. Illinois.
2. BabyFriendly USA, Guidelines and Evaluation Criteria for Facilities Seeking Baby Friendly Designation. Sandwich, MA: BabyFriendly USA, 2010.
3. BabyFriendly USA, Inc., (2013) Guidance Tool for Developing the Facility’s Maternity Care and Infant Feeding Policies: Implementing the Ten Steps to Successful Breastfeeding.
4. The US Department of Health and Human Services (2000). HHS Blueprint for Action on Breastfeeding, Office on Women’s Health, US Department of Health and Human Services, Washington, D.C.
5. Academy of Breastfeeding Medicine Protocol Committee (2009). Clinical Protocol #19: Breastfeeding promotion in the perinatal setting. Breastfeed Medicine, 4, 4345.
6. Academy of Breastfeeding Medicine Protocol Committee (2009), Clinical Protocol #3: Hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate. Breastfeed Medicine, 4, pp. 175182.
7. Academy of Breastfeeding Medicine Protocol (2010). Clinical Protocol #7: Model Breastfeeding Policy. Breastfeed Medicine, Volume 5, Number 3.
8. Mikiel Kostyra K, Masur J., Boltrusko, I. (2002) Effect of early skin to skin contact after delivery on duration of breastfeeding: A prospective cohort study. Acta Paediatr 29, pp.13011306.
9. Howard C, Howard F., and Lanphear B. et al (2005) Randomized clinical trial of pacifier use and bottle feeding or cup feeding and their affect on breastfeeding, Pediatrics, 111, pp. 511518.
10. Marinelli, K., Burke, G, Dodd, V. (2001) A comparison of the safety of cup feedings and bottle feedings in premature infants whose mothers intend to breastfeed. J Perinatology, 21, pp. 350355.
11. Gray, L, Miller, L, Philipp, B, et al. (2002) Breastfeeding is analgesic in healthy newborns. Pediatrics, 109, 590593.
12. Wight, N., Marinelli, K., Academy of Breastfeeding Medicine Protocol Committee. Clinical protocol #1: Guidelines for glucose monitoring and treatment of hypoglycemia in breastfed neonates, revision June 2006. Breastfeed Medicine 2006:1: 178184.
13. Academy of Breastfeeding Medicine Protocol Committee, Clinical protocol #2: Guidelines for hospital discharge of the breastfeeding term newborn and mother, ‘The going home protocol.’ Breastfeed Medicine 2, pp. 158165.
14. The Ten Steps to Successful Breastfeeding, Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services (1989). The World Health Organization (WHO), Geneva.
15. FeldmanWinter, L., Procaccini, D., Merewood, A. (2012). A Model Infant Feeding Policy for Baby –Friendly Designation in the USA. Journal of Human Lactation. Sage Publications.

AUTHORS
Lactation Consultants
Childbirth Services Coordinator Director of Perinatal Services