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Nursing guidelines

Breastfeeding support and promotion


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    Introduction

    The Royal Children’s Hospital is committed to the promotion, support and protection of breastfeeding as the optimal method to feed neonates and infants.  Breastmilk provides complete nutrition for an infant to 6 months of age, with the type and level of protein, carbohydrate and fat ideal for the optimal growth and development. The World Health Organisation recommends neonates and infants are exclusively breastfed for the first 6 months of life, and thereafter receive complementary foods with continued breastfeeding for up to 1 year or beyond.  Breast milk is readily available and contains anti-infective and anti-inflammatory properties that assists in preventing infections and necrotising enterocolitis. Long term benefits include improved neurodevelopmental outcomes and reduced risk of obesity. Benefits to the breastfeeding mother include enhanced bonding, reduced anxiety, reduced risk of ovarian and breast cancer and post-partum weight loss. For neonates and infants who require hospitalisation, access to the benefits of breast milk should be encouraged, and the mother supported throughout.

    Aim

    The aim of this clinical guideline is to enable all clinical staff to actively support and promote breastfeeding as the most beneficial form of nutrition for neonates and infants throughout all departments of the RCH, including for siblings of an admitted child at management discretion.
    The following guideline contains information to assist families with initiation, establishment, and continuation of breastfeeding. Details of the referral processes to further support services are also included.

    Definition of Terms

    CFR: Central Formula Room

    EBM: Expressed breast milk

    Extremely Preterm: A baby born before 28 weeks completed gestation

    Fortification: Additions made to breast milk to increase protein and caloric content

    Infant: A child under 1 year of age

    Late Preterm: A baby born between 32 and 36+6 weeks of completed gestation

    Milk Substitute: Represented as partial or total replacement for breast milk (generally infant formula). 

    NGT/OGT: Nasogastric Tube/Orogastric Tube

    PDM: Pasteurised donor breast milk

    PMU: Postnatal Mothers Unit

    Preterm: A baby born before 37 weeks of completed gestation

    Neonate: An infant under 28 days of age

    Term: A baby born after 37 weeks of completed gestation

    Very Preterm: A baby born between 28 and 31+6 weeks of completed gestation

    Information for staff

    • The RCH does not endorse one brand of milk substitute, and promotional materials for such are not permitted.  This is in line with the WHO International Code of Marketing of Breast-Milk Substitutes to ensure the provision of safe and adequate nutrition for infants, including the use of milk substitutes where necessary, without interfering with the protection and promotion of breastfeeding.
    • In conjunction with this clinical guideline, all staff are encouraged to attend education sessions on lactation management and breastfeeding support. This is to ensure that correct, current, and consistent information and support is provided to all mother’s wishing to breast feed or to provide their infant with expressed breast milk. Additional resource links are provided below.

    How breastfeeding works

    There are three phases to the lactation cycle: mammogenesis, secretory differentiation (or known as lactogenesis 1), and secretory activation (or known as lactogenesis 2).

    Mammogenesis occurs during pregnancy where hormones influence the ductal system of the breast branches, allowing the lobes to grow and the alveoli to form. This is typically associated with an increase in breast size and breast tenderness.

    Secretory differentiation occurs in mid to late pregnancy, where the differentiation of the mammary epithelial cells into lactocytes occur. This allows the secretion of fats, proteins and carbohydrates which are present in human milk. Therefore, women can produce small amounts of colostrum in the later stages of their pregnancy.

    The last phase, secretory activation, is triggered when the circulating progesterone level drops with the removal of the placenta, and prolactin increases. Milk secretion, or milk ‘coming in’, is often seen between 24-102 hours (average 60 hours – or day 2-3).

    When an infant feeds on the breast, nerves in the nipple and areola are stimulated, which sends impulses to the brain. Prolactin and oxytocin are released in response to this stimulation. Prolactin assists in stimulating milk production, and oxytocin allows the milk to flow from the alveoli, into the ducts and through the nipple pores. 

    Admission documentation

    On admission each neonate, infant or child will have a feeding history documented by the clinical team. This includes:

    • Intention to breastfeed or breastfeeding history
    • Current nutritional requirements and feeding regime, including any recent alterations to this pattern
    • Infant growth, hydration, and development
    • Medications and allergies
    • Comorbidities 
    • Reported feeding difficulties for the patient or mother 
    • If the family do not wish to breastfeed, any requested milk substitutes should be noted, and consent should be obtained and documented
    • Consent should also be sought for the use of dummies for non-nutritive sucking
    • Where possible, breastfeeding mothers are encouraged to stay with their child during admission to facilitate unrestricted breastfeeding. If this is not possible, level 2 accommodation should be considered. Any circumstances that might make it difficult for the mother to be present during the admission should be discussed, and the times that she will be available to optimise breast feeding documented.

    This information will be recorded in the infant’s electronic medical record (EMR: ADT Navigators – Admission – Nutrition – Diet Comments), as well as the admission note. Referral for further breastfeeding support should be completed if feeding difficulties are identified.

    Growth monitoring

    Anthropometric measurements, including analysis of weight, head circumference and length, are an integral aspect to the medical and nutritional management of neonates, infants and children.

    • Butterfly –Refer to the ‘ Neonatal Growth Monitoring’ guideline for further information on contraindications, procedures and management.
    • Wards – growth monitoring requirements vary dependent both on the ward and the patient.  Please see a member of the local senior nursing team, care coordinators, or medical treating team for further information and assistance.

    Demand breastfed infants may have weights recorded more frequently to gauge a more accurate assessment of feeding.

    Breastfeeding support

    Readiness to Feed

    • Beginning oral feeding is a team decision that places the infant and their family at the centre of the care, and as such, parents should be included in these early discussions. Clinically, this decision is based on the medical status of the infant, the ability to maintain respiratory and cardiovascular stability, to remain alert for feeding, to coordinate suck, swallow and breathe patterns, to communicate hunger and fullness, and to cope with the positioning and handling associated with feeding.
    • Communicating feed timing with parents is vital. This ensures that the infant and mother are provided with maximum opportunities for breastfeeding.
    • Hunger cues include stirring before a feed or at feed times, increasing movements and becoming more active, rooting reflexes, hand to mouth movements, sucking, opening the mouth in response to touch. Crying is a late sign of hunger.
    • COCOON Baby Cues information can be found here and Baby Cues and Baby Body Language: a Guide can be found here.
    • Disengagement cues include cessation of sucking, closing their mouth, spilling milk from their mouth, turning their head away from the breast, putting a hand up, gagging, and pushing the nipple out of their mouth with their tongue.

    While a rapid transition to sleep may be a disengagement cue, some infants who are just learning to breastfeed may need to be woken or prompted during their feed. Unwrapping the infant, exposing, and stimulating a foot, or stroking the jaw line may assist them to continue showing interest in their feed.

    Cue-based breastfeeding

    • For inpatients who have established breastfeeding, ‘cue-led’ or ‘baby-led’ feeding will be ordered via the EMR; Diet Orders – NICU Feeding Schedule. This involves responding to the infant’s readiness to feed cues (and disengagement cues) to offer feeds that are not guided solely by volume. After assessing readiness to feed, and ensuring the mother is comfortable to attend to the breastfeed, feeding is documented via EMR: Flowsheets – Fluid Balance – Intake – NICU Breastfeeding Code or under P.O.  
    • Pre and post breastfeeding weights are often used on the Koala Ward to assess intake for cardiac and renal infants.  If the infant has gained 10grams at the end of the feed it is estimated that the infant has had 10mls during the breast feed. See subheading Enteral Intake in the Ward Management of the Neonate Guideline. 

    Positioning and attachment 

    • When required the health professional should assist mothers to consistently achieve correct positioning and attachment at each breast. Where possible mothers should be shown a ‘hands off’ approach to correct positioning and attachment. Mothers will then feel more confident and skillful in their ability to independently attach and position their baby to their breast to feed. 
    • To avoid muscular strain and soreness, it is important that the mother finds a comfortable position to breastfeed. Select a comfortable chair to support the back and shoulders, footstools ensure the mother’s feet are stable and pillows assist in supporting the baby. Ensure privacy is facilitated.
    • A hand placed between the infant’s shoulder blades provides enough support to the head and neck while keeping the infant’s head free to move towards and latch to the breast.
      • Reclined Position:  The mother lies in a semi-reclined position, well supported with pillows.  The baby is positioned prone on the mother’s chest with the nipple level to the baby’s nose.  As the baby’s chin touches the breast, the baby can attach easily as the tongue and jaw fall forward to grasp the breast. This position is particularly useful if the baby is having difficulty attaching or require assistance for fast milk flow.
      • Cradle Hold: this is the most common feeding position.  The baby’s nose will be level to the nipple, with the baby well supported by the mother’s forearm. The baby’s arm may be around the mother’s waist, or against her abdomen with their bottom resting on the mother’s thigh. The mother’s elbow will be at her side, the heel of her hand or supporting arm will be between the baby’s shoulder blades. In the cross-cradle hold, the baby is held using the opposite arm to the breast being used.
      • Underarm hold/football hold: the baby lies supported on a pillow under their mother’s forearm, with their body turned against the mother’s side with the baby’s chest, legs and feet tucked around to the mother’s back. The mother supports the baby’s shoulders with her hand and the baby’s body rests on her forearms. This position is useful for women with twins, those after a caesarean birth, those with large breasts or who are overweight/obese.  

    Signs of correct positioning and attachment:

    • The rooting reflex is initiated, and the baby’s mouth will be wide open with both lips relaxed on the breast and flanged outwards.
    • The baby’s head is slightly extended, and the chin pressed to the breast
    • Rhythmic jaw movement with wriggling of the ears
    • Swallowing sounds heard or observed
    • The baby’s nose is free without the mother needing to hold back her breast
    • Absence of clicking sounds

    Signs of incorrect positioning and attachment:

    • Nipple pain or trauma
    • The baby’s lips are rolled inwards
    • Clicking or smacking sounds at the breast
    • Biting sensations during the feed
    • The nipple slips out of the mouth when the baby pauses
    • Poor weight gain
    • A poorly positioned baby may show frustration, crying and fussing at the breast. To ensure that feeding is not a negative experience, break the cycle and settle the baby before again trying at the breast. Ensure that the baby has sufficient postural support to stabilise their position at the breast.
    • If for any reason the baby needs to be taken off the breast due to poor attachment, healthcare workers can educate the mother to avoid pulling the baby away from her breast. Instead, encourage the mother to break the suction by inserting her little finger into the corner of the baby’s mouth between the gums, and gently remove the baby away from the breast.

    Video resources:

    Assessing feed quality is now integrated into EMR. When documenting a feed (Flowsheets > Fluid Balance) there is now coding to document the quality of the feed on left and right breast. 

    Infant reflexes and sucking

    • Rooting reflex - this reflex progressively strengthens from 32 weeks’ gestation and is important in helping the infant find the nipple to attach to the breast. It is elicited by touching the infant’s cheek or corner of mouth, with the infant readily turning their head towards the stimulus while also gaping the mouth and tilting the head slightly upwards. The tongue will drop from the roof of the mouth, moving forwards to lick the nipple. It is important to note that a crying infant will position their tongue in their palate and attempting to place an infant to the breast in this state inhibits the rooting reflex and the development of sucking.  
    • Tongue thrust reflex - when the lips are touched, the infant’s tongue will extend out of the mouth to take in the nipple
    • Gag reflex - elicited by stimulation to the back of the tongue and soft palate, causing the muscles of the soft palate to contract
    • Sucking reflex - when the infant’s hard palate is stimulated and liquid transfers into the mouth, the tongue moves it to the back of the mouth for swallowing. This reflex is present from 24 weeks’ gestation and begins to strengthen as a suck/swallow/breathe cycle at 28 weeks. By 32 weeks’ gestation the infant begins to coordinate the reflex in repeated bursts, however, effective coordination for sustained breastfeeding often does not develop until 37 weeks. An infant displaying feeding cues from 32-37 weeks’ gestation will benefit from being placed skin to skin and allowed to attempt breastfeeding, but full top up of the feed via the nasogastric/orogastric may be required (refer to Assessing Feed Quality). Sucking and swallowing occurs at a frequency of at least once per second when breastmilk is actively flowing but will increase if the milk flow lessens or ceases.  Feeding therefore begins as short and fast bursts of progresses to long and continuous sucks as the feed is established. progresses to long and continuous sucks as the feed is established.
    • Suck and swallow cycle:
      • The infant draws the nipple, areola, and underlying breast tissue deep into their mouth, creating a seal with their lips and cheeks. The infant’s lips should appear flanged outwards.
      • The tip of the tongue remains over the lower gum while the anterior tongue cups the areola and breast
      • The suction created by the infant’s mouth elongates the nipple to extend to the junction between the hard and soft palates. The nipple is held between the upper gum and the tongue that is covering the lower gum.
      • The infant’s jaw moves the tongue upwards to compress the breast
      • The anterior aspect of the tongue is raised while the posterior aspect is depressed. Peristaltic motions of the tongue form a grove that moves milk to the back of the oral cavity to stimulate swallowing.  The soft palate rises and closes off nasal passages, with the larynx moving up and forward to close the trachea and propel milk into the oesophagus.
      • The larynx moves to the previous position and the infant lowers their jaw to begin a new cycle.
      • As neonates are predominately nose-breathers, breathing continues throughout the cycle, however if the bulk of the milk bolus enters the pharynx at the onset of swallowing, brief swallowing apnoea occurs. If further apnoea’s occur with feeding, or the feeds are disorganised, pacing and review by the local Speech Pathology team may be required.

    Further breastfeeding support

    Lactation Consultants (LCs) at the RCH are International Board-Certified Lactation Consultants (IBCLCs).

    • Koala Lactation consultant
      Tuesday – Friday, excluding public holidays
      ASCOM 54167 for patients on Koala, or cardiac patients on Rosella
    • Butterfly Postnatal Midwives
      7 days per week
      ASCOM 52764 for all postnatal assistance and further breastfeeding support

    *Please note that the postnatal midwives attend to women admitted to the PMU, and while based in Butterfly, will assist other wards when available. 

    • Maternal Child Health Nurses (MCHN)
      Monday – Friday, excluding public holidays
      Extension 57011 or email mch@rch.org.au

    Expressing breast milk

    Parents can be directed to the COCOON Breastfeeding and Expressed Breastmilk Webpage here.

    • EBM can be obtained for purposes of:
      • Collecting breastmilk for the preterm neonate/ill infant
      • During infant and mother separation
      • Storing breastmilk
      • Relieving the breasts of fullness due to engorgement, or with blocked ducts or mastitis
      • Establishing and building a milk supply
      • Initiating or maintaining supply when the infant is unable to feed at the breast
    • A mother can either hand express, or express with a manual or electric breast pump
    • Expressing frequency to establish a good supply should be 8-10 times a day (including overnight)
    • Ensure EBM is correctly labelled and stored as per RCH Expressed Breast Milk Management Procedure
    • EBM is a body fluid and must be handled using standard precautions (e.g. hand hygiene, glove use and preventing contamination of environmental surfaces)
    • Ensure mothers are educated on hand hygiene and wash their hands with soap and warm water prior to and after expressing.

    Hand Expressing

    • Often utilised in the first few days postpartum to obtain colostrum (volume varies from a few drops to a few millilitres, increasing over time)
    • This is the gentlest way to express as there is no pressure to the nipple itself, instead focus is on compression of the breast tissue. The thumb and forefinger should be placed vertically, either side of the areola, about 3cm from the nipple. Gently press the thumb and the forefinger back into the breast to feel the breast tissue and then press them towards each other. This compresses the lactiferous ducts to push milk out via the nipple. Continue the compressing action in a rhythmical way. 
    • Hand expressing some milk from very full breasts immediately prior to a feed may help the infant attachment as well.
    • Expressing Breast Milk RWH Factsheet
    • Video on Hand Expressing

    Manual Breast Pumps

    • Manual breast pumps use a vacuum to create a suction to remove breastmilk from the breast.  The mother controls the amount of suction applied by the squeezing or pulling action of the pump.  It is important to ensure excessive suction is not applied so that nipple trauma is prevented
    • Usual recommendations are to express for 10 minutes on each side, and then repeating again for another 5 minutes on each side
    • Manual breast pumps are typically not recommended for long-term expressing/exclusive expressing due to lack of suction and inability to drain the breast
    • Using a Breast Pump RWH Factsheet
    • Video on Manual Breast Pump Expression

    Electric Breast Pumps

    • The RCH has electric breast pumps available in the expressing rooms, postnatal mothers unit and the wards. Pumps are also available for hire through the Equipment Distribution Centre (ext: 55325) and local pharmacies. 
    • Expressing kits are available for each mother. Different sized shields are available, with Medela (MEDELA GUIDE ON SIZE) stocking these in Small (21mm), Medium (24mm), Large (27mm) and Extra Large (30mm). After each use, breast shields should be rinsed with cold water, cleaned with warm soapy water, rinsed with hot running water and allowed to air dry.
    • Kits should be disposed of after 24 hours, or 8 uses, whichever comes first.
    • The electric breast pumps have adjustable suction pressures and mothers should begin with the lowest and increase without causing pain or trauma. 
    • Expressing for 20-30 minutes is common, expressing one breast until the flow slows to drips, and then switching breasts. Double pumping, or expressing both breasts at the same time, reduces expressing time to around 15 minutes and increases prolactin levels. 
    • For written information on use of the Medela Symphony breast pump – see here
    • Video on Using the Symphony Breast Pump.

    Equipment Cleaning

    1.Infant feeding equipment must be processed to prevent contamination of equipment and transmission of infection.

    • Breast milk is classified as a body fluid and may contain potentially infectious matter that is microorganisms, blood, and blood-borne viruses.

    2.       Equipment is not to be washed in hand basins or baby baths in the patient’s room. Use formula preparation area, kitchen/pantry area.

    3.       At RCH, all caps and bottles must be returned to the Central Formula Room where they are sanitised, reprocessed and reused. Used caps and bottles are to be rinsed and placed in the designated collection bins in the patient room or ward formula room. Standard teats can be place in the recycling bin. Specialised teats such as the Haberman teats and other speech pathology equipment should be reprocessed and reused as per RCH Management of Special Needs Feeder Systems Procedure.

    Storage, management, and administration of EBM 

    Non-nutritive sucking

    Non-nutritive sucking is any sucking that the infant will do without milk transfer, be it at empty breast or dummy. This assists to build positive associations between sensations in the mouth and hunger satisfaction, improves coordination and muscle tone, calms the infant to conserve energy and assists in the transition to oral feeding.  Consent for the use of dummies should be sought and documented at admission. 

    Skin to Skin care

    Skin-to-skin care, also known as kangaroo care, refers to the method of holding an infant in an upright and prone position, skin-to-skin, on the parent’s chest for a period of time.  Clothing or blankets are wrapped around the infant to provide a secure kangaroo-like pouch. Skin-to-skin care has numerous benefits including increased maternal breast milk supply, increased breastfeeding incidence and duration, a greater ability to recognise infant cues and increased parent-infant bonding. 

    Sham feeding 

    Sham feeding is offered only on the Butterfly Ward to allow infants with unrepaired long-gap oesophageal atresia to learn to feed orally.

    A Replogle Tube connected to suction drains the milk that the infant sucks from the breast or bottle from the upper oesophageal pouch to prevent aspiration, and the feed is then re-fed via the gastrostomy tube to allow the development of the association of oral feeding with milk entering the stomach.

    Breastfeeding mother meals

    To assist in breastfeeding support and promotion, and reduce separation, lunch and/or dinner is provided for breastfeeding mothers with inpatient children less than 2 year of age. Nursing staff must code the mother as ‘Breastfeeding Mother’ in EMR (Orders – Breastfeeding Mother Meal).

    • Indicate in the comments if the mother has any allergies or dietary requirements. 
    • Once ordered, the mother will need to take a patient MRN sticker from the ward to the RCH Kitchen (located on B2, next to the CFR) to collect their meals at lunch (1145 – 1230) and dinner (1730 – 1815).

    Breastfeeding challenges

    Absence of Mother

    • Contact the mother to discuss when they intend to come to the ward
    • If the infant’s feed cannot be delayed until the mother’s arrival, offer EBM if available. This may be stored in the ward fridge, the ward freezer (Butterfly Ward), or in the Central Formula Room (extension 55123). Use the EBM expressed at the earliest date first.
    • Adhere to the correct identification and checking process prior to administration of EBM to the patient as per the local policy
    • Ensure the EBM is warmed to room temperature via a bottle warmer prior to administration
    • Review the mode of feeding plan for the patient via EMR; Orders – Diet and Nutrition. The EBM can be administered via NGT/OGT, drops given by a syringe into the mouth, or by bottle. Consent is required for administration of the feed via the bottle. Information on specialised bottles or teats (varied size and flow speed) is available via COCOON.
    • Document feed in EMR; Flowsheets – Fluid Balance – Intake – Breast Milk 100%

    No EBM available

    • Contact the mother to discuss if they will be bringing EBM soon 
    • If feeding cannot be delayed, and EBM will not be available for the foreseeable future, consent to give formula is required. This is found via EMR; ADT – Admission – Nutrition – Diet Comments. A milk substitute must not be given unless consent is obtained and documented.

    Infant fasting

    • For patients less than 6 months of age, breastfeeding is permitted up until 3 hours prior to surgery. See RCH Fasting Guideline.
    • Provide breastfeeding mothers with an expressing kit (and assistance if required) to both maintain their supply and relieve discomfort, until their infants can breastfeed again post-operatively.

    Low supply

    Please refer to the Koala LC, NICU Postnatal Midwives, or the MCHN for further support if you believe the mother of your patient is experiencing a low milk supply. 

    Engorgement

    • About three days after having a baby, many mothers will experience breast ‘fullness' as their milk 'comes in'. This ‘fullness’ usually only lasts for 24 hours but may develop into engorgement, where the breasts become swollen and tender.
    • Engorgement is common, particularly when establishing breastfeeding, but does need to be managed. Early initiation of breastfeeding, with frequent and unrestricted feeds can assist in preventing full breasts and engorgement.
    • Signs of engorgement include:
      • Breasts are full and painful
      • Swelling down to the areola
      • Baby unable to attach to the breast due to fullness
    • If the positioning and attachment is correct on assessment, encourage the mother to either feed her baby more often, or to express to drain both breasts to comfort post feeding.
    • Further information:

    Blocked ducts and mastitis

    • A blocked milk duct may cause milk to build up behind the blockage, causing inflammation to the surrounding tissue. Blocked ducts are often caused by suboptimal management of engorgement, missed feeds/expressions, and a large supply
    • The breast will have a tender and palpable lump, with the surrounding skin red and warm to touch
    • Encourage the mother to feed from the affected side first, observing positioning and attachment, and positioning the infants chin towards the blockage if possible, to assist in draining
    • Advise the mother to gently massage the affected area towards the nipple during feeding/expressing or when in the shower
    • Blocked ducts may develop into mastitis, so discuss signs and symptoms of this with the mother
    • Mastitis is an inflammation of the breast tissue which may lead to infection. It is commonly caused by poor attachment, nipple damage, blocked milk ducts, missed feeds and engorgement or chronic oversupply. Signs and symptoms include a red, swollen, and painful area in the affected breast, flu-like symptoms, and fever
    • Breastfeeding and expressing from the affected breast is still safe. Observe and assist with correct positioning and attachment
    • Advise the mother that the use of heat packs on the affected area prior to feeding, and gentle massage of breast lumps (towards the nipple) when feeding, expressing or while having a warm shower may help with milk flow
    • Further information:
    • RWH Mastitis
    • RWH Factsheet
    • RWH Mastitis and Breast Abscess Guideline

    Please refer to the Koala LC, NICU Postnatal Midwives, or the MCHN for further support if you believe the mother of your patient is experiencing blocked ducts or mastitis symptoms, or refer them to their local GP or the RWH ED. 

    Flat or inverted nipples

    • Flat or inverted nipples commonly impact the infant’s ability to attach successfully at the breast  
    • With LC/midwife review, a nipple shield may be offered to assist effective milk transfer
    • Encourage the mother to express a few drops of milk onto the outside of the shield so that the scent can be detected by the baby. Feed duration may be longer due to reduced milk flow
    • A nipple shield should be rinsed and then washed in hot soapy water, before rinsing again and leaving to drain and air dry in a clean covered container
    • Advise the mother that with appropriate supports, the use of the shield is in most cases a temporary feeding aid
    • Wood Pharmacy, located on the ground floor of the RCH also stocks different shield sizes
    • See RWH Nipple Shield Factsheet 

    Nipple thrush

    • Nipple thrush is caused by an overgrowth of Candida albicans. The mother may describe a burning or stinging nipple pain that continues both during and after the feed. The nipples will be tender and appear red
    • If the mother has evidence of nipple thrush, it should be assumed that the breastfeeding infant is colonised. The infant may have signs of oral thrush, with white oral plaques on the tongue and inside cheeks, or a red papular rash around the nappy region
    • Both the mother and the infant should be prescribed oral and/or topical antifungal 
    • See RWH Breast and Nipple Thrush Factsheet 

    Tongue-tie

    • Tongue-tie (ankyloglossia) is a congenital condition in which the lingual frenulum is abnormally short and restricts tongue mobility. The ability of the infant to latch and suck effectively may be impaired and the mother may experience nipple pain and trauma. 
    • Tongue-ties do generally not require release. Referral to a LC, speech pathologist, or paediatric surgeon for an assessment of the tongue-tie and the infant during a feed is required.

    Severe Combined Immunodeficiency (SCID) infants

    • For infants diagnosed with SCID, whose mother is CMV serology positive, breastfeeding is strongly discouraged. At diagnosis, breastfeeding should be stopped while an urgent CMV serology on the mother and plasma PCR on the infant is completed.
    • The mother should be supported to express breast milk to maintain supply while the results are pending. If the mother returns CMV negative or the infant’s CMV PCR is positive, breastfeeding can be reinstituted.
    • If breastfeeding must be ceased, refer to
      Suppressing Lactation.

    Suppressing Lactation

    Special Considerations

    Breastfeeding/EBM for Procedural Pain Management

    Breastmilk is an alternative to oral sucrose for mild procedural pain management such as for venepuncture, immunisation, and heel lancing. Providing oral EBM, or by placing the infant to the breast where able, can assist in calming the infant’s response to pain, and by promoting the mother-infant comfort bond.

    Maternal considerations

    Medications

    • As the health benefits of breastfeeding are so important to the neonate and infant, breastfeeding should only be ceased in circumstances where there is evidence that the medication could be transferred to the infant in breastmilk and cause harm. These include cytotoxic, some antipsychotics and immunosuppressive medications.
    • It is not always possible to avoid taking medications during pregnancy and breastfeeding  
    • The medical team, pharmacists and lactation consultants will be able to assist with advice regarding the safety of breastfeeding and specific medication use

    Alcohol

    • Maternal alcohol abuse is documented within the EMR; ADT Navigators – Birth History – Family – Family History, as well as the Admission Note.
    • Alcohol is rapidly absorbed and has a peak concentration within breastmilk within 30-60 minutes after consuming (90 minutes if with food)
    • The concentration of alcohol present in breastmilk is comparable to simultaneously measured maternal blood alcohol levels 
    • Mothers who choose to consume alcohol should limit their intake and allow between two hours (one standard drink) to four hours (two standard drinks) before breastfeeding. If larger quantities are absorbed, mothers may express and discard the milk. The
      Australian Breastfeeding Association has developed a mobile app, Feed Safe that assists breastfeeding mothers to make the best decisions about alcohol consumption

    Smoking

    • Maternal smoking is documented within the EMR: ADT Navigators – Birth History – Family – Family History, as well as the Admission Note.
    • Smoking interferes with prolactin and oxytocin levels and therefore may impede breast milk supply. Nicotine in breast milk can also cause gastrointestinal irritability in the infant. Passive smoking is a risk for infants and smoking should therefore not occur in the same room as the infant.
    • Mothers who wish to cease smoking should be provided with appropriate supports, including the QUIT line number. Visit the website or telephone 13 78 48
    • If ceasing smoking is not an obtainable option for mothers, smoking should be avoided both an hour before, and during feeding

    Recreational drugs

    • Maternal Drug Use is documented within the EMR: ADT Navigators – Birth History – Family – Family History, as well as the Admission Note.
    • Recreational drugs are excreted into breast milk in varying amounts. This is dependent on drug type, administration, dosage and time of exposure
    • Narcotics may make the breastfed baby sleepy, whereas stimulants may cause infant irritability 
    • The Finnegan Score Chart is utilised to grade Neonatal Abstinence Syndrome (NAS). The scoring criteria and documentation is within the EMR; Flowsheets – Observations – NAS. If NAS scoring is required, scores should be discussed during the ward round
    • The Women’s Alcohol and Drug Service (WADS) provides medical care, counselling, and support to women with complex substance use, dependence, or those within a methadone stabilisation program

    Caffeine

    • Caffeine diffuses slowly into breast milk with a long half-life. Peak levels of caffeine in breastmilk are reached approximately one hour after consumption of caffeine-containing beverages.
    • Excessive maternal caffeine ingestion may cause irritability and poor sleeping in the infant
    • Two cups a day is the recommended limit for caffeine consumption.

    Companion Documents

    RCH Policies and Procedures

    RCH CPGs and Guidelines

    Evidence Table

    Evidence for this guideline can be viewed here. 


     Please remember to read the disclaimer.


    The revision of this nursing guideline was coordinated by Lauren Cross, CSN/CNS, NICU approved by the Nursing Clinical Effectiveness Committee. Published February 2023.