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MO-07-0037 BFP

Mothers and their infants should be assessed for effective breastfeeding and mothers should be offered instruction in breastfeeding as needed.




6.1 Nurses, certified nurse midwives and physicians should assist the mother with breastfeeding and provide guidance and support.

6.1.1 When an assessment identifies a dysfunction or the infant displays signs of inadequate intake, a lactation consultation should be ordered.

6.1.2 A functional reassessment of the infant at the breast should be performed by a trained physician, certified nurse midwife, nurse, or lactation specialist within 8 hours of birth, by utilizing an assessment tool (FAIB or LATCH) and at least once every 8 hours while in the hospital.



6.1 New mothers need consistent information and assistance in recognizing an adequate feeding. 2,3,9

6.1.1 An assessment provides for early identification of latch-on difficulties and direct observation of the infant at breast to assure adequate breastfeeding prior to discharge.4,7,12

6.1.2 Although scoring can be misleading and inconsistent, assessment tools can help the provider identify areas of need for intervention. 1,13,14,15


Caldwell, K; Turner-Maffei, C: Continuity of Care in Breastfeeding: Best Practices in the Maternity Setting (2009)

Walker, M: Breastfeeding Management for the Clinician (2006) 

Norms for the First 3 Days of Life (PDF)Opens a new browser window.

Videos to order that can be used to teach staff about Self Attachment and Latch includes:

FOLLOW ME MUM – Rebecca Glover

Video Reviews are available to members in the International Lactation Consultant Association Website

Examples of breastfeeding evaluation forms/methods

Review of Breastfeeding Assessment Tools

See example of Hospital's


6.2 Pillows should be available to support mother’s arms and bring the baby to breast level.


6.2 Nipple trauma can be prevented and nipple soreness minimized with proper attachment and positioning. Support and comfort of the mother and baby prevents fatigue and facilitates proper positioning of the baby at breast. 5,6,10,17


FAQs about positioning can be found at La Leche League International:

Patient handouts with drawings can be found in Dr. Jack Newman’s Handouts (link)

Link to web-based video clips on asymmetrical latch

6.3 Nurses, certified nurse midwives, and physicians should respond to complaints of nipple soreness by assessing the source of the discomfort and assisting the mother in resolving the problem.

6.3 Physiological nipple tenderness may occur during the first few minutes of a feeding and eases during the same feeding. 8,10

Nipple soreness is considered abnormal when a mother complains of nipple soreness throughout an entire feeding or between feedings. 5,10,12,166

Links to show short videos on asymmetrical latch can be found at: http://www.nbcionline.org/index.php?

When evaluating infant’s mouth, be aware of possible problems due to tongue-tie (ankyloglossia) See References

6.4 Mothers should be educated on the “supply and demand” principle of milk production.

6.4 Understanding of basic physiology enhances the lactation process. 2,3

See studies by Daly and Hartmann in References

6.5 Frequency and duration of feedings at the breast should be infant-led. Non-timed feedings and cue-based offerings will be the basis for mother-infant care. The infant needs to have active suckling and swallowing time at the breast during each feeding.

6.5 It often takes 1½-2 minutes after the onset of suckling for oxytocin release and subsequent milk ejection reflex. At times it may take as long as 6-10 minutes for oxytocin release.

Limiting suckling time has not been shown to reduce nipple soreness or trauma and may result in a decreased milk supply and a delay of lactogenesis..8,17,9,10

Patient Instruction Materials should be evaluated to assure they recommend allowing the infant to breastfeed until he/she releases rather than timed feedings.


6.6 Mothers should be assisted in identifying infant’s hunger cues and readiness to feed.


6.6.1 Breastfeeding according to baby’s cues should be supported by nurses and physicians who will help mothers respond to those cues.

6.6.2 Mothers should be encouraged to monitor their own and the infant’s signs of adequate/inadequate intake and output.

6.6.3 If the nurse or physician is concerned with the baby’s intake before discharge, consultation should be sought and the problem defined and addressed prior to discharge.

6.6 Newborns should be breastfed whenever they show signs of hunger such as increased alertness or activity, mouthing or rooting, rapid eye movement sleep, and hand-to-mouth movement.

6.6.1 Infants are more organized in their behavior and will breastfeed more successfully if they are not crying. Crying is a late sign of hunger.

6.6.2 Breastmilk is digested in approximately 90 minutes. Eight to twelve feedings every 24 hours has been associated with increased meconium passage and lower serum bilirubin levels in the infant.

6.6.3 Maternal prolactin levels fall three hours after breastfeeding. Frequent and early feedings enhance duration of breastfeeding and enhance milk production. It is within normal range for babies to “cluster feed” by feeding several times close together and then going several hours without feeding. Normal, healthy newborns may breastfeed every hour, or several times in one hour, during the first days of life. 4,9,10,11,17

From www.breastfeeding.com: Hunger Cues
Recognizing the way baby says, "I'm hungry!"
18 sec. QuickTime 1.31 MB  AVI Video 1.98 MB


Sample patient room poster about cue feeding:


6.7 The nurse, certified nurse midwife or physician should discuss the importance of colostrum with the mother. After appropriate education, however, a mother who feels very uncomfortable giving colostrum should be encouraged to pump and may discard the colostrum. This may be all that is needed to ensure an adequate beginning with breastfeeding. The nurse, certified nurse midwife, or physician should be aware of cultural differences regarding colostrum and be trained to address these issues sensitively.

6.7 Some mothers may choose not to initiate early breastfeeding due to misinformation about the nature of colostrum. Some nurses and physicians have reported that encouraging mothers to express and discard a small amount of the first milk has sufficed to get breastfeeding started.3

Information on cultural beliefs that can affect breastfeeding (Ethnic Awareness (PDF)Opens a new browser window.)

Policy #6 References:

1. Bocar, D. & Shrago, L. (1990). Functional assessment of the infant at the breast (FAIB). [Assessment tool] Oklahoma City, OK: Lactation Consultant Services.
2. Daly, S. E. J., & Hartmann, P. E. (1995). Infant demand and milk supply. Part 1: Infant demand and milk production in lactating women. Journal of Human Lactation, 11(1): 21-26. (Abstract)
3. Daly, S. E. J., & Hartmann, P. E. (1995). Infant demand and milk supply. Part 2: The short-term control of milk synthesis in lactating women. Journal of Human Lactation, 11(1), 27-37. [Abstract]
4. Kuan, L. W., Britto, M., Decolongon, J., Schoettker, P. J., Atherton, H. D., & Kotagal, U.R. (1999). Health system factors contributing to breastfeeding success. Pediatrics, 104, 28-34.
5. Huggins, K. (1999). The Nursing Mother’s Companion (4th ed.). (pp. 14-16). Boston: Harvard Common Press.
6. Ingram, J., Johnson, D., & Greenwood, R. (2002). Breastfeeding in Bristol: Teaching good positioning, and support from fathers and families. Midwifery, 18(2), 87-101.
7. Jensen, D., Wallace, S., & Kelsay, P. (1993). LATCH: A breastfeeding charting system and documentation tool. Journal of Obstetric, Gynecologic and Neonatal Nursing, 23(1), 27-32. [Abstract]
8. L’Esperance, C., & Frantz, K. (1985). Time limitation for early breastfeeding. . Journal of Obstetric, Gynecolgic and Neonatal Nursing, March/April, 114-118. [Abstract]
9. Lawrence, R. (1987). The management of lactation as a physiologic process. Clinics in Perinatology, 14(1), 1-10.
10. Lawrence, R. A., & Lawrence, R. M. (2005). Breastfeeding: A guide for the medical professional (6th ed.). St. Louis, MO: Mosby (pp. 282, 303, 275 & 289, 274-275, 296)
11. Newman, J. (1990). Breastfeeding problems associated with the early introduction of bottles and pacifiers. Journal of Human Lactation, 6(2), 59-63. (Abstract)
12. Righard, L. & Alade, M. (1992). Sucking technique and its effect on success of breastfeeding. Birth, 19(4), 185-189.
13. Riordan J. M., & Koehn, M. (1997). Reliability and validity testing of three breastfeeding assessment tools. Journal of Obstetric, Gynecologic and Neonatal Nursing, 26, 181-187.
14. Riordan, J., Bibb, D., Miller, M., & Rawlins, T. (2001). Predicting breastfeeding duration using the LATCH breastfeeding assessment tool. Journal of Human Lactation, 17(1): 20-23. (Abstract)
15. Schlomer, J. A., Kemmerer, J., Twiss, J. J. (1999). Evaluating the association of two breastfeeding assessment tools with breastfeeding problems and breastfeeding satisfaction. Journal of Human Lactation, 15(1), 35-39. (Abstract)
16. Shrago, L. & Bocar, D. (1990). The infant’s contribution to breastfeeding. Journal of Obstetric, Gynecologic and Neonatal Nursing, 19(3), 209-215.
17. Walker, M., & Driscoll, J. (1989). Sore nipples: The new mother’s nemesis. American Journal of Maternal Child Nursing, 14, 260-265.


Additional References:

Blair A, Cadwell K, Turner-Maffei C, Brimdyr K. The relationship between positioning, the breastfeeding dynamic, the latching process and pain in breastfeeding mothers with sore nipples. Breastfeed Rev. 2003 Jul;11(2):5-10. [Abstract]

De Carvalho, M., Klaus, M. H., & Merkatz, R. B. (1982). Frequency of breast-feeding and serum bilirubin concentration. Am J Dis Child, 136(8), 737-738. [Abstract]

De Carvalho, M., Robertson, S., Friedman, A., & Klaus, M. (1983). Effect of frequent breast-feeding on early milk production and infant weight gain. Pediatrics, 72(3), 307-311. [Abstract]

Edmond, K. M., Zandoh, C., Quigley, M. A., Amenga-Etego, S., Owusu-Agyei, S., & Kirkwood, B. R. (2006). Delayed breastfeeding initiation increases risk of neonatal mortality. Pediatrics, 117(3), e380-386 [Full Text]

Hall, R. T., Mercer, A. M., Teasley, S. L., McPherson, D. M., Simon, S. D., Santos, S. R., et al. (2002). A breast-feeding assessment score to evaluate the risk for cessation of breast-feeding by 7 to 10 days of age. J Pediatr, 141(5), 659-664. [Abstract]

Hill, P. D., Aldag, J. C., & Chatterton, R. T. (1999). Effects of pumping style on milk production in mothers of non-nursing preterm infants. J Hum Lact, 15(3), 209-216. [Abstract]

Hill, P. D., Aldag, J. C., & Chatterton, R. T. (2001). Initiation and frequency of pumping and milk production in mothers of non-nursing preterm infants. J Hum Lact, 17(1), 9-13. [Abstract]

Jones, F., & Tully, M. R. (2005). Best Practice for Expressing, Storing and Handling Human Milk in Hospitals, Homes and Child Care Settings. Raleigh, North Carolina: Human Milk Banking Association of North America (HMBANA).

Kerac M, McGrath M, Seal A. “Chapter 7: Review of Breastfeeding Assessment Tools” Management of Acute Malnutrition in Infants (MAMI) Project: Technical Review: Current evidence, policies, practices & programme outcomes. January 2010, Emergency Nutrition Network.  Downloaded 3/10/2011from: http://www.ennonline.net/resources/741

Shealy, K. R., Li, R., Benton-Davis, S., & Grummer-Strawn, L. (2005). The CDC Guide to Breastfeeding Interventions. Atlanta, Georgia: US Department of Health and Human Services, Centers for Disease Control and Prevention. [Download document]

Taha, Rouba, "A Case Study on Using the Via Christi Breastfeeding Assessment Tool in a Clinical Setting" (2009). Honors Scholar Theses. Paper 74. [Full Document]

Widstrom, A. M., Wahlberg, V., Matthiesen, A. S., Eneroth, P., Uvnas-Moberg, K., Werner, S., et al. (1990). Short-term effects of early suckling and touch of the nipple on maternal behaviour. Early Hum Dev, 21(3), 153-163. [Abstract]

Wilhelm S, et al. Influence of intention and self-efficacy levels on duration of breastfeeding for Midwest rural mothers. Applied Nursing Research, 08/2008. [Abstract]

This study explored the relationship of the intention to breastfeed for 6 months and breastfeeding self-efficacy with the duration of breastfeeding in primiparous women. The study found that the combined influence of higher intention and self-efficacy increased the likelihood of breastfeeding for the recommended 6 months. Interventions to reinforce both should be designed and evaluated.
Wolfe, L. S., & Glass, R. P. (1992). Feeding and Swallowing Disorders in Infancy: Assessment and Management. Tucson, Arizona: Therapy Skills Builders.

Hospital Self-Appraisal Questionnaire (Word)Opens a new browser window.

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Last modified on: 11/8/2012 1:38 PM