Welcome to the State of California 


 MO-07-0040 BFP

Mothers and infants should be encouraged to remain together during the hospital stay.




9.1 Babies should be cared for at their mothers’ bedside. Both the mother and family should be encouraged to assist with infant care.




9.1 Bonding, adaptation to extra-uterine life, and attachment are facilitated by the infant being with the mother.

9.1.1 If mother and infant are separated there is increased potential for supplementation with artificial milk.

9.1.2 Caring for mother and baby together provides the opportunity for individualized teaching and enhances the mother’s ability to learn her baby’s cues. 1,4,6,7,8,12


Academy of Breastfeeding Medicine:
Co-sleeping and Breastfeeding Protocol (PDF)Opens a new browser window.

Example of a patient handout that addresses safe sleeping areas:

9.2 Both the mother and the family should be educated that rest and recovery for the mother and infant is vital.

9.2.1 The nurse’s role is to protect the dyad from disturbances that impact their ability to recover.

9.2.2 Night feeding should be explained as a normal and healthy pattern for the infant.


9.2 Rest is an important physiologic and psychological need for all postpartum, lactating mothers.

9.2.1 With liberalized visiting hours, there may be limited time for mothers to rest unless naps are planned. 2,3,4,9,10,11

9.2.2 Often mothers anticipate their infant will “sleep through the night” long before the infant is physiologically ready. This can create conflict between the mother’s beliefs and the infant’s behavior.

Website resources:

A website with an excellent series of pictures showing infant states and feeding cues following the first few hours and days after birth: www.breastbabyproducts.com/firstdays.html

From Childbirth Graphics:
Bilingual Tear pads:

  • How to Tell if Your Baby is Hungry Tear Pad
  • Waking a Sleeping Baby Tear Pad

Feeding Cues and other educational tools and packets: Growing With Baby


9.3 If, after encouragement to room in, the mother requests the baby to stay in the nursery at night, the infant should be brought to the mother to breastfeed when the baby displays hunger cues or every three hours, whichever comes first. If the mother chooses not to breastfeed at night, she should be educated on the potential for breast engorgement...


9.3 Prolactin levels are highest at night and may contribute to optimal breastfeeding. Rooming-in provides additional opportunities for mothers and babies to establish effective nursing patterns prior to discharge. 3,4,6,9,10,12


Kent, JC, Mitoulas L R, Cregan M D., Ramsay D T, Doherty D A., Hartmann PE; Volume and Frequency of Breastfeedings and Fat Content of Breast Milk Throughout the Day: PEDIATRICS Vol. 117 No. 3 March 2006, pp. e387-e395


9.4 Evidence of patient teaching and professional recommendations should be documented in the patient’s chart.

9 4.1 An informed consent for supplementation plus a statement indicating the mother’s request not to breastfeed during the night should be included in the patient chart.

9.4 The mother needs to clearly understand the risks of the introduction of artificial nipples, early introduction of artificial infant milk, and failure to optimally provide colostrum to the newborn

9.4.1 Due to potential complications for mother and baby related to early supplementation of the breastfed infant, informed consent is essential.

Patient Information:

9.5 If the mother is unable or refuses to feed her infant during the night, the infant should be fed in a manner that is consistent with preserving breastfeeding and reflects the skills and knowledge of the perinatal caregivers in consultation with the infant’s physician. Alternative feeding methods such as cup, finger, or tube feedings should be used to provide adequate calories to the newborn. Alternative feedings should include colostrum or breastmilk, if available. The use of pacifiers, bottles with artificial nipples and water feedings are discouraged (note policies #7 and #8).

9.5.1 Mothers who receive sedative drugs, are out of the room for surgical procedures, or have an altered state of alertness should not bed-in with their newborn.

9.5 California law and hospital regulations, require a safe place for the infant to be during the hospital stay. If the mother chooses not to participate in rooming-in or chooses not to breastfeed her baby during the night, it is the responsibility of the nurses, in consultation with the patient’s physician, to provide care that will best promote the long-term health of the mother and infant.5,7,10



9.5.1 The safety of the infant is paramount.

Alternative Feeding Methods


Policy #9 References:

1. Anderson, G. (1989). Risk in mother-infant separation postbirth. Image: Journal of Nursing Scholarship, 21(4), 196-199. (Abstract) 2. Keefe, M. (1988). The impact of infant rooming-in on maternal sleep at night. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 17(2), 122-126. (Abstract)
3. Lawrence, R. A., & Lawrence, R. M. (2005). Breastfeeding: A guide for the medical professional (6th ed.). St. Louis, MO: Mosby (pp. 275, 299, 76).
4. Marasco, L. (1998). Cue vs scheduled feeding: Revisiting the controversy. Mother Baby Journal, 3(4), 39-42.
5. McKenna, J. J., Mosko, S. S., & Richard, C. A. (1997). Bedsharing promotes breastfeeding. Pediatrics, 100(2, Pt. 1), 214-219. (Abstract)
6. Mosko, S., Richard, C., & McKenna, J. (1997). Infant arousals during mother-infant bed sharing: Implications for infant sleep and sudden infant death syndrome research. Pediatrics, 100(5), 841-849 (Abstract) (PDF)Opens a new browser window.
7. Nurses Association of the American College of Obstetricians and Gynecologists (NAACOG) OGN Nursing Practice Resource. (March 1989). Mother-Baby Care. Author.
8. Rapley, G. (2002). Keeping mothers and babies together—breastfeeding and bonding. Royal College of Midwives, 5(10), 332-224. (Abstract)
9. Svensson, K., Mattiesen, A. S., Widström, A. M. (2005). Night rooming-in: Who decides? An example of staff influence on mother’s attitude. Birth, 32(2), 99-106. (Abstract)
10. Title 22 Licensing and Certification of Health Facilities and Referral Agencies. Article 70547, Section (k), p. 789.
11. Winikoff, B., Myers, D., Laukaran, V. H., & Stone, R. (1987). Overcoming obstacles to breast-feeding in a large municipal hospital: Applications of lessons learned. Pediatrics, 80(3), 423-433.
12. Yamauchi, Y., & Yamanouchi, I. (1990). The relationship between rooming-in/not rooming-in and breast-feeding variables. Acta Paediatrica Scandinavica, 79 (11): 1017-1022. (Abstract)

Additional References:

Arora S, McJunkin C, Wehrer J & Kuhn P. Major Factors Influencing Breastfeeding Rates: Mother's Perception of Father's Attitude and Milk Supply Pediatrics 2000;106;67

Blair PS, Fleming PJ, Smith IJ, et al. Babies sleeping with parents: case-control study of factors influencing the risk of the sudden infant death syndrome. BMJ. 1999;319:1457–1462 [Abstract] (PDF)Opens a new browser window.

Bruschweiler-Stern N. Early Emotional Care for Mothers and Infants. Pediatrics 1998; 102: 1278.

Buswell SD, Spatz DL. Parent-Infant Co-Sleeping and Its Relationship to Breastfeeding. Journal of Pediatric Health Care, 2007. [Abstract]
     Co-sleeping promotes breastfeeding; however, risks are also associated with co-sleeping. Pediatric nurse practitioners need to be informed on issues related to co-sleeping in order to educate parents regarding its risks and benefits, to assess the safety of an established sleeping environment, and to be aware of its prevalence in their patient populations.
     Article presents definitions of co-sleeping, reasons why some parents engage in the practice, cultural preferences for co-sleeping, associated risks and benefits, and its relationship to breastfeeding.

Carfoot, S Williamson, P Dickson, R (2005) A Randomized Controlled Trial in the North of England Examining the Effects of Skin-to-Skin Care on Breastfeeding, Midwifery 21(1), March 2005 [Abstract]

Cloherty M, Alexander J, Holloway I. Supplementing breast-fed babies in the UK to protect their mothers from tiredness or distress. Midwifery. 2004 Jun;20(2):194-204.

Edmond K.M. Zandoh C. Amengo-Etego S. Kirkwood B R. Delayed breastfeeding initiation increases risk of neonatal mortality. Pediatrics Vol 117 No. 3 March 2006 ppe380-e386 [Full Text (PDF)Opens a new browser window.]

Epstein K. (1993). The interactions between breastfeeding mothers and their babies during the breastfeeding session. Early Child Development and Care.87:93-104.

Epstein-Gilboa K.(2000).The psychological reality of breastfeeding. IMPrint. 28:18-21.

Erlandsson K, Fagerberg I. Mothers' lived experiences of co-care and part-care after birth, and their strong desire to be close to their baby.. Midwifery. 2005 Jun;21(2):131-8. Epub 2005 Mar 28. [Abstract]

Feldman R, Eidelman AI, Sirota L. & Weller A.Outcomes and Preterm Infant Development: Comparison of Skin-to-Skin (Kangaroo) and Traditional Care: Parenting Pediatrics 2002;110;16-26 [Full Text (PDF)Opens a new browser window.]

Health Canada (2000) Family-Centred Maternity and Newborn Care: National Guidelines,. Ch. 7, 2000. www.hc-sc.gc.ca 20

Kendall-Tackett K, Cong Z, Hale TW:  Mother-Infant Sleep Locations and Nighttime Feeding Behavior: U.S. Data from the Survey of Mothers' Sleep and Fatigue. Clinical Lactation Volume 1, Fall, 2010 pp 27-31 [Full Article]

Klaus M. Mother and Infant: Early Emotional Ties. Pediatrics 1998; 102: 1244 [Full Text]

McKenna JJ, Ball HL, Gettler LT. Mother-Infant Cosleeping, Breastfeeding and Sudden Infant Death Syndrome: What Biological Anthropology Has Discovered About Normal Infant Sleep and Pediatric Sleep Medicine; AM J Phys Anthropol. 2007; Suppl 45:133-61 [Abstract]
     Reviews two decades of research examining cosleeping and the behavior and physiology of mothers and infants who practice it. This assessment includes laboratory, hospital and home studies to assess the biological functions of cosleeping, especially with regards to breastfeeding promotion and SIDS reduction.
Anthropologists are encouraged to participate in pediatric sleep research using the unique skills and insights provided by the data. New research insights that influence the traditional medical paradigm and help to make it more inclusive.
     This article aims to lead infant sleep scientist, pediatricians, and parents to become more informed about the consequences of caring for human infants in ways that are not congruent with their evolutionary biology.

McKenna JJ, McDade T. Why babies should never sleep alone: A review of the co-sleeping controversy in relation to SIDS, bedsharing and breast feeding. Pediatric Respiratory Reviews, 2005.
     The review shows that the relationship between infant sleep patterns, infant sleeping arrangements, and development both in the short and long term, whether having positive or negative outcomes, is anything but simple and the traditional habit of labeling one sleeping arrangement as being superior to another without an awareness of family, social and ethnic context is not only wrong but possibly harmful. Also reviews the different types of co-sleeping and bedsharing and their relationship to SIDS.

Mizuno, K., Kani,: English Title: Sipping/lapping is a safe alternative feeding method to suckling for preterm infants: Acta Paediatrica, 2005 (Vol. 94)(No.5) 574-580 [Abstract]

Monson, S. A., Henry, E., Lambert, D. K., Schmutz, N., & Christensen, R. D. (2008). In-hospital falls of newborn infants: data from a multihospital health care system. Pediatrics, 122(2), e277-280. [Full Text]

Morrison, B., Ludington-Hoe, S., & Anderson, G. C. (2006). Interruptions to breastfeeding dyads on postpartum day 1 in a university hospital. J Obstet Gynecol Neonatal Nurs, 35(6), 709-716. [Abstract] http://www.ncbi.nlm.nih.gov/pubmed/17105635
     Recorded interruptions (door openings and telephone calls) of 29 healthy mother-infant dyads of singleton births who intended to breastfeed from 8 am to 8 pm on postpartum day 1 in single rooms of a tertiary level university hospital in midwestern US.
     Recorded interruptions totaled 1,555, yielding a mean of 54 interruptions each averaging 17 minutes in length. Half of the 24 episodes of time alone per dyad were less than or equal to 9 minutes; most commonly only 1 minute long. All mothers breastfed 2 to 10 times with an average duration of 20 minutes.

Nysaether H, Baerug A, Nylander G, Klepp KI. [Rooming-in in the maternity ward--are mothers satisfied?] Tidsskr Nor Laegeforen. 2002 May 10;122(12):1206-9 [Abstract]

Ungerer Rl, Miranda AT. Rooming In History. J Pediatr (rio J). 1999 Jan-Feb;75(1):5-10 [Abstract

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

Back to Main Page of Breastfeeding Toolkit

Last modified on: 3/17/2011 10:46 AM