EXPANDED HOSPITAL POLICY #8:

INTERVENTION / MANAGEMENT

RATIONALE

RESOURCES

8.1 Breastfeeding infants should be given only breastmilk, unless specifically ordered for a clinical condition by the physician or with the mother’s informed consent.

8.1 Colostrum and breastmilk completely meet the normal newborn’s nutritional and fluid needs (provides 17-20 kcal/oz).5 Colostrum is the least noxious substance if aspirated.4,5

8.1.1Water interferes with breastfeeding and fills the baby with non-nutritive fluid so that the baby is not hungry. There is no medical or nutritional value to water. Water decreases the frequency of breastfeeding, which in turn decreases the mother’s milk supply. 4

Sample patient handouts explaining why babies should be exclusively breastfed

• Southwest Healthcare System: English (PDF, 1.1MB)...Spanish, 1.1MB

Example of a Consent  to Supplement

• Consent 1 (Word)
• Consent 2 (Word)
• Consent 3 : English and Spanish (Word)

Example of a policy for supplementing a breastfeeding baby

• Kaiser (Word)
• Stanford Newborn Nursery Suggested feeding methods and amounts if baby has not latched x 12 hours

Supplementation methods:

• Spoon Feeding: See in Additional References below: Kumar et al

See the Academy of Breastfeeding Medicine Protocol on

• Hypoglycemia (PDF)
• Peripartum Breastfeeding Management (Revised, June 2008) (PDF)
• Supplementation (PDF)
• Hospital Supplementation Guidelines (PDF) based on ABM Clinical Protocol #3: Hospital Guidelines for the Use of Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2009

8.2 When supplementation is medically indicated, an alternate feeding method should be utilized to maintain mother-infant breastfeeding skills. Alternate feeding methods include cup, dropper, gavage, finger or syringe.

8.2.1 Artificial feeding should not exceed the physiologic capacity of the newborn stomach.

8.2 Some infants may have difficulty transitioning between an artificial nipple and the breast. Alternate feeding methods may be helpful in maintaining breastfeeding skills.2,3,6

8.2.1 Care should be taken not to exceed the physiologic capacity of the newborn stomach. In the first few days of life, volumes of less than 20cc should be given at each feeding. 3,7

References and summary of the studies(PDF)on the capacity of the infant's stomach

Information on "Paced Bottle feeding": A Caregivers Guide to the Breastfed Baby (PDF)

Resources for programs used to teach staff about supplementation:

• Perinatal Services Network
• Soft Hospital

Professional Education Distance Learning Courses

See resources in policy #4

8.3 Education regarding supplementation should be presented prior to obtaining consent for supplementation Risks of introducing artificial infant milk and/or water to the newborn should be discussed with the mother prior to supplementation.

8.3 Mothers should be made aware of potential risks to the infant who receives artificial infant milk, or water, or is fed by artificial feeding methods. 1,5

McNiel, M. E., Labbok, M. H. and Abrahams, S. W. (2010), What are the Risks Associated with Formula Feeding? A Re-Analysis and Review.Birth, 37: 50–58. doi: 10.1111/j.1523-536X.2009.00378.x

Stuebe, A: The Risks of Not Breastfeeding for Mothers and Infants.
Rev Obstet Gynecol. 2009 Fall; 2(4): 222–231.  Copyright © 2009 MedReviews, LLC PMCID: PMC2812877

Sample Script for Nurses to Educate Mothers About Supplementation (Word)

 Additional References: 

Academy of Breastfeeding Medicine. Clinical Protocol:

• #1: Guidelines for Glucose Monitoring and Treatment of Hypoglycemia in Breastfed Neonates (PDF) Revision June, 2006; Breastfeeding Medicine,  Volume 1, Number 3, 2006 © Mary Ann Liebert, Inc.
• #3: Hospital Guidelines for the Use of Supplementary Feedings in the Healthy Term Breastfed Neonate (PDF), Revised 2009. Breastfeeding Medicine, Volume 4, Number 3, 2009 © Mary Ann Liebert, Inc.DOI: 10.1089/bfm.2009.9991
• #7: Model Breastfeeding Policy (Revision 2010) (PDF), Breastfeeding Medicine Volume 5, Number 4, 2010 ª Mary Ann Liebert, Inc. DOI: 10.1089/bfm.2010.9986

American Academy of Pediatrics. Work Group on Breastfeeding. Breastfeeding and the Use of Human Milk, Pediatrics Feb.2005 http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;115/2/496

Almroth S, Bidinger PD.: No need for water supplementation for exclusively breast-fed infants under hot and arid conditions. Trans R Soc Trop Med Hyg 1990 Jul;84(4):602-604 [Abstract]

Ball TM, Wright AL; “Health Care Costs of Formula-feeding in the First Year of Life”. Pediatrics 1999;103;870-876 (abstract).

Breastfeeding Committee for Canada, Guidelines for WHO UNICEF Baby-Friendly TM Initiative (BFI) in Canada, October 14, 2003. http://www.breastfeedingcanada.ca/html/bfi.html

Breastfeeding Management for the Clinician By Marsha Walker, RN, IBCLC (2006) (www.ilca.org).

College of Family Physicians of Canada, Infant Feeding Policy Statement, 2004

Continuity of Care in Breastfeeding: Best Practices in the Maternity Setting, Copyright: 2009 By: Karin Cadwell, PhD, RN, FAAN, IBCLC, RLC, and Cynthia Turner-Maffei, MA, IBCLC, RLC.

Core Curriculum for Lactation Consultant Practice, 2nd Ed. - Editors: Rebecca Mannel, Patricia J. Martens and Marsha Walker (2007).

Dollberg, S et al (2001) A Comparison of Intakes of Breast-Fed and Bottle-Fed Infants During the First Few Days of Life, J Am College of Nutrition 20(3):209-211, 2001.

Duijts L, Jaddoe VWV, Hofman A, Moll HA. Prolonged and Exclusive Breastfeeding Reduces the Risk of Infectious Diseases in Infancy. PEDIATRICS Vol. 126 No. 1 July 2010, pp. e18-e25 (doi:10.1542/peds.2008-3256)

Evans, KC et al (2003) Effect of caesarean section on breast milk transfer to the normal term newborn over the first week of life, Arch. Dis. Child. Fetal Neonatal Ed. 2003;88;380-38220.

Gartner, LM, Herschel, M. Jaundice and Breastfeeding. Pediatric Clinics of North America, 2001: 389-400.

Hale & Hartmann Textbook of Human Lactation By: Thomas W. Hale, Ph.D. and Peter Hartmann, Ph.D.(2007)

Health Canada (2004) Exclusive Breastfeeding Duration, Health Canada's Recommendation 2004.

Ip S, Chung M, Raman G, et al. Breastfeeding and maternal and infant health outcomes in developed countries. Rockville, MD: US Department of Health and Human Services; 2007. Available at http://www.ahrq.gov/downloads/pub/evidence/pdf/brfout/brfout.pdf.

Kumar A, Dabas P, Singh B. (Epub 2009): Spoon feeding results in early hospital discharge of low birth weight babies. J Perinatol. 2010 Mar;30(3):209-17. [Abstract]

Ladomenou F, Moschandreas J, Kafatos A, Tselentis Y, Galanakis E. ”Protective effect of exclusive breastfeeding against infections during infancy: a prospective study”. Arch. Dis doi:10.1136/adc.2009.169912 (abstract)

Li R, Fein S, Grummer-Strawn L. Association of Breastfeeding Intensity and Bottle-Emptying Behaviors at Early Infancy with Infants’ Risk for Excess Weight at Late Infancy. Pediatrics, 11/2008.
     Study undertaken to test hypothesis that infants who were breastfed more intensively during early infancy will be less likely to have excess weight during late infancy and to examine the independent impact of infant-initiated bottle emptying and mothers’ encouragement of bottle emptying on infants’ risk for excess weight. [N=1896]
     Infants’ risk for excess weight during late infancy was negatively associated with breastfeeding intensity but positively associated with infant-initiated bottle emptying during early infancy, providing evidence for the potential risk of not breastfeeding or breastfeeding at low intensity in development of childhood obesity. Infant-initiated bottle emptying may be an independent risk factor as well. Unexpectedly, maternal encouragement of bottle emptying was negatively associated with infants’ risk for excess weight.

McNiel, M. E., Labbok, M. H. and Abrahams, S. W. (2010), What are the Risks Associated with Formula Feeding? A Re-Analysis and Review. Birth, 37: 50–58. doi: 10.1111/j.1523-536X.2009.00378.x 
     Most infant feeding studies present infant formula use as “standard” practice, supporting perceptions of formula feeding as normative and hindering translation of current research into counseling messages supportive of exclusive breastfeeding. To promote optimal counseling, and to challenge researchers to use exclusive breastfeeding as the standard, we have reviewed the scientific literature on exclusive breastfeeding and converted reported odds ratios to allow discussion of the “risks” of any formula use.

     Conclusions: Exclusive breastfeeding is an optimal practice, compared with which other infant feeding practices carry risks. Further studies on the influence of presenting exclusive breastfeeding as the standard in research studies and counseling messages are recommended. (BIRTH 37:1 March 2010)

Morelli L. Postnatal Development of Intestinal Microflora as Influenced by Infant Nutrition. The Journal of Nutrition,138,Supplement, 1791-95, 2008.
     The postnatal period of a new baby is characterized, microbiologically speaking, by the formation of a new ecosystem: the microflora of the human gut. In the last decade a number of articles have reported results on neonates microflora obtained by means of culture-independent analysis. Type of delivery and feeding method play dramatic roles in determining microflora composition. Data obtained in this manner are in agreement with those produced by selective media, but they also provide some new insights about the presence of anaerobic bacteria.

Neuberger Z: WIC FOOD PACKAGE SHOULD BE BASED ON SCIENCE: Foods with New Functional Ingredients Should Be Provided Only If They Deliver Health or Nutritional Benefits (PDF) ; Report to the Center on Budget and Policy Priorities, June 4, 2010.

UNICEF (1992) Acceptable Medical Reasons for Supplementation, Annex to the Global Criteria for Baby Friendly Hospitals, 1992. (see #4 above - BCC - BFI Hospital Indicators, page 19, March 2004).