In this section
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.
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.
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
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
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.
On admission each neonate, infant or child will have a feeding history documented by the clinical team. This includes:
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.
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.
Demand breastfed infants may have weights recorded more frequently to gauge a more accurate assessment of feeding.
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.
Signs of correct positioning and attachment:
Signs of incorrect positioning and attachment:
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.
Lactation Consultants (LCs) at the RCH are International Board-Certified Lactation Consultants (IBCLCs).
*Please note that the postnatal midwives attend to women admitted to the PMU, and while based in Butterfly, will assist other wards when available.
Parents can be directed to the COCOON Breastfeeding and Expressed Breastmilk Webpage here.
1.Infant feeding equipment must be processed to prevent contamination of equipment and transmission of infection.
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 the
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, 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 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.
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).
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.
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.
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.
RCH Policies and Procedures
RCH CPGs and Guidelines
Medicine : Growth monitoring for preterm infants (rch.org.au)
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.