In this section
****Note: guideline update in progress****
Definition of Terms
Information for staff
References and Links
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 of the infant throughout that time. 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 practice 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.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.
The breast is composed of glandular (secretory) and adipose (fatty) tissue that is supported by fibrous connective tissue known as Cooper’s ligaments. The glandular tissue consists of 15-20 lobes, each containing clusters of 10-100 alveoli (which comprise a lobule), and this is where breast milk is synthesised and stored. Surrounding the secretory cells of the alveoli is a network of myoepithelial cells that, with the influence of oxytocin, contract and eject the milk towards the ductules that lead from the alveoli. Ductules join to form a lactiferous duct, draining towards the areola. Ultrasound studies by Ramsay et al (2005) on lactating breasts found an average of 9 lactiferous ducts opening onto the nipple (range 4-11). Surrounding the areola are Montgomery’s glands which secrete an oily substance to protect the skin during lactation.
Development of the breast to prepare
(Week 16 of pregnancy - day 2 postpartum)
Breast size increases as epithelial cells differentiate into
secretory cells for milk production. There are large gaps between the
Prolactin (secreted in the anterior pituitary gland) stimulates the
secretory cells of the alveoi.
Secretory cells begin to produce small amounts of milk known as
colostrum. High levels of progesterone
While the volume of colostrum produced may begin as 2-3ml a day, this
milk is highly valuable to the neonate.
Colostrum is high in protein, minerals, fat-soluble vitamins, white
cells and antibodies. Colostrum
provides vital immune protection and the establishment of normal gut flora,
while also assisting to stimulate the passage of meconium. Colostrum is yellow in colour due to the
high levels of vitamin A.
Onset of lactation
(Day 3 postpartum - day 8 postpartum)
Delivery of the placenta triggers a rapid drop in progesterone and
elevated levels of prolactin
The junction complexes between the alveoli close
Onset of copious amounts of breastmilk production occurs
Maintenance of established lactation
(Day 9 postpartum - involution)
Often discussed in terms of supply versus demand. The more milk that
is removed from the breasts, the more milk will be produced (the emptier the
breast, the faster the rate of milk synthesis).
Prolactin levels rise with the infant sucking on the breast
In response to sucking, oxytocin causes the milk-ejection reflex (or
Weaning from breastfeeding
(average of 40 days following last
With the addition of alternate infant nutrition, milk production is
On admission each neonate, infant or child will have a feeding history documented within by the admitting doctor and nurse. This includes:
This information will be recorded in the infant’s electronic medical record (EMR; ADT Navigators – Admission – Caregiver Assessment, Admission Note and Progress Notes). Referral for further breastfeeding support should be completed if feeding difficulties are identified (refer to below).
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. Extrauterine growth restriction, which commonly occurs with hospital admission, is a recognised risk factor for impaired neurodevelopment, therefore, supporting nutritional care is a very high priority.
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. **LINK to COCOON**
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 breast feeding incidence and duration, a greater ability to recognise infant cues and increased parent-infant bonding. (**LINK to Skin-to-skin Care GL**)
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. (**LINK to Sham Feeding Guideline**)
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 – Place New Order – 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, via the green lifts) to collect their meals at lunch (1145 – 1230) and dinner (1730 – 1815).
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 (below).
Lactation Consultants at the RCH are International Board Certified Lactation Consultants (IBCLCs) and are located on Koala and Butterfly wards.
The sweet taste of breastmilk is proven to have an analgesic effect, and where available, is preferable over 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. (**LINK to sucrose GL**)
RCH Policies and Procedures
RCH Clinical Practice Guidelines
Breastfeeding Staff Members (via RCH HR department) - coming soon
Breastfeeding Support and Promotion evidence table.
Please remember to read the disclaimer.
The development of this nursing guideline was coordinated by Tara Doyle, ANUM, Butterflyapproved by the Nursing Clinical Effectiveness Committee. Published December 2018.