Neobfhi Core Document

Neo-BFHI Core document, revised draft, version October 26, 2013
THE BABY-FRIENDLY
HOSPITAL INITIATIVE
FOR NEONATAL WARDS
NEO-BFHI
THREE GUIDING PRINCIPLES AND TEN STEPS
TO PROTECT, PROMOTE AND SUPPORT
BREASTFEEDING
AN EXPERT GROUP FROM

DENMARK, FINLAND, NORWAY,
SWEDEN, AND QUEBEC, CANADA
BASED ON:
BABY-FRIENDLY HOSPITAL INITIATIVE
Revised, Updated and Expanded for
Integrated Care 2009
ORIGINAL BFHI GUIDELINES DEVELOPED 1992
UNICEF, WORLD HEALTH ORGANIZATION
OCTOBER 26, 2013
Members of the expert group

#$
Anna-Pia Hggkvist, RN, MSc, IBCLC
Mette Ness Hansen, RN, Midwife, IBCLC
#
Kerstin Hedberg Nyqvist, RN, PhD
Elisabeth Kylberg, nutritionist, PhD, IBCLC

Leena Hannula, RN, Midwife, PhD
Aino Ezeonodo, RN, CEN, CPN,CNICN, MHC
Katja Koskinen, RN, Midwife, IBCLC

Ragnhild Maastrup, RN, IBCLC, doctoral student
Annemi Lyng Frandsen, RN, IBCLC
!%
Laura N. Haiek, MD, MSc
!
Table of contents

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The expansion of the BFHI to neonatal wards
The initiation and maintenance of breast milk production is of great importance for the mother to be
able to breastfeed a preterm or ill infant. Early, systematic and continuing support for mothers to initiate
breast milk expression and feeding at breast as soon as the infant is stable is essential for helping them
to succeed in overcoming physiological and emotional challenges related to lactation and breastfeeding
(1, 2) This is the background for developing and expanding the WHO/UNICEFs Baby-Friendly
Hospital Initiative (BFHI) to neonatal wards. This world-wide initiative provides since 1991 an
evidence-based set of standards for the protection, promotion and support of breastfeeding in maternity
wards (3). Compliance with the BFHI Ten Steps to Successful Breastfeeding (Ten Steps) has been
proven to be effective in increasing breastfeeding duration and exclusivity (4). Evidence arises from
randomized control trials examining policies and practices outlined in the individual steps as well as one
large study the PROBIT trial that measured effectiveness of the initiative as a whole (4).
Furthermore, several observational studies suggest that there is a relationship between the number of
steps implemented in a facility, and breastfeeding exclusivity (5-7) and duration (6, 8-12).
WHO/UNICEF has updated and expanded the BFHI to ensure the health care system and other relevant
sectors support the recommendation of exclusive breastfeeding for six months and continued
breastfeeding for up to two years of age or beyond, while providing women with the support that they
require to achieve their breastfeeding goals, in the family, community and workplace (3).
This global effort recognizes breastfeeding as the normal way of providing infants and young children
with the nutrients they need for healthy growth and development (13, 14), including preterm and ill
newborn infants (15, 16). In fact, there is growing evidence that exclusive and prolonged breastfeeding
improves maternal-infant health in both developing and developed countries (4, 17-19). Furthermore,
breast milk is species-specific, and all substitute feeding preparations differ markedly from it, making
breast milk uniquely superior for infant feeding. Breast milk-fed preterm infants receive significant
benefits with respect to host protection and improved developmental outcomes compared with formulafed preterm infants (15, 20). More specifically, the immunological components of breast milk protect
premature children from infections, and in particular life threatening illness even in western countries
such as neonatal sepsis and necrotizing enterocolitis (15, 21, 22) and support the development and
maturation of the infants own immune system, which may explain some of the long-term health
benefits observed in breastfed children (17, 18)
According to the WHO Global Action Report on Preterm Birth "Born too soon" (19) 15 million infants
are born preterm every year; more than 1 in 10 infants are born preterm around the world, and the rate
of preterm birth is rising. Prematurity is the leading cause of newborn death. However, death from
prematurity complications can be reduced by over 75% even without neonatal intensive care. In low
income settings half of the infants born at 32 week infants continue to die due to a lack of feasible, cost5

effective evidence-based interventions, such as Kangaroo Mother Care and breastfeeding.
Implementation of these methods could save an estimated 450.000 infants each year. Education and
health promotion are essential to attain this goal.
Several countries have been expanding the BFHI to other settings that care for breastfeeding mothers
and babies, such as community health centres and neonatal care units (3). In the Nordic countries,
Norway and Denmark have adapted the BFHI Ten Steps to take into consideration the special context of
neonatalwards and the unique needs of premature and sick babies admitted to these wards. Norway has
developed a process similar to the one used for maternity wards; most Norwegian neonatal wards have
been successfully certified as Baby-Friendly (23). Denmark has conducted an unpublished pilot study in
two hospitals and developed the Ten Steps for preterm infants. In Sweden, neonatal wards were
evaluated and assessed as Baby-Friendly at the same time as maternitywards in the same hospital.
These adaptations have been supported by an increasing number of publications documenting the
effectiveness of breastfeeding-related best practices in neonatal wards. Three recent systematic reviews
have established the importance of professional and peer-support, implementing hospital practices such
as skin-to-skin, kangaroo mother care and rooming in as well as adopting effective methods to support
mothers initiate and maintain milk production (1, 2, 24). Early initiation of breastfeeding, with infant
stability as the only criterion is another important issue to be considered (25-27).
In addition, some studies report positive effects of implementing the Baby-Friendly standards on
breastfeeding rates and exclusivity in neonatal wards (28-29). To date, there is no consensus on which
breastfeeding-related policies and practices should be recommended for neonatal ward, nor have any
studies examined the effectiveness of these expanded initiatives.
The main difference between maternity and neonatal wards is that most neonatal wards separate the
mothers from their infants, there is little or no space for the mothers, and the possibility for having a
chair or a bed at the infants bedside is not always granted. In addition mothers to a premature or ill full
term infant have more need for support from the father or other family members because of their
emotional stress. For mothers in a neonatal ward, the transition to motherhood entails a crisis, a process
which takes time (30). In this setting, lactation often has to be initiated with expression using a pump or
manual expression. These mothers may perceive breastfeeding as mutually pleasurable and reciprocal,
or contrarily as task-oriented, non-reciprocal. There is a risk that hospital nutrition and feeding
practices are interpreted by mothers as a message that breastfeeding is a maternal responsibility: an
obligation to transfer a certain volume of milk, a norm to be fulfilled; if so, a mothers inability to meet
expectations on success in lactation and breastfeeding may lead to feelings of failure and shame (31,
32).
In Estonia, Levin introduced the concept "Humane neonatal care" including mother-infant nonseparation and breastfeeding support in a neonatal unit already in the early 1980s (33). In Sweden, the
6

recommendations of the Ten Steps were studied in the neonatal care setting. The results showed that
mothers need more, and to some extent different breastfeeding support. The views, experiences and
thoughts of the mothers resulted in a modified version of the Ten Steps (34). It is of importance to raise
the awareness among health and medical professionals about mothers feelings around breastfeeding, to
improve guidance and - of course - respect and support mothers who fail in breastfeeding or choose not
to breastfeed at all. These mothers and infants' special needs have to be taken in consideration when
developing standards for BFHI in neonatal wards.
Who is doing the adaptation?
The Nordic and Quebec working group was formed in Copenhagen, March 2009, by health
professionals from Sweden, Norway, Denmark, Finland and Quebec, Canada to address the expansion
of the BFHI to neonatal care. The working group has developed a unified expansion of the BFHI to
Neonatal Wards or Neo-BFHI, based on review of the evidence, expert opinion, and experiences in the
Nordic countries and other countries around the world (35, 36). To remain consistent with the
WHO/UNICEF 2009 update of the BFHI standards (i.e., the Global Criteria) (3), it was decided that
the expansion of the BFHI to neonatal wards should closely follow the revised Ten Steps. To ensure that
the recommended practices focuses on respect to mothers, a family-centred approach and continuity of
care, the working group formulated three Guiding Principles meant to be basic tenets in the Ten Steps.
In agreement with the BFHI, the adaptation also includes respect of the International Code of Marketing
of Breast milk Substitutes. It must be noted that in the spirit of this adaptation, neonatal wards typically
cover all levels of neonatal care, including healthier infants who may require episodic or short-term
monitoring or medical interventions.
Objectives of the adaptation

To expand and adapt the Ten Steps to protect, promote and support breastfeeding in the neonatal ward
based on the WHO/UNICEF BFHI program (3).
Objectives
1. To examine the evidence in relation to breastfeeding promotion, protection and support in
the neonatal ward
2. To develop and adapt standards and criteria
3. To develop an assessment tool to evaluate if neonatal s comply with the criteria
4. To pilot the new assessment tool
5. To promote implementation of the adapted standards
6. To encourage research to assess the effectiveness of the adaptation
In this document, the original title of each step is followed by the expanded version of the title.
7

1.
Renfrew MJ, Craig D, Dyson L, et al. Breastfeeding promotion for infants in neonatal units: a
systematic review and economic analysis. Health Technol Assess 2009;13:1-146, iii-iv.
2.
Rice SJ, Craig D, McCormick F, Renfrew MJ, Williams AF. Economic evaluation of enhanced
staff contact for the promotion of breastfeeding for low birth weight infants. Int J Technol Assess
Health Care 2010;26:133-40.
3.
World Health Organization/UNICEF. Baby-Friendly Hospital Initiative. Revised, Updated and

Expanded for Integrated Care. Section 1: Background and implementation. In. Geneva: World
Health Organization/UNICEF; 2009:70.
4.
Kramer MS, Chalmers B, Hodnett ED, et al. Promotion of Breastfeeding Intervention Trial
(PROBIT): a randomized trial in the Republic of Belarus. JAMA 2001;285:413-20.
5.
Declercq E, Labbok MH, Sakala C, O'Hara M. Hospital practices and women's likelihood of
fulfilling their intention to exclusively breastfeed. Am J Public Health 2009;99:929-35.
6.
Merten S, Dratva J, Ackermann-Liebrich U. Do baby-friendly hospitals influence breastfeeding

duration on a national level? Pediatrics 2005;116:e702-8.
7.
Toronto Public Health. Breastfeeding in Toronto: Promoting Supportive Environments. In.

Toronto: Toronto Public Health; 2010:109.
8.
Centers for Disease Control and Prevention. Breastfeeding-related maternity practices at hospitals
and birth centers--United States, 2007. MMWR Morb Mortal Wkly Rep 2008;57:621-5.
9.
DiGirolamo AM, Grummer-Strawn LM, Fein S. Maternity care practices: implications for
breastfeeding. Birth 2001;28:94-100.
10. DiGirolamo AM, Grummer-Strawn LM, Fein SB. Effect of maternity-care practices on
breastfeeding. Pediatrics 2008;122 Suppl 2:S43-9.
11. Murray E. Hospital practices that increase breastfeeding-duration: results from a population based
study. Birth 2006;34:202-10.
12. Rosenberg KD, Stull JD, Adler MR, Kasehagen LJ, Crivelli-Kovach A. Impact of hospital policies
on breastfeeding outcomes. Breastfeed Med 2008;3:110-6.
13. World Health Organization. Global Strategy for Infant and Young Child Feeding. In. Genve:
World Health Organization; 2003:30.
14. Breastfeeding. World Health Organization,
http://www.who.int/topics/breastfeeding/en/.)
2013.
(accessed
October
25,
2013,
at
15. Karen E, Rajiv B. Optimal feeding of low-birth-weight infants. Technical review. In. Geneva:
World Health Organization; 2006:121.
16. The Value of Human Milk. HMBANA Position Paper on Donor Milk Banking. (accessed October
25, 2013, at http://www.hmbana.org/downloads/position-paper-donor-milk.pdf.)
17. Horta B, Bahl R, Martins J, Victora C. Evidence on the long-term effects of breastfeeding.
Systematic reviews and meta-analysis. In. Geneva: World Health Organization; 2007:52.
18. Ip S, Chung M, Raman G, et al. Breastfeeding and Maternal and Infant Health Outcomes in
Developed Countries. Evidence Report/Technology Assessment No. 153. AHRQ Publication No.
07-E007. In: Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries
Evidence Report/Technology Assessment No 153 (Prepared by Tufts-New England Medical
Center Evidence-based Practice Center, under Contract No 290-02-0022) AHRQ Publication No
07-E007. Rockville, MD: Agency for Healthcare Research and Quality; 2007:186
19. World Health Organization. The Global Action Report. Born too soon. WHO 2012. ISBN 978 92 4
150343 3 http://www.who.int/pmnch/media/news/2012/preterm_birth_report/en/.
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20. Leon-Cava N, Lutter C, Ross J, Martin L. Quantifying the benefits of breastfeeding: A summary of
the evidence. In. Washington DC: Pan American Health Organization; 2002:168.
21. American Academy of Pediatrics. Breastfeeding and the Use of Human Milk. Pediatrics
2005;115:496-506.
22. Ronnestad A, Abrahamsen TG, Medbo S, et al. Late-onset septicemia in a Norwegian national
cohort of extremely premature infants receiving very early full human milk feeding. Pediatrics
2005;115:e269-76.
23. The Baby Friendly Hospital Initiative in Norwegian neonatal units. Norwegian Resource Centre for
Breastfeeding, 2011. (accessed April 1st, 2011, at
http://www.oslo-universitetssykehus.no/omoss/avdelinger/nasjonalt-kompetansesenter-foramming/Sider/neonatalavdelingene.aspx
24. McInnes RJ, Chambers J. Infants admitted to neonatal units--interventions to improve
breastfeeding outcomes: a systematic review 1990-2007. Matern Child Nutr 2008;4:235-63.
25. Nyqvist KH, Sjoden PO, Ewald U. The development of preterm infants' breastfeeding behavior.
Early Hum Dev 1999;55:247-64.
26. Nyqvist KH, Farnstrand C, Eeg-Olofsson KE, Ewald U. Early oral behaviour in preterm infants
during breastfeeding: an electromyographic study. Acta Paediatr 2001;90:658-63.
27. Nyqvist KH. Early attainment of breastfeeding competence in very preterm infants. Acta Paediatr
2008;97:776-81.
28. Dall'Oglio I, Salvatori G, Bonci E, Nantini B, D'Agostino G, Dotta A. Breastfeeding promotion in
neonatal intensive care unit: impact of a new program to a BFHI for high-risk infants. Acta
Paediatr 2007;96:1626-31.
29. Merewood A, Philipp BL, Chawla N, Cimo S. The baby-friendly hospital initiative increases
breastfeeding rates in a US neonatal intensive care unit. J Hum Lact 2003;19:166-71.
30. Shin H, White-Traut R. The conceptual structure of transition to motherhood in the neonatal
intensive care unit. J Adv Nurs 2007;58:90-8.
31. Flacking R, Ewald U, Nyqvist KH, Starrin B. Trustful bonds: a key to "becoming a mother" and to
reciprocal breastfeeding. Stories of mothers of very preterm infants at a neonatal unit. Soc Sci Med
2006;62:70-80.
32. Flacking R, Ewald U, Starrin B. "I wanted to do a good job": experiences of 'becoming a mother'
and breastfeeding in mothers of very preterm infants after discharge from a neonatal unit. Soc Sci
Med 2007;64:2405-16.
33. Levin A. The mother-infant unit at Tallinn Children's Hospital, Estonia: A truly Baby Friendly
Unit. Birth 1994;21:39-44.
34. Nyqvist KH, Kylberg E. Application of the baby friendly hospital initiative to neonatal care:
suggestions by Swedish mothers of very preterm infants. J Hum Lact 2008;24:252-62.
35. Nyqvist KH, Hggkvist AP, Hansen MN, E Kylberg E, Frandsen AL, Maastrup R, Ezeonodo, A,
Hannula L, Koskinen K, Haiek LN. Expansion of the Ten Steps to Successful Breastfeeding into
Neonatal Intensive Care: Expert Group Recommendations for Three Guiding Principles. J Hum
Lact J Hum Lact 2012;28 289-296.
36. Nyqvist KH, Hggkvist AP, Hansen MN, E Kylberg E, Frandsen AL, Maastrup R, Ezeonodo, A,
Hannula L, Koskinen K, Haiek LN. Expansion of the Baby-Friendly Hospital Initiative Ten Steps
to Successful Breastfeeding into Neonatal Intensive Care: Expert Group Recommendations. J Hum
Lact 2013;29 300-309.
Definitions and Abbreviations:

AFASS
Acceptable, feasible, affordable, sustainable and safe; criteria for infant

feeding/nutrition when the mother does not breastfeed.
GA
Gestational age at birth
KMC
Kangaroo Mother Care
NICU
Neonatal Intensive Care Unit
PMA
Postmenstrual Age (corresponds to gestational age after birth)
SSC
Skin-to-skin contact
24 h/d
24 hours a day
24 h/7 d
24 hours a day, 7 days a week

Breastfeeding
Feeding directly at the breast or providing the infant with breast milk by other
feeding methods.
Breast milk
feeding
Providing the infant with breast milk directly at the breast or by other feeding
methods.
Breastfeeding
policy
Overall policy for feeding, breastfeeding and nutrition including the Three
guiding principles and Ten steps, and the Code.
Breastfeeding
protocol
Guidelines for the implementation of the breastfeeding policy in the neonatal

ward.
Clinical staff
Staff in all levels of care including out-patient care. It includes nurses, doctors
and any professionals caring for infants and young children, and their families.
Complementary
feeding,
complementation
Giving partly breastfed infants breast milk or formula using any feeding
method.
Extremely preterm
infant
Born at a gestational age of less than 28 gestational weeks.
Father
Includes partner or significant other person.
Family
Includes significant others and is defined by the parents.
10

Head/director of
nursing services
The professional who has the main responsibility for nursing care in the ward.
Infant or baby
Infant or baby refers to preterm and/or ill infants/babies. Otherwise infants

or babies are described as healthy and/or full-term.
Late preterm infant
Infant born at a gestational age from 34+0 to 36+6 weeks + days.
Levels ***, **, *
Levels in meeting criteria for standards: *** gold ** silver * bronze.

The final goal should be to achieve level ***.
Kangaroo Mother
Care (KMC)
The definition of the KMC method is: Early, prolonged and continuous skin-toskin care between a mother and her low birth weight infant in hospital and after
early discharge, with (ideally) exclusive breastfeeding, early discharge and
adequate follow-up1. In this document, KMC is used for all models of skin-toskin care (intermittent and continuous) between parents and preterm/low birth
weight/ill infants requiring neonatal care.
Cattaneo, A., Davanzo, R., Uxa, R. & Tamburlini,G. Recommendations for the
implementation of Kangaroo mother care for low birthweight infants. Acta Paediatrica
1998; 87, 440-5
Maternal role
See definition below: Primary caregiver
Neonatal ward
Neonatal ward covers all levels of neonatal care (levels I-III) and pediatric
wards where infants are admitted, including infants in maternity/postpartum
wards, who require some kind of monitoring and medical and nursing
interventions.
Neo-BFHI
The expansion of the Baby-Friendly Initiative for Neonatal Wards.
Nursing
supplementer
A method for supplementation by using a feeding tube device with a bag/bottle

to hold milk, connected to fine tubing taped to the mothers nipple, delivering
supplementation to the baby at the same as he/she suckles the breast.
Pacifier
Also called dummy or soother.
Paternal role
See definition below: Primary caregiver.
Preterm infant
Born at a GA of less than 37 weeks
Primary caregiver
The person who provides an infant with all caregiving activities, except certain
medical-technical procedures, regarding which performance by individuals
without adequate training and knowledge can be considered a hazard for the
infant.
Stable infant:
Related to with
breastfeeding
Infants who do not respond to routine care and handling with severe apnoea,
desaturation and bradycardia.
Stable infant:
Related to
Kangaroo Mother
Care
Infants regarding whom there is ample research evidence of safety and positive
effects of Kangaroo Mother Care: Infants born at a gestational age of at least 28
weeks without severe physiological instability.
11

Tactile stimulation
Therapeutic intervention provided to the infant using touch by

containment/hand swaddling, stroking, massage, holding etc.
Supplementation/
Supplementary
feeding
Giving partly breastfed infants breast milk or formula using any feeding
method
Very preterm
infant
Born at a GA of 28-31 weeks
12
Guiding principle 1: The staff attitude toward the mother

must focus on the individual mother and her situation.
Mothers with infants in a neonatal ward may experience a delayed development of a maternal identity
(1). Mothers of preterm infants may give birth before they have passed all phases in the process of
becoming a mother, experienced by mothers who give birth at term (2). For mothers in a neonatal ward,
the transition to motherhood entails a crisis, a process which takes time (1). Their feelings can swing
between shock, sorrow, emotional exhaustion, and hope; they can feel as if they are hovering around the
edge of mothering (3). Preterm birth is a traumatic experience that may lead to maternal posttraumatic
stress, non-balanced attachment representations, with long term consequences for the mother-infant
relationship (4, 5). This requires early support, especially if the mother reports negative birth
experiences.
These mothers may perceive breastfeeding as mutually pleasurable and reciprocal, or contrarily - as
task-oriented, non-reciprocal. There is a risk that hospital nutrition and feeding practices are interpreted
by mothers as a message that breastfeeding is a maternal responsibility: an obligation to transfer a
certain volume of milk, a norm to be fulfilled; if so, a mothers inability to meet expectations on success
in lactation and breastfeeding may lead to feelings of failure and shame (6,7).
Mothers of preterm infants have described their milk as a connection between themselves and the infant,
an integral part of their construction of motherhood (8), and may not feel as mothers until they can
initiate breastfeeding (9). This makes the mothers own milk highly valued, at the same time as it can
places pressure on her to produce milk. When the mother considers breastfeeding a marker of good
motherhood, her inability to produce enough milk can result in feelings of inadequacy and guilt (6, 7).
This gives causes for concern, as maternal depressive symptoms and anxiety and mothers early feeding
behavior can have negative impact on the development of her maternal role. Mothers lack of
confidence in feeding has been associated with maternal perceptions of the infant as vulnerable and with
parenting stress (10).
In order to help mothers in attaining motivation for establishment of lactation and breastfeeding, support
should be offered with empathy, in a psychologically and culturally appropriate way (11, 12). Therefore,
the mother must be met as a person, not only as a producer of breast milk and a care-giver who
participates in the infants care by feeding the infant at the breast or by other feeding methods. She
should be supported in making and implementing informed decisions about milk production,
breastfeeding and infant feeding, according to her wishes.
All mothers of preterm infants and ill newborn infants must be recognized as vulnerable mothers. In
addition, increased attention should be paid to particularly vulnerable mothers (families): first time
mothers, mothers with previous breastfeeding difficulties, multiparous mothers with a long interval
since the last birth, mothers in resource-deprived settings, mothers with low socio-economic status
(SES), smokers, mothers with substance abuse, and mothers belonging to groups with low breastfeeding
incidence and duration. Epidemiological studies have consistently found less likelihood of breastfeeding
in mothers of preterm infants, mothers who are young, have a low level of education, and are smokers
(13).
13

1a
Every mother is treated with sensitivity (meaning staff was responsive to what the mother
communicates), empathy and respect for her maternal role.
1b
Mothers are supported in making informed decisions about milk production, breastfeeding,
and infant feeding .
1c
Focused individualized support is given to particularly vulnerable mothers (families) with

respect to milk production, breastfeeding and infant feeding.
1d
Respect is shown to mothers who decide or are advised not to breastfeed, or do not succeed in
reaching their breastfeeding goals.

GP1.1
At least 80 % of randomly selected mothers report that they were treated with sensitivity by
the clinical staff (meaning staff was responsive to what the mother communicates).
GP1.2 At least 80 % of randomly selected mothers report that they were treated with empathy by the
clinical staff.
GP1.3
At least 80 % of randomly selected mothers report that they were treated by the clinical staff
with respect for their maternal role.

GP1.4 At least 80 % of randomly selected mothers report that they were supported by the clinical
staff in making their own decisions about milk production, breastfeeding and infant feeding.

GP1.5 The breastfeeding policy defines which mothers (families) should be regarded as particularly
vulnerable and be given focused individualized support with respect to milk production,
breastfeeding and infant feeding.

GP1.6 At least 80 % of randomly selected mothers who do not breastfeed or do not breastfeed
exclusively report that the clinical staff respected their decision to give formula to their babies.

1.
2.
3.
4.
Shin H, White-Traut R. The conceptional structure of transition to motherhood in the neonatal

intensive care unit. Journal of Advanced Nursing 2007; 58(1):90-98.
Bruschweiler-Stern. Early emotional care for mothers and infants. Pediatrics 1998;102(5):1278-81
Lau R, Morse CA. Stress experiences of parents with premature infants in a special care nursery.
Stress and Health 2003;19:69-78.
Forcada-Guex M, Borghini A, Pierrehumbert B, Ansermet F, Muller-Nix C. Prematurity, maternal
posttraumatic stress and consequences on the mother-infant relationship. Early Human
Development 2001;87:21-26.
14

5.
6.
7.
8.
9.
10.
11.
12.
13.
Meijssen D, Wolf M-J, van Bakel H, Koldewijn K, Kok J, van Baar A. Maternal attachment
representations after very preterm birth and the effect of early intervention. Infant Behavior and
Development 2010, doi.10.1016/j.infbeh.2010.09.009
Flacking R, Ewald U, Hedberg Nyqvist K, Starrin B. Trustful bonds: A key to becoming a
mother and to reciprocal breastfeeding. Stories of mothers of very preterm infants at a neonatal
unit. Social Science & Medicine 2006;62:70-80.
Flacking R, Ewald U, Starrin U. I wanted to do a good job: Experiences of becoming a mother
and breastfeeding in mothers of very preterm infants after discharge from a neonatal unit. Social
Science & Medicine 2007;2405-16.
Sweet L. Expressed milk as connection and its influence on the construction of motherhood for
mothers of preterm infants: a qualitative study. International Breastfeeding Journal 2008;3:30.
Nyqvist KH, Kylberg E. Application of the Baby Friendly Hospital Initiative to neonatal care:
Suggestions by Swedish mothers of very preterm infants. Journal of Human Lactation 2008;
24(3):252-62.
Teti DM, Hess CR, OConnell M. Parental perceptions of infant vulnerability in a preterm sample:
Prediction from maternal adaptation to parenthood during the neonatal period. Developmental and
Behavioral Pediatrics 2005;26:283-92.
Lee R-Y, Liu T-T, Kuo S-H. The experience of mothers in breastfeeding their very low birth
weight infants. Journal of Advanced Nursing 2009;65(129:2523-3.
Ekstrm A, Matthiesen AS, Widstrm AM, Nissen E. Breastfeeding attitudes among counselling
health professionals. Scand J Public Health. 2005;33(5):353-9.
Zachariassen G, Faerk J, Grytter C, Exberg BH, Juvonen P, Halken S. Factors associated with
successful establishment of breastfeeding in very preterm infants. Acta Paediatr 2010; 99: 10001004.
15
Guiding principle 2: The facility must provide familycentered care, supported by the environment.
The ward should respect the rights, responsibilities, and duties of parents to provide appropriate
direction and guidance for their infant according to article 5 in the UN Convention on the Rights of the
Child (1).
A family-centred individualized developmentally supportive environment is characterized by the
attitude that parents are the most important persons in their infants life and are encouraged and
supported to act as the infants primary caregivers (as far as this is possible considering the infants
medical condition and treatment). Core concepts of patient- and family-centred care are dignity and
respect, information sharing, participation, and collaboration (2).
Family-centred care is a concept that must be integrated into the culture and functioning of a neonatal
ward. A physical and social environment that supports the presence and involvement of families may
enhance family-centred care. A high level of collaboration with the families is more dependent on the
attitudes of the staff and the relationships that the staff members establish with the families of infants in
the ward than on the physical facilities (3). Training in family-centred care should be arranged on a
regular basis and be included in the education of all new staff members (4).
Optimal support of parents as primary caregivers is achieved by offering parents freedom of choice
regarding performance of tasks and advancement of taking over care (4). Mothers want a family-centred
and supportive physical environment, support of the fathers presence, and early transfer of infants care
to the parents (5). The parents must be seen as a whole, but also as individuals, mothers and fathers
needs may not be the same. The fathers role is not only to act as the mothers supporter. Fathers of
preterm infants who experience support, security, and happiness, feel that they are in control and able to
handle the situation (6). Fathers have suggested that they could be included in the process of
breastfeeding, by providing a favourable environment for the mother and baby and be present during
breastfeeding (7). Fathers who began sharing the infants care with the mother soon after birth stated
that this helped them attain the paternal role and feel in control of the situation (8).
The design of the ward should accommodate parents presence as far as possible (9, 10). Stimuli such as
levels of illumination, sound and activity should be modified according to the individual infants and
parents needs (5), and measures should be taken for safeguarding privacy for the family. Providing the
mother in the neonatal unit with a comfortable arm chair/recliner/bed enables the mother to support the
preterm infants behaviour during breastfeeding (11).
The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) promotes
autonomic and motoric stability, better developed state regulation and improved attentional functioning,
and infants have shown significantly shorter stays on tube feeding. (12). Application of NIDCAP
principles during breastfeeding can support the infants breastfeeding behaviour (11).
Support of parents presence 24 hours seven days a week (24h/7d) is increasing. This is a possible
practice also during medical rounds and should be supported (13).

2a
Encourage the presence of the father without unjustified restrictions as the mothers supporter
and the infants caregiver.
2b
The infants care is transferred by the staff gradually to the parents, commencing soon after
birth.
2c
The ward provides practical possibilities, such as a place to rest, sleep and eat, for
16

mothers/parents to be able to stay with their baby as long as they want.
2d
The ward provides an individualized developmentally supportive environment that is

appropriate for the infant and the parents and facilitates breastfeeding.
2e
The ward provides family/single care rooms.

!

GP2.1
The breastfeeding policy states that the father/family member or significant others are
allowed in the ward (according to levels).
Without restrictions 24 h/7 d (level ***)
Maximum 2 hours restriction/24 hours (level **)
Restrictions during nightime and maximum 2 hours restrictions during the day (level *)
GP2.2
Observation confirms that the father/family member or significant others are allowed in the
ward (according to levels).

!

GP2.3
The breastfeeding policy states early transfer of the infants care to the parents after the birth.
GP2.4
At least 80 % of randomly selected mothers report that they began participating in the
performance of the infants care within the first 24 hours after the birth, unless there are
justifiable reasons for not doing it, such as the mothers and infants condition and medical
care.
GP2.5
At least 80 % of randomly selected mothers report that the father/family member or

significant other was encouraged and supported to participate in the infants care within the
first 24 hours after the birth if he was present.

!

GP2.6
Observation confirms that all mothers of infants in the neonatal ward have access to a bed or
mattress/comfortable arm chair - recliner/chair without arm rests at the infants bedside
(levels).
Bed/mattress (level ***)
Comfortable arm chair-recliner (level **)
Chair without arm rest at the infants bedside (level *)
GP2.7
At least 80% of randomly selected mothers report that they were able to eat not far from the
ward (according to levels).
Eat in the ward (level ***)
Close to the ward (5 minutes walking distance or less) (level **)
Not far from the ward (6 to 10 minutes walking distance) (level *)
17

!

GP2.8
Observation confirm that the illumination is individualized, preterm infants eyes are not
exposed to direct light, and that the sound level is low (conversations are held in a low voice,
alarms are set low and silenced promptly, and other sources of noice occur only
infrequently).
GP2.9
At least 80 % of mothers report that the environment is appropriate for their presence and
breastfeeding regarding light, sound, level of activity, and privacy.

!

GP2.10
Observation confirms that the ward provides family/single care rooms with
beds/recliners/mattresses that give parents the opportunity to stay 24h/7d.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Office of the United Nations High Commissioner for Human Rights. Convention on the rights of
the child: http://www.ohchr.org/en/professionalinterest/pages/crc.aspx (accessed October 25, 2013)
http://www.familycenteredcare.org/faq.html (accessed October 25, 2013)
Saunders RP, Abraham MR, Crosby MJ, Thomas K, Eds H. Evaluation and development of
potentially better practices for improving family-centered care in neonatal intensive care units.
Pediatrics 2003;111(4):e437-49.
Nyqvist KH, Engvall G. Parents as their infant's primary caregivers in a neonatal intensive care
unit. J Pediatr Nurs. 2009 Apr; 24(2):153-63.PMID: 19268237
Nyqvist KH, Kylberg E. Application of the Baby Friendly Hospital Initiative to neonatal care:
Suggestions by Swedish mothers of very preterm infants. Journal of Human Lactation 2008;
24(3):252-62.
Lundqvist P, Jakobsson L. Swedish men's experiences of becoming fathers to their preterm infants
Neonatal Netw. 2003 Nov-Dec; 22(6):25-31.
Pontes CM, Osrio MM, Alexandrino AC. Building a place for the father as an ally for
breastfeeding. Midwifery. 2009;25(2):195-202.
Blomqvist YT, Rubertsson C, Kylberg E, Jreskog K, Nyqvist KH. Kangaroo Mother Care helps
fathers of preterm infants gain confidence in the paternal role. Journal of Advanced Nursing 2011
Nov 23. doi: 10.1111/j.1365-2648.2011.05886.x. Epub ahead of print
Beck SA, Weiss J, Greisen G, Andersen M, Zoffmann V. Room for family-centered care - a
qualitative evaluation of a neonatal intensive care unit remodeling project. Journal of Neonatal
Nursing 2009;15(3):88-99.
Levin A. Humane Neonatal Care Initiative. Acta Paediatr. 1999 Apr;88(4):353-5.
Als H, Duffy FH, McAnulty GB. Effectiveness of individualized neurodevelopmental care in the
newborn intensive care unit (NICU). Acta Paediatr Suppl. 1996 Oct;416:21-3.
Nyqvist KH, Ewald U, Sjoden PO. Supporting a preterm infant's behaviour during breastfeeding: a
case report. J Hum Lact. 1996;12(3):221-80.
Greisen G, Mirante N, Haumont D, Pierrat V, Palls-Alonso CR, Warren I, Smit BJ, Westrup B,
Sizun J, Maraschini A, Cuttini M; ESF Network. Parents, siblings and grandparents in the Neonatal
Intensive Care Unit. A survey of policies in eight European countries. Acta Paediatr. 2009;
98(11):1744-50.
18
Guiding principle 3: The health care system must ensure

continuity of care that is, continuity of pre-, peri- and
post-natal, and postdischarge care
Continuity of care involves care delivered over time to an individual infant and his/her family (1). The
time frame may vary but includes distinct time periods or phases (2):
-
A prenatal care phase, when parents anticipate the arrival of an infant who will require hospital care
and may be in a critical condition. This period, which is anxiety-provoking and important to parents,
is the entry point for the neonatal continuum of care.
Birth and delivery room stabilization.
Admission to a neonatal ward in the birth hospital, or a neonatal transport before admission to a
neonatal ward at another hospital.
The phase of hospital care may include an intensive care phase and an intermediate care phase.
In case the infant was initially transferred to another hospital, the next phase involves back transfer
to a local hospital for a phase of continued care.
A pre-discharge preparatory phase followed by discharge to the home. An alternative is early
discharge for continued care of the infant at home provided by the parents, supported by staff at the
hospital, a home care agency or another health care provider.
A follow-up phase.
In case the infant requires continued long term care (for example for treatment with additional
oxygen or ventilator treatment) this means a continued phase of intensive care at home.
The phases in lactation and breastfeeding include initiation of lactation, attainment and maintenance of
an adequate milk production, initiation of breastfeeding and the mother attainment of her breastfeeding
goals (ideally exclusive breastfeeding) combined with a transition phase using feeding methods and
nutrition policies that are supportive of breastfeeding.
In moving through these stages, preterm and ill infants will be cared by several care providers who
could potentially work at cross purposes (1). Continuity is achieved when providers deliver consistent
care that is responsive to the infants and his/her familys changing needs (1, 3, 4), with a continuity in
approach (3). This necessitates shared policies and guidelines for infant care and for parents role, and
parent education programs (group activities, individual counseling or printed information) in order to
achieve management continuity (1). Continuity of care of the individual infant and approach to the
parents also refers to parents perceptions of the process of care (1, 4). On any given encounter, parents
should perceive that decisions about their infants are based on policies which are shared by all
caregivers and to which all are willing to adhere, without any conflicting information or advice. Parents
should feel confident that their caregivers know what has gone before, and that they (the parents) will
not have to inform caregivers about their infants medical history and current care plan (3).
Mothers have described experience of contradictory advice from different health professionals, frequent
change of strategies, a hands-on approach in breastfeeding counseling, judgmental, critical and uncaring
attitudes and minimal demonstration of empathy (5). In contrast, continuity of care by breastfeeding
counselors with adequate training improves mothers perception of support (6).
The family-centered care approach, addressed in Guiding Principles 1 and 2, provides a framework to
facilitate continuity of care (5) by, for example, promoting parents presence and participation as
primary caregivers (6). As nurses' role changes from caregiver to also acting as parent educator/coach,
and parents take over several or nearly all components in their infants' care, they will be more informed
about their infant's condition and actively participate in decisions about their care (7). This may act as a
safeguard of continuity of care. Furthermore, continuity of care affects parents confidence in their
infants safety and their own emotional status (8). Frequent staff changes, on the other hand, are
perceived as a risk for the infants safety and disregard of the parental role (9). Not surprisingly,
19

continuity of care is one of the main outcomes or activities in all comprehensive global maternal-infant
health initiatives (10-13). The continuity in neonatal ward physical environment (nursery environment,
parent rooms and other parent/family facilities) should also be considered.

GP3 a
Care in regards to the lactation and breastfeeding support during each stage of health care
delivery (prenatal care, arrival of a potentially critical infant, acute/critical care phase, a
stable-improving phase, a transfer-discharge phase, and a follow-up or continuing care) should
be consistent.
GP3 b
Information regarding the infants medical management and families preferences is shared
among the relevant health care providers, institutions, and organizations involved in lactation
and breastfeeding support.

"

GP3.1
Continuity of care is addressed in the breastfeeding policy.
GP3.2
All clinical protocols or standards in the hospital related to lactation, breastfeeding and
feeding support in preterm and sick infants indicate that they are in line with the BFHI in
neonatal ward standards and current evidence-based guidelines.
GP3.3
The head/director of nursing services of neonatal/paediatric services reports that the ward
has an identified person responsible for working with continuity of care related to lactation,
breastfeeding and feeding support during each stage of health care delivery.
GP3.4
At least 80 % of randomly selected clinical staff can name a person responsible for
working with continuity of care related to lactation, breastfeeding and feeding support.
GP3.5
At least 80 % of randomly selected mothers report that they receive consistent information
regarding lactation, breastfeeding and feeding support of their infant throughout the
continuum of care.

"

GP3.6
At least 80 % of randomly selected mothers report that clinical staff know what went on
before with their infants and that they did not have to repeat the history of their infants
medical condition and current care plan (including current lactation, breastfeeding and
feeding support strategy) to the caregivers involved in their infants care.
GP3.7
Information regarding the current situation and plan for maternal lactation, breastfeeding
and feeding support is included in the report provided by the neonatal ward when the
infants care is transferred to the next phase of care.
GP3.8
At least 80 % of randomly selected clinical staff report that information regarding the
current situation and plan for maternal lactation is included in the report provided by the
neonatal ward when the infants care is transferred to the next phase of care.
20

1
2
3
4
5
6.
7.
8
9
10
11
12
13
Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. Continuity of care: a
multidisciplinary review. BMJ. 2003; 327: 1219-21.
Conner JM, Nelson EC. Neonatal intensive care: satisfaction measured from a parent's perspective.
Pediatrics. 1999; 103: 336-49.
Green JM, Renfrew MJ, Curtis PA. Continuity of carer: what matters to women? A review of the
evidence. Midwifery. 2000; 16: 186-96.
Rodriguez C, des Rivieres-Pigeon C. A literature review on integrated perinatal care. 2007/09/06
ed, 2007. p. e28. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1963469/
Hauck YL, Graham-Smith C, McInterney J, Kay S. Western Australian women's perception of
conflicting advice around breast feeding. Midwifery, 2010, Apr 9. e-pub ahead of print
Ekstrom A, Widstrom A-M, Nissen E. Does continuity of care by well-trained breastfeeding
counselors improve a mother's perception of support? Birth 2006;33(2):123-30
The Institute for Family-Centered Care. What is patient- and family-centered care?
http://www.familycenteredcare.org/index.html (accessed October 25, 2013).
Nyqvist KH, Engvall G. Parents as their infant's primary caregivers in a neonatal intensive care
unit. J Pediatr Nurs. 2009; 24: 153-63.
Hurst I. Mothers' strategies to meet their needs in the newborn intensive care nursery. J Perinat
Neonatal Nurs. 2001; 15: 65-82.
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; 21: 131-8.
World Health Organization/UNICEF. Baby-Friendly Hospital Initiative. Revised, Updated and
Expanded for Integrated Care. Section 1: Background and implementation. Geneva: World Health
Organization/UNICEF, 2009. p. 70.
http://whqlibdoc.who.int/publications/2009/9789241594967_eng.pdf
The International MotherBaby Childbirth Organization. The International MotherBaby Childbirth
Initiative (IMBCI): 10 Steps to Optimal MotherBaby Maternity Services, 2013. www.imbci.org
(accessed October 25, 2013).
World Health Organization. Making pregnancy safer. Geneva: World Health Organization, 2013.
http://www.afro.who.int/en/clusters-a-programmes/frh/making-pregnancy-safer.html (accessed
October 25, 2013).
21
/&"# $ ! $

!
Expansion: Have a written breastfeeding policy that

is routinely communicated to all health care staff
Hospitals with comprehensive breastfeeding policies are likely to have better breastfeeding support
services and better breastfeeding outcomes (1, 2).The introduction of BFHI policy has been shown to
increase breastfeeding rates at 2 days and 2 weeks postpartum in maternity wards (2). BFHI promotion
increased the exclusivity and continuity of breastfeeding and decreased the risk of gastrointestinal tract
infections in maternity wards in Belarus (1). Facilities using Kangaroo Mother Care guidelines as part of
their policy have higher breastfeeding rates (3-7). Children born in a BFHI health facility were more
likely to be breastfed for a longer time, particularly if the hospital showed high compliance with
WHO/UNICEF guidelines. BFHI should be extended to include monitoring for compliance, to promote
the full effect of the BFHI. (8)
The implementation of a BFHI promotion program in neonatal wards had markedly positive effects on
exclusive breastfeeding rates early after discharge from hospital in USA and Italy (9, 10). The impact of
several recognized risk factors on exclusively breastfeeding rate was significantly reduced after the
program was implemented, except for higher maternal age.
Further studies are needed to adapt the BFHI approach to the neonatal ward setting, taking into account
the characteristics of high-risk infants (10).
Baby Friendly accreditation in hospitals with both maternity and neonatal care results also in
improvements in several breastfeeding-related outcomes for infants in the neonatal ward (11). Clear
guidelines are essential to support the implementation of BFHI in neonatal wards (12, 13).

1a
The health facility has a written breastfeeding or infant feeding policy that addresses the
Three Guiding Principles and all Ten Steps for Neonatal Wards.
1b
The policy protects breastfeeding by adhering to the International Code of Marketing of

Breast-milk Substitutes.
The Policy requires that all mothers, regardless of their feeding method, get feeding support
they need. Mothers who do not breastfeed, because of HIV or for other reasons, receive
counselling on infant feeding and guidance on selecting options likely to be suitable for their
situations. AFASS guidelines are used when applicable (13).
The policy includes guidance for how each of the Three Guiding Principles and Ten Steps
and other components should be implemented.
1c
The policy is available so that all clinical staff members who take care of mothers and infants
can refer to it.
Summaries of the policy covering the Three Guiding Principles and all Ten Steps for
Neonatal wards, the Code and subsequent WHA resolutions, and support for HIV-positive
mothers, are visibly posted or available as written and visual information in all areas of the
health care facility which serve pregnant women, mothers, infants, and/or children. These
areas include the labour and delivery area, antenatal care in-patient wards and
clinic/consultation rooms, postpartum/maternity wards and rooms, all infant care areas,
22

including well baby observation areas (if there are any) and neonatal wards.
The summaries are displayed in the language(s) and written with wording most commonly
understood by mothers and clinical staff.

1.1
The health facility has a written breastfeeding/infant feeding policy.

1.2
Review of the policy confirms that it includes guidance for how each of the Three Guiding
Principles and Ten Steps and the International Code of Marketing of Breast-milk
Substitutes should be implemented, and for counselling to HIV-positive mothers on infant
feeding .
1.3
Review of the policy confirms that all mothers, regardless of their feeding method, should
get the feeding support they need.

1.4
Observation confirms that a copy of the summary of the policy or visual images are
displayed in all areas of the health care facility which serve pregnant women, mothers,
infants and young children.
1.5
Observation confirms that summaries of the policy are displayed in the language(s) and
written with wording most commonly understood by mothers and clinical staff.

1. Kramer MS, Chalmers B, Hodnett ED, Sevkovskaya Z, Dzikovich I, Shapiro S, Collet JP,
Vanilovich I, Mezen I, Ducruet T, Shishko G, Zubovich V, Mknuik D, Gluchanina E, Dombrovskiy
V, Ustinovitch A, Kot T, Bogdanovich N, Ovchinikova L, Helsing E; PROBIT Study Group
(Promotion of Breastfeeding Intervention Trial). Promotion of Breastfeeding Intervention Trial
(PROBIT): a randomized trial in the Republic of Belarus. JAMA 2001; 24-31;285(4):413-420.
2. Rosenberg KD, Stull JD, Adler MR, Kasehagen LJ, Crivelli-Kovach A. Impact of hospital policies
on breastfeeding outcomes. Breastfeeding Med 2008; 3(2):110-116.
3. Cattaneo A, Davanzo R, Worku B, Surjono A, Echeverria M, Bedri A, et al. Kangaroo mother care
for low birthweight infants: a randomized controlled trial in different settings. Acta Paediatr.
1998;87:976-85.
4. Charpak N, Ruiz JG, Zupan J, Cattaneo A, Figueroa Z, Tessier R, et al. Kangaroo Mother Care: 25
years after. Acta Paediatr. 2005;94:514-22.
5. Hake-Brooks SJ, Anderson GC. Kangaroo Care and breastfeeding of mother-preterm infan dyads 018 months: A randomized, controlled trial. Neonatal Network 2008;27(3):151-159
6. Pineda R. Direct breastfeeding in the neonatal intensive care unit. J Perinatol, 2011:31, 540545.
7. Zachariassen G, Faerk J, Crytter C, Esberg B.H., Juvonen P,Halken S., Factors associated with
successful establishment of breastfeeding in very preterm infants. Acta Paediatrica, 2010; 99: 10001004.
8. Merten S, Dratva J, Ackermann-Liebrich U. Do baby-friendly hospitals influence breastfeeding
duration on a national level? Pediatrics 2005; 116(5):e702-708.
9. Merewood A, Philipp BL, Chawla N, Cimo S. The baby-friendly hospital initiative increases
breastfeeding rates in a US neonatal intensive care unit. J Hum Lact 2003; 19(2):166-71.
23

10. Dall'Oglio I, Salvatori G, Bonci E, Nantini B, D'Agostino G, Dotta A. Breastfeeding promotion in
neonatal intensive care unit: impact of a new program to a BFHI for high-risk infants. Acta Pediatr
2007; 96(11):1626-31.
11. Renfrew MJ, Craig D, Dyson L, McCormick F, Rice S, King SE, Misso K, Stenhouse E, Williams
AF. Breastfeeding promotion for infants in neonatal units: a systematic review and economic
analysis. Breastfeeding promotion for infants in neonatal units: a systematic review and economic
analysis. Health Technol Assess 2009; (40):1-146, iii-iv.
12. Taylor C, Gribble K, Sheehan A, Schmied V, Dykes F. Staff perceptions and experiences of
implementing the Baby Friendly Initiative in neonatal intensive care units in Australia. Journal of
Obstetric, Gynecologic and Neonatal Nursing 2011; 40(1):25-34. doi: 10.1111/j.15526909.2010.01204.x. Epub.
13. Guidelines on HIV and infant feeding. 2010. Principles and recommendations for infant feeding in
the context of HIV and a summary of evidence.
http://whqlibdoc.who.int/publications/2010/9789241599535_eng.pdf. ISBN 978 92 4 159953 5.
24
0' $

$'
Expansion: Educate and train all staff in the

specific knowledge and skills necessary to
implement this policy.
It is self-evident that training is necessary for the implementation of a breastfeeding policy. Health
workers who have not been trained in breastfeeding management cannot be expected to give mothers
effective guidance and provide skilled counseling, yet the subject is frequently omitted from curricula in
the basic training of, doctors and nurses.
The implementation of Baby-Friendly policies leading to a Baby-Friendly designation was associated
with increased breastfeeding initiation and duration rates (1, 2). Breastfeeding training for NICU staff
has been shown to have impact on the initiation rate and rates of breast milk feeding at discharge in a
study from USA (3). Siddell et al. (2003) could show a significant increase in NICU nurses'
breastfeeding knowledge after an educational session. Findings suggest that an educational intervention
has potential for improving NICU nurses' knowledge and certain attitudes about breastfeeding (4).
The need for practical aspects of breastfeeding to be included in the training is recognized as an
essential step for, but it may be necessary to update the practices of existing staff before basic training
can be effective (5, 6).
It is necessary to increase both knowledge and skills; otherwise the knowledge may not affect the
practice (7). There is also a need to change attitudes that create barriers to breastfeeding promotion.
These include: the assumption that health workers know enough already; a belief that there is no
important difference between breastfeeding and bottle feeding; a reluctance to allocate staff time to
breastfeeding support; and a failure to recognize the impact of inconsistent or inaccurate information.
Health workers may undermine mothers confidence, for example by implying criticism, or doubt about
a mothers milk supply. Ekstrom et al. (2005) showed how a process-oriented training in breastfeeding
of health staff can alter the attitudes to breastfeeding and to breastfeeding mothers (8).
For in-service training to be successful it must be mandatory and supported by supervisory personnel,
which requires a strong policy supported by senior staff. If training is voluntary, and senior staff
uncommitted, attendance is likely to be poor, and only those whose attitude is already favorable will
participate (9, 10).
Renfrew et al. (2009) concluded in their review that training of multidisciplinary staffas well as the
Baby Friendly accreditation has shown to be effective. Further it has been shown that skilled support
from trained staff in hospital could be potentially cost-effective from the health perspective of the
infants in the neonatal ward (11).
Jones et al. (2004) showed that training of the NICU-staff in breastfeeding resulted in mothers
producing higher milk production, more time spent mother-infant skin-to-skin, more cup-feeding and
higher frequency of feeding at the breast (12).
25

2a
All clinical staff at the neonatal ward are familiar with the existence of the policy and have
basic knowledge in breastfeeding as well as the special needs of infants and supporting
mothers to enable early initiation of breast milk production and breastfeeding.
2b
There is a plan in place for education and training of all new staff members, irrespective of
profession, and continuing education in the field should be provided on a regular basis.
2c
All clinical staff at the neonatal ward who have contact with mothers and/or infants and have
been on the staff 6 months or more have acquired knowledge corresponding to the content of
the 20 hours course of breastfeeding education that covers all 3 guiding principles and the 10
Steps, the Code and subsequent WHA resolutions, including at least three hours of supervised
clinical training. In addition to this all clinical staff at the neonatal ward get continuing
education on a regular basis.
2d
Training on how to provide support for non-breastfeeding mothers is also provided to staff. A
copy of the course session outlines for training on supporting non-breastfeeding mothers is
also available for review. The training covers key topics such as:
the risks and benefits of various feeding options;
helping the mother choose what is acceptable, feasible, affordable, sustainable and safe
(AFASS) in her circumstances;
the safe and hygienic preparation, feeding and storage of breast-milk substitutes;
how to teach the preparation of various feeding options, and
2e
Non-clinical staff members have received training that is adequate, given their roles, to provide
them with the skills and knowledge needed to support mothers in successfully feeding their
infants.

!

2.1
The head of maternity services reports that all health care staff members who have any
contact with pregnant women, mothers, and/or babies, have received orientation on the
breastfeeding/infant feeding policy. The orientation that is provided is sufficient.
2.2
At least 90 % of randomly selected clinical staff are able to identify at least 5 factors which
are important for early initiation of milk production: early initiation (within hours after
birth),frequent expression at least 6 times per 24 hours/day, breast milk expression also
during the night, early instruction in hand expression, easy access to a breast pump free of
charge.
2.3
At least 80 % of randomly selected clinical staff can adequately answer at least four out of
five answers (to questions related to breastfeeding support and promotion) are adequate

!

2.4
A copy of the curricula or course session outlines for training in breastfeeding promotion and
support for various types of staff is available for review
2.5
Observation confirms that there is/are (an) identified person(s) with special knowledge in
breastfeeding and lactation in the ward, who carry special responsibility for breastfeeding and
lactation support and training.
2.6
Documentation of training also indicates that non-clinical staff members have received training
that is adequate, given their roles, to provide them with the skills and knowledge needed to
26

support mothers in successfully feeding their infants.

!

2.7
Review of the training documentation indicates that 80% or more of the clinical staff members
who have contact with mothers and/or infants and have been on the staff 6 months or more
have received training at the hospital or prior to arrival, through a course, well-supervised selfstudies or on-line courses.
2.8
Review of the training documentation indicates that 80% or more of the clinical staff members
who have contact with mothers and/or infants have received supervised clinical experience as
part of this training
2.9
The training material covers the three guiding principles, all 10 Steps, the Code and subsequent
WHA resolutions.
2.10
At least 80 % of randomly selected clinical staff report they received at least 20 hours of
training or, if on job less than 6 months, at least received orientation on the policy.

!

2.11
The training on how to provide support for non-breastfeeding mothers is also provided by the
staff. A copy of the course session outlines for training on supporting non-breastfeeding
mothers is also available for review.
2.12
The training covers key topics such as: communication skills, the risks and benefits of various
feeding options; helping the non-breastfeeding mother choose what is acceptable, feasible,
affordable, sustainable and safe (AFASS) in her circumstances; the safe and hygienic
preparation, feeding and storage of breast-milk substitutes; how to teach the preparation of
various feeding options, and how to minimize the likelihood that breastfeeding mothers will
be influenced to use formula.
2.13
At least 80% of randomly selected clinical staff can describe what should be discussed with a
pregnant woman if she indicates that she is considering giving her baby something other than
breastmilk before six months.
2.14
The type and percentage of staff receiving this training is adequate, given the facilitys needs.

1. Merewood A, Philipp BL, Chawla N, Cimo S. 2003 The baby-friendly hospital initiative increases
breastfeeding rates in a US neonatal intensive care unit. J Hum Lact 2003;May;19(2):166-71.
2. Dall'Oglio I, Salvatori G, Bonci E, Nantini B, D'Agostino G, Dotta A. 2007 Breastfeeding
promotion in neonatal intensive care unit: impact of a new program to a BFHI for high-risk infants.
Acta Paediatr. 2007;Nov;96(11):1626-31.
3. Isaacson LJ. 2006Steps to successfully breastfeed the premature infant. Neonatal Netw 2006;MarApr;25(2):77-86.
4. Siddell E, Marinelli K, Froman RD, Burke G. 2003 Evaluation of an educational intervention on
breastfeeding for NICU nurses. J Hum Lact 2003;Aug;19(3):293-302.
5. Cattaneo A, Davanzo R, Uxa F, Tamburlini G. 1998 Recommendations for the implementation of
Kangaroo Mother Care for low birthweight infants. International Network on Kangaroo Mother
Care. Acta Paediatr. 1998;Apr;87(4):440-5.
27

6. Nyqvist KH, Kylberg E. 2008 Application of the baby friendly hospital initiative to neonatal care:
suggestions by Swedish mothers of very preterm infants. J Hum Lact 2008;Aug;24(3):252-62.
7. Hannula L, Kaunonen M, Tarkka MT. 2008 A systematic review of professional support
interventions for breastfeeding. J Clin Nurs. 2008;May;17(9):1132-43.
8. Ekstrm A,Widstrm AM, Nissen E. 2005 Process-oriented training in breastfeeding alters attitudes
to breastfeeding in health professionals. Scand J Publ Health 2005;33(6):424-31.
9. Stokamer CL. 1990 Breastfeeding promotion efforts: why some do not work. Int J Gyn Obst
1990;31(Suppl 1):61-65.
10. Iker CE, Mogan J. 1992 Supplementation of breastfed infants: Does continuing education for nurses
make a difference? J Hum Lact 1992;8(3):131-35.
11. Renfrew M, Craig D, Dyson L, McCormick F, Rice S, King S, Misso K, Stenhouse E, Williams A.
2009 Breastfeeding promotion for infants in neonatal units: a systematic review and economic
analysis. Health Technol Assess 2009;Aug;13(40):1-170.
12. Jones E, Jones P, Dimmock P, Spencer A. 2004 Evaluating preterm breastfeeding training.
Pract Midwife 2004;Oct;7(9):19, 21-4.
13. Wheeler JL; Johnson M; Collie L; Sutherland D. 1999 Chapman C. Promoting breastfeeding in the
neonatal intensive care unit. Breastfeeding Rev 1999;Jul;7(2):15-8.
28
1& #!

'
Expansion: Inform hospitalized pregnant

women at risk for preterm delivery or birth of a
sick infant about the management of lactation
and breastfeeding and benefits of breastfeeding.
7(&&('+'++-!!+,+,",#,&-+,#&)(*,',,(,%$,(%%)*!'',/(&'(-,#' ',
#'!3,()*)*,"& (*,"#++),( &(,"*"((79<:5
Prenatal consultation which includes information on the benefits and importance of breast milk
feeding and also practical information regarding the support systems for breast milk expression and
storage has been associated with significantly longer breast milk feeding in preterm infants, both in
hospital and after discharge. This finding suggests that hours and days immediately before preterm
delivery may be of critical importance in influencing maternal planning regarding the feeding of her
soon-to-be-born tiny infant (2).
Suggestions from mothers of very preterm infants regarding modification of Baby-Friendly Hospital
Initiative (BFHI) Ten Steps to Successful Breastfeeding emphasized the importance of early basic
information about lactation and breastfeeding, and that antenatal classes should cover breast milk
benefits for these infants, breastfeeding techniques and possible problems, establishment of lactation
by using a breast pump, and the fact that it may take some time before breastfeeding is possible (3).
A systematic review of professional support interventions for breastfeeding concluded that
interventions expanding from pregnancy to the intra-partum period and throughout the postnatal
period were more effective than interventions concentrating on a shorter period (4).

3a
Hospitalized pregnant women who are at risk of having an infant admitted to the neonatal
ward after birth are visited by the clinical staff to discuss about breastfeeding and how
lactation, breastfeeding/breast milk feeding may be established, depending on the infants
condition. The discussion reflects the needs of the family and include the following:
The neonatal ward open access policy and the importance of the parents presence for
the infants wellbeing.
The significance of early stimulation of milk production
Practical, specific information about how one goes about this.
The particular benefits with breastfeeding/breast milk feeding for preterm/ill infants
and their mothers.
The importance of skin-to-skin contact with the infant after birth, as early as possible,
The importance of letting the infant commence breastfeeding early.
The fact that also very and extremely preterm infants have the capacity for nutritive
sucking at the breast; however, this may be affected by their medical condition.
Information is given, taking into consideration the individual womans knowledge and
whatever previous experience she may have with breastfeeding, and the womans indication
(if this is the case) that she intends to give her baby something other than breast milk.
29

3b
Written information for mothers about breast milk, breastfeeding, including hand expression
and pumping, is available.
3c
There is a written summary for the staff of the breastfeeding information they should give
pregnant women. Provision of information is documented in the infants medical record.

"

3.1
The head/ director of nursing services can confirm that clinical staff from the neonatal ward
visit hospitalized pregnant women who are at risk of having an infant admitted to the
neonatal ward after birth to offer them information about breastfeeding and lactation
specific to their situation.
3.2
The breastfeeding policy states that hospitalized pregnant women who are at risk of having
an infant admitted to the neonatal ward after birth are visited by the clinical staff to discuss
about breastfeeding and how lactation, breastfeeding/breast milk feeding may be
established, depending on the infants condition.
3.3
At least 80 % of randomly selected clinical staff, including doctors, can describe at least
three out of the seven items in Standard 3 a.

"

3.4
Written information about breast milk, breastfeeding, including hand expression and
pumping is available.

"

3.5
There is a written summary for the staff of the breastfeeding information the pregnant women
should receive.

1. Evidence for the ten steps to successful breastfeeding. WHO/CHD/98.9. Geneva: World Health
Organization, Division of child health and development, 1998. http://www.who.int (30.10.09).
2. Friedman S, Flidel-Rimon O, Lavie E, Shinwell ES. The effect of prenatal consultation with a
neonatologist on human milk feeding in preterm infants. Acta Paediatr 2004; 93:775-778.
3. Nyqvist KH, Kylberg E. Application of the Baby Friendly Hospital Initiative to Neonatal Care:
Suggestions by Swedish mothers of very preterm infants. J Hum Lact 2008; 24(3): 252-262.
4. Hannula L, Kaunonen M, Tarkka M-T. A systematic review of professional support interventions for
breastfeeding. J Clin Nurs 2008; 17 (3): 11321143.
30
2' # (

! '
Expansion: Encourage early, continuous and

prolonged mother-infant skin-to-skin contact
(Kangaroo Mother Care) without unjustified
restrictions.
This step includes all infants, not just those who are going to be breastfed.
Mother-infant skin-to-skin contact promotes breastfeeding (1-8). The core concepts in Kangaroo Mother
Care (KMC) are: warmth, breast milk and love (1). The KMC method is defined as: early (as soon as
possible after birth), continuous (ideally 24 hours/day, 7 days/week) and prolonged (continuing during
the infants whole hospital stay or for as long as needed for prevention of hypothermia usually to about
term age or beyond) skin-to-skin contact between the mother and her low birth weight infant (<2.500 g.)
in hospital and after discharge, with exclusive breastfeeding (ideally), early discharge and adequate
follow-up.
Depending on the circumstances, KMC can also be practiced intermittently, as skin-to-skin contact for
variable periods of time. The kangaroo position means that the infant is cared for skin-to-skin in an
upright prone position on the mothers chest, with flexed arms and legs and the head turned sideways,
commonly supported by the mothers clothing. KMC contact is also recommended for ill full term
infants (2). In addition to the mother, the father and significant others can also participate as KMC
providers.
Tactile contact enhances the development of maternal identity after preterm birth (3). Increased milk
production was demonstrated in mothers of infants in a neonatal ward who had daily skin-to-skin
contact with their infants for a mean of 4 times/week, during a mean of one hour (4). A review of 310
studies identified skin-to-skin as one of the pre- and post-discharge interventions that improved
breastfeeding outcomes and weight gain among preterm infants (5). A multicenter study found that
exclusive breastfeeding was more common at discharge in infants treated with KMC (6). Mothers who
held their preterm infants (gestational age 32-36 weeks) skin-to-skin in hospital breastfed longer (5
months vs. 2 months) than a control group without skin-to-skin contact (7).
Better growth and a higher rate of exclusive breastfeeding in infants who received KMC were noted at
three months of age in a randomized controlled trial (8). Training in the World Health Organization
Essential Newborn Care (ENC) course, which includes KMC as one among several components,
resulted in a decrease in perinatal and neonatal mortality (9).
In 2003, the World Health Organization (WHO) issued a Practical Guide for KMC (10). In settings with
optimal health and medical care resources, initiation of KMC is recommended for stable infants from 28
postmenstrual weeks, from a birth weight of 600 g. Clinical guidelines for KMC have been published
by the Kangaroo Foundation in Bogot (11). Because of the massive evidence of benefits with KMC,
including enhanced establishment of lactation and breastfeeding, experts have recommended universal
promotion of the method in both high-tech and low income settings (12), and agreed on
recommendations for implementation of the method in a high-tech environment (13).

31

4a
The ward has a written KMC protocol.
4b
Parents are informed about and encouraged to commence provision of skin-to-skin contact
(SSC) as early as possible, ideally from birth, without unjustified delay.
4c
Parents are encouraged to opportunities to provide KMC for as long periods per day as they
want, also continuous SSC, without unjustified restrictions.
4d
Parents are encouraged to continue providing SSC as long as needed by infants in neonatal
care, including after early discharge.

#

4.1
The ward has a protocol, defining KMC, that includes initiation, duration of sessions, and
continuous KMC.
4.2
Review of the ward KMC protocol confirms that:

- A stable infant who is born by vaginal delivery or cesarean section without general
anesthesia should be placed in skin-to-skin contact/kangaroo position on the mother in the
delivery or operating room as early as possible, ideally from birth, without unjustified delay.
- A stable infant who is born by cesarean section under general anesthesia should be placed in
skin-to-skin/kangaroo position on the mother as soon as the mother is responsive and alert
(when appropriate considering the mothers condition).
-An initially instable infant should be placed in skin-to-skin/kangaroo position as soon as the
infant tolerates transfer back and forth from the mother.
- The father and significant others can also provide skin-to-skin/KMC as substitute of the
mother.
-Transport of a stable infant between the labour and delivery wards to the neonatal ward can
be performed in skin-to-skin/kangaroo position on a parents chest.
4.3
The ward KMC protocol states that a stable preterm/ill infant can remain in skin-to-skin
contact/kangaroo position continuously or for as long as the parent/significant other is able and
willing to continue skin-to-skin care, without unjustified resctrictions.

#

4.4
At least 80 % of randomly selected mothers report that they were adequately informed about
benefits of early initiation of skin-to-skin contact/KMC and the possibility of providing KMC
24/7.
4.5
At least 80% of randomly selected mothers of stable infants with vaginal delivery or ceasarean
section without general anesthesia confirm that their babies were placed in skin-to-skin
contact/kangaroo position on them as early as possible (according to levels), ideally from
birth, without unjustified delay.
KMC initiated immediately after birth (during the first five minutes) (level ***)
KMC initiated during the first hour after birth (after the first five minutes but during the
first hour) (level **)
KMC initiated during the 2nd 24th hours of life (later than one hour after the birth, but
during the first day of life) (level *).
32

4.6
At least 80 % of randomly selected mothers of stable infants born with cesarean section under
general anesthesia confirm that their babies were placed in skin-to-skin contact/kangaroo
position on them as early as possible (according to levels), without unjustified delay.
KMC initiated within a few minutes of becoming responsive and alert(during the first five
minutes) (level ***)
KMC initiated during the first hour after becoming responsive and alert(after the first five
minutes but during the first hour) (level **)
KMC initiated during the 2nd 24th hours after becoming responsive and alert (later than
one hour, but during the first day after becoming responsive and alert) (level *).
4.7
At least 80 % of randomly selected staff confirm that skin-to-skin contact/kangaroo position is

initiated in their unit as soon as the infant tolerate transfer back and forth from the mother.
4.8
At least 80 % of randomly selected clinical staff confirm that transport of a stable infant
between the labour and delivery wards to the neonatal ward can be performed in skin-to-skin
contact/kangaroo position on a parents chest.

#

4.9
At least 80 % of randomly selected mothers of infants who tolerate skin-to-skin contact/KMC

confirm that their infant can currently remain in skin-to-skin contact/kangaroo position in the
neonatal ward for as long and as many periods per day as the parents are able and willing to
continue (ideally 24h/7d), without unjustified restrictions.
4.10
At least 80 % of randomly selected mothers approaching discharge report that they

(themselves or taking turns with father/significant other) can provide skin-to-skin
contact/KMC continuously or with merely short interruptions, or for as long as they are able
and willing to during the whole hospitalization, without unjustified restrictions.
4.11
At least 80 % of randomly selected staff report that they encourage skin-to-skin/KMC

continuously or with merely short interruptions, or for as long as the parents are able and
willing, without unjustified restrictions.

#

4.12
At least 80 % of randomly selected mothers confirm that they were informed and encouraged
to continue providing skin-to-skin contact/KMC for as long as their infant would need it for
maintaining his/her temperature.

1.
2.
3.
4.
5.
Martinez HG, Rey ES, Marshall D. The Mother Kangaroo Programme. International Child Health
1992; 3: 55-67.
Cattaneo, A., Davanzo, R., Uxa, R. & Tamburlini,G. Recommendations for the implementation of
Kangaroo mother care for low birthweight infants. Acta Paediatrica 1998; 87, 440-5.
Reid R. Maternal identity in preterm birth. Journal of Child Health Care 2010;4: 23-29.
Hurst NM, Valentine CJ, Renfro L, Burns P, Ferlic L. Skin-to-skin holding in the neonatal
intensive care unit influences maternal milk volume. Journal of Perinatology 1997; 17(3):213-7.
Ahmed AH, Sands LP. Effects of pre- and postdischarge interventions on breastfeeding outcomes
and weight gain among premature infants. JOGGN 2010;39:53-63.
33

6.
7.
8.
9.
10.
11.
12.
13.
Cattaneo A, Davanzo R, Worku B, Surjono A, Echeverria M, Bedri A, Haksari E, Osorno L,

Gudetta B, Setyowireni D, Quintero S, Tamburlini G. Kangaroo mother care for low birthweight
infants: a randomized controlled trial in different settings. Acta Paediatrica 1998;87(9):976-85.
Hake-Brooks SJ, Anderson GC. Kangaroo Care and breastfeeding of mother-preterm infant dyads
0-18 months: A randomized, controlled trial. Neonatal Network 2008;27(3):151-9.
Gathwala G, Singh B, Singh J. Effect of Kangaroo Mother Care on physical growth, breastfeeding
and its acceptability. Tropical Doctor 2010;40(4):199-202.
Carlo WA, McClure EM, Chomga E, Chakraborty H, Hartwell T, Harris H, Lincetto O, Wright LL.
Newborn training of midwives and neonatal and perinatal mortality rates in a developing country.
Pediatrics 2010;126(5):e1064-71.
World Health Organization. Kangaroo Mother Care: A practical guide. Department of
Reproductive Health and Research, WHO, Geneva. 2003.
Fundacin Canguro and Department of Clinical Epidemiology and Biostatistics. Evidence based
clinical practice guidelines for an optimal use of the Kangaroo Mother.
method in preterm and/or low birth weight infants. Bogot: Pontificia Universidad Javeriana, 2007.
Nyqvist KH, Anderson GC, Bergman N, Cattaneo A, Charpak N, Davanzo R, Ewald U, Ibe O,
Ludington-Hoe S, Mendoza S, Palls-Allonso C, Ruiz Pelez JG, Sizun J, Widstrm AM. Towards
Universal Kangaroo Mother Care: Recommendations from the first European Conference and
seventh International Workshop on Kangaroo Mother Care. Acta Paediatr 2010;99(6):820-6.
Nyqvist KH; Expert Group of the International Network on Kangaroo Mother Care, Anderson GC,
Bergman N, Cattaneo A, Charpak N, Davanzo R, Ewald U, Ludington-Hoe S, Mendoza S, PallsAllonso C, Pelez JG, Sizun J, Widstrm AM. State of the art and Recommendations. Kangaroo
Mother Care: application in a high-tech environment. Acta Paediatr 2010;99(6):812-9.
34
3& # # #

%" $! '
Expansion: Show mothers how to initiate and

maintain lactation and establish early
breastfeeding with infant stability as the only
criterion.
The initiation and maintenance of breast milk production is of great importance for the mother to be
able to breastfeed a preterm or ill infant. Early, systematic and continuing support to mothers is
necessary for supporting their success in the establishment of lactation and breastfeeding and in
overcoming physiological and emotional challenges (1-4). Consistent positive effects of mother-infant
skin-to-skin contact on milk production and successful breastfeeding have been found (5-9). These
aspects are covered by step 4.
Several studies have shown lower rates of breastfed preterm infants in comparison to infants born at
term, probably due to delayed initiation of lactation, and lower maternal milk volume in these infants
(10-13). Mothers with a high proportion of breast milk feeds at discharge are more likely to succeed in
the establishment of breastfeeding, whereas mothers who face the challenge of breastfeeding
establishment at home are likely to encounter problems. These findings support the importance of
assisting mothers in the attainment of an adequate milk supply before discharge (10).
A study of 81 mothers of non nursing preterm infants initiating lactation with a breast pump reported an
association between the milk volume at day 4 post-partum and an adequate milk volume at week six
post-partum; these results emphasize the importance of support to mothers in early initiation of lactation
(14). If the baby is unable to suck sufficiently directly from birth, the mother should initiate milk
expression as soon as possible, preferably within 6 hours, when permitted by the mothers condition
(15-17). Expression by hand or pump should be encouraged about 8 times a day, especially in the
beginning of lactation, trying to simulate the normal physiological stimulation of lactation of healthy
babies (18, 19). Frequency of milk expression is closely correlated to milk volume (14-16, 20). An
observational study showed that pumping 7 or more times per day resulted in increasing milk volumes
at 2 weeks, compared to less than 7 times per day (21) According to a Cochrane review,
interventions including early initiation of milk production when not feeding at the breast,
relaxation, hand expression and low cost pumps are effective (22). Gentle breast massage during
pumping is associated with higher milk production (21, 23).
Hand expression is probably the best way to express colostrum; when this method was compared with
electric expression in a sequential cross-over study, mothers who hand expressed attained a higher milk
yield and felt less pain (24). All mothers should be offered to learn how to hand express their milk and
use this technique if they are more comfortable with it, and when pumps are not available. This method
can also be used for stimulating the milk ejection reflex and milk flow before pumping, and for making
it easier for the infant to latch on, if needed.
Infant stability, independent of gestational age, postnatal age, postmenstrual age or birth weight, should
be the only criterion for initiation of breastfeeding, as preterm infants have very early competence for
breastfeeding (25-27). (Here stability means absence of severe apnea, desaturation and bradycardia.)
Behavioral studies have shown that preterm infants are able to root, latch on and suck from 27 weeks
(the lowest PMA observed at breast) and are able to ingest milk from about 29 weeks. Observational
studies have found that preterm, and even very preterm, infants with free access to the breast, frequent
35

small feedings and early start of breastfeeding, with mothers who received adequate breastfeeding
support, are able to attain exclusive breastfeeding from 32 weeks PMA, with a median of 35 weeks (26,
27). Late preterm infants is a group in need of special attention related to breastfeeding; they have more
often jaundice, hypoglycemia and feeding difficulties than full term infants, and their ability to breastfed
and regulate their intake may be overestimated (28, 29).
Qualitative studies report that mothers of preterm infants may have negative or diverging feelings about
pumping, breastfeeding and mothering success and therefore need extra support and attention (28, 3033). Hands-off technique is preferable when supporting mothers and babies with positioning and
attachment, as mothers have reported that hands-on helping technique felt unpleasant and was not
helpful (34).

5a
Breastfeeding mothers are supported by staff - using hands-off technique (unless the mother
explicitly asks for hands-on assistance) - to position and attach their babies for breastfeeding at
the first feed, and are guided in observing the infants correct attachment and behavior at the
breast.
5b
Breastfeeding mothers have access to breastfeeding support by staff during the whole hospital
stay.
5c
Mothers wanting to provide their infants with breast milk should receive information, support
and practical help with initiation and maintenance of milk production within 6 hours of the
infants birth or arrival to the ward (in case of a transfer), and be shown how to express their
milk by hand or pump. The information should be given orally or in writing/pictures.
5d
Infant stability is the only criterion for early initiation of breastfeeding (nutritive sucking at the
breast), not gestational, postnatal, postmenstrual age or current weight.
5e
Mothers who have difficulties in establishing and maintaining milk production get focused
individualized support.
5f
Late preterm infants are treated as preterm infants.
5g
Mothers who do not breastfeedi or who use breast milk substitutes receive support on how to
safely prepare the feeds for their babies

$

5.1
At least 80% of randomly selected breastfeeding mothers report that the staff offered them
support with positioning and attaching their infants for breastfeeding at the first feed.
5.2
Reports that teaches mothers positioning and attachment (Q8a) and describes both positioning
and attachment correctly (Q8b) or, if doesnt teach, describes to whom to refer mothers
5.3
At least 80% of randomly selected breastfeeding mothers are able to describe signs that indicate
that their infants are well positionned and have a good latch .

$

5.4
At least 80% of randomly selected breastfeeding mothers report that they had access to
breastfeeding support by staff during the infants stay in the neonatal ward.

36

$

5.5
At least 80 % of randomly selected mothers wanting to provide their babies with breast milk
report that they have received information, support and practical help with initiation of milk
production within 6 hours of the infants birth or arrival to the ward (in case of a transfer), and
were shown how to express their milk by hand or pump. The information was given orally or in
writing/pictoral information.
5.6
At least 80% of randomly selected clinical staff report can describe or demonstrate how they
teach mothers an appropriate technique for hand expression, or describe to whom they refer the
mother for this instruction.
5.7
At least 80% of randomly selected clinical staff report can describe or demonstrate how they
teach mothers an appropriate technique for use of a breast pump , or describe to whom they
refer the mother for this instruction.
5.8
At least 80% of randomly selected mothers who breastfeed or intend to do so report that they
were initially told that breastfeeding or expressing their milk at least 6 times every 24 hours,
also during the night, is recommended for keeping up the milk supply.

$

5.9
At least 80% of randomly selected clinical staff describe infant stability as the only criterion for
early initiation of breastfeeding.
5.10
The breastfeeding policy describes infant stability is the only criterion for early initiation of
breastfeeding (not postmenstrual age or postnatal age or current weight, or any test of sucking
strength, or training of suck training).

$

5.11
The ward provides documentation describing routines for following up mothers milk
production and for counselling mothers with decreasing or inadequate milk supply.
5.12
At least 80 % of randomly selected clinical staff report they discuss with mothers how to
ensure sufficient milk supply. They also know who is/are the main responsible lactation
counselor/s (if this function exists).

$

5.13
The ward breastfeeding protocol recognizes late preterm infants (GA 34+0 to 36+6
weeks+days) as preterm, and states that their mothers should be offered the same support in the
establishment of lactation and breastfeeding as mothers of more immature infants.

$

5.14
Observation confirms that staff demonstratations how to safely prepare and feed breastmilk
substitutes for mothers who have decided on this feeding option are accurate, complete, and
include a return demonstration.
5.15
At least 80 % of randomly selected clinical staff reports that they teach mothers who are not
breastfeeding how to prepare their feeds and describes adequately what would discuss or, if
doesnt teach, describes to whom to refer mothers.
37

5.16
At least 80% of randomly selected mothers whose infants are given formula report that the
clinical staff offered help in preparing and giving their babies feeds, can describe the advice
they were given. and have been asked
5.17
At least 80% of randomly selected mothers whose infants are given formula report that the
clinical staff verified their capacity to prepare their infants feed by asking them to prepare
feeds themselves, after being shown how.

1. Sweet L. Breastfeeding a preterm infant and the objectification of breast milk. Breastfeed Rev 2006
Mar;14(1):5-13.
2. Weimers L, Svensson K, Dumas L, Naver L, Wahlberg V. Hands-on approach during breastfeeding
support in a neonatal intensive care unit: a qualitative study of Swedish mothers' experiences. Int
Breastfeed J 2006;1:20.
3. Sisk P, Quandt S, Parson N, Tucker J. Breast milk expression and maintenance in mothers of very
low birth weight infants: supports and barriers. J Hum Lact. 2010 Nov;26(4):368-75.
4. Meier PP, Engstrom JL, Mingolelli SS, Miracle DJ, Kiesling S. The Rush Mothers' Milk Club:
breastfeeding interventions for mothers with very-low-birth-weight infants. J Obstet Gynecol
Neonatal Nurs 2004 Mar;33(2):164-74.
5. Ahmed AH, Sands LP. Effect of pre- and postdischarge interventions on breastfeeding outcomes
and weight gain among premature infants. J Obstet Gynecol Neonatal Nurs 2010 Jan;39(1):53-63.
6. Cattaneo A, Davanzo R, Worku B, Surjono A, Echeverria M, Bedri A, et al. Kangaroo mother care
for low birthweight infants: a randomized controlled trial in different settings. Acta Paediatr 1998
Sep;87(9):976-85.
7. Gathwala G, Singh B, Singh J. Effect of Kangaroo Mother Care on physical growth, breastfeeding
and its acceptability. Trop Doct 2010 Oct;40(4):199-202.
8. Hake-Brooks SJ, Anderson GC. Kangaroo care and breastfeeding of mother-preterm infant dyads 018 months: a randomized, controlled trial. Neonatal Netw 2008 May;27(3):151-9.
9. Hurst NM, Valentine CJ, Renfro L, Burns P, Ferlic L. Skin-to-skin holding in the neonatal intensive
care unit influences maternal milk volume. J Perinatol 1997 May;17(3):213-7.
10. Wooldridge J, Hall WA. Posthospitalization breastfeeding patterns of moderately preterm infants. J
Perinat Neonatal Nurs 2003 Jan;17(1):50-64.
11. Flacking R, Nyqvist KH, Ewald U, Wallin L. Long-term duration of breastfeeding in Swedish low
birth weight infants. J Hum Lact 2003 May;19(2):157-65.
12. Flacking R, Hedberg NK, Ewald U. Effects of socioeconomic status on breastfeeding duration in
mothers of preterm and term infants. Eur J Public Health 2007 Mar 28.
13. Bonet M, Blondel B, Agostino R, Combier E, Maier RF, Cuttini M, et al. Variations in
breastfeeding rates for very preterm infants between regions and neonatal units in Europe: results
from the MOSAIC cohort. Arch Dis Child Fetal Neonatal Ed 2010 Jun 10.
14. Hill PD, Aldag JC, Chatterton RT. Effects of pumping style on milk production in mothers of nonnursing preterm infants. J Hum Lact 1999 Sep;15(3):209-16.
15. Furman L, Minich N, Hack M. Correlates of lactation in mothers of very low birth weight infants.
Pediatrics 2002 Apr;109(4):e57.
16. Hill PD, Aldag JC, Chatterton RT, Jr. Breastfeeding experience and milk weight in lactating
mothers pumping for preterm infants. Birth 1999 Dec;26(4):233-8.
17. Hill PD, Aldag JC, Chatterton RT. Initiation and frequency of pumping and milk production in
mothers of non-nursing preterm infants. J Hum Lact 2001 Feb;17(1):9-13.
18. Okechukwu AA, Okolo AA. Exclusive breastfeeding frequency during the first seven days of life in
term neonates. Niger Postgrad Med J 2006 Dec;13(4):309-12.
19. Yamauchi Y, Yamanouchi I. Breast-feeding frequency during the first 24 hours after birth in fullterm neonates. Pediatrics 1990 Aug;86(2):171-5.
38

20. Hopkinson JM, Schanler RJ, Garza C. Milk production by mothers of premature infants. Pediatrics
1988 Jun;81(6):815-20.
21. Morton J, Hall JY, Wong RJ, Thairu L, Benitz WE, Rhine WD. Combining hand techniques with
electric pumping increases milk production in mothers of preterm infants. J Perinatol 2009
Nov;29(11):757-64.
22. Becker GE, Cooney F, Smith HA. Methods for milk expression by lactating women. Cochrane
Database Syst. Rev. 2011, Issue 12, Art. No.: CD006170. DOI: 10.1002/14651858.CD006170.pub3
23. Jones E, Dimmock PW, Spencer SA. A randomised controlled trial to compare methods of milk
expression after preterm delivery. Arch Dis Child Fetal Neonatal Ed 2001 Sep;85(2):F91-F95.
24. Ohyama M, Watabe H, Hayasaka Y. Manual expression and electric breast pumping in the first 48 h
after delivery. Pediatr Int 2010 Feb;52(1):39-43.
25. Nyqvist KH, Farnstrand C, Eeg-Olofsson KE, Ewald U. Early oral behaviour in preterm infants
during breastfeeding: an electromyographic study. Acta Paediatr 2001 Jun;90(6):658-63.
2008 Jun;97(6):776-81.
27. Nyqvist KH, Sjden PO, Ewald U. The development of preterm infants' breastfeeding behavior.
Early Hum Dev 1999 Jul;55(3):247-64.
28. Raju NTNK, Higgins RD, Stark AR, Leveno Kj. Optimizing care and outcome for late-preterm
(near-term) infants: A summary of the workshop sponsored by the National Institute of Child Health
and Human Development. Pediatrics 2006;118:1207 -14.
29. Meier PM, Furman LM, Degenhardt M. Increased lactation risk for late preterm infants and
mothers: Evidence and management strategies to protect breastfeeding J Midwifery & Womens
Health 2007;52(6):579-87.
30. Sweet L. Expressed breast milk as connection and its influence on the construction of motherhood
for mothers of preterm infants: a qualitative study. Int Breastfeed J 2008;17(3):30.
31. Sweet L. Breastfeeding a preterm infant and the objectification of breast milk. Breastfeed Rev
2006;14(1):5-13.
32. Flacking R, Trustful bonds: a key to becoming a mother and reciprocal breastfeeding. Stories of
mothers of very preterm infants at a neonatal unit. Soc Sci Med 2006;62(1):70-80.
33. Sisk PM, Lovelady CA, Dillard RG, Gruber KJ. Lactation counseling for mothers of very low birth
weight infants: effect on maternal anxiety and infant intake of human milk. Pediatrics. 2006
Jan;117(1):e67-75.
34. Weimers L, Svensson K, Dumas L, Naver L, Wahlberg V. hands-on approach during breastfeeding
support in a neonatal intensive care unit: a qualitative study of Swedish mothers experiences. Int
Breastfeed J 2006;1:20.

39
4'"#

!$ '
Expansion: Give newborn infants no food or

drink other than breast milk unless medically
indicated.
Breastfeeding is the normal way of providing young infants with the nutrients they need for healthy
growth and development (1, 2), including preterm and ill newborns (3, 4). Breast milk is speciesspecific, and all substitute feeding preparations differ markedly from it, making breast milk uniquely
superior for infant feeding. Breast milk-fed preterm infants receive significant benefits with respect to
host protection and improved developmental outcomes compared with formula-fed preterm infants (3,
5). (*0&)%3,"*#+$( +),#&##'0,*&%1)*,*&#' ',+/+*-#',"(+#' ',+
/"(*#..*1*%1 -%%"-&'&#%$ #'!9?:5 -&'&#%$ #'!"+%+('+"(/',(
*-,"#'#'( '*(,#2#'!',*((%#,#+9:9A:3' has been associated with
considerable cost reduction. One study noted considerable net savings when a 100 % human milk-based
diet that included mother's milk fortified with donor human milk-based HMF was used for feeding
extremely preterm infants, an effect that were attributed to reduced incidence of NEC (7).
In situations where mothers' own milk is not available, provision of pasteurized, screened human donor
milk is the next best option particularly for ill or high-risk infants (3, 5, 6).
In situations where human donor milk is not available, provision of commercial formula is the best
option (3). Whenever possible, )*,*& (*&-%#+*(&&' (*,"'('"-&'6&#%$ #' ',
/#,"(1/#!",( %++,"'=;;;!3 (%%(/1#*('6 (*,# #+,'*#' ', (*&-%-',#%,"
#' ',#+<=&(',"+( !9>:5 The WHO revised the acceptable medical reasons for use of breastmilk
substitutes in 2009 (7).
Use of fortifiers varies between and within countries and indications remain controversial. As low birth
weight infants may cope well with large milk volumes, increasing volumes of milk intake as early as
possible to volumes of (or above) 200 mL/kg/day - a proactive feeding strategy - may be an alternative
to the addition of fortifiers as an intervention to promote infant growth (8). In extremely preterm infants,
high volume intake of mothers milk fortified with individualized supplementation of protein and
minerals has been associated with attainment of adequate infant growth (9).
For the purposes of this expansion of the BFHI Ten Steps, a fortifier is considered a medication (the
same way that vitamins, mineral supplements, medicines and intravenous solutions are allowed)."-+3
an infant receiving a fortifier can be considered exclusively breastfed for the statistics purpose, if
powdered fortifier is mixed with breast milk or the infant receives liquid fortifier (10). When
fortification of mothers own milk is prescribed, the mother should be informed about the reason for this
supplementation and that her milk remains the optimal nutrition for her baby, in order to protect her
intention to continue lactation/breast feeding (11). Powdered fortifier, when compared to liquid fortifier,
appears to be preferred by parents and have a positive effect on the duration of breastfeeding (12).
However, because of logistical difficulties in systematical provision to breastfed babies with fortified
mothers milk, this strategy may interfere with breastfeeding when practiced post-discharge (13).
40

6a
The breastfeeding policy states that the normal breastfeeding pattern should not be interrupted:
newborns are fed directly at the breast. If this is not possible or sufficient, they are given their
mothers own expressed milk using appropriate alternative feeding methods. They are not
given anything else unless there are justifiable medical reasons, and unless the mother has
made an informed decision not to express milk/feed directly at the breast. AFASS guidelines
are used when appropriate.
6b
When there are justifiable reasons as stated in Standard 6 a, mothers who do not provide all
breast milk required by their infants are informed about and have the option of using banked
human milk milk for feeding their infants - when available, or infant formula in this order of
priority. Their informed decision about feeding method is supported.
6c
When feasible considering infant feeding tolerance, appropriate feeding strategies for
increasing infants milk intake are applied before introduction of fortifier.
6d
No materials that recommend feeding breast milk substitutes or other inappropriate feeding
practices are distributed to mothers in accordance with the WHO International Code of
Marketing of Breast-milk Substitutes.
6e
Clinical staff discuss with mothers who have decided not to breastfeed or whose infants are
given formula the various feeding options available, and their risks and benefits to help them
decide what is suitable in their situations.
6f
The hospital does not accept free or low cost infant breast milk substitutes.

%

6.1
The breastfeeding policy indicates that newborns are given no food or drink other than their
mothers breast milk (at breast or expressed) unless there are acceptable medical reasons, and
that AFASS guidelines are used when appropriate.
6.2
Observation confirms that at least 80% of the infants are being fed only breast milk (at breast
or expressed) or banked human milk or, if they had received anything else, it was for
acceptable medical reasons
6.3
At least 80% of randomly selected mothers report that their infants received only breast milk
(at breast or expressed) or banked human milk or, if they received anything else, it was for
acceptable medical reasons.

%

6.4
The breastfeeding policy states that when there are acceptable medical reasons, mothers are
informed about and have the option of using banked human milk for feeding their infants when available, or the infant is given preterm infant breast milk substitutes (in this order of
priority).
6.5
At least 80% of randomly selected mothers who have decided not to breastfeed report that staff
talked with them about risks and benefits of various feeding options.
6.6
When there is a milk bank/similar service:

At least 80% of randomly selected mothers report that they received information about the
option of using banked human milk if their infants need for breasttmilk is not met.
41

%

6.7
The breastfeeding policy indicates that appropriate feeding strategies for increasing infants
milk intake are applied before introduction of fortifier.

%

6.8
Observation confirms that the hospital has an adequate facility/space and the necessary
equipment for giving demonstrations of how to prepare formula and other feeding options
away from breastfeeding mothers.

%

A5D
At least 80% of randomly selected mothers who have decided not to breastfeed or whose
infants are given formula report that the clinical staff discussed with them the various feeding
options available, their risks and benefits, and helped them to decide what was suitable in their
situations.

%

6.10
Documentation shows that the hospital does not accept free or low cost breast milk substitutes.

1.
2.
3
5.
6.
7.
8.
8.
9.
World Health Organization. Global Strategy for Infant and Young Child Feeding. Genve: World
Health Organization, 2003. p. 30. http://whqlibdoc.who.int/publications/2003/9241562218.pdf
World Health Organization. Breastfeeding. Geneva: World Health Organization, 2013.
http://www.who.int/topics/breastfeeding/en/ (accessed October 25, 2013).
Karen E, Rajiv B. Optimal feeding of low-birth-weight infants. Technical review. Geneva: World
Health Organization, 2006. p. 121.
Ronnestad A, Abrahamsen TG, Medbo S, Reigstad H, Lossius K, Kaaresen PI et al.. Late-onset
septicemia in a Norwegian national cohort of extremely premature infants receiving very early full
human milk feeding. Pediatrics 2005;115(3):e269-76.
Human milk banking association of North America. The Value of Human Milk. HMBANA
Position Paper on Donor Milk Banking. http://www.hmbana.org/downloads/position-paper-donormilk.pdf (accessed October 25, 2013).
Gephart SM, McGrath JM, Effken JA, Halpern MD.Necrotizing enterocolitis risk: state of the
science. Adv Neonat Care;2012. 12(2):77-87.
Ganapathy V, Hay W, Kim JH. American Academy of Pediatrics. Breastfeeding and the use of
human milk. Pediatrics 2005; 115: 496-506.
World Health Organization, UNICEF. Acceptable medical reasons for use of breast-milk
substitutes. Geneva: World Health Organization, 2009. p. 6.
http://whqlibdoc.who.int/hq/2009/WHO_FCH_CAH_09.01_eng.pdf
Funkquist E-L, Tuvemo T, Jonsson B, Serenius F, Nyqvist KH. Milk for small infants. Acta
Paediatr 2007;96:596-99.
Doege C, Bauer J. Effect of high volume intake of mother's milk with an individualized
supplementation of minerals and protein on early growth of preterm infants <28 weeks of
gestation. Clin Nutr 2007;26(5):581-8.
42

10. World Health Organization/UNICEF. Baby-Friendly Hospital Initiative. Revised, Updated and
Expanded for Integrated Care. Section 1: Background and implementation. Geneva: World Health
Organization/UNICEF, 2009. p. 70.
11. Nyqvist KH, Kylberg E. Application of the Baby Friendly Hospital Initiative to neonatal care:
Suggestions by Swedish mothers of very preterm infants. J Hum Lact 2008;24(3):252-62.
12. Fenton TR, Tough SC, Belik J. Breast milk supplementation for preterm infants: Parental
preference and post discharge lactation duration. Am J Perinatol 2000;17:329-33.
13. Henderson G, Fahey T, McGuire W. Multicomponent fortification of human breast milk for
preterm infants following hospital discharge. Cochrane Database System Review
2007;17(4):CD004866
43
5&
()#
)02!$'
Expansion: Enable mothers and infants to

remain together 24 hours a day.
This step includes all infants, including those who are not going to be breastfed.
The UN Convention on the Rights of the Child states that infants shall not be separated from their
parents against their will. This covers all children irrespective of the child's birth or other status (1). It is
therefore important to give all mothers the opportunity for rooming-in, irrespective of how their infants
are fed. A hospital cannot be considered friendly to the baby, if mother and baby are separated when the
baby is admitted to the neonatal ward (2). As rooming-in is beneficial for both the mother-infant
relationship and breastfeeding, mothers and babies in the neonatal ward should ideally stay together in
the same room day and night, right from delivery. However, this may not be possible for some mothers
facing personal situations.
Rooming-in promotes breastfeeding (exclusive and partial) (3, 4), as well as bonding/attachment and
parent empowerment (5). The mother can observe and react on the babys first feeding cues when
mother and infant are rooming-in. Preterm infants, who are commonly separated from their mothers for
a longer time achieve exclusively breastfeeding at a higher postnatal and postmenstrual age (6).
Neonatal wards with integrated maternity care, where the mother can be admitted together with her
infant into the neonatal ward right after birth, seem to facilitate breastfeeding. If the facilities only
provide limited opportunities for rooming-in so it is not possible from right after birth, it should be
offered to mothers as soon as possible, and for at least the last days before discharge to enhance
mothers opportunities for successful breastfeeding establishment.
Since the 1980s it has become more common in some countries that infants and children in paediatric
wards are together with their parent day and night. In neonatal wards, this practise is not yet common
(7). However, single-room care with parent rooming-in is being introduced in many settings, and has
been associated with shorter infant hospital stay (8). The new-born preterm or ill infants have at least as
much need of being together with their mothers as older children. Preterm and ill infants cared for by
their mother 24h/7d gained significantly more weight in the first month (9). Mothers separated from
their new-born infant experience emotional strain and anxiety; they feel like being an outsider, and
experience lack of control when the infant is admitted to neonatal intensive care (10).
Also partial (day) rooming-in may be beneficial in this respect. The possibility for rooming-in in a
neonatal ward can help the parents feel like a family and not just visitors to their own baby (5).
Rooming-in promotes maternal attachment scores, and there is an association between mother-infant
separation in the new-born period and parenting violence, abuse or neglect to the child in later
childhood (11-13).

7a
The ward respects that mothers are not separated from their infants against their will.
7b
Mothers and infants are together or, they have justifiable reasons for being separated
7c
The ward provides practical opportunities for mothers unrestricted presence day and night.
44

&

7.1
Review of the breastfeeding policy confirms the practice that the unit is open to the mothers
24h/7d (according to levels).
Unrestricted 24h/7d (level ***)
Unrestricted 24h/7d except during emergency situations (level **)
Unrestricted 24h/7d except during medical rounds (maximum 2 hours a day) (level *)
7.2
Observation in the ward confirms the practice that the unit is open to the mothers 24h/7d
(according to levels).
Unrestricted 24h/7d except during medical rounds (maximum 2 hours a day)(level *)
7.3
Observation of the ward confirms that there are no signs or posters conveying restrictions for
mothers to be together with their infant.
7.4
At least 80% of randomly selected mothers report that the ward is open to mothers 24h/7d

&

7.5
At least 80% of randomly selected mothers report that they have had possibility to be in the
same room with their infants admitted to the neonatal ward without separation or, if not, there
were justifiable reasons, according to levels (procedure where mother cannot be present such
as infant surgery, MRI etc., maternal illness/surgery/treatment, mother needing to temporarily
leave her bed or room and asking another person to supervise the baby, family reasons etc.).
7.6
Observation shows that at least 80% of the mothers and infants are together or, if not, have
justifiable reasons for being separated (according to levels).

&

7.7
At least 80% of randomly selected mothers of infants who are discharged home confirm that
they have the opportunity to sleep close to the infant (according to levels).
Bed in the same room as the infant (level ***)
Bed in another room in the ward (level **)
Bed in another area in the hospital (10 minutes walking distance from infant or less)(level *)
7.8
At least 80% of the randomly selected mothers of infants who are discharged home confirm
that they have the opportunity to sleep close to the infant for a part of the infants hospital stay
Infants whole hospital stay (level ***)
At least 50% of the infants hospital stay (level **)
45

At least one night just before infants discharge to home (level *)

1. Office of the United Nations High Commissioner for Human Rights. Convention on the rights of the
child: http://www.ohchr.org/en/professionalinterest/pages/crc.aspx (accessed October 25, 2013).
2. Levin A. Humane Neonatal Care Initiative. Acta Paediatr. 1999 Apr;88(4):353-355.
3. Pechlivani F, Vassilakou T, Sarafidou J, Zachou T, Anastasiou CA, Sidossis LS. Prevalence and
determinants of exclusive breastfeeding during hospital stay in the area of Athens, Greece. Acta
Paediatr. 2005 Jul;94(7):928-34.
4. Elander G, Lindberg T. Hospital routines in infants with hyperbilirubinemia influence the duration
of breast feeding. Acta Paediatr Scand. 1986 Sep;75(5):708-12.
5. Beck SA, Weiss J, Greisen G, Andersen M, Zoffmann V. Room for family-centred care - a
qualitative evaluation of a neonatal intensive care unit remodeling project. Journal of Neonatal
Nursing 2009;15(3):88-99.
6. Hedberg Nyqvist K, Ewald U. Infant and maternal factors in the development of breastfeeding
behaviour and breastfeeding outcome in preterm infants. Acta Paediatr. 1999 Nov;88(11):1194-203
7. Maastrup R, Bojesen SN, Kronborg H, Hallstrm I. Breastfeeding Support in Neonatal Intensive
Care: A National Survey. J Hum Lact. 2012;28(3):370-379.
8. rtenstrand A, Westrup B, Brostrm EB, Sarman I, kerstrm S, Brune T, Lindberg L,
Waldenstrm U. The Stockholm neonatal family centred study: Effects on length of stay and infant
morbidity. Pediatrics 2010;125;e278.
9. Levin A. The Mother-Infant unit at Tallinn Children's Hospital, Estonia: a truly baby-friendly unit.
Birth. 1994 Mar;21(1):39-44, discussion 45-6.
10. Nystrom K, Axelsson K. Mothers experience of being separated from their newborns. Journal of
Gynecological, Obstetrical and Neonatal Nursing 2002;31):275-82.
11. Klein M, Stern L. Low Birth Weight and the Battered Child Syndrome. Am J Dis Child.
1971;122(1):15-18.
12. Norr KF, Roberts JE, Freese U. Early postpartum rooming-in and maternal attachment behaviors in
a group of medically indigent primiparas. J Nurse Midwifery. 1989 ;34(2):85-91.
13. O'Connor S, Vietze PM, Sherrod KB, Sandler HM, Altemeier WA 3rd. Reduced incidence of
parenting inadequacy following rooming-in. Pediatrics. 1980; 66(2):176-82.

46
6'! ('
Expansion: Encourage demand breastfeeding or,

when needed, semi-demand feeding as a
transitional strategy for preterm and sick
infants.
Demand feeding means that the infant is breastfed based on the mothers observation of infant
behavioral cues of interest in sucking/rooting (baby-led feeding) (1). This strategy is
appropriate once the infant has reached sufficient neurological maturity, evidenced by coordination between hunger and satiety and behavioral state regulation (sleep-awake states) and
has also been called ad-libitum feeding (2). Preterm infants (including very preterm and
extremely preterm) are able to latch on to the breast, suck and swallow as soon as they no
longer require support for their ventilation, and are able to attain exclusive breastfeeding while
still preterm (3,4). A cue-based oral feeding policy may result in earlier attainment of full oral
feeding in preterm infants (2, 5). However, during the establishment of breastfeeding,
preterm/ill infants require supplementation by another feeding method in order to take the milk
needed for adequate growth.
Semi-demand breastfeeding means that the mother observes her infants signs of interest in
sucking (rooting) and behavioral state shifts, and breastfeeds when her infant shows such signs;
the feed ends when the infant stops sucking. Supplementation is given by another feeding
method as required. The mother actively offers her infant the breast in order to reach a
breastfeeding frequency per 24 hours that is sufficient for adequate infant milk intake; the
mother is guided in protecting the infants deep sleep by recognizing the infants discrete signs
of transition from deep to active sleep and waking up (6).
Before the infant has attained exclusive breastfeeding, a daily milk volume to be given by
another feeding method is prescribed, and supplementation is reduced in pace with the increase
in the infants oral milk intake, based on assessment of the infant growth/weight gain. An
alternative - which can be used when the mother chooses to test-weigh before/after nursing - is
the prescription of a total daily milk volume, including milk taken at the breast;
supplementation is given when required (6).
Mothers opinions about test-weighing for assessment of need of supplementation range from
find it supportive (7) or stressful (8). Still, in comparison with test-weighing, observation of
infant sucking and swallowing during breastfeeding for assessment of the volume infants milk
intake at the breast (so called clinical indices) is unreliable (9). Infants at a neonatal ward
where test-weighing was used attained exclusive breastfeeding and were discharged at a lower
postmenstrual age, when compared with infants at a ward that applied clinical indices, but as
there was no difference between the units in rate of exclusive breastfeeding, mothers can be
offered to choose which strategy they prefer (10). Thus, encouragement of mothers
participation in decisions about strategy for their infants feeding is an essential component in
support of their maternal role (11).
Administration of medications and performance of procedures should be scheduled to cause the
least possible disturbance of breastfeeding.
47
Standards
8a
The breastfeeding policy states that the breastfeeding process is guided by the
preterm and ill infants competence and stability, and not a certain postmenstrual or
postnatal age or weight.
8b
The ward breastfeeding protocol includes strategies for the transition from
scheduled feeding to demand feeding/cue based feeding, and from tube feeding to
breastfeeding.
8c
Transition from scheduled feeding with set volumes and frequencies to semidemand feeding is introduced when there is no medical indication for scheduled
feeding and the infant shows some milk intake at the breast.
8d
Mothers are offered alternative strategies for establishment of exclusive feeding at

breast and reduction of daily volume of milk given by other feeding methods, and
are supported in participating in decisions about selection of strategy.
8e
Mothers are guided in observing the infants signs of feeding cues and behavioral
state shifts (transition between sleep and alertness).
8f
Routine administration of milk after each breastfeeding episode given by another

feeding method is avoided, unless medically indicated.
8g
Medications are administered and procedures are scheduled so as to cause the least
possible disturbance of breastfeeding.

'

8.1
The breastfeeding policy states that the individual infants ability and stability
indicates when it is possible to finish scheduled feedings and tube feeding, not a
certain postmenstrual or postnatal age or weight.

'

8.2
A strategy (strategies) for transition from scheduled feedings to semi-demand feeding

is/are included in the ward breastfeeding protocol.

'

8.3
Infants with some milk intake at the breast are breastfed according to a semi-demand
feeding strategy.

'

8.4
At least 80 % of randomly selected mothers who intend to breastfeed state that they
have been involved in the choice of strategy for establishment of their breastfeeding
goal, ideally exclusive feeding at breast, and alternative strategies for reduction of
daily volume of milk given by other feeding methods.
48

'

8.5
At least 80 % of randomly selected mothers state that they have received guidance in
observing the infants signs of feeding cues and behavioral state shifts for knowing
when it is appropriate to position the infant at the breast.

'

8.6
Observation confirms that routine administration of milk given by other methods after
each nursing episode (to attain a certain milk volume) is only performed for justifiable
medical reasons.

'

8.7
Observation confirms that medications are administered and procedures are scheduled
so as to cause the least possible disturbance of breastfeeding.

1.
Nyqvist KH, Rubertsson C, Ewald U et al. Development of the preterm infant breastfeeding
behaviour scale (PIBBS), a study of nurse-mother agreement. J Hum Lact 1996;12:207-19.
2. McCormick FM, Tosh K, McGuire W. Ad libitum or demand/semi-demand feeding versus
scheduled interval feeding for preterm infants. Cochrane Database of Systematic Reviews 2010,
Isssue 2. Art No.: CKk005255.DOI:10.1002/14651858.Ck005255.Pub3
3. Nyqvist KH, Ewald U, Sjdn P-O. Development of preterm infants breastfeeding behaviour.
Early Hum Dev 1999:55:247-64.
2008;97:776-81.
5. Puckett B, Grover VK, Holt T, Sankaran K. Cue-based feeding for preterm infants: a prospective
trial. Am J Perinatol 2008;25(10):623-8.
6. Nyqvist KH. Breastfeeding support in neonatal care. An example of the integration of international
evidence and experience. Newborn Inf Nurs Rev 2005;5(1):34-48.
7. Kavanaugh K, Mead L, Meier P, et al. Getting enough: mothers concern about breastfeeding a
preterm infant after discharge. JOGGN 1995; 24:23-32.
8. Flacking R, Ewald U, Nyqvist KH, Starrin B. Trustful bonds. A key to becoming a mother and to
reciprocal breastfeeding. Stories of mothers of very preterm infants at a neonatal unit. Soc Sci Med
2006;62:70-80.
9. Meier PP, Engstrom JL, Fleming BA et al. Estimating milk intake of hospitalized preterm infants
who breastfeed. J Hum Lact 1996;12:21-6.
10. Funkquist E-L, Tuvemo T, Jonsson B, Serenius F, Nyqvist KH. Influence of test-weighing
before/after nursing on breastfeeding in preterm infants. Adv Neonat Care 2010;10(1):33-39.
11. Nyqvist KH, Kylberg E. Application of the Baby Friendly Hospital Initiative to neonatal care:
Suggestions by Swedish mothers of very preterm infants. J Hum Lact 2008; 24(3):252-62.
49
7'" *

!! + '
Expansion: Use alternatives to bottle feeding at

least until breastfeeding is well established and
use pacifiers and nipple shields only for
justifiable reasons.
Comparisons of bottle versus cup feeding in preterm infants found that cup feeding was
associated with higher breastfeeding rates at discharge (1), whereas the use of bottles has been
shown to negatively impact breastfeeding success in both full term (2,3) and preterm infants (47). Conversely, tube-feeding is not known to negatively influence breast-feeding success.
Whereas jaw and throat feeding movements during breast and bottle feeding differ (8), the
same oral muscles are involved in cup and breastfeeding (9).
Bottle feeding is associated with lower temperature, lower oxygen saturation, lower
transcutaneous pO2, and higher frequency of desaturations in preterm infants, compared to
breastfeeding and cup feeding (6, 10-12). Cup feeding can be introduced from around 29 weeks
PMA (13). Oral feeding methods, for which evidence of efficacy and safety is lacking, are the
use of spoon, paladai, finger-feeding, dropper, and nursing supplementer.
It is possible that feeding regimens with frequent feeding of small milk volumes, and the use of
semi-demand feeding in preterm infants (step 8) instead of regulated feeding (fixed volumes
and fixed intervals) is the optimal feeding pattern for all preterm/low birth weight and ill term
infants, will reduce the need for supplementary feeding, and facilitate the transition to exclusive
breast/oral feeding.
The use of a pacifier may disturb the normal breastfeeding physiology when the infant is
breastfed on demand and has been associated with lower breastfeeding rates (3, 14-15).
However, the use of pacifiers for infants who require neonatal care can be advocated for several
reasons. Non-nutritive sucking gives relief of pain during procedures, reduces stress and
anxiety and makes the infant less fussy and more relaxed during tube feeding. Pacifier should
therefore be offered when breastfeeding is not possible and when the mother is not available for
breastfeeding (16-20).
An ultra-thin nipple shield can be helpful for preterm and ill infants as it compensates for a
weak intra oral pressure, gives a continuous negative pressure that supports milk transfer, and
stimulates sucking (21, 22).
50

9a
Bottles are not introduced to breastfed infants and to infants whose mothers intend to
exclusively feed at breast unless the mother explicitly demands it and has been informed of the
risks.
9b
For infants of mothers who intend to breastfeed the first nutritive sucking experience is at the
breast.
9c
Clinical staff use, recommend and teach parents to use alternative oral feeding methods, instead
of bottles, in a safe way, before exclusive feeding at the breast is established.
9d
Pacifiers are used for justifiable reasons while the infant is in the neonatal ward and when the
mother is unavailable for comforting the infant and giving pain relief at her breast.
9e
Parents are informed about justifiable reasons for use of pacifiers in the neonatal ward, about
alternative ways of soothing the infant, and how to minimize its use after discharge from the
neonatal ward.
9f
Nipple shields are used in a proper way when the infant is unable to latch on, does not stay
fixed at the breast, and does not continue sucking - after the mother has got qualified
breastfeeding support, and after ample trying.

(

9.1
Observations in the ward indicate that at least 80% of the infants of breastfeeding mothers and
mothers intending to do so, are not using bottles.
9.2
At least 80% of randomly selected mothers who are breastfeeding, or intending to do so, report
that, as far as they know, their infants have not been fed using bottles with artificial teats
(nipples), unless the mother explicitly asked for it.
9.3
At least 80% of randomly selected clinical staff report that they do not introduce bottles to
breastfeeding infants unless justifiable reasons, and - when a mother wants to introduce bottle
feeding - they inform her of the risks.

(

9.4
The ward breastfeeding protocol states that the first nutritive sucking experience for infants of
those mothers who intend to feed directly at breast should be at the breast.

(

9.5
The ward breastfeeding protocol includes alternative methods to bottle feeding and describe
appropriate and safe ways of using these methods.
9.6
At least 80% of randomly selected mothers who are breastfeeding, or intending to do so, report
that they were taught how to feed their infant with feeding tube, nursing supplementer, or cup,
if supplementation was required.

(

9.7
The ward breastfeeding protocol describes justifiable reasons for using a pacifier.
51

9.8
At least 80% of randomly selected clinical staff can describe at least two justifiable reasons for
using a pacifier (pain relief, stimulation of sucking, comforting, helping infant to go to sleep).

(

9.9
At least 80% of randomly selected breastfeeding mothers report that they were informed
about justifiable reasons for use of pacifiers in the neonatal ward and the reasons why
pacifiers may reduce milk production during lactation.
9.10
At least 80% of randomly selected breastfeeding mothers report that they were informed
about alternative ways of soothing the infant, and how to minimize the use of a pacifier after
discharge from the neonatal ward.

(

9.11
The ward breastfeeding protocol describes justifiable reasons for use of nipple shields.
9.12
At least 80% of randomly selected clinical staff can describe how to use a nipple shield in a
proper way.
9.13
At least 80% of randomly selected clinical staff can describe at least two justifiable reasons for
use of a nipple shield out of the following: the infant has:
- difficulties in latching on,
- difficulties in staying fixed at the breast,
- shows minimal sucking and /or increase in milk intake in spite of frequent breastfeeding;
- mothers need of pain relief because of sore nipples.

1.
2.
3.
4.
5.
6.
7.
8.
9.
Flint A, New K, Davies MW. Cup feeding versus other forms of supplemental enteral feeding for
newborn infants unable to fully breastfeed. Cochrane Database of Systematic Reviews 2007, Issue
2. Art. No.: CD005092. DOI: 10.1002/14651858.CD005092.pub2.
WHO. Evidence for the ten steps to successful breastfeeding. WHO/CHD/98.9 ed. World Health
Organization Child Health and Development; 1998.
Ho CR, Ho FM, Lanphear B, Eberly S, deBlieck EA, Oakes D, et al. Randomized clinical trial of
pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding. Pediatrics
2003;111(3):511-8.
Collins CT, Ryan P, Crowther CA, McPhee AJ, Paterson S, Hiller JE. Effect of bottles, cups, and
dummies on breast feeding in preterm infants: a randomised controlled trial. BMJ 2004 Jul
24;329(7459):193-8.
Collins CT, Makrides M, Gillis J, McPhee AJ. Avoidance of bottles during the establishment of
breast feeds in preterm infants. Cochrane Database Syst Rev 2008;(4):CD005252.
Rocha NM, Martinez FE, Jorge SM. Cup or bottle for preterm infants: effects on oxygen saturation,
weight gain, and breastfeeding. J Hum Lact 2002 May;18(2):132-8.
Abouelfettoh AM, Dowling DA, Dabash SA, Elguindy SR, Seoud IA. Cup versus bottle feeding
for hospitalized late preterm infants in Egypt: A quasi-experimental study. Int Breastfeed J 2008
Nov 21;3(1):27.
Aizawa M, Mizuno K, Tamura M. Neonatal sucking behavior: comparison of perioral movement
during breast-feeding and bottle feeding. Pediatr Int 2010;52(1):104-8.
Gomes CF, Trezza EM, Murade EC, Padovani CR. Surface electromyography of facial muscles
during natural and artificial feeding of infants. J Pediatr (Rio J). 2006 Mar-Apr;82(2):103-9.
52

10. Chen CH, Wang TM, Chang HM, Chi CS. The effect of breast- and bottle-feeding on oxygen
saturation and body temperature in preterm infants. J Hum Lact 2000 Feb;16(1):21-7.
11. Meier P, Anderson GC. Responses of small preterm infants to bottle- and breast-feeding. MCN Am
J Matern Child Nurs 1987 Mar;12(2):97-105.
12. Marinelli KA, Burke GS, Dodd VL. A comparison of the safety of cupfeedings and bottlefeedings
in premature infants whose mothers intend to breastfeed. J Perinatol 2001 Sep;21(6):350-5.
13. Gupta A, Khanna K, Chattree S. Cup feeding: an alternative etc. J Trop Pediatr 1999 45 (2): 108110.
14. Victora CG, Behague DP, Barros FC, Olinto MT, Weiderpass E. Pacifier use and short
breastfeeding duration: cause, consequence, or coincidence? Pediatrics 1997 Mar;99(3):445-53.
15. Victora CG, Tomasi E, Olinto MT, Barros FC. Use of pacifiers and breastfeeding duration. Lancet
1993 Feb 13;341(8842):404-6.
16. Carbajal R, Gall O, Annequin D. Pain management in neonates.Expert Rev Neurother. 2004
May;4(3):491-505.
17. Carbajal R, Chauvet X, Couderc S, Olivier-Martin M. Randomised trial of analgesic effects of
sucrose, glucose, and pacifiers in term neonates. BMJ. 1999 Nov 27;319(7222):1393-7.
18. Lago P, Garetti E, Merazzi D, Pieragostini L, Ancora G, Pirelli A, Bellieni CV. Pain Study Group
of the Italian Society of Neonatology. Guidelines for procedural pain in the newborn. Acta
Paediatr. 2009 Jun;98(6):932-9.
19. Pinelli J, Symington A. Non-nutritive sucking for promoting physiologic stability and nutrition in
preterm infants.Cochrane Database Syst Rev. 2005 Oct 19;(4):CD001071.
20. Cignacco E, Hamers JP, Stoffel L, van Lingen RA, Gessler P, McDougall J, Nelle M. The efficacy
of non-pharmacological interventions in the management of procedural pain in preterm and term
neonates. A systematic literature review. Eur J Pain. 2007 Feb;11(2):139-52.21.
21. Meier PP, Brown LP, Hurst NM, Spatz DL, Engstrom JL, Borucki LC, et al. Nipple shields for
preterm infants: effect on milk transfer and duration of breastfeeding. J Hum Lact 2000
May;16(2):106-14.
22. Chertok IR. Reexamination of ultra-thin nipple shield use, infant growth and maternal satisfaction.

. 2009 Nov;18(21):2949-55.
53
/.' !

!
'
Expansion: Prepare parents for continued

breastfeeding and ensure access to support
services/groups after hospital discharge.
All mothers of infants who received neonatal care, who initiated breastfeeding and/or are expressing
their milk need qualified support and follow-up on lactation and breastfeeding after discharge. The most
vulnerable period for breastfeeding of preterm/ill infants is the first month after discharge (1).
Continued breastfeeding is dependent on many factors; the infants medical condition, the mothers
emotional state and milk production, breastfeeding technique, and the use of different feeding methods
(2). The task of the NICU staff is to make parents confident in feeding issues before discharge and
prepare the mother for common challenges in breastfeeding preterm/ill infants and where to find
lactation and breastfeeding support after discharge (3).
All mothers of infants who received neonatal care, who initiated breastfeeding and/or are expressing
their milk need qualified support and follow-up on lactation and breastfeeding after discharge. The most
vulnerable period for breastfeeding of preterm/ill infants is the first month after discharge (1).
Continued breastfeeding is dependent on many factors; the infants medical condition, the mothers
emotional state and milk production, breastfeeding technique, and the use of different feeding methods
(2). The task of the NICU staff is to make parents confident in feeding issues before discharge and
prepare the mother for common challenges in breastfeeding preterm/ill infants and where to find
lactation and breastfeeding support after discharge (3).
When the infant of a mother who intends to feed exclusively at breast is discharged before this goal is
established, support for the attainment of exclusive breastfeeding, given by an experienced
nurse/professional has been associated with longer feeding with mothers milk and longer breastfeeding
(4). Positive associations have been found between mothers success with provision of milk at discharge
and mothers putting their infants directly to breast in the NICU (5). When mother and child are
discharged before exclusive feeding at breast is achieved there should be a plan, to be adhered to by all
professionals involved in their care, in how to make the transition from tube to oral feeding, while
promoting and protecting direct breastfeeding (6).
Preparation of parents for continued breastfeeding after discharge from the NICU by professionals in
cooperation with peer counsellors has enhanced mothers inclination for breastfeeding their infants (710). A RCT-study showed that a higher prevalence of exclusive breastfeeding in low-weight infants was
achieved when mothers were supported by peer counsellors (8). Careful selection and adequate training
of peer counsellors and lay volunteers is important so they adhere to defined roles, and effective
collaboration between them and the NICU is essential for achieving common breastfeeding goals (9-10).
New technologies offer several possibilities for support, such as video-conferences, contact via cell
phones etc. to facilitate early discharge and for follow-up after discharge (11).
54

10 a
The facility fosters the establishment of and/or coordinates activities with breastfeeding
support groups or networks for mothers/parents of infants treated in neonatal care.
10 b
Mothers are given oral and written information about how they can get breastfeeding peer
support during hospital stay and after discharge, if available.
10 c
Discharge is planned in collaboration with the family and the community health services.
10 d
When the infant of a mother who intends to breastfeed is discharged before breastfeeding is
established, there should be a plan for her how to attain her breastfeeding goal (exclusivity
and duration).
10 e
The clinical staff encourages mothers and their infants to be seen soon after discharge
(individualized according to the infants condition) at the facility or in the community by a
professional breastfeeding support person
10 f
Parents are given oral or written information about where they can get breastfeeding support
after discharge by a professional breastfeeding support person in the community.

10.1 The head/director of nursing services states that the facility fosters the establishment of
breastfeeding and/or coordinates breastfeeding support groups or networks and other
community services that provide breastfeeding/infant feeding support to mothers, and can
describe at least one way this is done.

10.2
At least 80% of randomly selected mothers report that they are given information on how
they can get breastfeeding peer support if needed during the infants hospital stay and after
discharge, if available.
10.3
A review of documents indicates that printed information distributed to mothers includes

information on how and where they can find breastfeeding peer support, if available.
10.4
The head/director of nursing services states mothers are given information on where they can
get support if they need help with feeding their babies after returning home and can mention
at least one source of information.

10.5
The head/director of nursing services states that infants discharge is planned in

collaboration with the community health services and describes how this is done.
10.6
At least 80 % of randomly selected mothers report that the infants discharge is

planned in collaboration with the family.

10.7
A review of documents shows that there is a plan for the mothers establishment of
breastfeeding when the infant is discharged before she has attained her breastfeeding goal
(exclusivity and duration).
55

10.8 At least 80 % of randomly selected mothers report that they were seen soon after discharge
(individualized according to the infants condition) at the facility, or in the community by a
professional breastfeeding support person who assessed feeding and gave the support needed,
or encouraged to see a such a support person
10.9
The head/director of nursing services states that the staff encourages mothers and their babies
to be seen soon after discharge (individualized according to the infants condition) at the
facility, or in the community by a professional breastfeeding support person who can assess
feeding and give any support needed and can describe an appropriate referral system and
adequate timing for the visits.
10.10 The ward breastfeeding protocol describes an appropriate referral system for mothers/babies
to be seen soon after discharge.

10.11 At least 80% of randomly selected mothers report that they were given oral or written
information on where they can/ could get professional breastfeeding support if needed after
discharge in the community and mentions at least one type of help available.

1. Zachariassen G, Faerk J, Grytter C, Exberg BH, Juvonen P, Halken S. Factors associated with
successful establishment of breastfeeding in very preterm infants. Acta Paediatr 2010;99(7):1000-4.
2. Callen J, Pinelli J, Atkinson S, Saigal S. Qualitative analysis of barriers to breastfeeding in very-low
birthweight infants in the hospital and postdischarge. Adv Neonat Care 2005;5 (2): 93-103.
3. Brdsgaard:Hjlp til familier med for tidligt fdte brn. Sygeplejersken nr 50/2001
4. Meerlo-Habing ZE, Kosters-Boes EA, Klip H, BrandPL. Early discharge with tube feeding at home
for preterm infants is associated with longer duration of breast feeding. Arch Dis Child Fetal
Neonatal Ed 2009;94:F294-27.
5. Pineda R. Direct breast-feeding in the neonatal intensive care unit: Is it important? J Perinatol 2011;
31(8):540-5.
6. Renfrew MJ, Craig L, Dyson L, McCormick F, Rice A, King SE, Misso K, Stenhouse E, Williams
AF. Breastfeeding promotion for infants in neonatal units: A systematic review and economic
analysis. Health Technology Assessment 2009; 13(40):1-146.
7. Bolton TA, Chow T, Benton PA, Olson BH. Characteristics associated with longer breastfeeding
duration: An analysis of a peer counselling support program. J Hum Lact 2009; 25(1):18-27.
8. Agrasada G, Gustafsson J, Kylberg E, Ewald U. Postnatal peer counsellors on exclusive
breastfeeding of low-birthweight infants: A randomised controlled trial. Acta Peadiatr
2005;94:1109-15.
9. Meier PP, Engstrom JL, Mingolelli SS, Miracle DJ, KieslingS. The Rush mothers milk club:
Breastfeeding interventions for mothers with very-low-birth-weight infants. JOGNN
2003;33(2):164-14.
10. Merewood A, Chamberlain LB, Cook JT, Philipp BL, Malone K, Bauchner H.The effect of peer
counselling on breastfeeding rates in the neonatal intensive care unit. Arch Pediatr Adolesc Med
2006; 160:681-85.
11. Lindberg B, Axelsson K, Ohrling K. Experience with videoconferencing between a neonatal unit
and the families' home from the perspective of certified paediatric nurses. Journal of Telemedicine
and Telecare 2009;5(6):275-80.
56
The International Code of Marketing of Breast-milk

Substitutes
The Baby-Friendly Hospital Initiative for Neonatal Wards or Neo-BFHI has been formulated in
accordance with the International Code of Marketing of Breast-milk Substitutes, published in 1981 by
the WHO (1), and the subsequent WHO resolutions. Hence, in addition to the assessment of the Three
General Principles and Ten Steps of the Neo-BFHI, compliance with the Code should also be assessed
as outlined in the revised 2009 Global Criteria (2):
The head/director of nursing services reports that:

C.1
No employees of manufacturers or distributors of breast-milk substitutes, bottles, teats or

pacifiers have any direct or indirect contact with pregnant women or mothers.
C.2
The hospital does not receive free gifts, non-scientific literature, materials or equipment,
money, or support for in-service education or events from manufacturers or distributors of
breast-milk substitutes, bottles, teats or pacifiers.
C.3
No pregnant women, mothers or their families are given marketing materials or samples or
gift packs by the facility that include breast-milk substitutes, bottles/teats, pacifiers, other
infant feeding equipment or coupons.
A review of the breastfeeding or infant feeding policy indicates that it uphold the Code and
subsequent WHA resolutions by prohibiting:
C.4
The display of posters or other materials provided by manufacturers or distributors of

breastmilk substitutes, bottles, teats and dummies or any other materials that promote the use
of these products.
C.5
Any direct or indirect contact between employees of these manufacturers or distributors and
pregnant women or mothers in the facility.
C.6
Distribution of samples or gift packs with breast-milk substitutes, bottles or teats or of

marketing materials for these products to pregnant women or mothers or members of their
families.
C.7
Acceptance of free gifts (including food), literature, materials or equipment, money or

support for in-service education or events from these manufacturers or distributors by the
hospital.
C.8
Demonstrations of preparation of infant formula for anyone that does not need them.
C.9
Acceptance of free or low cost breast-milk substitutes or supplies.
57

A review of records and receipts indicates that:
C.10
Any breast-milk substitutes, including special formulas and other supplies, are purchased by
the health care facility for the wholesale price or more (fortifiers are considered a
medication, not a breast-milk substitute).
Observations in the neonatal ward indicate that:

C.11
No materials that promote breast-milk substitutes, bottles, teats or dummies, or other

designated products as per national laws, are displayed or distributed to mothers, pregnant
women, or staff.
C.12
The hospital keeps infant formula cans and pre-prepared bottles of formula out of view
unless in use.
At least 80% of the randomly selected clinical staff members can give two reasons why:
C.13
It is important not to give free samples from formula companies to mothers (fortifiers are
considered a medication, not a breast-milk substitute).
At least 80% of the randomly selected mothers report that:

C.14
They did not receive a demonstration of preparation of formula if they did not needed them
C.15
They did not observe posters or others materials provided by manufacturers or distributors of
breastmilk substitutes, bottles, teats and dummies or any other materials that promote the use
of these products.
C.16
They were not given any marketing materials or samples or gift packs by the facility that
include breast-milk substitutes, bottles/teats, pacifiers, other infant feeding equipment or
coupons.

1. World Health Organization. International Code of Marketing of Breast-milk Substitutes. Geneva:
World Health Organization: 1981. Available from:
http://whqlibdoc.who.int/publications/9241541601.pdf
2. World Health Organization/UNICEF. Baby-Friendly Hospital Initiative. Revised, Updated and
Expanded for Integrated Care. Section 1: Background and implementation. In: Geneva:
World Health Organization/UNICEF:2009:70.
58
Required Contents of the Breastfeeding Policy

The hospital has a written breastfeeding or infant feeding policy that addresses the
Three Guiding Principles and all Ten Steps for Neonatal Wards.
The policy includes guidance for how each of the Three Guiding Principles and Ten Steps and other
components should be implemented, which means that the following should be included:
GP 1
A definition of which mothers (families) should be regarded as particularly vulnerable and

be given focused individualized support with respect to milk production, breastfeeding and
infant feeding.
GP 2
A statement that the father/family member and significant others are allowed in the ward
Statement about early transfer of the infants care to the parents after the birth.
GP 3
A statement that continuity of care in regards to the lactation and breastfeeding support during
each stage of health care delivery is addressed.
Step 1
Guidance for implementation of the Three Guiding Principles and Ten Steps and the
International Code of Marketing of Breast-milk Substitutes and for counselling to HIVpositive mothers on infant feeding..
Requirement that all mothers, regardless of their feeding method, get feeding support they
need, and that mothers who do not breastfeed, because of HIV or for other reasons, receive
counselling on infant feeding and guidance on selecting options likely to be suitable for their
situations.
Step 3
A statement that hospitalized pregnant women who are at risk of having an infant admitted to
the neonatal ward after birth are visited by the clinical staff to discuss about breastfeeding and
how lactation, breastfeeding/breast milk feeding may be established, depending on the infants
condition.
Step 4
A protocol or standards defining KMC that includes initiation, duration of sessions, and
continuous KMC.
Step 5
A description of infant stability as the only criterion for early initiation of breastfeeding (not
postmenstrual age or current weight).
A statement that late preterm infants (GA 34+0 to 36+6 weeks + days) should be recognized
as preterm, and states that their mothers should be offered the same support in the
establishment of lactation and breastfeeding as mothers of more immature infants.
A statement that staff should be using hands-off technique when supporting mothers with
positioning and attaching their infants for breastfeeding, unless the mother explicitly ask for
hands-on assistance.
Step 6
Statements that newborns are given no food or drink other than their mothers breast milk (at
breast or expressed) unless there are acceptable medical reasons, and that AFASS guidelines
are used when appropriate.
59

Statement that when there are acceptable medical reasons, mothers are informed about and
have the option of using banked human milk for feeding their infants - when available, or the
infant is given preterm infant breast milk substitutes (in this order of priority).
Application of appropriate feeding strategies for increasing infants milk intake before
introduction of fortifier.
Step 7
Confirmation of the practice that the unit is open to the mothers 24 h/7 d (according to levels).
Unrestricted 24 h/7 d (level ***)
Unrestricted 24 h/7 d except during emergency situations (level **)
Unrestricted 24 h/7 dexcept during medical rounds (maximum 2 hours a day) (level *)
Step 8
A statement that the individual infants ability and stability indicates when it is possible to
finish scheduled feedings and tube feeding, not a certain postmenstrual or postnatal age or
weight.
A strategy (strategies) for transition from scheduled feedings to semi-demand feeding.
Step 9
A statement that the first nutritive sucking experience for infants of those mothers who intend
to feed directly at breast should be at the breast.
Alternative methods to bottle-feeding and appropriate and safe ways of using these methods.
Justifiable reasons for use of a pacifier.
Justifiable reasons for use of nipple shields.
Step 10. An appropriate referral system for mothers/babies to be seen soon after discharge.
Code
The following are prohibited:
Display of posters or other materials provided by manufacturers or distributors of

breastmilk substitutes, bottles, teats and dummies or any other materials that promote
the use of these products.
Any direct or indirect contact between employees of these manufacturers or distributors
and pregnant women or mothers in the facility.
Distribution of samples or gift packs with breast-milk substitutes, bottles or teats or of
marketing materials for these products to pregnant women or mothers or members of
their families.
Acceptance of free gifts (including food), literature, materials or equipment, money or
support for in-service education or events from these manufacturers or distributors by
the hospital.
Demonstrations of preparation of infant formula for anyone that does not need them.
Acceptance of free or low cost breast-milk substitutes or supplies.
60
Contact information
Ragnhild Mstrup, RN, IBCLC, doctoral student
Project Nurse
Knowledge Centre for Breastfeeding
Infants with Special Needs, NICU,
Rigshospitalet
Blegdamsvej 9-5023
DK-2100 Copenhagen
Denmark
+45 35 45 53 30
[email protected]
Coordinator of the group:

Anna-Pia Hggkvist, RN, MSc, IBCLC
Medical adviser
Norwegian Resource Centre for Breastfeeding
Women and Childrens Division
Oslo University Hospital
Pb. 4950 Nydalen
0424 Oslo
Norway
[email protected]
[email protected]
+ 47 23 07 54 09 or 00
Aino Ezeonodo, RN, CEN, CPN, CNICN, MHC

Helsinki University Central Hospital (HUCH)
Children's Hospital
Dept for Neonatology
Neonatal Intensive Care Unit, K7
P.O. Box 281
FIN-00029 HUS
Mette Ness Hansen RN, Midwife, IBCLC

Medical adviser
Norwegian Resource Centre for Breastfeeding
Women and Childrens Division
Oslo University Hospital
Pb. 4950 Nydalen
0424 Oslo
Norway
[email protected]
+ 47 23 07 54 05 or 00
Leena Hannula, RN, Midwife, MNSc, PhD

Principal Lecturer
Faculty of Health Care and Nursing
Helsinki Metropolia University of Applied Sciences
PO Box 4030, FI- 00079 Metropolia,
Finland
Mobile +358 40 334 1685
[email protected]
Elisabeth Kylberg Nutritionist, PhD, IBCLC

Associate professor
School of Life Sciences
University of Skvde
Skvde
Sweden
[email protected]
+46 18 30 30 04
Mobile +46 730 28 65 05
Katja Koskinen, RN, Midwife, MNSc, IBCLC

Breastfeeding Coordinator
Helsinki University Central Hospital,
Department of Gynaecology and Pediatrics,
P.O. Box 281
FIN-00029 HUS
Finland
[email protected]
+358 50 4286837
P.O. Box 610, FI-00029 HUS
Kerstin Hedberg Nyqvist, RN, PhD

Associate Professor in Pediatric Nursing, emerita,
Department of Women's and Children's Health,
University Children's Hospital, 751 85 Uppsala,
Sweden
[email protected]
Laura N. Haiek, MD, MSc

Mdecin conseil
Direction gnrale de la sant publique
Ministre de la Sant et des Services sociaux
1075, Chemin Sainte-Foy, 12e tage
Qubec, Qc, Canada G1S 2M1
Assistant professor in Family Medicine
McGill University, Montreal, Qc, Canada
+1 418 266 6770
[email protected]
Annemi Lyng Frandsen, RN, IBCLC

Pediatric Department
Holbaek Hospital
Smedelundsgade 60
4300 Holbaek
Denmark
+45 59484243
[email protected]
61

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