Point 4 - Sustaining breastfeeding

• A full breastfeeding assessment should be carried out with each breastfeeding mother at the first face-to-face contact by community health-care staff, resulting in the development of an individualised plan of care. The assessment will include:
  • signs in the baby that indicate sufficient milk intake (urine output, stooling, weight gain and general condition of the baby);
  • signs in the mother that indicate effective feeding (comfortable breasts, no evidence of nipple pain or damage).
• The assessment will incorporate a discussion of:
  • the mother’s understanding of the importance of effective positioning and attachment for breastfeeding and her confidence in managing this;
  • how to recognise effective milk transfer – and what the mother should do if she suspects it is inadequate;
  • demand feeding and how to recognise feeding cues;
  • strategies for coping with night-time feeds;
  • the appropriate use of teats and dummies.
• All breastfeeding mothers should be offered the opportunity to learn how to hand express their breastmilk and given information about its potential importance in the prevention and management of breastfeeding challenges such as engorgement and mastitis.
• All breastfeeding mothers should be offered information on how they can continue to breastfeed if and when they return to work.
• All written materials intended for new mothers should be accurate and effective, and free from the promotion of breastmilk substitutes, bottles, teats and dummies.
• All health-care staff with primary responsibility for supporting breastfeeding mothers should have the skills necessary to teach mothers how to position and attach their baby for breastfeeding, and how to hand express their breastmilk.
• All health-care staff with primary responsibility for supporting breastfeeding mothers should have the knowledge to support a mother effectively to maintain lactation during periods of separation from her baby, for example, when returning to work.

• A written description of the mechanism for ensuring that a breastfeeding assessment is carried out at the first face-to-face contact with all breastfeeding mothers, including recording whether this assessment has taken place, and documenting the resulting plan of care (if any).
• An example of the tool to be used for carrying out the breastfeeding assessment.*
• The written minimum standard for the information to be provided to all breastfeeding mothers.
• A written description of the mechanism for ensuring that all breastfeeding mothers receive a discussion/ information on:
  • the importance of effective positioning and attachment;
  • how to recognise effective breastfeeding (signs relating to milk transfer and breast health) – and what to do if they have concerns;
  • the importance of demand feeding and recognition of feeding cues;
  • strategies for coping with night-time feeds;
  • using teats and dummies appropriately;
  • hand expression of breastmilk (including why it is a useful skill and the offer of an opportunity to learn how to do it);
  • maintaining breastfeeding when returning to work.
• The written training curriculum/a for staff with primary responsibility for supporting breastfeeding mothers to show how these staff are educated to acquire the skills necessary to teach mothers to position and attach their babies for breastfeeding and to hand express their breastmilk.
• Written information for new mothers to be accurate and effective, and free from advertising for breastmilk substitutes, bottles, teats and dummies.

NB: In order for staff to acquire the necessary skills to teach mothers how to position and attach their babies for breastfeeding, and to hand express breastmilk, we recommend classroom teaching, role plays and supervised practical skills reviews. The curriculum should include details of the type and length of any skills-based training provided.

*An sample form for assessing breastfeeding has been developed and is available for download in on the right-hand side of the page.

Requirements at Stage 2:

• Staff with responsibility for supporting breastfeeding mothers and babies to:
  • demonstrate how they would teach a mother to position and attach her baby for breastfeeding;
  • give a satisfactory description of how they would assess the sufficiency of milk intake in a baby;
  • demonstrate how they would teach a mother to hand express her breastmilk;
  • give a satisfactory description of the information they would give to a mother to enable her to continue to breastfeed on returning to work.

• Mothers to confirm that breastfeeding was reviewed at the first face-to-face contact with a community staff member and that the following were discussed (either at that time or soon afterwards):
  • the mother and baby’s current progress with breastfeeding
  • positioning and attachment for breastfeeding (its importance and the mother’s confidence with it)
  • how to recognise when breastfeeding is/is not going well (signs relating to milk transfer and breast health)
  • demand feeding and how to recognise feeding cues
    strategies for coping with night-time feeds
  • the appropriate use of teats and dummies
  • hand expression of breastmilk – both how to do it and its importance in the prevention and management of breastfeeding challenges such as engorgement and mastitis.