Maryland Hospital Breastfeeding Policy Recommendations

Maryland

Hospital Breastfeeding Policy

Recommendations

October 2012

Martin O’Malley, Governor

Anthony G. Brown, Lt. Governor

Joshua M. Sharfstein, M.D., Secretary

Maryland Hospital Breastfeeding Policy Recommendation Committee

Jacqueline Marlette-Boras, MHS, RD, LDN

Director

Maryland WIC Program

Maternal and Child Health Bureau

Maryland Department of Health and Mental Hygiene

Amy Resnik, MS, RD, CSP, LDN, IBCLC

Breastfeeding Coordinator

Maryland WIC Program

Maternal and Child Health Bureau

Maryland Department of Health and Mental Hygiene

Bonnie S. Birkel, CRNP, MPH

Acting Director

Maternal and Child Health Bureau

Maryland Department of Health and Mental Hygiene

Nadine Rosenblum, RN, BSN, IBCLC

Master of Nursing Community/Public Health

Candidate

University of Maryland School of Nursing

Maura Dwyer, DrPH, MPH

Health Policy Analyst

Office of Family Planning and Home Visiting

Maternal and Child Health Bureau

Maryland Department of Health and Mental Hygiene

Sherri Sabol, RD, LDN, CLC

Chief, Breastfeeding Services

Maryland WIC Program

Maternal and Child Health Bureau

Maryland Department of Health and Mental Hygiene

Erin Penniston, MSW

Program Manager

Community Transformation Grant Center for Chronic

Disease Prevention and Control

Cancer and Chronic Disease Bureau

Maryland Department of Health and Mental Hygiene

S. Lee Woods, MD, PhD

Director

Office of Surveillance and Quality Initiatives

Maternal and Child Health Bureau

Maryland Department of Health and Mental Hygiene

Rachel Ready, MPP

Health Policy Analyst

Maryland WIC Program

Maternal and Child Health Bureau

Maryland Department of Health and Mental Hygiene

Supporting Breastfeeding in Maryland

Introduction

DHMH encourages all birthing hospitals in the State to become “Maryland Best Practices Hospitals,” by

either attaining Baby Friendly certification through the Baby Friendly Hospital Initiative (BFHI) the details

of which are available at http://www.babyfriendlyusa.org/eng/o1.html, or, by meeting the ten criteria

contained in these policy recommendations, described in detail further below. A hospital may choose to

implement none of these criteria, or, it may choose to fulfill one or more of these criteria. If a hospital

chooses to satisfy all ten of the criteria in these policy recommendations, then the hospital will be

considered a “Maryland Best Practices Hospital.”

Background

There is extensive scientific evidence that breast milk is the optimal food for infants. The American

Academy of Pediatrics recommends that babies receive nothing but breast milk for the first 6 months of

life and continue breastfeeding for at least one year. Many other professional organizations encourage

breastfeeding, including the American College of Obstetricians and Gynecologists, the American

Academy of Family Physicians, the American College of Nurse-Midwives, the American Hospital

Association, the National Association of Pediatric Nurse Practitioners, the Association of Women’s

Health, Obstetrics and Neonatal Nurses, the United States Breastfeeding Committee and the Academy

of Nutrition and Dietetics, formerly the American Dietetic Association.

While breastfeeding initiation is the essential first step, duration and exclusivity are key to obtaining the

myriad of benefits to public health and society provided through breastfeeding. Babies who are fed

formula or stop breastfeeding early have higher risks of obesity, diabetes, respiratory and ear infections,

and sudden infant death syndrome (SIDS), and tend to require more doctor visits and hospitalizations.

Every two years, CDC administers the national Maternity Practices in Infant Nutrition and Care (mPINC)

http://www.cdc.gov/breastfeeding/data/mpinc/index.htm survey to all hospitals and birth centers in

the U.S. that provide maternity care. The 2009 mPINC survey, showed both strengths and areas for

improvement related to breastfeeding support in Maryland hospitals and concluded, “Improvement is

needed in maternity care practices and policies in Maryland. Many opportunities exist to protect,

promote, and support breastfeeding mothers and infants in Maryland.” Other CDC data, summarized in

the CDC Breastfeeding Report Card for 2012, http://www.cdc.gov/breastfeeding/data/reportcard.htm

further define the current status of breastfeeding support in Maryland. With 72.6 percent of babies in

Maryland who are counted as “ever breastfed,” Maryland has work to do to reach the 2020 Healthy

People goal of 81.9 percent. Beyond initiation, Maryland’s numbers fall short with only 48.5% of babies

breastfed at six months of age and only 15.0% exclusively breastfed. The 2020 goals are 60.6% and

25.5%, respectively.

iii

Barriers to breastfeeding exclusivity and duration have been extensively reported in the literature, and

several common themes have been identified. The main reasons mothers give for stopping

breastfeeding before 3 months of age are perceived lack of breast milk supply, pain, infants given infant

formula in the hospital, and technical difficulties such as infant latching problems and sore nipples.

Breastfeeding decisions are influenced by many factors, including a mother’s initial breastfeeding

experience, family support, challenges on returning to work or school, and community support. In the

United States, most babies are born in a hospital, and mother and baby have their first feeding

experience in that setting. A mother’s comfort with breastfeeding and her commitment to continue can

be greatly influenced by hospital practices and staff support. First impressions have a lasting effect on

subsequent behavior, making the birthing hospital stay a critical opportunity to impact breastfeeding

success. It has been demonstrated that hospitals that adopt a series of policies and become designated

as Baby-Friendly are able to increase breastfeeding rates substantially.

14, 16

The Process

Recognizing the vital role that hospitals play in the success of breastfeeding, the Maryland Department

of Health and Mental Hygiene (DHMH) formed a committee to develop breastfeeding policy

recommendations that will strengthen and improve current maternity care practices. A stakeholders’

meeting was held in December 2011 to obtain input. The first edition recommendations were posted on

the DHMH website for public comment in February 2012. Over 130 comments were received in this first

round and shared with the Committee. 56% of the respondents strongly agreed and 30% agreed that

the policy recommendations focused on correct strategies to promote and support breastfeeding. The

second edition recommendations were post on the DHMH website for public comment in August 2012.

34 comments were received and reviewed by the Committee. 85% of the respondents agreed with the

updated policy recommendations. In September 2012, the Committee finalized the policy

recommendations and hospital self-assessment form. These policy recommendations, based on the

WHO/UNICEF Ten Steps to Successful Breastfeeding, http://www.unicef.org/newsline/tenstps.htm

include evidence-based hospital practices that increase rates of breastfeeding initiation, duration, and

exclusivity for healthy, full term infants whose mothers have chosen to breastfeed them.

Summary of Maryland Hospital Breastfeeding Policy Recommendations

The “Maryland Best Practices Hospitals” will:

#1: Have a written breastfeeding policy that is routinely communicated to all hospital staff.

#2: Train all hospital staff in the skills necessary to implement this policy.

#3: Inform all pregnant women about the benefits and management of breastfeeding.

#4: Help breastfeeding mothers initiate breastfeeding within 1 hour of birth.

#5: Encourage breastfeeding on demand.

#6: Show breastfeeding mothers how to breastfeed and how to maintain lactation, even if they

are separated from their infants.

#7: Practice “rooming in” – encourage breastfeeding mothers and infants to remain together 24

hours a day.

#8: Give breastfed infants no food or drink, other than breast milk, unless medically indicated.

#9: Give no pacifiers or artificial nipples to breastfeeding infants in the hospital, unless

medically indicated.

#10: Foster the establishment of breastfeeding support groups and refer breastfeeding mothers

to them on discharge from the hospital or clinic.

Department of Health and Mental Hygiene | Maryland Hospital Breastfeeding Policy Recommendations

#1 – Have a written breastfeeding policy that is routinely communicated to all

hospital staff.

Criteria

a. Create an interdisciplinary team (hospital administrators, physician and nursing staff, lactation

consultants and specialists, nutrition staff, other appropriate staff, and parents) to develop and

review breastfeeding policies annually.

b. Communicate policy to all hospital staff who provide care for breastfeeding mothers and their

infants.

c. Post breastfeeding policy in appropriate form, as per established hospital guidelines.

d. Create a comprehensive breastfeeding policy addressing all UNICEF/WHO Ten Steps to

Successful Breastfeeding, consistent with the International Code of Marketing of Breast Milk

Substitutes. Link: www.who.int/nutrition/publications/infantfeeding/9241541601/en/

References: 1, 5, 8, 9, 15, 17, 18, 19, 20, 21, 22

#2 – Train all hospital staff in the skills necessary to implement this policy.

Criteria

a. Designate at least one hospital staff member, who is trained in breastfeeding physiology and

management, to be responsible for ensuring the implementation of an effective breastfeeding

training program based on training resources provided by DHMH or curriculum developed by

the facility.

b. Require all hospital staff with primary responsibility for the direct care of mothers and their

infants during the neonatal period to complete training on breastfeeding physiology and

management, with annual updates. Curriculum developed by the facility or resources provided

by DHMH may be used.

c. Require all providers who have privileges to provide care to new breastfeeding mothers and/or

newborn infants to complete training with annual updates in breastfeeding promotion and

lactation management. DHMH will provide information on training resources or curriculum

developed by the facility may be used.

d. Employ at least one hospital maternity staff member who is an International Board Certified

Lactation Consultant (IBCLC) with designated time to focus on breastfeeding.

e. Expect hospital staff (including support staff), who come in contact with pregnant women,

breastfeeding mothers, and newborns, to provide positive messages about breastfeeding.

References: 1, 2, 4, 5, 8, 9, 11, 15, 17, 18, 19, 20, 21, 22

Department of Health and Mental Hygiene | Maryland Hospital Breastfeeding Policy Recommendations

#3 – Inform all pregnant women about the benefits and management of

breastfeeding.

Criteria

a. Assure the availability of prenatal childbirth education classes that provide structured

breastfeeding information, taught by an International Board Certified Lactation Consultant (if

possible), for all women pre-registered to deliver at the facility.

b. Provide pregnant women with complete and commercial-free information about the benefits of

breastfeeding for mother and baby, contraindications to breastfeeding, and management of

breastfeeding so an informed feeding decision can be made.

c. Recommend exclusive breastfeeding as the ideal nutrition for newborns, unless medically

contraindicated.

References: 1, 2, 4, 17

References: 1, 2, 8, 17

#4 – Help breastfeeding mothers initiate breastfeeding within 1 hour of birth.

Criteria

a. Promote and support early breastfeeding (within 1 hour of birth) in the delivery room and/or

recovery area.

b. Encourage babies to be placed skin-to-skin on breastfeeding mother’s chest as the preferred

source of body warmth, unless medically contraindicated. Delay the administration of vitamin K

and eye ointment and the measurement of weight and length for the first hour after birth to

support uninterrupted mother-infant contact and breastfeeding, if possible.

c. Encourage breastfeeding mothers to exclusively breastfeed throughout the hospital stay, unless

medically contraindicated.

d. Inform a breastfeeding mother when breastfeeding is medically contraindicated including:

 the specific contraindication

 whether she can save expressed breast milk during that time or if she should discard it

and

 what criteria need to be met before she can resume breastfeeding.

Department of Health and Mental Hygiene | Maryland Hospital Breastfeeding Policy Recommendations

#5 – Encourage breastfeeding on demand.

Criteria

a. Encourage and support breastfed infants to be fed on demand. The frequency and duration of

breastfeeding should be infant-led, based on each infant’s early feeding cues, at least 8 in 24

hours after the first day of life. Emphasize the normalcy of frequent night feedings.

b. If the medical condition of both mother and baby allows, make every effort to arrange for a

separated mother and infant to be together for feedings.

c. Teach breastfeeding mothers feeding cues and encourage each mother to feed as soon as her

infant displays early infant feeding cues.

d. Document all feedings in the infant’s medical record.

e. Have a visitation policy that allows a baby to be a visitor in the breastfeeding mother’s room

when the mother is a patient outside of the maternity area.

References: 1, 2, 8, 17

Department of Health and Mental Hygiene | Maryland Hospital Breastfeeding Policy Recommendations

References: 1, 2, 4, 17

#6– Show breastfeeding mothers how to breastfeed and how to maintain

lactation, even if they are separated from their infants.

Criteria

a. Provide instruction and assistance to each breastfeeding mother to facilitate lactation.

b. Provide breastfeeding mothers with information on how to obtain help from a hospital staff

member trained in breastfeeding support and breast milk expression.

c. When feeding at breast is not possible, make every effort to have the baby receive his/her

mother’s expressed milk until medically able to breastfeed.

d. If a breastfeeding mother or baby is re-hospitalized after the initial delivery stay, make every

effort to continue to support breastfeeding.

e. Ensure that at least one hospital staff member, trained in breastfeeding management, is

available at all times to assist breastfeeding mothers.

f. Instruct all breastfeeding mothers, provide written information, and observe for ability to:

 Position the baby correctly at the breast

 Latch the baby to breast properly

 State when the baby is swallowing milk

 State that the baby should be nursed a minimum of 8 to 12 times a day, with some

infants needing to be fed more frequently

 State age-appropriate elimination patterns

 List indications for calling a healthcare professional

 Manually express breast milk

 State appropriate use of pacifiers (after breastfeeding is well established) to reduce the

risk of SIDS.

g. Assist breastfeeding mothers, who require extended pumping, to obtain a medical order for an

appropriate breast pump and provide a list of community resources for obtaining a breast

pump.

h. Instruct breastfeeding mothers on proper handling, storage, and labeling of breast milk.

i. The hospital will provide individual instruction in formula preparation and feeding techniques

for mothers who have chosen formula feeding or for whom breastfeeding is medically

contraindicated.

Department of Health and Mental Hygiene | Maryland Hospital Breastfeeding Policy Recommendations

References: 1, 2, 8, 17

#8 – Give breastfed infants no food or drink, other than breast milk, unless

medically indicated.

Criteria

a. Do not give sterile water, glucose water or formula to a breastfed infant without a health care

provider’s order or the mother’s request after education. Discuss the potential negative impact

sterile water, glucose water, formula or feeding these with a bottle nipple may have on

breastfeeding success.

b. Document a woman’s desire to breastfeed in her medical record, her infant’s medical record,

and on her infant’s bassinet.

c. Provide and document education about the use of supplementation and its possible negative

impact on the establishment of breastfeeding so breastfeeding mothers can make an informed

decision about supplementation. After making an informed decision, the breastfeeding mother’s

choice will be respected and supported by the hospital staff.

d. Do not accept free formula, advertisements, or formula coupons for use in the hospital or

distribution to breastfeeding mothers.

e. Store formula and supplies for formula feedings in a medication cart or separate storage space

out of view to patients.

References: 1, 2, 6, 8, 13, 17

#7 – Practice “rooming in” – encourage breastfeeding mothers and infants to

remain together 24 hours a day.

Criteria

a. Establish rooming-in for each breastfeeding dyad throughout the hospital stay, unless medically

contraindicated.

b. Perform medical procedures in the mother’s room when possible and practical.

Department of Health and Mental Hygiene | Maryland Hospital Breastfeeding Policy Recommendations

#9 – Give no pacifiers or artificial nipples to breastfeeding infants in the

hospital, unless medically indicated.

Criteria

a. Do not offer pacifiers or artificial nipples to healthy, full-term breastfed infants in the hospital

while breastfeeding is being established.

b. Inform breastfeeding mothers that the use of pacifiers and artificial nipples in the hospital could

have a negative impact on the establishment of breastfeeding. After making an informed

decision, the breastfeeding mother’s choice will be respected and supported by the hospital

staff.

c. Use skin-to-skin contact and breastfeeding during procedures requiring soothing and pain relief.

d. Do not accept free or low-cost pacifiers.

References: 1, 2, 3, 7, 8, 10, 12, 17

#10 – Foster the establishment of breastfeeding support groups and refer

breastfeeding mothers to them on discharge from the hospital.

Criteria

a. Provide breastfeeding mothers with information about breastfeeding resources in their

communities, including information on availability of breastfeeding consultants, support groups

and breast pumps, if applicable.

b. Refer current participants and potential income-eligible women to the Supplemental Nutrition

Program for Women, Infants and Children (WIC) for additional breastfeeding support.

c. When indicated, provide the family with a written feeding plan, developed in collaboration with

the health care team, with appropriate follow-up recommended.

References: 1, 2, 8, 17

Department of Health and Mental Hygiene | Maryland Hospital Breastfeeding Policy Recommendations

References

1. Academy of Breastfeeding Medicine Clinical Protocol #7 (ABM #7): Model Breastfeeding Policy

(Revision 2010). Breastfeeding Medicine, Volume 5, Number 4, 2010.

http://www.bfmed.org/Resources/Protocols.aspx

2. American Academy of Pediatrics Policy Statement (2012). Breastfeeding and the Use of Human

Milk, Pediatrics, 129(4): e827-e841.

3. Barros, F. C., Victoria, C. G., Semer, T. C., Filho, S. T., Tomasi, E., & Weiderpass, E., (1995).

Use of pacifiers is associated with decreased breastfeeding duration. Pediatrics, 95(4):

497-499.

4. Chezem, J., Friesen, C., & Boettcher, J. (2003). Breastfeeding knowledge,

breastfeeding confidence, and infant feeding plans: Effects on actual feeding

practices. Journal of Obstetric, Gynecologic and Neonatal Nursing, 32(1): 40-47.

5. Declercq, E., Labbok, M., Sakala, C., & O’Hara, M. (2009). Hospital Practices and Women’s

Likelihood of Fulfilling Their Intention to Exclusively Breastfeed. American Journal of Public

Health, 99(5): 929-935.

6. DelliFraine, J., Langabeer, J., Williams, J., Gong, A., Delgado, R., & Gill, S. (2011). Cost

Comparison of Baby Friendly and Non-Baby Friendly Hospitals in the United States. Pediatrics,

127(4): e989-e994.

7. Dewey, K.G., Nommsen-Rivers, L.A., Heinig, J., Cohen, R.J. (2003). Risk Factors for Suboptimal

Infant Breastfeeding Behavior, Delayed Onset of Lactation, and Excess Neonatal Weight Loss.

Pediatrics, 112(3): 607-619.

8. DiGirolamo, A. M., Grummer-Strawn, L. M., & Fein, S. (2008). Effect of Maternity-Care

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9. DiGirolamo, A. M., Grummer-Strawn, L. M., & Fein, S. (2001). Maternity care

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10. Hauck, F.R., Omojokun, O.O., & Siadaty, M.S. (2005). Do Pacifiers Reduce the Risk of Sudden

Infant Death Syndrome? A Meta-analysis. Pediatrics, 116(5): e716-e723.

11. Hospital Support for Breastfeeding: Preventing Obesity Begins in Hospitals. CDC Vitalsigns;

August 2011. http://www.cdc.gov/VitalSigns/Breastfeeding/index.html

12. Kramer M. S., Barr, R.G., Dagenais, S., Yang, H., Jones, P., Ciofani, L. & Jane F.

(2001). Pacifier use, early weaning, and cry/fuss behavior: A randomized controlled

trial. Journal of the American Medical Association, 286(3): 322-326.

Department of Health and Mental Hygiene | Maryland Hospital Breastfeeding Policy Recommendations

13. Martin-Calama, J., Bunuel, J., Valero, M. T., Labay, M., Lasarte, J. J., Valle, F., et al.

(1997). The effect of feeding glucose water to breastfeeding newborns on weight,

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Successful Breastfeeding. Sandwich, MA: Baby-Friendly USA, 2004.

http://www.babyfriendlyusa.org/eng/docs/BFUSAreport_complete.pdf

16. Philipp B.L., Merewood A., Miller L.W., Chawla N., Murphy-Smith M.M., Gomes J.S., Cimo

S., & Cook J.T. (2001). Baby-Friendly Hospital Initiative Improves Breastfeeding Initiation Rates in

a US Hospital Setting. Pediatrics, 108(3): 677-681.

17. Sample Hospital Breastfeeding Policy for Newborns. Safe and Healthy Beginnings: A Resource

Toolkit for Hospitals and Physicians’ Offices. American Academy of Pediatrics; 2009.

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Care Core Measure on Exclusive Breast Milk Feeding. Revised. Washington, DC: United States

Breastfeeding Committee, 2010.

http://www.usbresatfeeding.org/HealthCareSystem/HospitalMaternityCenterPractices/ToolkitI

mplementingTJCCoreMeasure/tabid/184/Default.aspx

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Breastfeeding. Washington, DC: U.S. Department of Health and Human Services, Office of the

Surgeon General; 2011. http://surgeongeneral.gov

20. World Health Organization. (1981). International Code of Marketing of Breast-milk Substitutes

(Document WHA34/1981/REC/1, Annex 3). Geneva, Switzerland: World Health Organization;

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Expanded for Integrated Care. World Health Organization, UNICEF, 2009.

http://www.unicef.org/newsline/tenstps.htm

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