HomeMy WebLinkAboutbreastfeeding-pocket-guide BREASTFEEDING POCKET GUIDEfor Health Care Providers
BREASTFEEDING POCKET GUIDEfor Health Care Providers
Health care providers are an important source of
breastfeeding information. Breastfeeding provides unique
health benefits to infants and mothers. You and your staff
play a critical role in promoting exclusive breastfeeding
(no supplemental formula) and increasing the number of
days breastfeeding. Your counseling and support efforts
should start while patients are pregnant and continue
through the neonatal period and beyond.
This pocket guide has been developed to assist you in your
efforts to promote, support and protect mothers’ efforts
to breastfeed.
PRENATAL CARE
Encourage prenatal women to breastfeed
exclusively for six months and continue
after solids are introduced, up to
age one and beyond.1,2,3,4
What you say to expectant mothers
and their families can have a positive
influence on the decision to breastfeed. If
you recommend exclusive and continued
breastfeeding, more new mothers will
breastfeed for longer periods of time.
4
Prenatal breastfeeding education, starting in the
1st trimester, includes the following:5,6
• Exclusive breastfeeding for the first 6 months.
• Early skin-to-skin contact.
• Early initiation of breastfeeding.
• Rooming-in on a 24-hour basis.
• Feeding on demand or baby-led feeding.
• Frequent feeding to help assure optimal milk production.
• Effective positioning and attachment.
• Breastfeeding continues to be important after
6 months when other foods are given.
• Signs of effective breastfeeding or breastfeeding
problems.
• The benefits of breastfeeding to mother, baby,
and society.
• Resources for help with problems.
Breastfeeding Friendly Outpatient Care Settings:
For additional information on practices and policies that
support breastfeeding, see “The 9 Steps to Breastfeeding
Friendly: Guidelines for Community Health Centers and
Outpatient Settings” from the California Department of
Public Health.7
PRENATAL CARE | 5
PRENATAL CARE | 6
Mothers CAN breastfeed even if they…
• Have cesarean deliveries:
Recommend initiating breastfeeding immediately after
delivery by placing baby on mother’s chest. Later, mother
can breastfeed by using a semi-recumbent position or
side-lying position.
• Take medications:
According to the American Academy of Pediatrics
(AAP), only a small proportion of medications are
contraindicated in breastfeeding mothers or associated
with adverse effects on their infants.1, 8 The AAP
recommends LactMed as the most comprehensive, up-
to-date source of information regarding the safety of
maternal medications.9 https://www.toxnet.nlm.nih.gov/
newtoxnet/lactmed.htm. See also: Clinical Therapy in
Breastfeeding Patients.10
• Have had breast surgery such as augmentation,
reduction or biopsy:
Monitor infant growth as milk supply may be
compromised.11 Refer to an International Board Certified
Lactation Consultant (IBCLC) if there are supply issues.
• Have Hepatitis B:
Initiate breastfeeding immediately and follow up with
HBIG and the first dose of hepatitis B vaccine within
12 hours of birth.12
• Have Hepatitis C:
Initiate breastfeeding immediately after delivery. If the
mother has hepatitis B or C, breastfeeding technique
should be followed closely during the first couple of
weeks to avoid nipple damage. If nipples become cracked
or bleeding, temporarily stop breastfeeding, pump to
keep up milk supply and discard milk until wounds heal.12
Refer to an IBCLC for preventive measures.
• Have pierced nipples:
To avoid risk of choking, mother should remove nipple
accessories before feeding.
• Have an occasional alcoholic drink:
Avoid breastfeeding for two hours after a single serving
of alcohol.13
• Smoke cigarettes:
Mothers who smoke should quit, but it is better to
breastfeed than not. If a mother continues to smoke
while breastfeeding, the mother should smoke as little
as possible, wash hands and change clothes before
breastfeeding, smoke after breastfeeding rather than
before, and smoke out of the home and away from baby.
For more information and free help to quit smoking, call
1-800-NO-BUTTS.13, 14
• Have Tuberculosis (TB):
Breastfeeding is not contraindicated in women treated
with first-line antituberculosis medications since the
concentration in breast milk is too small to be toxic to
newborns. Breastfeeding is not advisable for women with
untreated, active TB.15
PRENATAL CARE | 7
• Use hormonal contraception:
Hormones can reduce milk supply but they will not harm
baby. It is best to avoid hormonal contraception until
mother is six weeks postpartum in order to establish the
milk supply.16
• Develop an infection:
Viruses are not transmitted through breastmilk during
acute maternal infections such as gastroenteritis, upper
respiratory infection and influenza. However, protective
maternal antibodies pass through breastmilk to the baby.
Infants MAY BE ABLE TO breastfeed even if they…
• Are born with challenging conditions such as prematurity
and/or are in the NICU.1, 17 If mother’s own milk is
unavailable despite significant lactation support,
pasteurized donor milk should be used.1
• Have cleft lip or cleft pallet.Babies should be evaluated
for breastfeeding on an individual basis. Breastmilk
feeding (via cup, spoon, bottle, etc.) should be promoted
in preference to artificial milk feeding.18
Mothers SHOULD NOT breastfeed if they…1, 2
• Are infected with HIV
• Are infected with HTLV (Human T-cell Lymphotropic Virus)
• Use illegal drugs
• Are receiving cancer chemotherapy agents that interfere
with DNA replication and cell division
PRENATAL CARE | 8
• Are receiving radiation therapies; however nuclear
medicine therapies require only a temporary interruption
• Have active herpes lesions on the breast, including
varicella (can breastfeed on other breast if lesion-free)
• Have an infant with galactosemia
• Have untreated, active TB (pumping and feeding
in a bottle is acceptable)
PRENATAL CARE | 9
AT THE HOSPITAL
Provide leadership in breastfeeding support
from delivery through discharge.
10
Baby-Friendly Hospital Initiative: Ten Steps to
Successful Breastfeeding
The Ten Steps to Successful Breastfeeding were developed
by a team of global experts and consist of evidence-based
hospital practices that have been shown to increase
breastfeeding initiation and duration. Baby-Friendly
hospitals and birthing facilities must adhere to the Ten
Steps to receive, and retain, a Baby-Friendly designation.19
The Ten Steps to Successful Breastfeeding are: 19
1. Have a written breastfeeding policy that is routinely
communicated to all health care staff.
2. Train all health care staff in the skills necessary to
implement this policy.
3. Inform all pregnant women about the benefits and
management of breastfeeding.
4. Help mothers initiate breastfeeding within one hour
of birth.
5. Show mothers how to breastfeed and how to maintain
lactation, even if they are separated from their infants.
6. Give infants no food or drink other than breast milk,
unless medically indicated.
7. Practice rooming in — allow mothers and infants to
remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no pacifiers or artificial nipples to
breastfeeding infants.
AT THE HOSPITAL | 11
10. Foster the establishment of breastfeeding support
groups and refer mothers to them on discharge from
the hospital or birth center.
All California hospitals that have a perinatal unit
are required to adopt the Ten Steps to Successful
Breastfeeding, the California Model Hospital Policy
Recommendations or an alternate process that includes
evidence-based policies, practices and targeted outcomes
by January 1, 2025.19, 20, 21
Immediately after delivery: 5
• All mothers should be given their infants to hold with
uninterrupted and continuous skin-to-skin contact
immediately after birth and until the completion of the
first feeding, unless there are documented medically
justifiable reasons for delayed contact or interruption.
• Routine procedures (e.g. assessments, Apgar scores,
etc.) should be done with the infant skin-to-skin with the
mother. Procedures requiring separation of the mother
and infant (bathing, for example) should be delayed until
after this initial period of skin-to-skin contact and should
be conducted, whenever feasible, at the
mother’s bedside.
• Skin-to-skin contact should be encouraged throughout
the hospital stay. If mother and infant are separated for
documented medical reasons, skin-to-skin contact should
be initiated as soon as mother and infant are reunited.
AT THE HOSPITAL | 12
Optimize breastfeeding by: 5
• Encouraging rooming-in to support on-demand feeds.
Inform the mother that unrestricted, frequent feedings
will help baby learn how to breastfeed and improve
milk supply.
• Assessing the mother’s breastfeeding techniques and,
if needed, demonstrating appropriate breastfeeding
positioning and attachment with the mother and infant,
optimally within 3 hours and no later than 6 hours
after birth.
• Encouraging exclusive breastfeeding with no bottles
and no supplementation unless there is a true
contraindication.
• Scheduling maternal procedures after breastfeeding
or arranging the use of hospital electric pump prior to
procedure if the mother will be away from baby for more
than 2 hours.
• Scheduling routine pediatric care and breastfeeding
follow-up visit on day 3 to 5 of life.
• Educating mothers on basic breastfeeding
practices including:
1. The importance of exclusive breastfeeding
2. How to maintain lactation for exclusive
breastfeeding for about 6 months
3. Criteria to assess if the infant is getting enough breast
milk, including signs of milk transfer, urine and stool
output, and growth
AT THE HOSPITAL | 13
4. How to express, handle, and store breast milk,
including manual expression
5. How to sustain lactation if the mother is separated
from her infant and will not be exclusively
breastfeeding after discharge
Education as the mother prepares to
go home: 1, 22, 23, 24, 25, 26
• Breastfeed when baby exhibits early hunger cues like
rooting, hands to mouth, increased movement and
sucking noises. Do not wait for baby to cry.
• Colostrum is rich, thick, small in volume, and all
baby needs.
• Feedings should be frequent, at least 10 times per 24
hours in the first few days after birth. Babies should
be aroused to feed if 4 hours have elapsed since the
beginning of the last breastfeeding.
• During growth spurts, the baby may want to feed
more frequently.
• Mother’s milk supply will increase and she may not feel
changes in her breast until day 3 or 4.
• Offer both breasts at a feeding until milk supply is
established. Alternating breasts if baby only takes
one breast at a feeding will help to establish a good
milk supply.
AT THE HOSPITAL | 14
• Time should not be limited at the breast. Healthy,
full-term babies will signal satiety by falling asleep, letting
go of the breast, or no longer actively sucking
and swallowing.
• Pacifiers and bottles can interfere with establishing
a good milk supply. They should be avoided until
breastfeeding is well-established, usually around 3–4
weeks postpartum.
• All new mothers need plenty of rest, nutrient-rich foods,
and help during the first few weeks.27
• Breastfeeding mothers should drink plenty of fluids
to stay hydrated (but fluid intake does not affect the
amount of breastmilk made). A common suggestion is to
drink a glass of water or other beverage every time the
mother breastfeeds.28
• If the mother has feelings of frustration, sadness, or
being disconnected from her baby, these should be
discussed with the health care provider.
AT THE HOSPITAL | 15
AFTER DISCHARGE
16
During Visits: 3, 22, 23
• Encourage exclusive breastfeeding for 6 months and
continued breastfeeding for at least one year.
• Observe breastfeeding for a good latch and
swallowing sounds.
• Encourage positions that support a good latch, such as
the “laid back” position where the mother leans back
in chair.
• Explore barriers, work through solutions, and
provide resources.
• Refer to lactation consultant and/or community
resources such as WIC and breastfeeding support groups.
• Discuss return-to-work plans:
»Breast pumps may be available through the patient’s
insurance including Medi-Cal. In select circumstances,
WIC may be able to supply a pump.
»The Lactation Accommodation Law protects
breastfeeding mothers returning to work and is
enforced by the Labor Commission. Employers are
required to provide break time and a clean, private
location, other than a toilet stall, to pump. Additional
time beyond usual breaks may be unpaid.29
AFTER DISCHARGE | 17
DIAGNOSIS CODES
18
Commonly used ICD-10 CM Codes for Baby 30
Feeding Problems
Bilious vomiting of newborn P92.01
Other vomiting of newborn P92.09
Regurgitation and rumination of newborn P92.1
Slow feeding of newborn P92.2
Underfeeding of newborn P92.3
Neonatal difficulty in feeding at breast P92.5
Other feeding problems of newborn P92.8
Feeding problem of newborn, unspecified P92.9
Vomiting, unspecified (>28 days old)R11.10
Projectile vomiting (>28 days old)R11.12
Bilious vomiting (>28 days old)R11.14
Jaundice
Neonatal jaundice associated with
preterm delivery P59.0
Neonatal jaundice from breast milk inhibitor P59.3
Neonatal jaundice from other specified causes P59.8
Neonatal jaundice, unspecified P59.9
DIAGNOSIS CODES | 19
Weight and Hydration
Dehydration of newborn P74.1
Hypernatremia of newborn P74.21
Hyponatremia of newborn P74.22
Hyperkalemia of newborn P74.31
Hypokalemia of newborn P74.32
Failure to thrive in newborn P92.6
Failure to thrive in child over 28 days old R62.51
Abnormal weight loss R63.4
Abnormal weight gain R63.5
Underweight R63.6
Infant Distress
Excessive crying of infant R68.11
Fussy infant R68.12
Colic R10.83
DIAGNOSIS CODES | 20
GI Issues
Change in bowel habit R19.4
Other fecal abnormalities R19.5
Diarrhea R19.7
Other specified symptoms and signs involving
the digestive system and abdomen R19.8
Mouth
Ankyloglossia Q38.1
Congenital malformations of palate
(high arched palate)Q38.5
Other
Encounter for follow-up examination after
completed treatment (When the original reason
for visit has resolved)
Z09
DIAGNOSIS CODES | 21
Commonly used ICD-10 CM Codes for Mother30
Breast and Nipple Issues
Candidiasis, breast or nipple B37.89
Impetigo, unspecified L01.00
Infection of nipple associated with the
puerperium O91.02
Infection of nipple associated with lactation O91.03
Abscess of breast associated with lactation/
Mastitis purulent O91.13
Nonpurulent mastitis associated with lactation O91.23
Retracted nipple associated with lactation O92.03
Cracked nipple associated with lactation O92.13
Other congenital malformations of breast
(ectopic or axillary breast tissue)Q83.8
Hyperesthesia (burning)R20.3
Constitutional
Circadian rhythm sleep disorder, irregular
sleep wake type G47.23
Sleep disorder, unspecified G47.9
Fatigue R53.83
DIAGNOSIS CODES | 22
Lactation
Agalactia O92.3
Hypogalactia O92.4
Suppressed lactation O92.5
Galactorrhea O92.6
Unspecified disorders of lactation O92.70
Galactocele (Other disorders of lactation)O92.79
Encounter for care and examination of lactating
mother (Excludes encounter for conditions
related to O92.-)
Z39.1
Other
Encounter for follow-up examination after
completed treatment (When the original
reason for visit has resolved)
Z09
HCPCS Codes for Breast Pumps
Breast pump, manual, any type E0602
Breast pump, electric (AC and/or DC), any type E0603
Breast pump, hospital grade, electric
(AC and/or DC) any type E0604
DIAGNOSIS CODES | 23
RESOURCES
24
RESOURCES | 25
References From Text
(All links accessed on December 16, 2020)
1.Breastfeeding and the Use of Human Milk. American
Academy of Pediatrics Policy Statement. Pediatrics
2012; 129 (3): e827–e841.
pediatrics.aappublications.org/content/pediatrics/
early/2012/02/22/peds.2011-3552.full.pdf
2.Breastfeeding, Family Physicians Supporting (Position
Paper). American Academy of Family Physicians. 2015.
https://www.aafp.org/about/policies/all/
breastfeeding-position-paper.html
3.American College of Obstetricians and Gynecologists.
Optimizing Support for Breastfeeding as Part of
Obstetric Practice, Committee Opinion. 2018; 756.
https://www.acog.org/clinical/clinical-guidance/
committee-opinion/articles/2018/10/
optimizing-support-for-breastfeeding-as-part-of-
obstetric-practice
4.How Doctors Can Help. Surgeon General’s Call to
Action to Support Breastfeeding 2000.
http://www.cdc.gov/breastfeeding/pdf/actionguides/
doctors_in_action.pdf
5.The Guidelines & Evaluation Criteria. Baby-Friendly
USA. 2016.
http://www.babyfriendlyusa.org/get-started/
the-guidelines-evaluation-criteria
RESOURCES | 26
6. Centers for Disease Control and Prevention. Strategies
to Prevent Obesity and Other Chronic Diseases: The
CDC Guide to Strategies to Support Breastfeeding
Mothers and Babies. Atlanta: U.S. Department of
Health and Human Services; 2013: 34.
http://www.cdc.gov/breastfeeding/pdf/
BF-Guide-508.PDF
7. California Department of Public Health. 9 Steps to
Breastfeeding Friendly: Guidelines for Community
Health Centers and Outpatient Care Settings. 2015.
http://www.calwic.org/storage/documents/
bf/2016/9StepGuide.pdf
8. The Transfer of Drugs and Therapeutics into Human
Breast Milk: An Update on Selected Topics. American
Academy of Pediatrics 2013.
http://pediatrics.aappublications.org/content/
early/2013/08/20/peds.2013-1985
9. LactMed. Drugs and Lactation Database. National
Institutes of Health. U.S. National Library of Medicine
Toxnet Toxicology Data Network.
https://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm
Updated Monthly | (LactMed has a free phone App)
10. Hale T, Berens P. Clinical Therapy in Breastfeeding
Patients. 3rd ed. Amarillo, TX: Hale Publishing; 2010.
11. Lawrence R, Lawrence R. Breastfeeding A Guide for
the Medical Profession. 8th ed. Philadelphia, PA:
Elsevier; 2016.
RESOURCES | 27
12. Centers for Disease Control and Prevention. Hepatitis
B and C Infections. Updated 2020.
https://www.cdc.gov/breastfeeding/disease/
hepatitis.htm
13. Reece-Stremtan S, Marinelli,KA. ABM clinical protocol
#21 Revised 2015: Guidelines for breastfeeding
and substance use or substance use disorder.
Breastfeeding Med. 2015; 10(3): 135–141.
https://www.bfmed.org/protocols
14. U.S. Department of Health and Human Services.
National Institutes of Health. National Cancer
Institute. Smokefree Woman.gov website.
http://women.smokefree.gov/for-health-
professionals.aspx
15. Centers for Disease Control and Prevention.
Tuberculosis and Pregnancy. Updated 2014.
https://www.cdc.gov/tb/topic/populations/pregnancy/
default.htm
16. ABM Clinical Protocol #13: Contraception During
Breastfeeding, Revised 2015. Breastfeeding Med.
2015; 10(1): 1–10.
www.bfmed.org/protocols
17. Boies E, Vaucher YE, and Academy of Breastfeeding
Medicine. ABM Protocol #10: Breastfeeding and Late
Preterm (34–36 6/7 Weeks of Gestation) and Early
Term Infants (37–38 6/7 Weeks of Gestation), Second
Revision 2016. Breastfeeding Med. 2016; 11(10):
494–500.
www.bfmed.org/protocols
18. Academy of Breastfeeding Medicine. ABM Clinical
Protocol #17: Guidelines for Breastfeeding Infants
with Cleft Lip, Cleft Palate, or Cleft Lip and
Palate. 2019.
www.bfmed.org/protocols
19. The Ten Steps to Successful Breastfeeding.
Baby-Friendly USA.
https://www.babyfriendlyusa.org/about-us/
baby-friendly-hospital-initiative/the-ten-steps
20. Breastfeeding Model Hospital Policy
Recommendations On-Line Toolkit. California
Department of Public Health.
Please do an internet search. Document currently is
under revision.
21. Senate Bill No. 402. Hospital breastfeeding support
law. 2013.
http://leginfo.legislature.ca.gov/faces/billNavClient.
xhtml?bill_id=201320140SB402
22. Clinician’s Guide: Suggested Questions to Assess
Breastfeeding in Primary Care Practice. American
Academy of Pediatrics. 2009.
http://www.aap.org/en-us/Documents/
Breastfeeding_SAMPLE.pdf
23. Meek JY, Hatcher AJ, AAP Section on Breastfeeding.
The Breastfeeding-Friendly Pediatric Office Practice.
Pediatrics. 2017;139(5):e2017064.
http://pediatrics.aappublications.org/content/
pediatrics/139/5/e20170647.full.pdf
RESOURCES | 28
24. Wight N, Marinelli K. Academy of Breastfeeding
Medicine. ABM Clinical Protocol #1: Guidelines
for Blood Glucose Monitoring and Treatment of
Hypoglycemia in Term and Late-Preterm Neonates,
Revised 2014. Breastfeeding Med. 2014; 9(4):173–179.
www.bfmed.org/protocols
25. Evans A, Marinelli KA, Taylor JS, Academy of
Breastfeeding Medicine. ABM Clinical Protocol #2:
Guidelines for Hospital Discharge of the Breastfeeding
Term Newborn and Mother: “The Going Home
Protocol,” Revised 2014. Breastfeeding Med. 2014;
9(1): 3–8.
www.bfmed.org/protocols
26. Walker, M. Breastfeeding Management for the
Clinician: Using the Evidence.4th ed. Burlington, MA:
Jones & Bartlett Learning; 2017: 261–262, 397–417.
27. Breastfeeding Basics for New Moms. Academy of
Nutrition and Dietetics. 2020.
https://www.eatright.org/health/pregnancy/breast-
feeding/breastfeeding-basics-for-healthy-babiesast-
feeding/breast-feeding-basics-for-healthy-babies
28. Office of Women’s Health, U.S. Department of
Health and Human Services. Your Guide to
Breastfeeding. 2018.
https://www.womenshealth.gov/patient-materials/
resource/guides
29. California Lactation Accommodation law. AB-1025
Labor Code, Chapter 3.8, [1030–1033] 2001.
http://leginfo.legislature.ca.gov/faces/billNavClient.
xhtml?bill_id=200120020AB1025
RESOURCES | 29
30. Supporting Breastfeeding and Lactation: The
Primary Care Pediatrician’s Guide to Getting Paid.
Current Procedural Terminology. American Medical
Association. 2020.
https://downloads.aap.org/AAP/PDF/coding_
breasfeeding_lacation.pdf
Additional Resources
Academy of Breastfeeding Medicine
Clinical Protocols
http://www.bfmed.org/
American Academy of Pediatrics
https://www.aap.org/en-us/Pages/Default.aspx
American Academy of Pediatrics Section on
Breastfeeding. Sample Hospital Breastfeeding
Policy for Newborns. 2009.
https://ihcw.aap.org/Documents/POPOT/PDFs/
hospital%20breastfeeding%20policy_final.pdf
Breastfeeding Support: Time and Space Solutions.
Office of Women’s Health.
http://www.womenshealth.gov/breastfeeding/
employer-solutions/common-solutions/support.html
California Department of Public Health—WIC Program
Breastfeeding Information for Health Care Providers
https://www.cdph.ca.gov/Programs/CFH/DWICSN/
Pages/HealthCareProviders.aspx
RESOURCES | 30
California WIC Association. 9 Steps to Breastfeeding
Friendly Clinics: An Online Toolkit for Implementation.
2016.
https://www.calwic.org/9-steps-to-breastfeeding-
friendly-clinics-online-toolkit/
International Board of Lactation Consultants
Find a Lactation Consultant
https://uslca.org/resources/find-an-ibclc
La Leche League
1-800-525-3243 (1-800-LaLeche)
http://www.llli.org
Mother’s Milk Bank, San Jose, California
https://mothersmilk.org/
Office of the Surgeon General. Centers for Disease
Control and Prevention; Office on Women’s Health.
The Surgeon General’s Call to Action to Support
Breastfeeding. Rockville, MD; 2011.
https://www.cdc.gov/breastfeeding/resources/
calltoaction.htm
Office of Women’s Health: Supporting Nursing Moms
at Work: Employer Solutions
http://www.womenshealth.gov/breastfeeding/
employer-solutions/
RESOURCES | 31
United States Breastfeeding Committee Core
Competencies in Breastfeeding Care and Services for
all Health Professionals. 2015.
http://www.usbreastfeeding.org/core-competencies
Acknowledgment for source material:
New York State Department of Health, Breastfeeding
Promotion Program and New York City Department of
Health and Mental Hygiene.
RESOURCES | 32
The Science of breastfeeding
medicine is an evolving field.
Please contact us if you have any suggestions regarding
the content of these materials at CDPHWICRBL@cdph.
ca.gov or 800-852-5770.
To contact your local WIC office please see
MyFamily.WIC.ca.gov
This document is considered a resource, but does not define the standard of
care in California. Readers are advised to adapt the guidance based on their
local facility’s level of care and patient population served and also are advised
to not rely solely on the guidelines presented here.
California Department of Public Health, California WIC Program
This institution is an equal opportunity provider.
1-800-852-5770 | MyFamily.WIC.ca.gov
Rev 02/21