The following evidence-based recommendations for the pediatric outpatient practice should be considered as part of the practice-improvement process to increase breastfeeding rates to meet or exceed the AAP recommendations and the Healthy People 2020 goals. Next time you come, ask us how we implement each one!
Provide a lactation room with supplies for employees who breastfeed or express breast milk at work. This room could also be used by breastfeeding mothers. Collaborate with the entire team, including colleagues and office staff.
Trained staff in the skills necessary to support breastfeeding, especially nurses and medical assistants. The staff is aware of community resources, including IBCLCs and other lactation support personnel, especially if one is not available in the practice.
Knowledge regarding the rare but true contraindications to breastfeeding, which include infants with the classic form of galactosemia, maternal HIV or antiretroviral therapy, untreated active tuberculosis, human T-cell lymphotropic virus type I or II, use of illicit drugs, or mothers undergoing chemotherapy or radiation treatment. Most maternal medications are compatible with breastfeeding. Specific drug information can be verified through the National Institutes of Health Toxicology Data Network, LactMed, which is accessible online or through a mobile device application.
We introduce the subject of breastfeeding as early as possible, ideally with prenatal visits and early postpartum visits. We encourage attendance by both parents and/or partners at all visits, and consider discussions with grandparents or other important decision-makers in the family.
Encourage breastfeeding mothers to feed newborn infants only human milk and to avoid offering supplements, including formula, glucose water, or other liquids, unless medically indicated. This education ideally should begin prenatally, in anticipation of the newborn infant’s stay in the maternity hospital, and should continue through the early postnatal visits.
Work with committees within the local hospital or birthing center to implement breastfeeding-friendly care. Provide the hospital or birthing center with your office policies regarding breastfeeding. Show support for breastfeeding during hospital rounds by reinforcing the benefits of breastfeeding, encouraging exclusive breastfeeding, educating about the importance of frequent breastfeeding, and assessing the adequacy of breastfeeding. During rounds, either evaluate a feeding directly or review the chart for documentation of adequacy of feeding. Encourage mothers to attend breastfeeding classes. Advocate for lactation consultation for mothers who are experiencing any breastfeeding problems or who have concerns.
Schedule the first newborn visit by the third to fifth day of life, or approximately 24 to 48 hours from the time the newborn infant is discharged depending on the length of the hospital stay. At office visits, we incorporate anticipatory guidance that supports exclusive breastfeeding until infants are approximately 6 months old, followed by continued breastfeeding for 1 year or longer, as mutually desired by the infant and mother. Anticipatory guidance should include appropriate guidance about weight-gain expectations with the use of appropriate growth charts, such as the WHO growth standards for ages 0 to 2 years recommended by the CDC.
Educate mothers regarding the provisions of the Patient Protection and Affordable Care Act (Pub L No. 111-148 ), which cover access to breastfeeding support services, breaks to breastfeed or pump at work, as applicable, and the ability to obtain breast pumps through insurance.
Provide mothers with anticipatory guidance about returning to work. Workplace support in the pediatric practice and in other work environments can be optimized through the implementation of guidance from the Health Resources and Services Administration Maternal and Child Health Bureau’s Business Case for Breastfeeding. Provide information and education to mothers about both the expression and the storage of human milk, which may include providing parents with handouts detailing the recommendations regarding expression and storage.
Have the front office staff advise the family, when the first follow-up appointment is scheduled, that the pediatrician or other trained office staff may wish to observe a feeding during the first visit, so that the family will be aware. Encourage the family to let the staff know when the infant is ready to feed while waiting for the appointment. For the first and subsequent appointments, feedings should be observed when the mother identifies any breastfeeding problem, or if weight gain is not appropriate.
Provide appropriate educational resources for parents. These resources could cover, at a minimum, the benefits of breastfeeding for mother and child, AAP recommendations for duration of breastfeeding, education regarding feeding cues, how to tell whether the infant is getting enough milk, latch and holding techniques, and a list of peer support groups and local breastfeeding resources. The literature should be culturally sensitive and appropriate for the literacy of the patient population. Avoid distributing literature provided by manufacturers of infant formula.
Allow and encourage breastfeeding in the waiting room. Do not interrupt or discourage breastfeeding, either in the waiting room or in the examination room. Provide a comfortable, private area for mothers to breastfeed if they prefer privacy. An examination room may suffice as a private room for breastfeeding. This is what we use.
Eliminate the practice of distribution of free formula and other infant items from formula companies to parents. In accordance with the WHO International Code of Marketing of Breast-milk Substitutes, the storage of formula supplies, which may be purchased by the practice as applicable for formula-fed infants, should be out of the view of patients. The breastfeeding-friendly pediatric office practice should not accept gifts (formula and other feeding supplies, pens, writing pads, calendars, mugs, etc) from companies manufacturing infant formula, feeding bottles, or pacifiers. Consumer publications that advertise infant formula or have tear-off cards or inserts to receive free or discounted formula should be discouraged.
Train staff to follow telephone triage protocols to address breastfeeding concerns and problems. Train staff on providing appropriate breastfeeding telephone advice, including when to refer to an IBCLC or to a physician with special expertise in breastfeeding management. Telehealth consults.
Acquire or maintain a list of community resources and be knowledgeable about referral procedures. Refer expectant and new parents to peer, community support, and resource groups.Get to know peer and community support groups in your area. WIC breastfeeding support services, La Leche League International, and peer counselors are some options.
Frenulum clipping of the tongue/upper lip has become a popular practice, which may improve infant latch and the effectiveness of breastfeeding and milk transfer. We work closely with local lactation consultants or breastfeeding specialists to determine if frenotomy is appropriate.
Collaborate with the obstetric community to develop optimal breastfeeding support programs, because it is clearly documented that a mother’s decision to breastfeed starts in the prenatal period and, in many cases, before pregnancy.
Monitor breastfeeding initiation and duration rates in the pediatric practice. Be able to access state and national trends as tracked by the CDC through the National Immunization Survey and hospital practices through the Maternity Practices in Infant Nutrition and Care biannual survey data. #WBW2021 #WABA #ProtectBreastfeeding #SharedResponsibility #breastfeeding #SDGs #worldbreastfeedingweek2021 #ProtectBreastfeedingaSharedResponsibility #protectbreastfeedingtogether #buildingbackbetter #warmchain4breastfeeding #breastfeeding4publichealth