Breastfeeding, Dietary supplementation, Maternal skin-to-skin contact, Pacifiers, Rooming-in



  1. Smith, Pat Bohling MS, RNC
  2. Moore, Karen MSN, RNC, IBCLC
  3. Peters, Liz BSN, RNC, CLC


Abstract: Breastfeeding is widely viewed as the optimal feeding method for infants among professional nursing and medical organizations. Its health benefits have been comprehensively studied and documented for both infants and mothers. Hospitals and birthing centers can strongly influence the outcomes for mothers who choose to breastfeed by establishing effective breastfeeding behaviors immediately after birth and during the hospital stay. The Baby-Friendly USA initiative outlines 10 steps to successful breastfeeding. Although these steps have been successfully supported in practice, they can be difficult to implement due to a variety of factors, including resistance to change. Specific steps generate more barriers to overcome than others-namely exclusive breastfeeding without supplementation or pacifiers, rooming-in for 23 out of 24 hours, and skin-to-skin contact with a parent immediately after birth and during the hospital stay. Our hospital spent 5 years implementing Baby-Friendly practices to prepare for a successful site visit. In the process, barriers to key Baby-Friendly steps were overcome through creative approaches and strategic education for staff, physicians, and parents. The purpose of this article is to outline specific actions taken that assisted our hospital in its successful journey. Those actions and strategies will hopefully be of value to others in their journey toward designation.


Article Content

Overwhelming scientific evidence shows that breast milk is the ideal food for infants, providing numerous benefits for both the infant and the mother. It is well documented that breastfed infants experience significantly lower rates of diabetes, childhood leukemia, necrotizing enterocolitis, and sudden infant death syndrome (American Academy of Pediatrics, 2012). Infants also experience lower incidences of respiratory infections, otitis media, and diarrhea (Ip, Chung, Raman, Trikalinos, & Lau, 2009). Mothers who breastfeed experience a lower risk for breast cancer, ovarian cancer, and type 2 diabetes (Ip et al.). Today, breastfeeding is recognized as the optimal source of nutrition by most professional organizations (United States Department of Agriculture, Food and Nutrition Service, Breastfeeding Promotion Consortium, 2010).

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Often the key to sustained breastfeeding is offering a good start at the hospital or birthing center. Maternal child nurses have a significant role in helping new mothers establish effective breastfeeding behaviors. If barriers to breastfeeding are removed in the birthing room, it has been shown women will successfully initiate breastfeeding (Komara et al., 2007). When hospitals institute five key practices that promote breastfeeding (breastfeeding within 1 hour of birth, exclusive breastfeeding, rooming-in, no pacifiers, and providing mothers with resources for breastfeeding support), the rate of mothers who initially breastfeed and continue breastfeeding increases substantially. A population-based study of Colorado hospitals showed that 68% of mothers who experienced these five key practices in the hospital setting were still breastfeeding at 16 weeks versus 53% of mothers who did not (Murray, Ricketts, & Dellaport, 2007).


According to the most recent data from the Centers for Disease Control and Prevention (CDC), 75% of new mothers initiate breastfeeding, but only 13% of infants are breastfed exclusively for 6 months and only 22% of that group continue some breastfeeding to 1 year (CDC, 2011). The Healthy People 2020 targets aim to increase these rates to 81.9% initiating breastfeeding, 23.7% breastfeeding exclusively through 6 months, and 34.1% continuing at 1 year (U.S. Department of Health and Human Services, 2010).


To address these lower-than-desired rates of initial and continued breastfeeding, UNICEF (United Nations Children's Fund) and the WHO (World Health Organization) joined forces to create the Baby-Friendly Hospital Initiative (BFHI) in 1997. The initiative outlines 10 steps to successful breastfeeding for hospitals and includes a rigorous process of implementing the 10 steps and an on-site survey to receive designation. Research shows that a Baby-Friendly USA hospital designation substantially increases the rates of initial breastfeeding (from 58% to 87% for one of the first participating hospitals) and increases rates of exclusive breastfeeding, rooming-in, and patient satisfaction for participating hospitals (Philipp et al., 2001). Mothers who experienced six Baby-Friendly practices were 13 times more likely to continue breastfeeding than mothers who experienced none (DiGirolamo, Grummer-Strawn, & Fein, 2009). As of December 22, 2011, there are 225 hospitals in the United States that have achieved the designation.


Despite the fact that Baby-Friendly practices have been shown to increase breastfeeding rates significantly, the majority of hospitals in the United States have not yet implemented the Ten Steps (Merewood, Mehta, Chamberlain, Philipp, & Bauchner, 2005). This can be attributed to a variety of factors, as was experienced at our hospital. While information was shared about how use of the BFHI USA 10 steps could positively affect breastfeeding rates at birth and in infancy, adjusting to the changes in practice proved difficult for some nurses and physicians. Addressing these challenges through policy revisions, staff education, and ongoing training helped in implementing Baby-Friendly practices. The greatest opportunities for change came when promoting exclusive breastfeeding, rooming-in, and providing skin-to-skin time shortly after birth.


Strategies for Success: Education

Baby-Friendly USA guidelines ask caregivers to reverse age-old ideas of sending infants to the nursery so mothers can sleep, supplementing breastfeeding with formula until lactation is established, offering pacifiers, and separating healthy mothers and babies during the hospital stay. Many caregivers and nurses have spent their careers carrying out these practices, making the changing of existing habits, policies, and protocols a daunting task. Specific strategies to implement new practices go a long way in turning around both the perception and actions of staff and physicians.


Becoming a Baby-Friendly hospital requires changes in practice for both nurses and physicians. To begin, we formed a Baby-Friendly committee to update policies and standards of care to reflect Baby-Friendly USA requirements. A key policy titled Feeding for the Medically Stable Term Infant was created; it states that department staff will "actively support breastfeeding as the preferred method of providing nutrition to infants" and all staff will be educated on the Baby-Friendly 10 steps. A study of Oregon hospitals shows that having a written policy on breastfeeding and educating staff on that policy are key factors in establishing breastfeeding and having it continue to 2 weeks postpartum (Rosenberg, Stull, Adler, Kasehagen, & Crivelli-Kovach, 2008).


Along with the new policy, caregivers were initially educated on Baby-Friendly practices in a variety of ways. Nurses were required to complete 18 hours of education on breastfeeding benefits and practices. A variety of opportunities were available for nurses to meet this requirement. A goal was set to have 100% of the leadership team (such as patient care coordinators and clinical educators) trained as Certified Lactation Consultants by the end of the 5-year process of becoming a Baby-Friendly hospital. Although the majority of the leadership team is certified, this remains an ongoing challenge with staff changing roles. The expectation is certification within 2 years of assuming a leadership role within the department. Today the overall rate of Certified Lactation Counselors for staff nurses and the leadership team within the women and family service line is at 27%. Within the mother-baby unit the certification rate is 54%.


To continue to educate nurses on Baby-Friendly policies and procedures, the following education opportunities are currently in place:


* An 8-hour didactic breastfeeding class offered twice a year and required for new staff.


* Orientation that includes 4 to 8 hours of supervised clinical experience with a member of the Lactation Program.


* Baby-Friendly USA requirements and education integrated into ongoing nursing competency training, which includes periodic skills instruction on manual expression, latch on, spoon feeding, and pumping techniques.


* Criterion checklists to assess competency of staff and offer a method of self-assessment on breastfeeding practices.


* Resources for nurses such as examples of "consistent messaging" that use key phases when educating parents on topics such as rooming-in or exclusive breastfeeding. Tip sheets and self-learning packets are also used to standardize practice among staff.


* Posters on the 10 Steps to Baby-Friendly displayed throughout units and in areas where mothers/infants are cared for in the organization.


* Successful breastfeeding and pacifier education tip sheets created for parents and used by staff when educating parents.


* Breastfeeding policy posted on the intranet and available to all staff and providers.


* Breastfeeding benefits and techniques available on Healthlink (electronic health information for patients).



In addition to nurse education, physicians were educated on the revised breastfeeding policy, the benefits of breastfeeding and evidence-based management techniques. Physicians were also invited to a 3-hour training presented by Baby-Friendly USA at the beginning of the hospital's 5-year journey to become a Baby-Friendly hospital. Ongoing education geared to physicians is offered annually. Physicians are specifically educated on avoiding supplementation and pacifiers, the importance of skin-to-skin time immediately after birth, and rooming-in.


According to Bond (2009), the most difficult Baby-Friendly 10 Steps to implement are (1) having a written breastfeeding policy, (2) educating staff on the benefits of breastfeeding, and (3) avoiding supplementation unless medically necessary. However, as more steps are implemented, there is better chance of increasing breastfeeding rates.


Strategies for Success: Exclusive Breastfeeding

All of the Baby-Friendly steps to successful breastfeeding support exclusive breastfeeding. Some steps are harder to implement than others; these include Step 6: Give infants no food or drink other than breastmilk unless medically indicated and Step 9: Give no pacifiers or artificial nipples to breastfeeding infants (Baby-Friendly USA, Inc., 2010).


While implementing the Baby-Friendly initiative, our hospital came across specific barriers to Step 6. Prior to the change to Baby-Friendly policies, mothers were allowed to supplement on request. In addition, if a mother or infant was having trouble breastfeeding, staff and physicians would suggest supplementing with formula until breastfeeding was established. Also, the hospital distributed diaper bags at discharge that included formula samples, thereby promoting the use of formula.


Some nurses promoted supplementation with formula when the infant was not voiding adequately, had a weight loss greater than 10%, or displayed symptoms of hypoglycemia. Other mothers may want to supplement because they desire to sleep during the night or perceive their infant is not receiving enough nutrition. Additionally, there are some cultures that endorse formula feeding shortly after birth (Komara et al., 2007).


Step 3 of the Baby-Friendly initiative is that mothers of all healthy infants should be encouraged to breastfeed and receive information on the benefits of breastfeeding. Mothers still have a choice of how to feed their babies, but if their choice is not to breastfeed, nurses at the hospital provide education related to the benefits of breastfeeding (Table 1). If the mother's decision remains the same, nurses document that education on the benefits of breastfeeding was provided. For mothers who chose to formula feed, appropriate education is provided.

Table 1 - Click to enlarge in new windowTable 1 The Ten Steps to Successful Breastfeeding

Table 2 shows results of a Top Box survey that indicates mothers at our hospital felt strongly that they learned how to "properly feed their babies" compared to other hospitals nationwide. Top Box is the percent of parents who gave a score of five or "strongly agree" to a question on the survey. Although mothers of comparison hospitals in the Top Box database indicated this was true 71.88% of the time, at our hospital mothers felt it was true 79.07% of the time in 2011. This reveals a nearly 12% increase from 2007 for the hospital when Baby-Friendly techniques were fairly new. Although 12% represents a significant increase, we continue to monitor our scores monthly and search for ways to reach and maintain a score of 80%.

Table 2 - Click to enlarge in new windowTable 2 Top Box Outcomes Data Comparing Pre Baby-Friendly Implementation to Post (2007-2011)

This hospital fully adopted the Baby-Friendly requirement to avoid supplementation for healthy infants. Caregivers were given ideas on how to communicate the hospital's policy to not supplement unless medically necessary. The hospital policy on supplementation reads that "no supplemental water, glucose (or formula for the breastfeeding infant) will be given unless medically indicated and ordered by a healthcare professional or at a mother's request." Supplementation is given at the parents' request and only after education is provided as to the benefits of exclusive breastfeeding.


Skills laboratories were held for nurses on how to teach hand expression and spoon feeding to mothers. On the hospital educational TV channel, information on hand expression and spoon feeding is offered in English and Spanish. Physicians received information during educational sessions and departmental meetings on the importance of avoiding supplementation. One of the first steps on the journey to become Baby-Friendly was to eliminate diaper bags with formula samples. Focus groups with mothers indicated there was not a need to offer a replacement to the diaper bag.


The hospital had to do an about-face in regards to pacifier use. Prior to becoming Baby-Friendly, pacifiers were given out automatically or on request with no education. No policy existed on pacifier use. Now, per policy, nurses only offer pacifiers during painful procedures such as a circumcision or heel stick for laboratory work. When parents request a pacifier, education is provided as to why pacifiers are not routinely used until breastfeeding is established, typically three to four weeks of age. A commercially available product that contains sucrose can also be used during painful procedures.


Nurses document information on exclusive breastfeeding practices on electronic health record (EHR) screens in the patient's care plan. The following items have been integrated into the EHR: pacifier use and education, supplementation, education on the benefits of breastfeeding, skin-to-skin time, and hand expression. Nurses document that they have observed one feeding per shift, offered one-on-one lactation education and support, and discussed community resources on breastfeeding.


Adding to the hospital's success in achieving high rates of exclusive breastfeeding is extensive patient education. The hospital provides information on breastfeeding prior to admission in childbirth and breastfeeding classes, during the hospital stay, and at discharge and offers ongoing breastfeeding education and support groups. Patients receive several tip sheets on successful breastfeeding, breastfeeding positions, manual expression of breast milk, and pacifier use-along with one-to-one education.


Strategies for Success: Rooming-In

Rooming-in-keeping infants with their mothers-is an important Baby-Friendly practice. In the Baby-Friendly guidelines, Step 7 reads: Practice rooming-in-allow mothers and (healthy, full-term) infants to remain together twenty-four hours a day (Baby-Friendly USA, Inc., 2010). Although this hospital certainly allowed rooming-in prior to becoming a Baby-Friendly USA hospital, it had no set policy on rooming-in. The result was that rooming-in was promoted inconsistently among staff, as was breastfeeding on-demand. With education and support, the staff encourages mothers to keep their infants with them during their hospital stay. Because nights are more difficult for parents and staff, an educational flyer on the benefits of rooming-in was developed and placed in all patient rooms. We have found rooming-in to be the most challenging of all the steps for parents, staff and providers. It requires constant attention to ensure parents understand the importance of keeping their baby with them.


Rooming-in is an important part of mothers' learning their infants' hunger cues and being able to respond immediately to them. Mothers gain confidence in caring for their infants and reassurance that their infants are doing well. Mothers who have their infants room-in spend more time holding, talking to, and touching their infants than mothers who do not room-in with their infants (Prodromidis et al., 1995).


Some barriers to rooming-in experienced by our hospital were staff and physician reluctance to stop using the nursery and a timed feeding schedule. It also was difficult for staff to adjust to performing medical procedures at the bedside. However, providers realized that parental education and support can be provided during these procedures, thereby saving them time.


In regard to nursery care, the hospital changed its practice from asking mothers if they wanted their baby to go to the nursery when leaving the Labor and birthing room to automatically moving the infant with the mother to the mother-baby units. During this transition time and throughout the hospital stay, nurses discuss with families the benefits of rooming-in. When infants are brought to the nursery, nurses document the time in and leaving the nursery. Most importantly, documentation includes the reason for the nursery stay and that mothers were informed of the hospital's rooming-in philosophy. Initially, nursing staff and physicians resisted rooming-in as some believed it would interfere with the mother's need to sleep. Nurses have become skilled in assisting families to rest when the infant is sleeping and to learn the infant's feeding cues to facilitate successful rooming-in.


The hospital promotes on-demand feeding (Step 8 of the Baby-Friendly USA initiative) by reinforcing with physicians and training caregivers to not put time limits on feedings. On-demand feeding is now a part of patient and staff education. Outcomes are measured for rooming-in. The 2010 rate for rooming-in was 81.38 %, according to data collected from documentation in the EHR. Recently the timing of infants' weights was changed to every 24 hours instead of routinely weighing infants at approximately the same time every day. Initial findings indicate the weights more accurately reflect the hydration status of the infant if done every 24 hours.


Strategies for Success: Skin-to-Skin Time Directly After Birth

Step 4 of the Baby-Friendly recommendations calls for placing infants skin-to-skin with their mothers immediately following birth for at least 1 hour and as often as possible thereafter. Skin-to-skin time within minutes of birth allows infants to naturally crawl to and latch on to the breast-of nine babies studied, all but one crawled and latched on to their mother's breast spontaneously within 74 minutes of birth (Walters, Boggs, Ludington-Hoe, Price, & Morrison, 2007). Of these mothers, all nine were still exclusively breastfeeding at 2 weeks. When infants are placed at the breast immediately and latch on, mothers perceive breastfeeding success (Komara et al., 2007). Immediate skin-to-skin time results in better physiological outcomes for these infants compared to incubated infants (Bergman, Linley, & Fawcus, 2004).


Our hospital experienced resistance to a key factor in skin-to-skin time-delaying medical procedures, assessments, and baths that were previously done right after birth and away from the mother. A standard of care for skin-to-skin time was created, stating that certain procedures-namely the gestational age examination, baths, and footprints for birth certificates should be delayed. Other procedures, such as cutting the cord and performing an Apgar assessment, were to be performed while the infant remained on the mother. Instead of a bath, the infant is initially wiped off with a dry cloth. The hospital's general feeding policy supports skin-to-skin time, stating that "unnecessary medical treatment should be delayed for the first hour after birth to allow uninterrupted mother/infant contact" and "mother and infant are encouraged to remain together throughout their hospital stay, including at night."


The hospital changed its method of transferring the infants between the labor and birthing room and the mother-baby unit. Before, the infants were often transported separately unless mothers requested differently. Now, infants are transferred in their mothers' arms. Nurses are required to document skin-to-skin time-for example, "within 15 minutes, for 30 minutes" and enter this information in the EHR. The hospital's goal is to have skin-to-skin time within 10 minutes of birth, and the hospital has made progress toward this goal.


To make the transition to more frequent skin-to-skin time, the hospital created an action plan. Staff and physicians received a packet of information and education on the importance of skin-to-skin time through skills laboratories, forums, and luncheons for physicians. Nurses and other caregivers learned a script on why the hospital promotes skin-to-skin time. Patients are given information on skin-to-skin time during prenatal classes and prebirthing tours.


A major barrier to implementing skin-to-skin time occurred with mothers who had cesarean sections. Some physicians and nurses believed that the mother was not stable enough to have her baby skin-to-skin in the obstetrics postanesthesia care unit (PACU). The past procedure for cesarean sections was to transfer the baby shortly after birth to the transition area. Sometimes, the transition nurse and labor/birthing nurse failed to communicate that the infant was ready for the mother, or vice versa, delaying skin-to-skin time. Now transition nurses document skin-to-skin time and the mother's status-whether she is able to respond-and the nurses on the units communicate immediately when the mother's or infant's status changes. When both are ready, the transition nurse brings the infant to the mother in the PACU.


The hospital applies similar skin-to-skin guidelines to mothers who have had cesarean sections as it does to mothers with vaginal births: delaying the gestational age examination, bath, and footprints, and placing the infant at the breast while giving the mother encouragement and assistance. A section on skin-to-skin tips with cesarean sections was added to the staff reference book. Specific solutions to situations where skin-to-skin is not immediately possible are to keep infants "cheek-to-cheek" or have staff stand behind a patient as to allow a clear line of vision to her infant. For times when infants are in the operating room, a substitute for skin-to-skin time is having the spouse or partner sit by the warmer and touch the infant.



Baby-Friendly practices increase exclusive breastfeeding rates. Implementing these practices and overcoming long held beliefs and practices can be challenging. A well-thought-out plan of creating policies, education tools, messaging/scripting, documentation, and outcome measures encourages the successful transition to Baby-Friendly practices. This hospital's perinatal core measure for exclusive breastfeeding during hospitalization was 76% in 2011. Through time and effort, barriers to Baby-Friendly practices can be overcome, and hospitals can achieve its-and the public's-goal of increasing breastfeeding rates.


Clinical Implications


* Form a Baby-Friendly Committee to update policies and develop standards of care


* Develop an educational plan for nurses and providers


* Implement practical changes to promote rooming-in


* Use pacifiers for painful procedures


* Provide follow-up breastfeeding support after discharge



Academy of Breastfeeding Medicine

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Baby-Friendly USA


Centers for Disease Control and Prevention


Healthy People 2020, Maternal, Infant and Child


United States Breastfeeding Committee (USBC)


USDA-Food & Nutrition Service Women, Infants and Children (WIC) Program




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