Breastfeeding, Infant, Infant feeding, Mothers, Motivational interviewing, Newborn



  1. Wood, Rainey Banick MSN, RN


Abstract: During prenatal care and postpartum hospitalization, nurses have an important role in assisting new mothers to make informed decisions about feeding their newborn infants. There is overwhelming evidence that breastfeeding is beneficial for most new mothers and babies; therefore, perinatal nurses encourage breastfeeding. Newborn infant feeding conversations with women who have chosen to formula feed may be complicated and may cause tension in the nurse-patient relationship. Despite this potential difficulty, these conversations are essential to establish a feeding plan for the newborn infant and to promote healthy outcomes for mothers and babies. Tools are offered for nurses to guide conversations about infant feeding choices and to help to ensure that all mothers receive support and encouragement on their feeding choice.


Article Content

There is abundant and rigorous evidence that breastfeeding has numerous benefits for the new mother and her baby (American Academy of Pediatrics [AAP], 2012). Breastfeeding is associated with decreased risk of multiple illnesses in children including otitis media, asthma, type 1 and type 2 diabetes mellitus, and sudden infant death syndrome (SIDS) (AAP). Breastfeeding women have lower rates of breast and ovarian cancer, and type 2 diabetes (AAP).

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Perinatal nurses encourage new mothers to exclusively breastfeed during their hospital stays and educate mothers who use formula to supplement breastfeeding about the risks of artificial supplementation as per the Joint Commission, the Baby-Friendly Hospital Initiative (BFHI), many state health departments, and institutional facilities (Baby-Friendly USA, 2016; Joint Commission, 2016). Mothers who choose formula feeding must be educated about all feeding methods so that they are able to make informed decisions on how to feed their newborn babies (Baby-Friendly USA).


A therapeutic nurse-patient relationship is important to ensure that the formula-feeding mother is receptive to education offered by the nurse about feeding methods and safe formula preparation. When mothers have already chosen to formula feed their babies, it may be challenging for the perinatal nurse to provide the required education about the risks and benefits of various feeding methods without sounding biased toward breastfeeding. Some women have reported lying to or deceiving healthcare professionals to maintain autonomy and avoid criticism regarding their choice to formula feed their infant (Hoddinott & Pill, 2000). If a new mother feels criticized by her nurse, the therapeutic nurse-patient relationship and patient outcomes may be adversely affected. Therefore, education about infant feeding should be offered in a way that prevents the mother from feeling criticized and having to defend her choice to formula feed.


Effective, supportive, and therapeutic education should help the new mother feel empowered to make an informed decision on infant feeding options. The purpose of this article is to increase nurses' knowledge and skills for discussing and promoting safe infant feeding practices including breastfeeding, formula feeding, supplementation, or combination feeding in the immediate postpartum period. Strategies that enable nurses to provide effective education during postpartum hospitalization to the new mother on newborn infant feeding while promoting a therapeutic relationship and acknowledging the shared goal of supporting healthy nutrition for the baby are offered.


Despite overwhelming evidence that breast milk provides superior nutrition and is recommended by AAP (2012), breastfeeding rates in the United States remain relatively low. In 2013, 81.1% of newborns were ever breastfed; at 6 months, only 51.8% were receiving some breast milk and 22.3% were exclusively breastfed. (Centers for Disease Control and Prevention [CDC], 2016). Seventeen percent of newborns received supplementation with formula in the first 2 days of life (CDC). Breastfeeding education in the prenatal period had been found to be most effective, and can lead to higher rates of breastfeeding than education provided in the postpartum period (Rosen, Krueger, Carney, & Graham, 2008; Wen, Simpson, Rissel, & Baur, 2012). However, continued breastfeeding and exclusivity is greatly influenced by ongoing support and resources during postpartum (Forster & McLachlan, 2007). The goal of the conversation during postpartum hospitalization with new mothers who choose to formula feed is not to force them to change their minds, but to provide them with accurate information and then support their decision. It is important to consider that breastfeeding is contraindicated for a select group of mothers and babies (Table 1).

Table 1 - Click to enlarge in new windowTable 1. Is Breastfeeding Contraindicated?

The U.S. Department of Health and Human Services set Healthy People 2020 goals to increase the rates of breastfeeding and reduce the use of formula supplementation in the United States (United States Breastfeeding Committee, 2013). In 2007, in an effort to increase breastfeeding rates, and to discourage nonmedical use of formula in the hospital, the Joint Commission included exclusive breast milk feeding as one of their perinatal care measures (Joint Commission, 2016). Similarly, the BFHI mandates that all mothers who give birth in hospitals that are designated as Baby Friendly be educated about benefits of breastfeeding and risks associated with formula feeding (Baby-Friendly USA, 2016). However, regardless of feeding choice, all new mothers should receive education and support while in the hospital (Association of Women's Health, Obstetric and Neonatal Nurses [AWHONN], 2015; Baby Friendly USA).


Establishing and supporting safe feeding practices while in the hospital during the early postpartum period is critical for success after discharge (CDC, 2016). Nurses are among the most trusted professionals, and are instrumental in the promotion of safe newborn feeding practices. When new parents have questions about how to care for their babies, a majority of them trust and seek advice from healthcare professionals (Gildea, Sloan, & Stewart, 2009). Because they are trusted by their patients, and will likely be asked questions about infant feeding, perinatal nurses must feel comfortable providing infant feeding education and understand how to approach this education in a way that encourages autonomy of the mother and supports the therapeutic nurse-patient relationship. Providing support during pregnancy and postpartum on infant nutrition is essential; however, there are limited research data to provide tools for nurses when having these conversations. Further research is needed to determine which interventions are most useful in providing education during the immediate postpartum period.


Nurses' Role in Newborn Infant Feeding Education

Nurses caring for women hospitalized for childbirth typically receive education about infant feeding including breastfeeding, formula feeding, and supplementation with formula. Nurses at BFHI facilities receive specialized education about safe infant feeding practices including management and support of breastfeeding (Baby-Friendly USA, 2016). This education includes 15 hours of didactic training and 5 hours of clinical competence training (Baby-Friendly USA).


Nurses are responsible for providing information about benefits of breastfeeding to help the new mother to make a fully informed decision about infant nutrition (AWHONN, 2015). Once the mother decides whether to breastfeed or use formula, the nurse's responsibility becomes to support the mother's decision and provide the best possible maternal-baby care, which should be woman-centered and holistic (Hoddinott & Pill, 2000). Nurses should be aware of personal biases when it comes to infant care, and avoid attempting to persuade new mothers to breastfeed rather than formula feed once the mother's decision has been made. The goal of infant feeding is to maintain a thriving, contented baby; mothers who feel their nurses are not supportive of their decisions may feel that the nurse has a different goal (Hoddinott & Pill).


If it has not already been documented in the hospital setting that the mother has received education or had a discussion about use of formula, there must be a conversation about risks and benefits about various feeding options. If the use of formula has been documented, along with documentation on education and informed decision-making, the nurses' role is to provide support as needed, just as with a breastfeeding mother. As per the AWHONN (2015) position statement, if a woman chooses formula or cannot breastfeed, nurses should provide education for her and the family about how to safely prepare, store, handle, and feed formula. The new mother should receive education and resources about risks of contamination, feeding systems, and water supply. For undecided mothers, nurses can use the opportunity to have a discussion about risks and benefits of the different feeding methods and use a motivational interviewing approach.


Tips for a Successful Conversation on Newborn Infant Feeding with the New Mother during Postpartum Hospitalization

Prepare for the Conversation

To prepare for the conversation, the nurse should know the patient (Price, 2017). The nurse should review the medical record to see if any infant feeding conversations have been documented or if there is a birth plan that includes information about her feeding choices. A time should be chosen when they will not be interrupted and will be able to have an in-depth conversation. The mother should be comfortable and awake, and her support person should be present with fewer visitors to avoid distractions and overwhelming input. This type of uninterrupted time for discussion can be a challenge during postpartum hospitalization as there are often many visitors and support persons present. Women who have given birth via cesarean may be uncomfortable with postoperative pain. Ideally, pain management issues and minimal visitors during the initial newborn feeding discussion can be resolved.


Watch Your Body Language

Nonverbal communication is important in communicating with the mother. Be aware of your tone of voice, posture, facial expressions, and pace of talking (Chambers, 2003). Sitting at eye level with the mother rather than towering over the bed provides more equality in the conversation and demonstrates openness and a nonjudgmental attitude.


Make a Connection

When talking with the mother about sensitive topics, it is important to establish trust (Price, 2017). In the postpartum setting, knowing some of the mother's history is important. Is this her first baby? Is the baby a boy or girl? What is the baby's name? Are there any documented contraindications to breastfeeding or a history of difficulty with breastfeeding with a previous baby? All of these are important aspects that have an impact on the care of the mother. Some of these answers can be found in the medical record and are potential conversation starters.


The Approach

The World Health Organization (WHO) and United Nations International Children's Emergency Fund's (UNICEF) (2006) educational materials suggest that when healthcare professionals offer parent education, they should use nonverbal communication, open questions, and demonstrate interest, reflection, and empathy while avoiding judgment. The WHO and UNICEF (2006) recommend building confidence and providing support by accepting how the patient feels and by providing praise and suggestions rather than commands.


Motivational interviewing uses targeted conversational action and allows the mother to direct the conversation (Elliott-Rudder, Pilotto, McIntyre, & Ramanathan, 2014). These conversations allow the mother and nurse to discuss future challenges and provide anticipatory guidance (Elliott-Rudder et al.). Applying motivational interviewing techniques to breastfeeding support and education have been found to increase initiation and maintenance of breastfeeding for a variety of populations (Elliott-Rudder et al.; WHO & UNICEF, 2006). Helping the mother to determine her motivations in selecting an infant feeding choice allows for autonomy and encourages open conversation.


Motivation, opportunity, and capability are factors that influence initiation of a feeding method (Russell et al., 2016). The mother's motivation includes the desire to breastfeed, plans, beliefs about consequence to the baby and mother, and emotional connection (Russell et al.). Opportunity includes support and advice received in the hospital, social norm, and support (Russell et al.). Capability is the physical establishment of feeding and the practical skills to overcome challenges (Russell et al.). When discussing infant feeding, it is important to be aware of the mother's motivation, opportunity, and capability as well as common concerns about breastfeeding (Table 2).

Table 2 - Click to enlarge in new windowTable 2. Possible Reasons Mothers Do Not Want to Breastfeed

Mothers Who Have Chosen Breastfeeding

If the mother indicates that breastfeeding is her choice, use this excellent opportunity to have a conversation about her motivation to breastfeed. Use open-ended questions about what motivated her, any concerns or questions, and help her locate services for ongoing support. Early initiation of breastfeeding in the hospital has demonstrated increased success of breastfeeding after discharge (Holmes, 2013; Su et al., 2007). Providing physical and emotional support during this period is essential.


When Breastfeeding is Contraindicated

Although breastfeeding is generally considered the optimal choice for infant feeding, there are instances where breastfeeding is not recommended or additional research is required (Table 1). There are also special recommendations and certain instances where breastfeeding is not contraindicated despite common misconceptions (Table 2). It is important that the nurse know these situations and be able to discuss them with mothers. When talking to mothers about these contraindications, personal bias can influence the conversation. The goal of the conversation is to provide education and support for the couplet.


Mothers Who Have Chosen Formula Feeding

If a mother indicates that she would like to formula feed and there is no documentation about education, discuss feeding options with her and document an informed decision. As this can be a sensitive area, see Table 3 for a sample conversation. It is essential for nurses to provide resources to the new mother about how to feed their infant including safe formula preparation and sterilization (Tarrant, Sheridan-Pereira, Younger, & Kearney, 2013; WHO & UNICEF, 2002). Mothers should receive information about how much the infant should receive, how often the infant should be fed, and how to hold the infant during feedings.

Table 3 - Click to enlarge in new windowTable 3. Sample Conversation for the Mother Who Chooses Formula Feeding

The conversation in Table 3 is an example of how to incorporate motivational interviewing with open questions into the discussion with mothers. Using an approach that starts by allowing the mother to talk about her desires and reasoning for her newborn infant feeding choice selection is patient-centered and allows the mother to feel that she is directing the conversation. With an understanding of the goal of the mother, the nurse can direct the conversation to required areas such as risks and benefits of feeding methods and then provide support in needed areas.


In the conversation in Table 3, the nurse highlights potential areas on which the mother may need additional education, such as formula preparation. The goal of these conversations is to obtain and provide required information and to foster a supportive relationship. When talking with mothers, it is important for the mother to feel that the nurse has the best interest of the mother-baby couplet in mind and the mother is supported in her decisions. In conversation, the nurse should avoid biases and statements that may sound judgmental and instead encourage the mother to direct the conversation and acknowledge her contributions to the conversation. Table 4 provides examples of statements that nurses should be aware of when discussing feeding options with mothers.

Table 4 - Click to enlarge in new windowTable 4. Supportive and Unsupportive Statements

Implications for Practice

Education about newborn infant nutrition is an essential part of support that perinatal nurses provide to new mothers during pregnancy and postpartum hospitalization. The nurse should have broad knowledge of all methods of feeding to be able to offer adequate education to new mothers including when breastfeeding may not be appropriate. Hands-on physical support to both breastfeeding and formula-feeding mothers is required, as are good communication skills to foster a therapeutic relationship while promoting the best interests of the mother and baby. The nurse must implement supportive communication strategies during education about infant feeding, especially when providing this education to a mother who has elected to formula feed. It is not uncommon for formula-feeding mothers to misunderstand nurses' intentions when they recommend breastfeeding, causing the mother to feel defensive about her choice to formula feed. This can create tension, hinder communication, and prevent effective education and therapeutic communication between the nurse and the mother. It is, therefore, crucial that the nurse understands supportive communication strategies so that education may be provided effectively and productive communication may occur. Providing an encouraging and supportive environment to all mothers benefits the nurse-patient relationship and gives patients autonomy when making difficult decisions.


There are many dimensions to breastfeeding and success of breastfeeding. No matter the feeding choice, parents are concerned about the health of their baby. A mother should feel empowered to make decisions based on information and should not be shamed for her choice. With the appropriate skill set, nurses have the ability to influence the health outcomes of the new mother and her baby as well as the postpartum hospital experience related to newborn infant nutrition.


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Effective Communication Strategies for Nurses to Discuss Infant Feeding with New Mothers During Postpartum Hospitalization


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