1. BREASTFEEDING MEDICINE
Volume 1, Number 2, 2006
© Mary Ann Liebert, Inc.
ABM Protocols
ABM Clinical Protocol #14:
Breastfeeding-Friendly Physician’s Office, Part 1:
Optimizing Care for Infants and Children
THE ACADEMY OF BREASTFEEDING MEDICINE
PROTOCOL COMMITTEE
A central goal of the Academy of Breastfeeding Medicine is the development of clinical proto-
cols for managing common medical problems that may impact breastfeeding success. These pro-
tocols serve only as guidelines for the care of breastfeeding mothers and infants and do not de-
lineate an exclusive course of treatment or serve as standards of medical care. Variations in
treatment may be appropriate according to the needs of an individual patient.
DEFINITIONS periencing fewer problems related to breast-
feeding.6,7 The World Health Organization’s
B REASTFEEDING-FRIENDLY physician’s office: A
physician’s practice that enthusiastically
promotes, supports, and protects breastfeeding
Baby Friendly Hospital Initiative describes 10
Steps for Successful Breastfeeding.8 These 10
steps are based on scientific evidence and the
through a warm office environment and edu- experience of respected authorities. The scien-
cation of health care professionals and families. tific basis of many of these recommendations
Breast milk substitutes: Infant formula, glucose can be extended to outpatient pediatric prac-
water. tices.5,9 Initiating incremental changes to im-
proving breastfeeding support is of value be-
BACKGROUND cause there is a dose-response relationship
between the number of steps achieved and
Prenatal intention to breastfeed is influenced breastfeeding outcomes.10
to a great extent by health care providers’ opin-
ion and support.1,2 Ongoing parental support
through in-person visits and phone contacts
with health care providers results in increased RECOMMENDATIONS
breastfeeding duration.3 Pediatric health care
providers are in a unique position to contrib- 1. Establish a written breastfeeding-friendly
ute to the initial and ongoing support of the office policy.8 Collaborate with colleagues
breastfeeding dyad.4,5 Practices that employ a and office staff during development. In-
health care professional trained in lactation form all new staff about policy. Provide
have significantly higher breastfeeding initia- copies of your practice’s policy to hospitals
tion and maintenance rates, with mothers ex- and physicians covering for you.
115

2. 116 ABM PROTOCOLS
2. Encourage breastfeeding mothers to feed infant breastfeeds 8 to 12 times in 24 hours.
newborns only breast milk and avoid of- Encourage rooming-in and breastfeeding on
fering supplemental formula or glucose demand.
water unless medically indicated.11 In- 6. Schedule a first follow-up visit for the in-
struct mother to not offer bottles or a paci- fant 48 to 72 hours after hospital discharge*
fier until breastfeeding is well estab- or earlier if breastfeeding related problems,
lished.12 such as excessive weight loss ( 7%) or
3. Offer culturally and ethnically competent jaundice are present at the time of hospital
care.11 Understand that families may fol- discharge.11,13,17 Ensure access to a lacta-
low cultural practices regarding infant tion consultant/educator or other health
colostrum consumption and maternal diet care professional trained to address breast-
during lactation. Provide access to a mul- feeding questions or concerns during this
tilingual staff, translators, and ethnically visit. Provide comfortable seating and a
diverse educational material. nursing pillow for the breastfeeding dyad
4. Offer a prenatal visit and show your com- to facilitate adequate evaluation. Assess
mitment to breastfeeding during this latch and successful and adequate breast-
visit.13 If providing antenatal care to the feeding at the early follow-up visit. Iden-
mother, broach the subject of infant feed- tify lactation risk factors and assess infant’s
ing in the first trimester and continue to ex- weight, hydration, jaundice, feeding activ-
press your support of breastfeeding ity, and output. Provide medical help for
throughout the course of the pregnancy. women with sore nipples or other mater-
Inquire about a feeding plan and previous nal health problems that impact breast-
breastfeeding experience. Provide educa- feeding. Begin by asking parents open-
tional material that highlights the many ended questions and then focus on their
ways in which breastfeeding is superior to concerns. Take the time to address the
formula feeding. Direct education and ed- many questions that a mother may have,
ucational material to all family members especially if it is her first nursing experi-
involved in child care (father, grandpar- ence. Provide close follow-up until the in-
ents, etc.).1,11,14 Encourage attendance of fant is doing well with adequate weight
both parents at prenatal breastfeeding gain and parents feel confident.
classes before parents decide about feeding 7. Ensure availability of appropriate educa-
plan. Identify patients with lactation risk tional resources for parents. Educational
factors (e.g., flat or inverted nipples, his- material should not be commercial and not
tory of breast surgery, no increase in breast advertise breast milk substitutes, bottles,
size during pregnancy, previous unsuc- or nipples.18 Educational resources may
cessful breastfeeding experience). be in the form of handouts, visual aids,
5. Collaborate with local hospitals and mater- books, and videotapes. Recommended top-
nity care professionals in the com- ics for educational material are growth pat-
munity.11 Convey to delivery rooms and terns, feeding, and sleep patterns of breast-
newborn units your office policies on breast- fed babies; management of growth spurts;
feeding initiation. Leave orders in the hos- recognition of hunger and satiety cues;
pital not to give formula/sterile water/glu- latch-on and positioning; management of
cose water to baby without orders and not sore nipples; mastitis; low supply; blocked
to dispense commercial discharge bags con- ducts; engorgement; reflux; normal stool-
taining infant formula and/or feeding bot-
tles to mothers.15,16 Show support for breast-
feeding during hospital rounds. Facilitate *In cultures or medical situations in which the dyad
breastfeeding within 1 hour of infant’s birth. has remained hospitalized for long enough that weight
Help mothers initiate and continue breast- gain and parental confidence are established prior to hos-
pital discharge, follow-up may be deferred until the ini-
feeding. Counsel mothers to follow infant’s tial well child care visit at 1 to 2 weeks of age if otherwise
hunger and satiety cues and ensure that the appropriate.

3. ABM PROTOCOLS 117
ing and voiding patterns; maintaining lac- 13. Set an example for your patients and com-
tation when separated from the infant munity. Have a written breastfeeding pol-
(e.g., during illness, prematurity, return to icy and provide a lactation room with sup-
work); postpartum depression; maternal plies for your employees who breastfeed or
medication use; and maternal illness dur- express breast milk at work.
ing breastfeeding. 14. Acquire or maintain a list of community re-
8. Do not interrupt or discourage breastfeed- sources (e.g., breast pump rental locations)
ing in the office. Allow and encourage and be knowledgeable about referral pro-
breastfeeding in the waiting room. Display cedures. Refer expectant and new parents
signs in waiting area encouraging mothers to community support and resource
to breastfeed. Provide a comfortable pri- groups. Identify local breastfeeding spe-
vate area to breastfeed for those mothers cialists, know their background and train-
who prefer privacy.13 ing, and develop working relationships for
9. Ensure an office environment that dem- additional assistance. Support local breast-
onstrates breastfeeding promotion and feeding support groups.21
support. Eliminate the practice of distri- 15. Work with insurance companies to en-
bution of free formula and baby items courage coverage of breast pump costs and
from formula companies to parents.18 lactation support services.11 Bill lactation
Store formula supplies out of view of par- support codes.22
ents. Display posters, pamphlets, pictures, 16. Encourage community employers and day-
and photographs of breastfeeding moth- care providers to support breastfeed-
ers in your office.13 Do not display images ing.11,23 The following website provides
of infants bottle feeding. Do not accept material to help motivate and guide em-
gifts (including writing pads, pens, or cal- ployers in providing lactation support in
endars) or personal samples from compa- the workplace:24 www.hmhbwa.org/for-
nies manufacturing infant formula, feed- prof/materials/BCW_packet.htm.
ing bottles, or pacifiers. Specifically target 17. All clinical physicians should receive
material to populations with low breast- education regarding breastfeeding.13,25
feeding rates. Areas of suggested education include the
10. Develop and follow telephone triage pro- benefits of breastfeeding, physiology of
tocols to address breastfeeding concerns lactation, management of common breast-
and problems.13 Conduct follow-up phone feeding problems, and medical contraindi-
calls to assist breastfeeding mothers. Pro- cations to breastfeeding. Make educational
vide readily accessible resources such as resources available for quick reference by
books and protocols to triage nurses. health care professionals in your practice
11. Commend breastfeeding mothers during (books, protocols, etc.). Staff education
each visit for choosing and continuing and training should be provided to the
breastfeeding. Provide breastfeeding antic- front office staff, nurses, and medical as-
ipatory guidance in routine periodic health sistants. Identify one or more breastfeed-
maintenance visits. Encourage fathers of ing resource personnel on staff. Consider
infants to accompany mother and baby to employing a lactation consultant or nurse
office visits.14,19 trained in lactation.6,7
12. Encourage mothers to exclusively breast- 18. Volunteer to let medical students and res-
feed for 6 months and continue breast- idents rotate in your practice. Participate in
feeding with complementary foods until medical student and resident physician
at least 24 months and thereafter as long education.25,26 Encourage establishment of
as mutually desired.20 Discuss introduc- formal training programs in lactation for
tion of solid food at 6 months of age, em- future and current healthcare providers.11
phasizing the need for high-iron solids 19. Track breastfeeding initiation and duration
and assess need for vitamin D supple- rates in your practice and learn about
mentation.11 breastfeeding rates in your community.

4. 118 ABM PROTOCOLS
RECOMMENDATIONS FOR 7. Jones D, West R. Effect of a lactation nurse on the suc-
FUTURE RESEARCH cess of breast-feeding: A randomized controlled trial.
J Epidemiol Commun Health 1986;40(1):45–49.
8. UNICEF Breastfeeding Initiatives Exchange. The
1. There are currently no studies demonstrat- Baby Friendly Hospital Initiative. Accessed Nov. 24,
ing the effectiveness of specific educational 2005. Available at: www.unicef.org/programme/
interventions related to breastfeeding (e.g., breastfeeding
distribution of handouts, counseling by the 9. Shariff F, Levitt C, Kaczorowski J, et al. Workshop to
primary care provider, group counseling, implement the baby-friendly office initiative. Effect
on community physicians’ offices. Can Fam Physician
counseling by nurse) during pediatric pre-
2000;46:1090–1097.
ventative care visits. 10. DiGirolamo A, Grummer-Strawn L, Fein S. Maternity
2. More studies are needed about specific office care practices: Implications for breastfeeding. Birth
practices and their effects on breastfeeding 2001;28(2):94–100.
initiation, exclusivity, and maintenance. 11. American Academy of Pediatrics Section on Breast-
3. More studies on the short- and long-term ef- feeding. Breastfeeding and the use of human milk. Pe-
diatrics 2005;115(2):496–506.
fectiveness of educational programs for 12. Howard C, Howard F, Lanphear B, et al. Randomized
physicians would be helpful. clinical trial of pacifier use and bottle-feeding or cup
4. Research on specific challenges to providing feeding and their effect on breastfeeding. Pediatrics
support in the outpatient setting is needed. 2003;111(3):511–518.
5. Studies regarding the cost-effectiveness of 13. Section on Breastfeeding. Ten Steps to Support Parents’
Choice to Breastfeed Their Baby. American Academy of
steps related to making an outpatient prac-
Pediatrics, Elk Grove Village, IL, 2003.
tice breastfeeding-friendly are needed. 14. Ingram J, Johnson D. A feasibility study of an inter-
vention to enhance family support for breast feeding
in a deprived area in Bristol, UK. Midwifery 2004;20(4):
ACKNOWLEDGMENT 367–379.
15. Donnelly A, Snowden H, Renfrew M, Woolridge M.
Commercial hospital discharge packs for breastfeeding
This work was supported in part by a grant women. Cochrane Database Syst Rev 2000;2:CD002075.
from the Maternal and Child Health Bureau, 16. Snell B, Krantz M, Keeton R, et al. The association of
U.S. Department of Health and Human Ser- formula samples given at hospital discharge with the
vices. early duration of breastfeeding. J Hum Lact 1992;8
67–72(2):67–72.
17. American Academy of Pediatrics Subcommittee on
Hyperbilirubinemia. Management of Hyperbiliru-
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