1. The main aim of these guidelines is promotion of successful breastfeeding.
2. Mothers should be encouraged to breastfeed their babies soon after birth.
   • Newborns should be nursed whenever they show signs of hunger, such as increased alertness or activity, mouthing or rooting.
   • Ideally, they should be nursed frequently, 8-12 times per 24 hours until baby is satisfied, usually 10-15 minutes of effective sucking on each breast.
   • Milk delivery time varies between mothers. Some babies may be satisfied with less frequent feeds.
   • When breastfeeding is well established, feeding frequency gradually decreases and most babies will be satisfied with around 6 feeds per day.
3. Healthy term babies do not require supplements (water/formula). See section on indications for supplementation of breastfeeding.
4. Premature Babies
   • Well premature babies usually at 35-36 gestation are often admitted to postnatal wards with their mothers.
   • These babies should be offered the breast as soon as possible after birth and then demand up to 3 hourly.
   • For those who latch and suck well on the breast, there is no need for supplementation.
   • Serum glucose may be checked if there is uncertainty about feeding success or if there are risk factors (e.g., hypothermia).
   • On the other hand if the baby does not show interest in feeding, is having difficulties latching, or does not suckle for long, a supplementary feed will be required.
   • A feeding plan needs to be individualised.
   • Feeding volumes should follow the recommended standards.
   • Expressed breast milk is the food of choice, but if this is not available in sufficient quantity, infant formula may be offered.  Advice may be sought from a Lactation Consultant.
5. Supplementation
   • Supplementation of breastfeeding is usually requested when there is concern that baby is at risk for hypoglycaemia. In that context consider the following:
   • Expressed breast milk is preferable to formula.
   • Birth asphyxia
     • Significant birth asphyxia may be a risk factor for hypoglycaemia.
     • Such babies remain unwell after the initial resuscitation and are admitted to NICU.
     • Term babies, depressed at birth, but responding quickly and fully to resuscitation and are judged well enough to go to the postnatal ward, should be considered well babies and encouraged to proceed with normal breastfeeding.
   • Small for gestational age babies.
     • Keep in mind that babies below the 10th centile in birthweight are not necessarily SGA.
     • Consider such factors as ethnic background, parity and maternal height which may influence birthweight.
     • Asymmetrically small babies with disparity between head circumference and weight are more at risk for hypoglycaemia.
   • Infants of Diabetic Mothers
     • These babies who are clinically macrosomic are at a greater risk for hypoglycaemia.
     • Babies with adequate weight for gestational age are at a lower risk.
     • Should these babies require supplementation for initial hypoglycaemia, attempt to expedite transfer to full breastfeeding. (See nursing management of infants of diabetic mothers of postnatal wards separate guideline).
   • Large for Gestational Age Infants
     • Currently the NWH guidelines advise checking glucose levels in babies above 4500g.
     • Hypoglycaemia is typically early in such babies and is rare beyond 8 hours of age.
     • Early feeding should be stressed again and any supplementation should be limited to the initial few feeds, with attempts to expedite full breastfeeding.
   • Occasionally babies are seen on postnatal wards who may have been receiving suboptimal quantity of breast milk, appear clinically dehydrated, may have had significant weight loss from birthweight (7-10% below birthweight), may have elevated temperature and show excessive sucking activity.
     • These babies need to be supplemented with EBM/formula until they are clinically well.
     • To support breast feeding, always offer breast feeds first and supplement after this.
   • Phototherapy
     • Phototherapy causes an increase in insensible water loss and in stool water contents, equivalent to 15-25ml/kg/day.
     • This should be balanced by increased demand for breast milk in a well term baby who has established breastfeeding.
     • Thus routine supplementation of babies under phototherapy is not recommended.
     • If breastfeeding is not well established or baby appears clinically under-hydrated, then formula supplementation is advised.

References