How to implement Baby Friendly standards â A guide for ... - Unicef UK

HOW TO IMPLEMENT BABY FRIENDLY STANDARDS 

A guide for maternity settings 

1

This document covers how to implement the standards 

required to achieve Baby Friendly accreditation. Each of the 

Ten Steps to Successful Breastfeeding is covered in a separate 

chapter which covers the rationale and individual criteria of each 

Step along with recommended extra guidance and resources. 

There is then an overview of what is required for this step at 

each Stage of the accreditation process. 

Further documentation and guidance on each individual 

point is available via the Baby Friendly Initiative website 

(www.babyfriendly.org.uk). For more complex queries, 

you can contact the Baby Friendly Initiative directly at 

bfi@unicef.org.uk 

© UNICEF UK 2011 

The content of this booklet has been produced by 

the UNICEF UK Baby Friendly Initiative. 

All images © UNICEF UK/Jill Jennings. 

The Baby Friendly Initiative is a global programme of UNICEF 

and the World Health Organization which works with the health 

services to improve practice so that parents are enabled and 

supported to make informed choices about how they feed 

and care for their babies. Health-care facilities which adopt 

practices to support successful breastfeeding receive the 

prestigious UNICEF/WHO Baby Friendly award. In the UK, the 

Baby Friendly Initiative is commissioned by various parts of the 

health service to provide advice, support, training, networking, 

assessment and accreditation. 

For more information about all aspects of the 

UNICEF UK Baby Friendly Initiative’s work, 

visit our website at www.babyfriendly.org.uk 

UNICEF UK Baby Friendly Initiative 

UNICEF House 

30a Great Sutton Street 

London EC1V 0DU 

Tel: 020 7490 2388 

Fax: 020 7250 1733 

E-mail: bfi@unicef.org.uk 

UNICEF is a Registered Charity, No. 1072612. 

How to implement Baby Friendly standards – A guide for maternity setting 2

IMPLEMENTING STEP 1 

Standards for Step 1 

The Trust 

should ensure 

that mothers 

are made aware 

of the policy 

The Trust should have a written breastfeeding policy that 

addresses all Ten Steps and prohibits the display or distribution 

of materials that promote breastmilk substitutes, feeding bottles, 

teats and dummies. Any additional guidelines or policies which 

may impact on the care of breastfeeding mothers and babies 

should be evidence-based, accurate and effective. 

The policy, or a synopsis of it in the form of a mother’s/parents’ 

guide, should be displayed prominently in all areas of the facility/ 

Trust which serve pregnant women, mothers and babies. 

Alternatively the Trust should ensure that mothers are made aware 

of the policy by an alternative means (for example by inserts 

into documentation intended for mothers). The policy should 

be displayed/communicated in the language(s) most commonly 

understood by clients and staff. 

A copy of the full policy should be available at all times for 

staff and users to refer to. Compliance with the policy should 

be mandatory and should be audited annually, with the results 

used to ensure continuing full implementation of the Ten Steps. 

Breastfeeding statistics should be collected. 

Criteria measured at each stage 

of the assessment process 

Pre-assessment (Implementation visit) 

The policy will be examined to ensure that it: 

• Covers all Ten Steps; 

• Prohibits the display and/or distribution of materials which promote the use 

of breastmilk substitutes, feeding bottles, teats or dummies; 

Stage 1 

The content of the policy will be examined as above. In addition, the head of 

service of the facility/Trust will be asked to confirm: 

• That the policy is displayed in all areas of the facility which serve pregnant 

women,* mothers and babies, or that an alternative effective means of 

communicating the policy to all pregnant women is in place; 

• The mechanism which will be used to audit compliance with the policy; 

• Breastfeeding statistics are collected – at initiation and/or discharge from 

hospital.** 

Stage 2 

The visiting assessors will confirm that: 

• Any changes which have been made to the policy do not affect its basic 

content or mandatory status. 

* An exception to the requirement to 

display the policy may be made for 

sensitive areas of the facility, such 

as a fetal assessment unit. 

** Ideally statistics will also be 

collected at a later time point such 

as neonatal screening day or transfer 

to health visitor. 

Stage 3 


• Any changes which have been made to the policy do not affect its basic 

content or mandatory status; 

• The policy is displayed (if that is the chosen method) in the areas and manner 

required. 


Following accreditation 

• The results of an audit of compliance with the policy must be submitted 

annually to the Baby Friendly Initiative office. 

Guidance for the successful 

implementation of Step 1 

A sound policy 

helps to ensure 

good practice 

and high 

standards of care 

1. The policy and accompanying guidelines 

The breastfeeding policy is not merely a requirement in its own right; a sound 

policy helps to ensure good practice and high standards of care and therefore 

underpins all other Baby Friendly Initiative standards. However, for this to work, 

compliance with the policy must be mandatory for all staff, according to their 

role. Deviation from the policy should occur only when the health or safety of 

mother or baby demands it, or when the mother has had the policy explained 

to her and has made a fully informed choice to follow a practice which deviates 

from that expected. 

The Baby Friendly Initiative produces sample policies which may be used as a 

framework for the development of a facility’s own policy. These include sample 

maternity, joint maternity with community and also a template which will help 

the facility develop a policy which is acceptable to both the Baby Friendly 

Initiative and the NHSLA. Facilities are welcome to adopt a sample policy in its 

entirety, to incorporate parts of it into an existing policy, or to use it in another 

way. It is important to note, however, that deviation from any of the basic 

elements of the policy will result in a policy which does not meet the criteria for 

Step 1. 

A distinction should be made between the policy and any accompanying 

guidelines for practice. A policy sets out aims, principles and minimum 

standards of care; guidelines provide further supporting information on the 

practicalities of implementing or interpreting the policy but are not usually 

applicable to all situations or enforceable as a basic standard of care. They are 

therefore not in themselves sufficient to meet the requirement for a written 

policy, nor are they likely to be specific enough to enable easy audit. 

Guidelines are commonly adopted for the management of the more common 

breastfeeding complications. All such guidelines should be evidence-based 

and effective and should not conflict with the main tenets of the breastfeeding 

policy. The purpose of the guidelines should be to identify best practice and to 

outline how this may be most effectively implemented in the area covered by 

the facility, the overall aim being to ensure consistent information for mothers. 

We recommend that facilities check their own policy against the requirements 

for Step 1 before submitting it for review at any time to the Baby Friendly 

Initiative and at any other time when the policy has undergone changes. We 

provide a policy self-evaluation checklist for this purpose. 

The purpose of 

the guidelines 

should be to 

identify best 

practice and 

to outline how 

this may be 

most effectively 

implemented 

2. Communication of the policy 

The essence of the policy must be communicated to users of the service so 

that they know what standard of care to expect. This communication can be 

achieved either through the display of a synopsis of the policy in all areas which 

serve pregnant women, mothers and babies (with the possible exception of 

sensitive areas such as a fetal assessment unit) or by giving each mother her 

own written copy. 

This synopsis or mother’s/parents’ guide should include a statement advising 

that a copy of the full policy will be made available on request. The Baby 

Friendly Initiative produces sample mother’s/parents’ guides, the text of which 

may be adopted in its entirety or used as the basis for the development of the 

facility’s own version. 


An eye-catching 

design, using colour 

and illustrations, 

will help to ensure 

that the guide is 

not ‘lost’ on a large 

notice board 

If displayed, the mother’s/parents’ guide to the policy should be displayed 

clearly and prominently. An eye-catching design, using colour and illustrations, 

will help to ensure that the guide is not ‘lost’ on a large notice board. A large 

poster, possibly framed, can be effective. However, care should be taken to 

ensure that the design does not trivialise the content and that any drawings or 

photographs of babies at the breast show effective positioning and attachment. 

The policy (and the accompanying mother’s/parents’ guide) should be written 

in the language(s) most commonly understood by clients and staff. Facilities 

are encouraged to make efforts to translate these documents into any other 

language(s) understood by a significant percentage of the local population. 

3. Audit of the policy 

Annual audit of compliance with the breastfeeding policy is required once the 

facility has achieved full accreditation – that is, following successful completion 

of all three stages of the assessment. However, to monitor the effectiveness of 

both the policy and the staff training programme, more frequent audit is strongly 

recommended as facilities work towards accreditation. 

The policy should be 

reviewed routinely 

on an annual basis 

The UNICEF UK audit tool to monitor breastfeeding support in the maternity 

services is recommended, since this has been designed with Baby Friendly 

assessment and accreditation in mind. Section 1 of the UNICEF audit tool 

and the appendix ‘Writing and evaluating the breastfeeding policy’ together 

enable audit of Step1, while the other sections are designed to audit the 

implementation and maintenance of the remaining Steps. 

The policy should be reviewed routinely on an annual basis. However, on the 

basis of audit results it may be necessary to update it more frequently than this, 

or if the emergence of new research requires it. 

4. Collecting breastfeeding data 

The Baby Friendly Initiative requires collection of data for the number of 

mothers breastfeeding on initiation or discharge from hospital. It is also 

helpful to collect statistics at a later point e.g. on day 5 or 6 when the neonatal 

screening test is carried out or on the date of discharge to the health visitor. 

This enables monitoring of the effectiveness of the care provided. When 

collecting breastfeeding data it is vital that the definitions of what constitutes 

‘breastfeeding’ are understood. The following definitions are recommended: 

Initiation: That a breastfeed/breastmilk is given as the baby’s first feed. 

Full (or total) breastfeeding: The baby is currently* receiving only breastmilk, 

with no other liquids or solids except vitamin or mineral supplements, or 

medicines. (NB: S/he may have received infant formula or other foods or drinks 

in the past.) 

Partial breastfeeding: The baby is currently* receiving some feeds of 

breastmilk and some artificial feeds and/or complementary (weaning) foods. 

Artificial feeding / no breastfeeding: The infant is not currently* receiving 

any breastmilk. S/he is fed on infant formula, with or without complementary 

(weaning) foods. 

When considering how to collect breastfeeding data it is important to select 

only methods that will be easy for the staff to fit into their existing routines. 

Asking staff to complete new or complicated forms or procedures will inevitably 

lead to poor compliance and inaccurate statistics. Adding a simple question to 

an existing form, or computer data collection programme, is much more likely to 

lead to good compliance and therefore accurate statistics. 

* currently means over the last 24 hours. 




A mechanism 

should exist for the 

orientation of all 

new staff 

within one week 

of commencement 

of employment 

All health-care staff who have contact with pregnant women, 

mothers and babies should be orientated to the policy and 

understand their role within it. A mechanism should exist for the 

orientation of all new staff within one week of commencement 

of employment. 

A written curriculum/curricula should exist for the training, in 

breastfeeding and lactation management, of staff who are 

directly involved in the care of pregnant women and/or mothers 

and babies. The training should cover all Ten Steps and the 

International Code of Marketing of Breastmilk Substitutes. It is 

recommended that the training for midwifery, neonatal nursing 

and other staff who provide breastfeeding support should be at 

least 18 hours in total, including a minimum of three hours of 

supervised clinical practice. Training for medical and other staff 

should be sufficient to enable them to fulfil their role within 

the policy. 

All staff caring for pregnant women and/or mothers and babies 

should have completed (or be scheduled to complete) the relevant 

training programme within six months of commencement of 

employment. Accurate records must be kept of staff attendance 

and a mechanism should exist to ensure that all staff are rostered 

to attend the training and to follow up non-attenders. 



Stage 1 

The head of service of the facility will be asked to: 

• Confirm that the breastfeeding policy is routinely communicated to all staff; 

• Outline the mechanism used to ensure communication of the policy to all 

new staff within one week of commencement of employment; 

• Provide a written curriculum/a for the training of clinical staff in breastfeeding 

and lactation management, showing how all Ten Steps and the International 

Code are covered; 

• State the number of hours of training provided and, where relevant, how this 

is divided into theoretical and practical sessions; 

• Outline the mechanism used to ensure attendance at the training sessions 

by all staff members; 

• Describe how records of staff attendance are maintained. 

Stage 2 

The visiting assessors will look for evidence that: 

• The policy is routinely communicated to all staff; 

• Staff who have been in post for six months or more have completed a 

training programme relevant to their role; 

• Staff directly involved in providing care for pregnant women and/or mothers 

and babies are able to answer questions on breastfeeding management 

correctly. 


Stage 3 

There is no formal assessment of staff knowledge and skills at Stage 3. 

However, the effectiveness, in practice, of the staff education programme 

will be evident through assessment of the care provided to pregnant women, 

mothers and babies. 






Sound basic training 

is fundamental 

to the successful 

implementation of 

the breastfeeding 

policy 

During the 

orientation 

discussion, the 

staff member’s 

role within the 

policy should be 

made clear 

1. Basic requirements 

Sound basic training in the benefits, management and practical aspects 

of breastfeeding for all staff who provide clinical care for breastfeeding 

mothers and babies is fundamental to the successful implementation of the 

breastfeeding policy. Other members of staff who have contact with pregnant 

women and/or breastfeeding mothers and babies should have sufficient 

understanding of why breastfeeding is important and how it works to enable 

them to fulfil their role within the policy. 

Attendance at the UNICEF UK Baby Friendly Initiative Train the Trainer course is 

recommended for those charged with teaching colleagues. This course provides 

useful information and ideas for ensuring that the best use is made of limited 

teaching time, together with a range of teaching materials which will enable the 

infant feeding lead to put together a programme which effectively covers all of 

the necessary criteria. Previous completion of the UNICEF UK Baby Friendly 

Initiative Three-day course in breastfeeding management is a pre-requisite of 

attendance at the course. 

2. Orientation to the breastfeeding policy 

It is important that all members of staff are orientated to the policy in the first 

week of their employment. Ideally, this should take place on a one-to-one basis, 

with a mentor or senior member of staff going through the policy with the new 

employee. Both should sign a confirmation that the orientation has taken place 

and the new member of staff should be given a copy of the policy for later 

reference. In order to decide which groups of staff will require this orientation, 

it is worth considering whether they will have direct contact with pregnant 

women and new mothers in a situation which may result in some breastfeeding 

related communication. So for example all health care staff providing direct 

care such as midwives, neonatal nurses, health care support staff and medical 

staff would be in that situation. Ward clerks, admin staff and porters on the 

other hand would not, so such a rigorous process for orientation would not 

be necessary with this group of staff. It would be pertinent to find some way 

of communicating to such staff however about the work being carried out to 

implement Baby Friendly and why breastfeeding (exclusively) is important – this 

could possibly be communicated through their own induction processes, Trust 

newsletters, intranet etc. 

During the orientation discussion, the staff member’s role within the policy 

should be made clear. For example, if support or reception staff are not 

expected to give breastfeeding advice to mothers, this should be explained 

to them and they should be informed about how, and to whom, to refer the 

mother. 

Orientation to the policy is also important for any agency staff who may be 

employed from time to time, to ensure that their practice does not impact 

negatively on the overall care provided by the facility. Consideration may need 

to be given to their terms of reference in relation to decisions about patient care 

while they are working in/for the facility. 


For staff who are in post when it is first introduced, orientation to the policy is 

necessary in theory but, is rarely required in practice as these staff will be the 

first to attend the training programme during the introduction of the standards 

into the facility. There should, however, be a mechanism for allowing all 

members of staff to access a copy of the policy at any time and to alert them 

to any changes which may be made to it. Many organisations have an intranet 

service which can be used for this purpose. 

It is important that 

a realistic amount 

of time be allocated 

for staff training 

3. Hours of training 

It is important that a realistic amount of time be allocated for staff training. 

The UNICEF UK Baby Friendly Initiative recommends a total of 18 hours, 

including at least three hours of practical skills review, for staff with a clinical 

role in supporting breastfeeding mothers. This length of training is not a 

requirement but it is unlikely that effective training can be delivered in much 

less time than this. 

Many organisations struggle to release staff from their clinical duties to attend 

training sessions; where time is at a premium the best use needs to be 

made of the time which can be allocated, and alternatives to formal teaching 

sessions should be exploited wherever possible. For example, while much of 

the information which staff members require can most effectively be delivered 

to large groups in a classroom setting, other teaching may lend itself to small, 

ward / clinic-based sessions or workbooks or e-learning. What matters is 

that the training provided is sufficient to ensure that staff have the skills and 

knowledge they require. 

The training must be mandatory and all members of staff should be rostered 

to receive all elements of it within six months of taking up post. To ensure 

compliance, there needs to be a robust mechanism in place for chasing up 

any individuals who do not attend when scheduled. An electronic database is 

the best way to record attendance at / completion of the training by individual 

staff members. For midwives, confirmation of compliance with the training 

requirements of the unit can be incorporated into the regular meetings that take 

place with the individual’s supervisor. 


Close working 

relationships 

between the 

facility and the 

local university will 

help to ensure that 

newly-qualified staff 

do not need to be 

retrained on taking 

up their post 

There is no universal Baby Friendly Initiative requirement for update or 

refresher training of staff who have completed the initial training programme. 

This is because facilities tend to have their own unique ‘culture’ which means 

that practices which are never questioned in one prove extremely difficult to 

introduce in another. For example, some maternity units have a stronger history 

of nursery care for babies than do others. Audit (see below) is the best way to 

identify where top-up training is needed. 

Staff who have recently received training in another Baby Friendly hospital, 

or who have just completed a university course accredited by the Baby 

Friendly Initiative may be exempted from the mandatory training but the lead 

professional / infant feeding co-ordinator should satisfy her/himself that the 

individual’s knowledge and skills are of an adequate standard. Close working 

relationships between the facility and the local university will help to ensure that 

newly-qualified staff do not need to be retrained on taking up their post. 

4. The curriculum/a 

The content of the training must equip staff to implement the Ten Steps and to 

practise in accordance with the International Code of Marketing of Breastmilk 

Substitutes. Information about the questions staff are expected to answer at 

assessment interview can be found in the Baby Friendly Initiative document 

Guidance notes for Stage 2 assessment and the accompanying application 

form for Stage 2 assessment, both of which can be downloaded from the Baby 

Friendly Initiative web site. 

The written training curriculum/a must be submitted at Stage 1 assessment. 

This should describe how the various elements of the policy and the Baby 

Friendly standards are covered, and in what order. Ideally, the curriculum should 

be sufficiently detailed that it would enable someone with teaching ability and a 

good knowledge of the subject to deliver the programme in the absence of the 

usual teacher. We strongly recommend that those devising training programmes 

refer to the Guidelines for the development of a training curriculum, which is 

also available to download from the Baby Friendly Initiative web site: 

www.babyfriendly.org.uk 

Staff need to 

be trained not 

only in the skills 

themselves but, 

crucially, in how to 

pass them on 

to mothers 

5. Practical skills training 

The teaching of practical skills in positioning and attachment for breastfeeding 

and hand expression of breastmilk is a crucial part of the delivery of care for 

breastfeeding mothers. Staff need to be trained not only in the skills themselves 

but, crucially, in how to pass them on to mothers. These skills can be taught 

to a limited degree in the classroom but one-to-one or small group supervision 

should be considered essential if consistency and high standards are to be 

achieved. 

Ideally, skills training should be carried out with a mother and baby in the 

clinical setting but, if this is not possible, role play using a doll is a reasonable 

alternative. The DVD, Teaching Breastfeeding Skills, which is available to buy 

from the Baby Friendly Initiative, provides useful guidance on the level of 

knowledge and skill the Baby Friendly Initiative expects staff to demonstrate 

and the Guidelines for the development of a training curriculum contain 

suggestions for conducting practical skills reviews and providing feedback to the 

staff member. 

While a single infant feeding advisor may be able to deliver all the classroombased 

education unaided, it is unlikely, except in the smallest organisations, 

that s/he will be able to manage one-to-one teaching for all the members of 

staff who require it. Most facilities that have tackled this have found that the 

best solution is to train a small group of ‘key workers’, who will in turn take 

responsibility for training identified groups of staff. Key workers need to work 

closely with the lead professional / infant feeding advisor, and have their own 

practice reviewed regularly, to ensure ongoing consistency throughout the 

team. 


It may be possible 

to request time 

for breastfeeding 

training within 

existing compulsory 

updating sessions 

6. Medical staff 

Medical staff clearly do not need to be able to teach a mother how to position 

and attach her baby for breastfeeding but they do need training to enable them 

to practise in line with the facility’s breastfeeding policy. Accessing them and 

freeing up their time for training can present a challenge. 

The initial training of consultants and registrars who are already in post may 

require several sessions to be provided so that everyone can attend. It may be 

possible to request time for breastfeeding training within existing compulsory 

updating sessions which normally cover other topics. For newly appointed 

doctors, training can be delivered on a one-to-one basis. In the case of senior 

house officers in hospital, where there is a new intake every four to six months, 

group training can be negotiated with senior staff as part of the senior house 

officers’ routine induction training package. 

The UNICEF UK Baby Friendly Initiative has developed teaching packs to enable 

infant feeding advisers to deliver training to paediatricians (and obstetricians). 

This training can be delivered in two hours, as either one session or two. The 

packs can be purchased from the Baby Friendly Initiative office. 

7. Assessment and evaluation 

It is important that the effectiveness of any training is assessed in terms of 

outcomes on the day, retention of information later and the application of new 

information to practice. Methods of immediate course evaluation are discussed 

as part of the Train the Trainer course but audit is strongly recommended as a 

way of assessing retention of information and standards of practice. 

We recommend 

regular audit from 

the beginning 

The UNICEF UK audit tool to monitor breastfeeding support in the community 

services has been developed to enable health care facilities to audit practices 

in a way which is meaningful in terms of the Baby Friendly standards. We 

recommend regular audit from the beginning, firstly to establish a baseline of 

current practice and then to inform the development of the training programme 

and the need, if any, for update sessions on specific topics. 

As with practical skills training, it is common for a team of ‘key workers’ to 

be identified to carry out audit. It is strongly recommended that as many 

as possible of these should attend the UNICEF UK Baby Friendly Initiative 

Workshop on auditing practices to support breastfeeding to enable them to do 

this work effectively. 

While Step 2 itself is assessed formally at Stage 2, the true outcomes of 

the training programme are evidenced only at Stage 3. Ongoing audit and 

adjustments to the curriculum are therefore vital to ensure that the training is 

translated into enduring and consistent high standards of practice. 




All pregnant women are to be given up-to-date information about 

the benefits and management of breastfeeding within the first 34 

weeks of pregnancy. Ideally, this should be provided as part of a 

one-to-one discussion and backed up by leaflets or other written 

information. 

Any written 

information should 

be accurate and 

effective and free 

from promotion 

of breastmilk 

substitutes, bottles, 

teats and dummies 

A written description should exist of the information provided. 

Information on the benefits of breastfeeding should include: 

• The health benefits of breastfeeding for both mother and baby; 

• The importance of exclusive breastfeeding for the first six 

months (for health outcomes). 

Information on the management of breastfeeding should include: 

• The importance of skin-to-skin contact at delivery; 

• The importance of effective positioning and attachment 

for breastfeeding; 

• The importance of keeping the baby close; 

• The importance of feeding when the baby shows signs of 

wanting to feed; 

• The importance of exclusive breastfeeding (for ensuring 

optimal lactation); 

• The importance of avoiding teats and dummies during the 

establishment of breastfeeding. 

Any written information, including teaching materials, provided for 

or displayed to pregnant women should be accurate and effective 

and free from promotion of breastmilk substitutes, bottles, teats 

and dummies (see also Implementing the International Code). 

Antenatal parent education classes (where these are provided) 

should provide good quality and effective information to 

supplement that provided during one-to-one discussion. 


Key issues investigated at 

each stage of the assessment 

Stage 1 

The head of service of the facility/Trust will be asked to: 

• Confirm that information about the benefits and management of 

breastfeeding is provided for all pregnant women by the facility; 

• Confirm that the information (to be) provided covers the required health 

benefits and management topics; 

• Provide a copy of any checklist in use; 

• Describe how the giving of information to women antenatally is (to be) 

recorded; 

• Provide details of antenatal parent education programmes (where these 

exist); 

• Provide details and – and, where possible, examples – of leaflets, posters 

and other materials distributed or displayed to pregnant women, all of which 

must be accurate and effective and free from promotion for breastmilk 

substitutes, bottles, teats and dummies. 

Stage 2 

There is no formal assessment of this Step at Stage 2. 

Stage 3 


• All women who are more than 34 weeks pregnant have received accurate 

information on the health benefits of breastfeeding for themselves and their 

baby; 

• All women who are more than 34 weeks pregnant have received 

accurate information on the required topics related to the management of 

breastfeeding; 

• Any new or amended materials (since Stage 1) provided for, or displayed 

to, pregnant women are accurate and effective and free from promotion for 

breastmilk substitutes, bottles, teats and dummies; 




Pregnancy provides 

an opportunity for 

all women to be 

properly informed 

about breastfeeding 

and to see it as 

a real option 



1. Providing basic information for all women 

It is important that basic information about breastfeeding be provided to all 

pregnant women, regardless of how they plan to feed their baby. Many women 

know little or nothing about breastfeeding when they first become pregnant, 

relying on media reports or family and friends to inform them. Myths abound 

and facts are often distorted. Pregnancy provides an opportunity for all women 

to be properly informed about breastfeeding and to see it as a real option. 

Women should be given information about the health benefits of breastfeeding 

for them and their baby. This information should be factual and up to date, not 

merely a vague reference to breastfeeding being ‘better’ for babies, or to its 

role in ‘preventing illnesses’. They should also be given information about the 

management of breastfeeding so that they are equipped to make decisions 

which will increase the likelihood of breastfeeding being successful. 

In order for all pregnant women to have a meaningful discussion about 

breastfeeding the topic should be covered as part of each woman’s individual 

antenatal care, not merely in parent-craft classes – which, inevitably, not all 

women will attend. Classes and group sessions should be seen as a way of 


Encouraging staff 

to spread the 

discussion, or to 

revisit aspects of 

it, over several 

antenatal contacts 

is very effective 

providing more detailed information for women who want this, not relied on 

as a means of providing basic care to all. However, for those women who do 

attend classes, it is vital that facilities make the most of the opportunity to 

provide good quality and effective information to supplement that provided 

during one to one discussion. It is also vital that information provided does not 

undermine or conflict with other information given and that women can rely on 

a consistent standard of provision irrespective of which class they choose, or 

are allocated to attend, therefore standards for the minimum content are set. 

When deciding how and when breastfeeding will be discussed it is important 

to consider what other information it must compete with in terms of the 

time needed for delivery and women’s focus of attention. There is no reason 

why it needs to be discussed entirely (and only) at one contact with the 

pregnant woman. Many Trusts have found that encouraging staff to spread the 

discussion, or to revisit aspects of it, over several antenatal contacts is very 

effective, both in relieving the burden of ‘having to fit breastfeeding in’ and in 

ensuring better retention of the information by the client. 

It is also crucial that consideration be given to how staff are guided to offer the 

information. Experience has shown that merely lecturing women about what 

they should do, is ineffective and may actually be counterproductive. Finding out 

about the woman’s knowledge and feelings about breastfeeding can be a good 

starting point for the conversation, accepting these feelings and then offering 

tailored information related to her own concerns or family health can mean that 

women are more likely to take this information on board. More information / 

guidance about this will be available from Baby Friendly in summer 2011. 

We strongly 

recommend that 

pregnant women 

are not merely 

asked a closed 

question about how 

they plan to feed 

their baby 

We strongly recommend that pregnant women are not merely asked a closed 

question about how they plan to feed their baby. This is for several reasons: 

• Firstly, asking this question implies that the woman should have made this 

decision already when, in practice, she can be directed by her instincts once 

her baby is born. 

• Secondly, the response “I’m going to bottle feed” can make it more difficult 

for the health professional to continue the conversation with information 

relating to breastfeeding. 

• Thirdly, it is easy to assume that mothers who have decided to breastfeed, 

especially those who have breastfed before, know what they need to know 

about the benefits and management of it. This can be far from the truth and 

these mothers can miss out on important information as a result. Staff may 

need to adjust the way they give information when faced with an obviously 

experienced breastfeeding mother. This is a useful training point. 

If necessary, records which require the documentation of antenatal feeding 

intention should be amended to avoid this. 

It is worth remembering (and pointing out to staff during training sessions) that 

not all the topics that need to be discussed with women antenatally as part 

of this Step relate directly to breastfeeding. For example, skin-to-skin contact, 

keeping the baby close and baby-led/demand feeding are worthy of discussion 

regardless of expected feeding method. 

In general, one or 

two well-chosen 

leaflets will be more 

effective than a 

multitude of them 

In general, one or two well-chosen leaflets will be more effective than a 

multitude of them. Encouraging staff to refer directly to them when discussing 

breastfeeding with women can promote consistency of terminology and 

information as well as provide an easily-accessible source of suitable phrasing 

for staff. 

While locally-produced leaflets can be valuable, they take a lot of time to 

develop and can be expensive. The Department of Health and UNICEF UK 

Baby Friendly Initiative leaflet Off to the best start is recommended as suitable 

for use in all facilities (Northern Ireland and Scotland have their own similar, 


If women are to 

make informed 

choices they need 

to know about the 

health and lifestyle 

implications of all 

available methods 

centrally-produced leaflets). Until translation of this leaflet into a range of 

languages is possible, UNICEF’s older style leaflet Feeding your new baby, 

available in 17 languages including English, may be useful. In addition the 

Department of Health DVD Bump to breastfeeding should be offered to all 

pregnant women. 

A word-free teaching pack on breastfeeding has been produced by the UNICEF 

UK Baby Friendly Initiative in conjunction with Family Care. It is recommended 

for use in explaining breastfeeding management wherever the spoken or 

written word may be a barrier to understanding. 

2. Antenatal parent education 

Those facilities which provide antenatal parent education classes for pregnant 

women, with or without their partners, should ensure that they make the 

most of the opportunity to provide good quality and effective information to 

supplement that provided during one-to-one discussion. It is also vital that 

information provided does not undermine or conflict with other information 

given and that women can rely on a consistent standard of provision 

irrespective of which class they choose, or are allocated to attend. 

The following content will be expected: 

• Skin to skin contact* – why this is important, its role in maintaining 

temperature, calming both mother and baby, enhancing digestion, enhancing 

hormone production to encourage mothering instinct and supporting 

breastfeeding. 

• Feeding when baby shows signs of wanting to feed* – what to expect in 

terms of newborn feeding frequency, recognising feeding cues. 

• Keeping the baby close* – the importance of keeping the baby close to 

enable feeding cues to be recognised, enable mothers to gain confidence in 

caring for their baby and to help the baby learn to recognise his/her mother. 

• The health benefits of breastfeeding/risks of formula feeding 

• The importance of effective positioning and attachment for 

breastfeeding – including how this can be achieved. 

• Exclusive breastfeeding – why supplementary feeds of formula milk should 

be avoided both in terms of the baby’s health and milk supply. 

• Why teats and dummies should be avoided during the establishment 

of breastfeeding 

• Local and national support systems available 

It is quite in order for antenatal discussions and teaching about infant feeding 

to include consideration of bottle and formula feeding. Indeed, if women are 

to make informed choices they need to know about the health and lifestyle 

implications of all available methods. For example, the session could helpfully 

be developed to cover issues such as how a baby should be held to feed 

whatever the feeding method – the importance of eye contact, and close 

physical contact leading to the development of a relationship with one key 

care giver. 

* The above content is relevant to all 

women, irrespective of how they 

consider they are planning to feed 

their baby. Many experienced 

antenatal class facilitators find that 

introducing the session with this 

type of information helps to engage 

women. The session can then be 

developed to include the health 

benefits of breastfeeding and practices 

which can be helpful to/hinder 

breastfeeding success. 

However, instruction in the preparation of formula feeds should not form part of 

routine group teaching sessions. This is because such teaching implies that all 

women will require this information, thus undermining the message that ‘breast 

is best’ or implying that exclusive breastfeeding is not a realistic expectation. If 

a pregnant woman requests a one -to-one demonstration of how to prepare a 

formula feed, this can be provided but it is preferable to defer this teaching to 

the postnatal period when it will be more meaningful. 

3. Implications for staff time 

There are rewards for staff as well as mothers in the successful implementation 

of Step 3, since giving women information about what to expect from 

breastfeeding and how to help it to work well empowers them to avoid many 


of the common problems which have, in the past, been associated with 

breastfeeding. The result is that less staff time is taken up with supporting 

women to overcome feeding problems or in caring for a baby who is not 

feeding well. 

Some staff find it relatively easy to adjust their practice to allow more effective 

use of their time – as, for example, the midwife who commented, “I used to 

chat to women about their holidays while I was palpating them; now I tell them 

about skin-to-skin contact.” In other cases, Trusts have found that they need to 

make organisational adjustments (for example to the timing of antenatal clinic 

appointments) to allow sufficient time for effective discussions about infant 

feeding to take place. 

Audit is crucial to ensuring high standards of care for mothers and babies. It 

is recommended at all stages of a facility’s progress towards Baby Friendly 

accreditation as a way of establishing a baseline, informing the development 

of the staff education programme and monitoring progress. Section 3 of the 

UNICEF UK Baby Friendly Initiative audit tool is recommended for the audit of 

Step 3. 

Many facilities have found Step 3 to be one of the more difficult to implement 

successfully. The main reason for this is staff not understanding either the 

importance of antenatal information for mothers or of their own role in 

providing this. Early attention to Step 3 is strongly recommended, both in the 

development of the staff education programme and its audits in practice, as 

it also has the potential to affect positively the implementation of the Steps 

relating to postnatal care. 




All mothers should 

be given their 

baby to hold in 

skin-to-skin contact 

in an unhurried 

environment as 

soon as possible 

after delivery 

All mothers should be given their baby to hold in skin-to-skin 

contact in an unhurried environment as soon as possible after 

delivery. This period should last for at least one hour or until after 

the first breastfeed, whichever is sooner. They should be given 

support and encouragement to give the first breastfeed as soon 

as the baby is receptive. If skin contact has to be delayed or 

interrupted because the health of either mother or baby demands 

it, it should be started or resumed as soon as possible. 



Stage 1 

This Step is not assessed at Stage 1. 

Stage 2 

There is no formal assessment of this Step at Stage 2 but staff may be asked 

to explain the value of skin contact, both in the immediate postnatal period and 

later. 

Stage 3 


• All mothers are enabled to hold their baby in skin-to-skin contact as soon as 

possible after delivery; 

• All mothers are enabled to hold their baby for at least one hour or until after 

the first breastfeed whichever is sooner; 

• All mothers are offered support and encouragement to initiate breastfeeding 

during this time. 






Skin contact calms 

the baby, regulates 

his heartbeat, 

breathing and 

temperature and 

stimulates him to 

seek the breast 

1. Definition and rationale 

The first hour or so after birth are crucial for mother and baby in terms of their 

wellbeing, the opportunity to bond with each other and the first breastfeed. 

Skin-to-skin contact promotes all three of these things. Provided the condition 

of both allows it, an unhurried and unlimited period of skin contact should be 

facilitated for all mothers and babies immediately the baby is born, or as soon as 

possible afterwards. 

Skin contact calms the baby, regulates his heartbeat, breathing and temperature 

and stimulates him to seek the breast. The mother goes through physical 

and emotional changes at this time, which prepare her for breastfeeding and 

mothering. It is therefore important that all mothers and babies be provided 

with this opportunity for breastfeeding to begin unless the mother herself has 

declared that she does not want it. 

An important point to note is that Step 4, while referring to the ‘initiation of 

breastfeeding’, carries no stipulation that the baby must feed. It simply requires 


Most routine 

newborn checks 

and procedures 

can be carried 

out while the baby 

is in skin contact 

with the mother 

the circumstances to be arranged so that the baby has the opportunity to feed. 

There is no need to hurry either the baby or the mother or to try to force the 

baby on to the breast – indeed, this may prove counter-productive and hinder 

the baby’s ability to attach effectively later on. If there are concerns about 

the baby’s need for food, the mother can be encouraged to express some 

colostrum to give to him (see also Step 6 and Step 8). 

Healthy, term babies are known to have both an instinct towards breastfeeding 

and the ability to find the breast and self-attach, both of which are at their 

strongest in the first hour or so after birth. Facilitation of an early breastfeed 

is known to have a significant impact on the later progress of breastfeeding. 

Ensuring an unhurried period of skin contact for all mothers and babies can 

mean that many of the common difficulties and complications associated with 

breastfeeding are avoided. This results in improvements in the experiences of 

mothers and savings in staff time. 

The benefits of skin contact for infant wellbeing extend beyond the immediate 

postnatal period. In particular, skin contact can help babies and mothers to 

overcome many common breastfeeding difficulties. Community staff are in 

a good position to recommend skin contact for all mothers and their babies, 

regardless of age. 

2. Facilitating skin contact 

When the baby is born he should be dried quickly and placed skin-to-skin 

with his mother. Note that ‘skin-to-skin contact’ means that the baby’s skin is 

touching the mother’s skin over the greater part of his body. There should be 

nothing between them (other than a nappy on the baby, if preferred), i.e. no 

nightdress, sheet, blanket or towel. However, a warm blanket or towel placed 

over both of them will ensure that the baby does not lose heat and that the 

mother’s privacy is maintained. If the baby is very small, a hat is recommended. 

When the baby is 

born he should be 

dried quickly and 

placed skin-to-skin 

with his mother. 

Note that ‘skin-toskin 

contact’ means 

that the baby’s skin 

is touching the 

mother’s skin over 

the greater part 

of his body 

A newborn baby’s temperature is more effectively maintained through skin 

contact with his mother than by any other means. Most routine newborn 

checks and procedures can be carried out while the baby is in skin contact with 

the mother so there should not normally be any need to separate mother and 

baby in the immediate post-birth period. If the health of either demands that 

they be separated, they should be reunited, skin to skin, as soon as possible. 

3. Safety considerations 

Vigilance as to the baby’s well-being is a fundamental part of postnatal care 

in the first few hours after birth. For this reason, normal observations of the 

baby’s temperature, breathing, colour and tone should continue throughout the 

period of skin contact, in the same way as they would if the baby were in a cot. 

Observations should also be made of the mother, with prompt removal of the 

baby if the health of either gives rise to concern. 

It is important to ensure that the baby cannot fall on to the floor or become 

trapped in bedding or by the mother’s body. Particular care should be taken with 

the position of the baby, ensuring the head is supported so the infant’s airway 

does not become obstructed. 

Many mothers can continue to hold their baby in skin-to-skin contact during 

perineal suturing. However, adequate pain relief is required, as a mother who 

is in pain is unlikely to be able to hold her baby comfortably or safely. Mothers 

should be discouraged from holding their baby when receiving analgesia which 

causes drowsiness or alters their state of awareness (e.g. entonox). 


The period of skin 

contact should 

normally last at 

least one hour 

If immediate 

skin-to-skin contact 

is not feasible it 

should be started 

as soon as the 

circumstances 

make it possible 

We strongly 

recommend that 

any policies and 

procedures which 

support early 

separation of 

mother and baby 

are examined 

and changed 

4. Ending the period of skin contact 

The period of skin contact should normally last at least one hour, until the baby 

has had a breastfeed or until the mother wishes to end it, whichever is the 

sooner. A mother can make an informed choice to end it before this but should 

not be pressurised into doing so by staff. Even apparently innocuous questions 

such as, “Are you ready for your shower now?” can carry the suggestion 

that the mother should relinquish her baby in order to conform with what is 

expected of her. Many mothers who have received care in a Baby Friendly 

Hospital report, with delight, periods of skin contact lasting several hours. 

A little creative thinking can enable skin contact to continue while mother and 

baby are transferred to the postnatal ward, whether this be in a chair or on a 

bed. If they have to be separated during transfer, or if the mother requests this, 

then she should be encouraged to resume skin contact on arrival on the ward. 

This is especially important if the baby has not yet fed. The safety precautions 

outlined above should be adhered to as much during transfer to the ward and 

the continuation of skin contact thereafter as during the time spent in the 

delivery or recovery room. The Baby Friendly Initiative has produced a sample 

bed sharing policy which can assist with the safe implementation of skin 

contact on the postnatal ward. 

5. Delayed skin contact 

If immediate skin-to-skin contact is not feasible it should be started as soon as 

the circumstances make it possible. If the baby needs to be transferred from 

the delivery room to the neonatal unit, skin contact should be encouraged as 

soon as mother and baby are well enough to be together (see below and also 

Step 5). 

If the mother is unavailable but the baby is well, skin contact with another 

family member (commonly the father) is a useful alternative. However, parents 

(and staff) should understand that the mother should be the first choice, for 

two key reasons: Firstly, it is only from her that the baby will be able to access 

colostrum, and secondly, the touch of the baby on the breasts and nipples is 

important for the stimulation of milk production. In addition, the response of her 

body to the birth and the beginning of lactation means that her chest is likely to 

be warmer than anyone else’s. 


6. Operative deliveries 

Where delivery takes place in an operating theatre (e.g. by Caesarean section), 

skin-to-skin contact should be facilitated in the theatre whenever possible. 

However, this initial period will necessarily be limited (by the time taken to 

complete the surgery) and the mother’s position may not be conducive to 

breastfeeding. Time spent in the recovery room and/or on the postnatal ward 

should therefore be seen as the most appropriate opportunity for ensuring an 

unhurried period of skin contact and facilitation of the first breastfeed. 

In some hospitals it is routine practice for the father to accompany the midwife 

and baby to the postnatal ward while the mother’s surgery is completed. This 

can result in a long gap between the birth and the reunion of mother and 

baby, with the optimum time for the first breastfeed being missed. Given the 

importance of this period to the later progress of breastfeeding, we strongly 

recommend that any policies and procedures which support early separation of 

mother and baby are examined and changed. 

If the mother 

is experiencing 

difficulties, more 

active help can be 

offered but care 

should be taken not 

to override or hurry 

the baby’s efforts 

7. Skin-to-skin contact in the neonatal unit 

Preterm and sick babies within the neonatal setting also benefit from spending 

time in skin-to-skin contact or kangaroo care with their mothers. Not only does 

this close contact stimulate a better milk supply but it also has a calming effect 

on both mother and baby which results in improved oxygenation levels for 

the baby. Although it is not yet a requirement for Baby Friendly accreditation 

it is strongly recommended that the practice is adopted within neonatal units 

as part of a developmental care programme and to support the initiation and 

maintenance of lactation. 

8. ‘Help’ with the first breastfeed 

It is important that staff understand what is meant by the requirement to 

provide ‘help’ with the first breastfeed. Babies’ natural instinct is to seek the 

breast and self-attach and there is evidence to suggest that, if they are allowed 

to do this, problems with attachment at subsequent feeds are less likely. Staff 

are therefore expected to facilitate this process rather than interfere with it. 

It is expected that the member of staff (normally the midwife) will observe 

mother and baby, noting when the baby is showing signs of wanting to feed. 

S/he can then alert the mother to this if she is unaware of it. The staff member’s 

role then is to help the mother to find a comfortable position in which to lie or 

sit and to explain to her (if necessary) how to hold her baby in a way which will 

enable him to attach and feed. 

Staff should not expect to touch the mother or her baby unless invited to do so. 

If the mother is experiencing difficulties, more active help can be offered but 

care should be taken not to override or hurry the baby’s efforts. 

Babies who are affected by drugs administered to the mother in labour are often 

much slower than unmedicated babies to attach to the breast and feed. Hurrying 

them is counter-productive, as is removing them from their mother until they 

show interest in feeding. Instead, the aim should be to facilitate an extended, 

unbroken period of skin contact for these babies, to allow them time to respond. 

Ideally, the potential effect of medications on the baby’s early responses to the 

breast should be discussed with women before and during labour. 

Ideally, weighing 

should be left 

until after the 

baby has fed 

9. Weighing the baby 

Many people feel the need to know a baby’s weight the moment it is born. 

Weighing a baby has the potential to interrupt the baby’s naturally programmed 

behaviour and interfere with, or delay, the success of the first breastfeed. 

Ideally, therefore, weighing should be left until after the baby has fed. Fathers 

are often content to be told that, “We don’t weigh babies straight away here,” 

if an explanation is given of why this is. 


If there is likely to be a need to know the baby’s weight before the first 

breastfeed has taken place (for example to allow the midwife to complete 

electronic details about the birth) then the best option is to weigh the baby as 

soon as it is born, so that skin contact can then proceed without interruption. 

10. Promoting skin contact 

Skin contact should be the default method of care after delivery for all babies. 

Mothers are unlikely to turn this opportunity down, especially if the nature and 

benefits of it have been explained to them antenatally (see Step 3). Asking the 

mother whether she wants skin contact – or, offering to ‘clean the baby up’ for 

her first – suggests that it is not something which she would be expected to 

want. 

Staff need to be aware that their verbal and body language can have a huge 

impact on the choices mothers make at this sensitive time. Their role should be 

to protect the closeness of mother and baby and the initiation of breastfeeding. 

This may include discouraging mothers from handing the baby to the father or 

welcoming other visitors into the room until the baby has had a chance to feed. 

All babies deserve the chance for their mother to make this choice in the 

unhurried atmosphere of the delivery room. Mothers who definitely do not want 

to experience skin contact, or who welcome this but do not wish to breastfeed 

will normally ensure that staff understand this. They must, of course, have their 

wishes respected. 




written word may be a barrier to understanding. The pack contains a section on 

skin-to-skin contact. 

The requirement 

to document skin 

contact is another 

way to ensure 

that all mothers 

are provided with 

the opportunity to 

spend this time 

with their babies 

11. Making skin contact a routine part of intra-partum care 

Staff training and antenatal information for women are key to the successful 

implementation of this Step. Policies and procedures which conflict with the 

provision of this type of care (such as policies which require babies and/or 

mothers to be bathed/showered on the labour ward) should be examined and 

amended as necessary to ensure that the right of all mothers and babies to 

good quality, sensitive care at delivery is upheld. 

The requirement to document skin contact is another way to ensure that all 

mothers are provided with the opportunity to spend this time with their babies. 

Some hospitals require staff to complete a checklist of the basic care and 

information provided in the postnatal period, beginning with skin-to-skin contact. 

The UNICEF UK Baby Friendly Initiative provides a sample postnatal checklist 

which Trusts can adopt, or use as the basis for the development of their own. 




of the staff education programme and monitoring progress. Section 4 of 

the UNICEF UK Baby Friendly Initiative audit tool for maternity services is 

recommended for the audit of Step 4. 


All health-care 

staff with primary 

responsibility 

for supporting 

breastfeeding 

mothers should 

have the necessary 

skills to teach 

mothers how 

to position and 

attach their baby 

for breastfeeding 

and how to hand 

express breastmilk 



All breastfeeding mothers should be offered further assistance 

with breastfeeding within six hours of delivery. They should 

be given help to learn how to position and attach their baby 

for breastfeeding. They should be shown how to express their 

breastmilk by hand, or given written information about this 

together with details of where and how to get help, should they 

need it. 

All breastfeeding mothers should receive information, both verbally 

and in writing prior to transfer home about how to recognise 

effective feeding. In addition, a breastfeeding assessment will be 

carried out at around day 5. 

Mothers of babies in the Neonatal or Special Care Baby Unit 

should be encouraged to express their breastmilk for their baby. 

They should be shown how to express their milk by hand and 

preferably also by pump. They should be encouraged to express 

their milk as soon as possible after the birth and to continue to do 

so at least 8 times in 24 hours, including at night. 

All health-care staff with primary responsibility for supporting 

breastfeeding mothers should have the necessary skills to teach 

mothers how to position and attach their baby for breastfeeding 

and how to hand express breastmilk. 

Hospitals should ensure that all mothers who are not 

breastfeeding are able to correctly prepare a bottle of infant 

formula prior to discharge from hospital. 

Any written information, including teaching materials, provided for 

or displayed to new mothers should be accurate and effective and 

free from promotion of breastmilk substitutes, bottles, teats and 

dummies (see also Implementing the international code). Written 

materials on hand expression of breastmilk should contain details 

of where and how the mother can access help with this if needed. 



Stage 1 


• Describe how the giving of information to new mothers is recorded; 

• Describe the mechanism for ensuring that all new breastfeeding mothers 

receive information, both verbally and in writing about how to recognise 

effective feeding; 

• Describe the mechanism for ensuring that a feeding assessment is carried 

out on or around day 5; 

• Provide a copy of written information about effective feeding and a 

breastfeeding assessment tool; 


• Provide a written curriculum / a for the training of clinical staff in 

breastfeeding and lactation management. This should show how these staff 

are educated to acquire the skills needed to teach mothers to position and 

attach their babies for breastfeeding and to hand express breastmilk; 

• Provide details – and, where possible, examples – of leaflets, posters and 

other materials distributed or displayed to pregnant women, all of which 

must be accurate and effective and free from promotion for breastmilk 

substitutes, bottles, teats and dummies. 

Stage 2 


• All staff who may be called upon to do so are able to provide effective 

teaching for mothers on positioning and attachment for breastfeeding and 

hand expression of breastmilk; 

• All staff who may be called upon to do so can give a satisfactory description 

of how they would assess the sufficiency of milk intake in a baby. 

Stage 3 


• All breastfeeding mothers are offered further help with breastfeeding within 

six hours of delivery; 

• All breastfeeding mothers are shown (or supported to learn) how to position 

and attach their baby effectively for breastfeeding; 

• All breastfeeding mothers (including those whose babies are in the Neonatal/ 

Special Care Baby Unit) are shown how to express their breastmilk by hand, 

or given written information on how to do this together with details of where 

and how to get help, should they need it; 

• All breastfeeding mothers have received information about how to recognise 

effective feeding; 

• All breastfeeding mothers, of five days or more following the birth, confirm 

that a midwife or other member of staff has carried out a full breastfeeding 

assessment; 

• All mothers of babies in the Neonatal/Special Care Baby Unit are encouraged 

to express their breastmilk for their baby as soon as possible after the birth 

and to continue to do so at least 8 times in 24 hours, including at night; 

• All mothers of babies in the Neonatal/Special Care Baby Unit are shown how 

to express their milk by pump as well as by hand; 

• All mothers who have chosen to bottle feed report that staff ensured they 

were able to correctly prepare a bottle of infant formula prior to discharge 

from hospital; 

• Any new or amended materials (since Stage 1) provided for, or displayed 

to, pregnant women are accurate and effective and free from promotion for 

breastmilk substitutes, bottles, teats and dummies; 

• Any new or amended written information about hand expression of 

breastmilk is accurate and effective and includes details of how help may be 

accessed. 

Many common 

complications could 

be prevented, or 

solved promptly, if 

mothers understood 

both the importance 

of effective 

attachment and 

how to achieve it 






1. Why all mothers need support to learn practical skills 

The vast majority of breastfeeding problems have their roots in poor attachment 

of the baby at the breast. Many common complications could be prevented, 

or solved promptly, if mothers understood both the importance of effective 

attachment and how to achieve it. For this reason, it is vital that all mothers are 

offered whatever help and support they need to learn the practical skills that are 

relevant to breastfeeding. 


Breastfeeding is instinctive on the part of the baby but is a learned skill for 

the mother. A common pitfall in ensuring that mothers are equipped with the 

practical skills of positioning and attachment is the assumption that they already 

possess them. This assumption is often made on behalf of multiparous women, 

especially those who have breastfed before. In reality, many mothers who have 

had babies before require as much support with breastfeeding as those who 

have just had their first baby. Reasons for this include: 

• Breastfeeding may not have been successful last time around; 

• Breastfeeding may have gone well last time through good fortune rather than 

knowledge; 

• The new baby may behave very differently, or have different needs, from 

their previous child; 

• They may recently have fed (or still be feeding) a toddler and have forgotten 

quite how much help a newborn needs; 

• Their previous child may have been born at a time when underpinning 

information which we now know to be outdated was thought to be correct. 

The importance of observing babies at the breast cannot be over-emphasised 

and staff need to understand this, both as part of routine teaching and as a 

tool to assist in the solving of breastfeeding problems. This applies as much in 

community health care as in hospital settings. 





UNICEF UK audit tool to monitor breastfeeding support in the community 

services is recommended for the audit of Step 5. 

All mothers need to be provided with information and support until they are 

able to breastfeed effectively and confidently. There are no short cuts to this 

process. 

Hand expression 

of breastmilk 

is a simple 

technique which 

all breastfeeding 


be given the 

opportunity to learn 

2. Hand expression of breastmilk 

Hand expression of breastmilk is a simple technique which all breastfeeding 

mothers should be given the opportunity to learn. It is a useful self-help 

measure which can prevent or resolve a variety of common breastfeeding 

problems. For instance, it can enable a mother to: 

• Understand how breastfeeding works; 

• Gain confidence in her ability to produce milk; 

• Produce a few drops of milk to tempt her baby to feed; 

• Soften a full breast to ease discomfort or enable the baby to attach; 

• Clear a blocked duct; 

• Provide milk for her baby when they are separated, or when the baby is 

unable to breastfeed; 

• Increase her milk supply. 

Hand expression is particularly useful in the early postnatal period, when 

volumes of colostrum/milk are small and breast pumps are ineffective. In some 

circumstances, a mother’s ability to hand express can be key to her sleepy or 

sick baby avoiding the need for a formula feed. 

The minimum requirement, for both hospital and community, is that all 

breastfeeding mothers should be either shown how to express their milk by 

hand or given written information about the technique and informed how to 

access help if they should need it. 


3. Staff training 

If staff are to provide effective practical support for mothers they first need 

to be trained themselves. Step 5 therefore overlaps significantly with Step 2, 

especially in the area of practical skills review. 

It is no longer acceptable for health-care workers to ‘latch babies on’, 

disempowering mothers in the process. Instead, their training should equip 

them not only with an understanding of the processes of positioning and 

attachment and hand expression but with the skills to explain them effectively 

to mothers, so that the mothers can achieve effective breastfeeding 

themselves. The same applies to hand expression, which staff should be 

able to teach without the need to touch the mother unless she requests this. 

Experience has shown us that staff seem to find learning and demonstrating 

hand expression particularly difficult, especially those who practice it less 

frequently, so great care should be taken over this when undertaking practical 

skills reviews and audit, including ensuring that all of the team of key workers 

are teaching and assessing consistently. 

Section 5 of ‘Implementing Step 2’ has more information on how to train staff in 

the necessary practical skills. 

If the baby is very 

premature or 

milk production is 

poor, encouraging 

expressing more 

frequently than 

eight times will 

enhance the 

mother’s ability to 

lactate effectively 

and increase future 

milk production 

4. Separation of mother and baby for clinical reasons 

Mothers and babies can find themselves separated for a variety of reasons, 

including if one of them is ill. Where the health of either the mother or baby 

is the reason for the separation, the responsibility for assisting the mother to 

maximise her lactation and provide breastmilk for her baby should normally 

be shared between those professionals who are caring for her and those 

responsible for her baby. If one group of staff is to be given this responsibility, 

this should be made clear to all involved. 

When separation occurs soon after birth, action is needed urgently to stimulate 

milk production in order to ensure a good supply for both the short and long 

term. Ideally, the mother and baby should have a period of skin contact, 

preferably with a first breastfeed, before the separation occurs but this is not 

always possible. If it is not, hand expression and stimulation of the breasts and 

nipples should begin straight away, whether or not the baby needs breastmilk at 

that time. 

If it is necessary for mother and baby to be cared for separately for more than a 

few hours, they should be enabled to spend as much time together as possible 

throughout the period of separation, preferably skin to skin. 

The mother should be shown how to express her milk and encouraged to do 

so at least 8 times in 24 hours. There is no need for expression to take place at 

set intervals provided that it is frequent. Indeed, many mothers find it easier to 

fit in more expressing sessions if it is explained to them that the gaps between 

sessions do not have to be regular. Long gaps should, however, be discouraged 

and the value of night-time expression emphasised. 

If the baby is very premature or milk production is poor, encouraging expressing 

more frequently than eight times will enhance the mother’s ability to lactate 

effectively and increase future milk production. Where a breast pump is in use, 

starting and ending each session with hand expression will provide additional 

stimulation and assist in collecting the fat-rich milk at the end of the ‘feed’. 

5. Useful tips 

The first criterion, chronologically, that relates to Step 5 is the requirement that all 

new mothers be offered help with breastfeeding within six hours of delivery. This is 

easy to overlook on a busy postnatal ward unless procedures are in place to ensure 

that it happens. A requirement to document this interaction between mother and 

staff member can help, as can prompts on a whiteboard or in a day book. 


Many wards have 

a supply of simple 

‘props’, such as 

dolls and cloth 

breast models, 

which can be 

used to teach skills 

to both staff 

and mothers 

The routine distribution of leaflets can help to ensure that all mothers are given 

the same minimum information. In general, one or two well-chosen leaflets will 

be more effective than a multitude of them. Encouraging staff to refer directly 

to them when discussing breastfeeding with women can promote consistency 

of terminology and information, as well as providing an easily-accessible source 

of suitable phrasing for staff to use. 

While locally-produced leaflets can be valuable, they take a lot of time to 

develop and can be expensive. The Department of Health and UNICEF UK 

Baby Friendly Initiative leaflet Off to the best start is recommended as suitable 

for use in all facilities (Northern Ireland and Scotland have their own similar, 

centrally-produced leaflets). The Department of Health DVD, From bump to 

breastfeeding contains valuable clips which will reinforce and enhance the 

mothers understanding. Until translation of this leaflet into a range of languages 

is possible, UNICEF’s older style leaflet Breastfeeding your baby, available in 17 

languages, may be useful. 

Many wards have a supply of simple ‘props’, such as dolls and cloth breast 

models, which can be used to teach skills to both staff and mothers, and many 

community staff carry similar items with them for use in clinics and during 

home visits. 

The bath or shower is an ideal place for women to practise hand expression; 

laminated instructions placed on the wall in ward bathrooms can encourage 

women to try out the technique in privacy. 

The DVD Teaching Breastfeeding Skills, which is available to buy from the Baby 

Friendly Initiative, provides useful guidance on the level of knowledge and skill 

the Baby Friendly Initiative expects staff to demonstrate and the Guidelines for 

the development of a training curriculum contain suggestions for conducting 

practical skills reviews and providing feedback to the staff member. 

Staff should 

be guided to 

encourage bottle 

feeding mothers 

to have skin-toskin 

contact with 

their babies, hold 

their baby close 

and have plenty 

of eye contact 

during bottle feeds 

and for mothers 

to feed their 

babies themselves 

whenever possible 




written word may be a barrier to understanding. The pack contains sections on 

positioning, attachment, hand expression, storage of expressed breastmilk and 

sterilisation of feeding equipment. 


information provided in the postnatal period. Such a checklist will not only 

prompt the delivery of care but can also act as a means of recording it. It can 

require staff to document both the offer of help with breastfeeding within six 

hours of the birth and the later teaching of practical skills. The UNICEF UK Baby 

Friendly Initiative provides sample postnatal checklists which Trusts can adopt, 

or use as the basis for the development of their own. 

6. Mothers who formula feed 

The Baby Friendly Initiative requires that mothers who are formula-feeding their 

babies should be shown how to make up formula feeds or that staff ensure that 

the mother is able to this correctly prior to leaving hospital. Written information 

to reinforce the demonstration should be given. A local decision should be made 

regarding which staff will work with mothers to ensure this, and training to 

ensure their competence should be provided. 

Staff should be guided to encourage bottle feeding mothers to have skin-to-skin 

contact with their babies, hold their baby close and have plenty of eye contact 

during bottle feeds and for mothers to feed their babies themselves whenever 

possible. These are important factors in developing a strong mother-baby bond 

and which happen almost automatically during breastfeeding. However, their 

importance is often ignored if a mother is bottle feeding. 




Mothers should 

be encouraged 

to breastfeed 

exclusively and 

staff should ensure 

that any decision 

not to do this is 

the result of fully 

informed choice 

by the mother 

• Maternity staff should not give breastfeeding babies anything 

other than breastmilk except where there is a clear clinical 

indication that this is needed. Mothers should be encouraged 

to breastfeed exclusively and staff should ensure that any 

decision not to do this is the result of fully informed choice 

by the mother. 



Stage 1 


• Provide a copy of hypoglycaemia/reluctant feeder policy/policies. These 

should be evidence based, safe and protect breastfeeding. 

Stage 2 

There is no formal assessment of this Step at Stage 2 but staff may be asked to 

explain the potential consequences for the health of the mother and baby, and for 

lactation, of the giving of other foods or drinks to babies under six months old. 

Stage 3 


• All breastfeeding mothers are advised to breastfeed exclusively unless 

supplementation is clinically indicated; 

• Breastfeeding babies are not given anything other than breastmilk except 

where there is a clear clinical indication that this is needed or in the case of a 

fully informed choice by the mother; 

• All policies and guidelines underpin good practice. 






1. Background 

There is now clear research evidence that exclusive breastfeeding for the 

first six months, with partial breastfeeding until at least one year, provides the 

best health outcomes for both mother and baby – and that supplementation 

of breastfed babies under six months old with anything other than breastmilk 

carries potential health risks and may compromise lactation. Supplementation 

should therefore happen only where clinically indicated or where the mother has 

made a fully informed choice to do so. 

In order to ensure the successful implementation of Step 6 staff need to be 

aware of the impact of giving any other food or drink (including water and 

solid foods as well as infant formula) to a breastfed baby and of appropriate 

actions that can be taken (or suggested to the mother) to avoid the need to 

supplement. 

It is tempting to make Step 6 the first Step that is tackled when beginning to 

introduce the practical changes that will enable Baby Friendly accreditation. This 


is not advisable, and can carry serious risks for mother and baby. Abandoning 

supplements without ensuring that the adequate support for breastfeeding is in 

place can expose infants to unacceptable risks. 

The issue of supplementation of breastfed babies is closely linked to the issues 

covered by several of the remaining Ten Steps. If the implementation of these 

Steps is poor, inappropriate supplementation is more likely. On the other hand, 

attention to the implementation of these Steps can mean that the challenge 

presented by Step 6 is automatically reduced without any obvious direct effort 

towards reducing the incidence of supplementation. 

Step 6 is linked to certain other Steps in the following ways: 

• Step 2: Staff training should include information on the health implications of 

inappropriate supplementation. 

• Step 3: If mothers are made aware, antenatally, of the health implications of 

giving supplements to their breastfed baby, they are less likely to expect or 

request this postnatally. 

• Step 4: Successful implementation of skin contact as soon as possible after 

birth ensures that the majority of babies have an early, effective breastfeed, 

thus setting breastfeeding off on the right track. 

• Step 5: A high level of skill amongst staff in teaching mothers positioning 

and attachment and hand expression will maximise the chances that 

breastfeeding will be effective and reduce the need for supplements. 

• Steps 7 and 8: Where rooming-in and baby-led feeding are encouraged and 

facilitated, supplements are less likely. 

• Step 9: Discouragement of the use of teats and dummies means that 

demand feeding and effective attachment are more likely and therefore that 

supplementation is less likely. 

Fundamental to the effective implementation of Step 6 is the existence of 

sound policies and/or guidelines for the management of babies whose condition 

causes concern. These policies will have local names but will generally cover 

issues such as hypoglycaemia, babies who are reluctant to feed, jaundice and 

weight loss. Any policy of this type must enable staff to differentiate between 

babies who may need supplementation and those who are unlikely to do so, 

and describe clearly the appropriate management in each case. Guidance on the 

writing of a hypoglycaemia policy and reluctant feeder guidelines can be found 

on the Baby Friendly Initiative website. 


Hand expression 

of breastmilk has 

been found in 

many hospitals to 

be key to reducing 

supplementation 

rates 

Hand expression of breastmilk has been found in many hospitals to be key to 

reducing supplementation rates. Ensuring that staff have the skills to teach 

effective hand expression to mothers can not only provide breastmilk for 

babies who would otherwise require a formula supplement but it also tends to 

increase the confidence of both mothers and staff in the ability of breastmilk 

to meet babies’ needs. Familiarity with hand expression enables formula 

supplementation to be a last resort, rather than the first, in cases of difficulty. 

Mothers commonly request supplementation because their baby is unsettled, 

because they believe that their own milk is insufficient to meet their baby’s 

needs, or because they are finding breastfeeding difficult. Whilst it is essential 

that staff are sensitive to the mother’s situation and feelings, they should also 

ensure that she has access to information about the risks of and alternatives 

to supplementation to assist her decision-making. Reassurance about feeding 

frequency in the early days and assistance to find positions which enable 

mothers to both rest and breastfeed can do much to avoid unnecessary 

supplementation. 

Please note: It is important that staff understand that the method of giving 

a supplement is a separate issue from that of the supplement itself. A 

supplement is not excusable merely because it is not given using a bottle and 

teat; neither is it acceptable to assume that a mother who says she wants her 

baby ‘to be given a bottle’ is consenting both to the giving of formula and the 

use of a teat. (See also ‘Implementing Step 9’.) 

Reassurance about 

feeding frequency 

in the early days 

and assistance 

to find positions 

which enable 

mothers to both 

rest and breastfeed 

can do much to 

avoid unnecessary 

supplementation 

2. Assistance with implementation 


information provided in the postnatal period. This provides a convenient 

memory-prompt for staff and a means of recording that the relevant information 

has been given. The UNICEF UK Baby Friendly Initiative provides sample 

postnatal checklists which Trusts can adopt, or use as the basis for the 

development of their own. 





UNICEF UK Baby Friendly Initiative audit tool is recommended for the audit of 

Step 6. Simple audit of the incidence of supplementation will give basic data; 

however, audit of the documentation surrounding each incident will provide 

more in-depth information. This may throw light on why supplements are being 

given and enable the issue to be tackled, for example through changes to 

policies or the provision of additional staff training. 




Keeping her baby 

near her enables 

a mother to get 

to know him and 

to recognise his 

hunger cues 

All babies should stay with their mothers 24 hours a day on the 

maternity unit unless the health of either of them precludes this or 

the mother has made a fully informed choice not to have her baby 

with her. 



Stage 1 


Stage 2 


explain the value keeping mothers and babies together. 

Stage 3 


• All mothers are enabled and encouraged to keep their babies with them 24 

hours a day; 

• Any separation of mother and baby is the result of a clinical indication or of 

fully informed choice by the mother. 







be encouraged to 

continue to keep 

their baby near 

them day and 

night when they 

are at home 

1. Rationale 

Keeping her baby near her enables a mother to get to know him and to 

recognise his hunger cues. It facilitates baby-led feeding, and thus the 

establishment of breastfeeding, and helps to create realistic expectations 

for mothers of what caring for a baby involves. Keeping mothers and babies 

together also helps to reduce the risks of infection and cot death for the baby 

and recognises the need of a new mother to know that her baby is safe. 

Rooming-in, 24 hours a day, should be the default method of care for mothers 

and babies in the postnatal ward and there should not normally be a room 

designated as a nursery. Mothers should be encouraged to continue to keep 

their baby near them day and night when they are at home. 

2. Facilitating informed choice about rooming-in 

Not all mothers want or expect that their baby will remain with them throughout 

their hospital stay. In these circumstances, staff need to explain that roomingin 

is the norm and why it is beneficial. A mother who, despite this explanation, 

wishes her baby to be taken away should be counselled about where the baby 

will be put and who, if anyone, will be looking after him. A card displayed at 

each mother’s bedside, or attached to each cot, which explains the rooming-in 

policy, can assist the implementation of this Step. 


If a baby is unsettled and staff have been unable to help the mother to settle 

him at the bedside, it is acceptable for them to remove the baby for settling, 

provided that he is returned as soon as he is quiet. 

Co-sleeping on 

a sofa carries a 

significantly greater 

risk of sudden infant 

death than 

co-sleeping in a bed 

3. Bed sharing 

Bed sharing refers to a baby sharing his/her mother’s bed while in hospital and 

any other person’s bed (usually the parents’) when at home. It is a practice 

which enables easy breastfeeding at night and which is practised by the 

majority of parents at some time. Bed sharing is, however, associated with risks 

to the baby if practised when contraindicated or in an unsafe environment. 

Bed sharing is a useful alternative to removing an unsettled baby from his 

mother’s bedside in hospital but it must take place in the context of safety for 

the baby. A robust policy should be in place to ensure safe practice, including 

clear specification of the contraindications to bed sharing and guidance on the 

precautions to be taken. These should include frequent checks on the wellbeing 

of the baby while he is in the mother’s bed. The Baby Friendly Initiative 

has produced a sample bed sharing policy which may be used as the basis for 

the development of local policies. The policy should be backed up by training to 

enable staff to implement it appropriately. 

Co-sleeping refers to parents (usually) and babies sleeping together, whether 

in bed or on, for example, a sofa. It often happens unintentionally, for instance 

when the mother falls asleep while breastfeeding. Since co-sleeping on a sofa 

carries a significantly greater risk of sudden infant death than co-sleeping in a 

bed, it is clearly not sufficient simply to tell parents that they must not bring 

their baby into their bed. 

Bed sharing and co-sleeping should be fully discussed with all mothers, both 

antenatally and on more than one occasion postnatally, whether or not they 

intend to practise it. The UNICEF leaflet Sharing a bed with your baby is a useful 

resource which can act as the basis for a discussion about bed sharing with 

parents. 

Some maternity units have found the use of cots which clip on to a mother’s 

bed valuable. These allow mothers to care for their babies easily at night 

without the risks associated with bed sharing. 

4. Facilitating implementation 




written word may be a barrier to understanding. It includes a section which can 

be used to facilitate the giving of information on rooming-in and bed sharing. 

It is important to ensure that all mothers receive information about the 

importance of keeping their baby near them. Some hospitals require staff to 

complete a checklist of the basic care and information provided in the postnatal 

period. This provides a convenient memory-prompt for staff and a means of 

recording that the relevant information has been given. The UNICEF UK Baby 

Friendly Initiative provides sample postnatal checklists which Trusts can adopt, 

or use as the basis for the development of their own. 





UNICEF UK audit tool to monitor breastfeeding support in the community 





There should be 

no restriction on 

either the frequency 

or the length of 

feeds except where 

clinically indicated 

Breastfeeding mothers should be advised to feed their babies as 

soon as they show signs of wanting to feed. Feeding cues should 

be explained to mothers. There should be no restriction 

on either the frequency or the length of feeds except where 

clinically indicated. 



Stage 1 


Stage 2 


describe feeding cues and explain the importance of baby- led/demand feeding. 

Stage 3 


• All breastfeeding mothers are advised to observe for feeding cues, to feed 

their babies whenever the baby wants and for as long as the baby wants. 






Baby-led/demand 

feeding It is key 

to the successful 

establishment and 

maintenance of 

breastfeeding 

1. Definition and rationale 

Baby-led/demand feeding means allowing each baby to feed according to 

a pattern decided by him/her and his/her mother. It is key to the successful 

establishment and maintenance of breastfeeding. As well as enabling sufficient 

intake for the baby, it ensures that the breasts are given adequate stimulation to 

ensure adequate ongoing milk production and allows both mother and baby to 

practise the skills of positioning and attachment in a relaxed and timely fashion. 

Baby-led feeding does not mean feeding babies only when they cry; it means 

feeding them when they want to be fed. Babies display cues (such as moving 

their heads, sucking their fists and rooting) when they are ready to feed and 

staff need to point these out to mothers so that they can respond promptly. 

Some hospitals have placed a card listing common early feeding cues in each 

cot, to highlight to mothers the importance of watching for them. 

It is also important that mothers understand that they, too, can initiate a feed, 

for instance if their breasts are full. This is an important part of preventing some 

of the more common breastfeeding complications, such as engorgement and 

blocked duct. Similarly, where a baby is feeding infrequently, the mother can be 

informed about ways to encourage the baby to feed, the value of skin contact 

and hand expression and stimulation of the breasts and nipples as ways to 

encourage milk production. 



normally be advised 

to allow the baby 

to determine the 

length of the feed 

Baby-led feeding refers not only to the frequency of feeds but also to their 

duration. Mothers should normally be advised to allow the baby to determine 

the length of the feed, offering the second breast when the baby lets go of the 

first. However, both staff and mothers should be made aware that persistent, 

prolonged episodes of feeding may mean that attachment is ineffective, and 

that skilled help is indicated in these circumstances. It is also helpful to give 

mothers some guidance on what to expect from an effective feed, regardless 

of its length. For example, explaining that once the milk is being taken, the 

initial rapid sucks will lead into slow rhythmic sucks with pauses, and swallows 

will be heard. As the baby completes the feed, the pattern tends to speed up 

again to rapid and shallow sucking with occasional swallows. This information is 

more likely to support the mother to recognise effective breastfeeding and milk 

transfer that alluding to times. 

Giving parents 

a realistic idea 

of normal infant 

feeding behaviour 

will help to ensure 

that they recognise 

a baby who is not 

behaving normally 

The principle of feeding babies when they want, for as long as they want has 

underpinned practice for some years now. However, staff need to be aware 

that mothers who have their first babies some years ago, and grandmothers of 

babies being born now, may expect that babies will be fed on rigid schedules. 

It is therefore important to ensure that all mothers understand what demand 

feeding means and why it matters. 

2. Managing sleepy babies 

Some babies are not able to demand feeds sufficiently for their own needs 

when they are newborn. For these babies, encouragement to feed frequently 

is vital and mothers should be shown how this can be achieved through 

such techniques as skin-to-skin contact and hand expression of breastmilk. A 

robust policy for the care of babies who are reluctant to feed will ensure that 

babies are not subjected to unnecessary investigations or given unwarranted 

supplementary feeds (see also Implementing Step 6.) Guidance on the writing of 

reluctant feeder guidelines is available on the Baby Friendly Initiative website. 

Babies who are weak or otherwise compromised often do not feed well. As a 

result they can enter a downward spiral of increasing lack of energy. Community 

staff, in particular, need to be alert to the ‘good’ baby who demands only a few 


feeds in 24 hours and be prepared to intervene to ensure effective, frequent 

feeding. This information will be gained as part of the formal breastfeeding 

assessment (See Step 5). Giving parents a realistic idea of normal infant feeding 

behaviour will help to ensure that they recognise a baby who is not behaving 

normally. 

If a minimum frequency of feeds needs to be imposed while a baby is small, 

weak or unwell, staff should ensure that the mother understands that this 

regime is only temporary and that demand feeding is the ultimate aim, with the 

possibility that this will mean more frequent feeds and/or an irregular feeding 

pattern. This is particularly important in a Special Care situation, where a baby 

may need to follow a scheduled pattern of feeds for several weeks before 

demand feeding is possible. In some instances, with particularly preterm or 

sick infants (where the baby cannot ever be relied upon to waken and demand 

sufficient feeds to maintain his immediate needs and allow for growth), 

then a modified form of demand feeding may be recommended, one which 

encourages mothers to respond to any cues shown, but with a minimum 

number of feeds required within the 24 hours. 




for use in explaining breastfeeding management, including demand feeding, 

wherever the spoken or written word may be a barrier to understanding. 

It is important to ensure that all mothers receive information about demand 

feeding. Some hospitals require staff to complete a checklist of the basic care 

and information provided in the postnatal period. This provides a convenient 









the UNICEF UK audit tool to monitor breastfeeding support in the maternity 





Breastfeeding 

mothers should be 

discouraged from 

using teats and 

dummies while their 

babies are learning 

to breastfeed 

Breastfeeding mothers should be discouraged from using teats 

and dummies while their babies are learning to breastfeed, with 

the reasons for this explained to them. 

Staff should not feed a breastfeeding baby using a teat without 

ensuring that the mother has made a fully informed choice that 

this should happen. Staff should not give a breastfeeding baby a 

dummy unless there is a clinical indication, and only then with the 

mother’s fully informed consent. 



Stage 1 


Stage 2 

There is no formal assessment of this Step at Stage 2. 

Stage 3 


• No breastfeeding babies are given feeds using a bottle and teat except 

where the mother has made a fully informed choice that this should happen; 

• No breastfeeding babies are given dummies except in cases of clinical 

indication or where the mother has made a fully informed choice that this 

should happen; 

NB. It remains a strong recommendation that dummies and teats are used with 

caution in the neonatal unit setting, particularly when the baby is learning to 

breastfeed. This standard will not, however, be assessed formally as part of the 

Baby Friendly assessment process. 







be informed of 

the ongoing 

potential effects 

of dummy use on 

demand feeding 

1. Background 

There is much controversy about the degree of harm to breastfeeding that may 

be caused by the use of artificial teats and dummies. However, it is likely that 

the mechanical and dynamic aspects of the technique used for sucking on an 

artificial teat or dummy may cause difficulty for babies who are still acquiring 

the skills needed for breastfeeding. In addition, the use of a dummy to settle a 

baby who might otherwise be offered a breastfeed may be detrimental to the 

mother’s milk supply, both in the early postnatal period (when the effects may 

be permanent) and later on. 

For these reasons, the Baby Friendly Initiative recommends that teat and dummy 

use should be avoided wherever possible while babies are learning to breastfeed 

and that mothers should be informed of the ongoing potential effects of dummy 

use on demand feeding, so that they can make informed choices. 


Dummies may be used within the neonatal setting where clinically indicated or 

as part of a non-nutritive sucking programme. It is important that an individual 

approach is adopted to prevent routine dummy use for all babies. It is strongly 

recommended that, where possible, dummy use is discontinued when the baby 

begins to show signs of readiness to breastfeed and that a full discussion takes 

place with the parents at this time, thus enabling them to make an informed 

decision about their use. 

2. Use of teats 

Sometimes a mother in the postnatal ward will ask that her baby be given ‘a 

bottle’. In this situation it is not uncommon for staff to discuss the possible 

impact (on the baby and the breastfeeding experience) of the use of infant 

formula but omit to mention the potential implications of the use of a teat. 

These two issues need to be discussed separately and the mother’s consent for 

both obtained before a formula feed is given using a bottle and teat. (See also 

‘Implementing Step 6’.) 

Cup feeding can be used as an alternative when the baby is unable to 

breastfeed. It works extremely well for preterm babies but is less appropriate 

for term babies, whose tendency to suck rather than lap makes the procedure 

messy and wasteful, and whose need for larger volumes may make the 

process unacceptably slow. 

The benefits 

of continued 

breastfeeding 

for the preterm 

baby need to be 

considered and 

discussed with 

parents and 

support provided 

Bottle feeding and cup feeding are both commonly resorted to when the 

mother and baby are experiencing difficulties with breastfeeding. As with 

Step 6, skilled support from staff can help mothers to avoid the need to use 

alternative feeding methods. 

In the neonatal unit, bottle-feeding is associated with earlier discharge from 

hospital and mothers may choose to adopt this method of feeding expressed 

breastmilk in an effort to bring their baby home earlier. However, evidence 

suggests that once home mothers struggle with the additional pressure of 

expressing and sterilising equipment and often resort to introducing formula 

within weeks of discharge. The benefits of continued breastfeeding for the 

preterm baby need to be considered and discussed with parents and support 

provided to enable them to make the transition to breastfeeding prior to 

discharge from hospital. 


3. Use of dummies 

Dummies are often used to placate babies who are unsettled. Often this 

is because they are not breastfeeding effectively or need to be fed more 

frequently but this may not be recognised by the parents – or indeed by the 

health care worker. Good information and skilled support are vital to ensure 

that dummies are not used to cover up the symptoms of a breastfeeding 

relationship that is in difficulties and that parents understand their potential 

impact on breastfeeding. 

Dummy use has recently been highlighted as a way of reducing the risk of 

Sudden Infant Death Syndrome (SIDS), also known as ‘cot death’. More 

research is needed in this area, in particular into whether the use of a dummy 

has an equally beneficial role in breastfeeding and bottle-feeding babies. Until 

more evidence is available, it would seem unreasonable not to support the use 

of a dummy for a breastfeeding baby once breastfeeding is established, should 

the mother choose – provided that this is only for periods of sleep and not as a 

way of extending the interval between breastfeeds. 



information provided in the postnatal period. This provides a convenient 














All breastfeeding 


be advised how 

to contact both 

professional and 

national and 

local voluntary 

sources of help 

All breastfeeding mothers should be given information before 

they leave hospital about all the support available to them in 

the community. They should be advised how to contact both 

professional and national and local voluntary sources of help and 

of the existence of any local support groups. 



Stage 1 


• Confirm that all breastfeeding mothers are given information about all the 

support available to them in the community, both professional and voluntary, 

and how they may access this; 

• Describe the mechanism for ensuring that this information is accurate and up 

to date. 

Stage 2 

This Step is not formally assessed at Stage 2. 

Stage 3 


• All breastfeeding mothers are given information about the all support 

available to them in the community, both professional and voluntary, and how 

they may access this; 






1. The information to be provided 

The criteria state that mothers must be given information before they leave 

hospital, about the support available to them at home. It is expected that this 

information will normally be provided in written format. 

Information should be provided on all available sources of breastfeeding 

support, including: 

• Contact telephone numbers for community midwives; 

• Telephone numbers for 24-hour hospital helplines; 

• Telephone numbers, venues, days and times for any local mother 

support groups; 

• Helpline numbers for the national breastfeeding support organisations (the 

NCT, the Breastfeeding Network, La Leche League, the Association of 

Breastfeeding Mothers) and the national breastfeeding helpline number. 


Many hospitals include this information in a discharge pack or within the 

mother’s hand-held notes. This works well provided that: 

• The mother knows the information is there and understands how it may be 

useful to her; 

• The information is not either confined to a sticker on an envelope which is 

likely to be thrown away, or contained within the hand-held records which 

will be returned to the hospital once the community midwife’s visits are 

completed. 

In some areas the Personal Child Health Record (PCHR) is given to the mother 

during pregnancy or while she is in the postnatal ward. In this case, insertion 

of professional and voluntary contact information in the book is a useful way 

to ensure that all mothers receive it. A potential drawback, especially where 

the book is given to the mother antenatally, is that the information may not be 

current by the time her baby is born. 

It is better to give 

her the information 

during her stay, 

when she will 

have a chance to 

read it and ask 

any questions 

It is important that the information is current. A mechanism should be in place 

for checking this on a regular basis and for ensuring that out-of-date information 

is not distributed. Sticky labels are a convenient way to add the information to 

printed leaflets shortly before they are distributed, so preventing wastage. 

Mothers should be given national breastfeeding helpline numbers, whether or 

not there are also support groups and breastfeeding counsellors in their local 

area. It is helpful to explain to them that they do not have to be, or become, 

a member of any breastfeeding support organisations in order to access help 

from that organisation. 

2. Timing of the information 

There is no reason to wait until the mother is on her way out of the ward to give 

her the necessary information. Indeed, at this point she probably has a good 

deal else to think about. It is better to give her the information during her stay, 

when she will have a chance to read it and ask any questions. 

It is important that mothers whose babies are in the neonatal unit are also 

given information about how to contact professional and voluntary help with 

breastfeeding before they themselves go home. It should be explained to them 

that their baby does not have to be at home with them in order for them to 

access this type of support. 

3. Documentation and handover of care 


information provided in the postnatal period, including the giving of contact 

information for support available to breastfeeding mothers at home. This 

provides a convenient memory-prompt for staff and a means of recording that 

the relevant information has been given. The UNICEF UK Baby Friendly Initiative 

provides sample postnatal checklists which Trusts can adopt, or use as the basis 

for the development of their own. 








IMPLEMENTING THE 

INTERNATIONAL CODE OF 

MARKETING OF BREASTMILK 

SUBSTITUTES 

Standards for the International Code 

There must be no advertising or promotion of breastmilk 

substitutes, bottles teats and dummies within or by the facility/ 

Trust, either to the general public or to staff. All antenatal and 

postnatal services must be free of such promotion and these 

items must not be sold on the facility’s premises or by its staff. In 

the hospital, supplies of infant formula, bottles and teats must be 

paid for in full. 



Stage 1 

The head of service of the head of service of the facility/Trust will be asked to 

confirm that: 

• There is no advertising or promotion of breastmilk substitutes, bottles, teats 

or dummies on the facility’s premises or by its staff; 

• All supplies of infant formula, bottles and teats are be paid for in full. 

Stage 3 


• There is no advertising or promotion of breastmilk substitutes, bottles, teats 

or dummies on the facility’s premises or by its staff. 




Guidance for the successful implementation 

of the International Code 

Advertising and 

other promotion 

of breastmilk 

substitutes, feeding 

bottles, teats 

and dummies 

has the potential 

to undermine 

breastfeeding 

1. Rationale 

Advertising and other promotion of breastmilk substitutes, feeding bottles, teats 

and dummies has the potential to undermine breastfeeding in two key ways: 

Firstly, the use of any of these products may itself interfere with either the 

supply and demand mechanism which regulates breastmilk supply or with the 

baby’s feeding technique (especially in the early days), or both. 

Secondly, the literature (both text and images) which accompanies, or which is 

used to promote the products tends to carry messages – either overt or subtle 

– which may undermine confidence in breastfeeding. At worst, the information 

provided is inaccurate or misleading; at best it is necessarily biased in favour 

of the product. This makes such information inadequate, both as a means of 

providing scientific and clinical information for staff and for enabling pregnant 

women and mothers to make fully informed choices. 

The International Code of Marketing of Breastmilk Substitutes (WHO, 1981, 

and subsequent WHA Resolutions) exists to restrict the activities of companies 


that manufacture or distribute products which may harm breastfeeding. The UK 

law (The Infant Formula and Follow-on Formula Regulations, 1995) deals with a 

similar area but is less strict than the Code. Baby Friendly health-care facilities 

are required to ensure that their practices are in line with the Code. 

2. Monitoring practice and ensuring compliance 

Staff training plays an important part in reducing the amount of promotional 

materials in circulation but it is not enough to ensure that none makes its way to 

clients. Constant vigilance is necessary, for example with regard to leaflets and 

posters, which can seem to appear in clinic and waiting areas almost of their 

own accord. In community facilities, particular attention should be paid to leaflet 

racks which may be topped up by outside contractors. 

It is the 

responsibility of 

senior staff to liaise 

with companies 

to ensure that 

no items in 

breach of the 

Code are included 

Many hospitals distribute bags of literature and product samples to new 

mothers. It is the responsibility of senior staff to liaise with the companies 

supplying these to ensure that no items in breach of the Code are included. 

Contact between representatives of companies that manufacture or distribute 

breastmilk substitutes, bottles, teats and/or dummies and the general public is 

restricted by the UK law. However, distribution of their materials by the health 

service, and contact with health service personnel is not. This means that 

health-care staff are a key target for the dissemination of information to parents. 

Company representatives can take up a great deal of health-care staff time to 

deliver a limited amount of factual information. Direct contact also provides 

the opportunity for items such as diary covers and pens to make their way into 

the facility. A more appropriate use of health-care resources is for a named 

individual in the Trust or facility to meet with company representatives on a 

regular basis and to disseminate information to staff as and when appropriate. 

Staff often resort to using company-branded tools to carry out their work, 

pointing out that alternatives are not available to them. It is the responsibility 

of the organisation to ensure that items such as tourniquets and weight 

conversion charts are provided for their staff so that promotional items are not 

needed. 

Companies with an interest in bottle feeding often put on study days, to which 

health-care staff are invited. It is important to recognise that subtle promotional 

messages will always be delivered on such occasions and that the content 

of speakers’ talks may also be biased. While the facility cannot dictate how 

staff will spend their own time, it can ensure that promotion and sponsorship 

by companies whose products may undermine breastfeeding play no part in 

training provided by the organisation. 

Many hospitals, particularly those built recently, have independently run shops 

within their buildings. It may not be possible for the facility to dictate what is 

sold in an independent outlet, although some facilities have had experience of 

items such as dummies and infant formula being removed when a carefully 

worded letter has been sent. Where this is not possible, it should certainly be 

feasible to ask the store manager to avoid overt displays and promotions as this 

would certainly contravene the Code. 

Formula milk research trials – In response to queries related to whether trials 

may proceed in Baby Friendly facilities, the Baby Friendly Initiative 

has developed a position paper which is available for download: 

www.babyfriendly.org.uk/researchtrials

How to implement Baby Friendly standards â A guide for ... - Unicef UK

Create successful ePaper yourself

Delete template?

Save as template?

How to implement Baby Friendly standards â A guide for ... - Unicef UK