The first three steps (see table 1) constitute the foundations of good breastfeeding care. Staff education is the central component of the Baby‐Friendly program and only with well‐trained staff can the necessary practice changes be made. Health professionals who have contact with breastfeeding women need the knowledge and skills to support them to breastfeed successfully. The majority of health professionals in the UK have had little formal education in breastfeeding and commonly lack the practical skills needed to help a mother make enough milk for her baby and feed effectively and without pain.20
A breastfeeding policy should set out the measurable aims and standards to be achieved and will establish a framework to support and guide staff as they change their practice and provide Baby‐Friendly care to mothers. The right of mothers to full information about their care, and support in their chosen feeding method, is integral to the Baby‐Friendly approach. For informed choice to function effectively, all pregnant women should receive clear information on the health benefits of breastfeeding and practices which are beneficial to success.
Steps 4 to 9 describe the pillars of good practice necessary for optimum support of breastfeeding mothers. The principles of informed choice are followed, whereby mothers are given accurate information in a timely manner and then supported in their decisions (even if these are not in line with the Ten Steps).
The routine in a Baby‐Friendly hospital is for mothers to be given their babies to hold in skin‐to‐skin contact immediately after birth (or as soon as mother and baby are able). This takes advantage of the alert period in a baby's first hours of life and facilitates a successful first breastfeed. Babies who are put to the breast soon after birth establish breastfeeding faster and breastfeed for a longer duration. Early suckling also significantly increases the concentration of plasma and probably brain oxytocin (“the love hormone”) in the mother, contributing to maternal/infant bonding.21
Fundamental to successful breastfeeding is ensuring that mothers know how to hold and attach their babies to the breast, since this is crucial for a good milk supply and pain free feeding. Putting babies to the breast when they indicate they are hungry, and feeding for as long and as often as they want – feeding on demand – is also essential for milk production. Rooming‐in permits and encourages breastfeeding on demand. Infants should be breastfed when they demonstrate feeding cues which include hand to mouth activity, smacking lips, rooting, eye movements in light sleep, and movement of extremities. Crying is a late indicator of hunger. A mother cannot respond to a feeding cue if her baby is in a nursery or parked in a cot by the nurses' station. Rooming‐in and other Baby‐Friendly hospital policies have been shown to increase breastfeeding initiation and duration24
and enhance maternal‐infant bonding.25
All breastfeeding mothers should also be taught how to express their milk by hand, a skill which will help to alleviate or avoid common complications such as engorgement. Expressing is also of particular importance for newborn infants separated from their mothers for reasons such as prematurity or illness. Breast milk remains the food of choice for these babies. Therefore, health care staff should provide support and guidance that will assist mothers in establishing and maintaining lactation, and expressing their milk while separated. A mother with an infant in the NICU should be advised and supported to express her milk at least six, and preferably eight or more, times in 24 h including at night. She should also be encouraged to stay with her infant and hold him/her in skin‐to‐skin contact as much as possible.
According to the AAP, exclusive breastfeeding, which is recommended for the first 6 months of life, is defined as “an infant's consumption of human milk with no supplementation of any type (no water, no juice, no nonhuman milk, and no foods) except for vitamins, minerals, and medications. Exclusive breastfeeding has been shown to provide improved protection against many diseases and to increase the likelihood of continued breastfeeding for at least the first year of life”.8
Mothers should therefore be encouraged to not give their babies food or drink other than breast milk during their first 6 months and hospital staff should ensure that formula supplements are only given where there is a true clinical need. To avoid any risk of confusion in the baby, necessary supplements should be fed by alternative methods appropriate to the baby's condition, such as cup, spoon or syringe, rather than by bottle teat. Similarly, pacifiers can adversely affect breastfeeding in healthy term newborns since time spent sucking on a pacifier is time not spent sucking at mother's breast, and the lack of stimulation can delay the arrival of the full milk supply.27
There is no promotion for, or sampling of, infant formula or other breast milk substitutes in a Baby‐Friendly hospital which must pay the fair market price for all formula and infant feeding supplies. Distribution of products provided free of charge by commercial interests, such as baby bags made by infant formula manufacturers (regardless of whether they contain formula samples), has been shown to undermine breastfeeding success.30
UK legislation prohibits formula sampling and free supplies and some other promotion is also illegal, but these issues continue to present a major obstacle to Baby‐Friendly implementation in the USA and many other countries.
Good practice is capped off by step 10, which requires that mothers be given information about the support they can access in their communities, such as continuing help with breastfeeding from the health services or mother‐to‐mother support from voluntary groups. This contact will help maintain mothers' confidence, avoid or solve problems which arise, and increase the duration of breastfeeding.