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Countywide Infant Feeding Care Pathway

Breastfeeding is recognised as best for baby, and the benefits of breastfeeding extend well beyond basic nutrition. As well as containing all the vitamins and nutrients a baby needs in the first six months of life, breast milk has also been found to protect babies from illness such as stomach viruses, lower respiratory illnesses and ear infections. Health professionals should encourage mothers to breastfeed and ensure they have the support they need.

If a mother is having difficulties with breastfeeding refer them to their midwife or health visitor for expert advice and support.  Health visitors also hold baby hubs where a mother can go for help, details of these are in the child's 'Personal Child Health Record ' (PCHR) or 'red book'. Breastfeeding should be promoted, encouraged and supported whenever possible.

For any queries or concerns regarding the suitability of medication to be taken whilst breastfeeding contact Drugs In Breastmilk service via their Facebook page or email .The Drugs in Breastmilk service was set up by The Breastfeeding Network (BfN) in response to the number of calls received concerning medication. The service is run by a qualified pharmacist who is also a BfN Registered Breastfeeding Supporter. The service is provided over and above full-time work commitments so messages are generally not responded to during the day. The service is open to mothers and professionals.


Red Flags
Intense unbearable breast pain
Signs of a poor feeding
  • Less than 6 heavy wet nappies and/ or less than 2 soft yellow stools, £2 coin size (minimal size) in 24 hours after the breastmilk comes in.   It is never normal for a newborn to go 24 hours or more without stooling. Newborn stools should change colour from a dark greeny/black meconium (1st stool) to a greenish/brownish/yellow ‘changing’ stool by days 2/3 and to a yellow stool by days 4/5. The changing colour is due to the digestion of milk, and if the stool colour does not change it indicates that baby is receiving insufficient milk
  • Rapid weight loss the first few days of life, more than 10%- 12% of body weight.
Refer to midwife if support is required over the weekend or baby is less than 28 days old.
Initial Primary Care Assessment

A woman's experience with breastfeeding should be discussed at each contact to assess if she is on course to breastfeed effectively and identify any need for additional support. Breastfeeding progress should then be assessed and documented in the postnatal care plan at each contact.

Position of baby

  • Baby held close to mother
  • Head and body supported in a straight line, baby able to tilt head back
  • Nose opposite nipple
  • (CHIN: close, head free, in line, nose to nipple)

Enabling effective attachment

  • Stimulate baby to gape if necessary (touch upper lip with nipple)
  • Wait for wide open mouth, tongue down
  • Bring quickly to breast with chin leading (maintaining extension of the head)
  • Aim for bottom lip to touch breast well away from the base of the nipple
  • Nipple will reach towards the back of the roof of baby's mouth

Signs of effective attachment

  • Mouth wide open
  • Lower lip curled back (cannot always be seen)
  • Chin indents the breast
  • Cheeks full and rounded
  • If visible, more areola seen above top lip than below bottom lip
  • Rapid initial sucks, changing to slow deep rhythmical sucks with pauses and swallows
  • Contented baby who stays on breast
  • Feeding is pain free

Position made sustainable

  • Attention to mothers comfort and support for baby if required*


NB *support if needed should be brought in after baby has attached, as putting it in place before attachment can make effective positioning and attachment more difficult.

Please see NHS Choices Breastfeeding: positioning and attachment video


  • Audible and visible swallowing
  • Sustained rhythmic suck
  • Relaxed arms and hands
  • Moist mouth
  • At least 6 regular soaked/heavy nappies after 5-6 days
  • At least 2 soft yellow stools, the size of a £2 coin should be passed by baby every 24 hours after the time the milk comes in (from about day 4)

This is because less stooling in a young baby often indicates an inadequate milk intake. This stooling pattern should continue for the first 4-6 weeks of life, after which stooling may become much less frequent. This is normal, breast fed babies are very rarely constipated.

  • Breast softening
  • No compression of the nipple at the end of the feed
  • Woman feels relaxed and sleepy

NB. No pain should be felt during or after breastfeeding

If a mother is having difficulties with breastfeeding refer them to the midwife or health visitor for expert advice and support.

Please also see the Local breastfeeding support section.

Initial Primary Care Management

Perceived insufficient milk supply

If an insufficiency of milk is perceived by the woman, attachment and positioning should be reviewed and her baby's health should be evaluated. Reassurance should be offered to support the woman to gain confidence in her ability to produce enough milk for her baby.

Increased milk supply will only occur if attachment and positioning is effective and baby is fed frequently, as this stimulates the breastfeeding hormones. Babies need to be fed at least 8 times/24 hours or more in order to increase milk supply and allowed to suck at the breast for as long as they desire, releasing the breast spontaneously when they have finished a feed. Mothers should be made aware of a baby's feeding cues (rooting, sucking of fists or blankets, restlessness, rapid eye movement, waving) so the mother can recognise when her baby needs to be fed before they begin to cry.

If the baby is not taking sufficient milk directly from the breast and supplementary feeds are necessary, expressed breast milk should be given preferably by a cup, as introduction of a teat can make successful attachment at the breast more difficult when a baby is learning to feed.

Please see the Faltering Growth pathway for further information on slow weight gain in breastfeeding infants.

Cracked and painful nipples are usually caused by incorrect attachment at the breast, and an assessment of feeding should be undertaken by a trained health professional and the mother helped to achieve effective positioning and attachment. Refer mother to the midwife or health visitor for expert advice and support and direct them to breastfeeding support groups in the area.

  • Advise on considering the application of a thin layer of white soft paraffin or expressed breast milk, if the nipple skin is cracked, fissured, or there is nipple exudate.

Sometimes delayed healing may be due to a bacterial infection and a topical antibiotic cream may be indicated, consider swabbing.

  • If there is suspected bacterial infection, prescribe fusidic acid 2% cream to be applied to the nipples after every breastfeed for 5-7 days.
  • If there is suspected thrush (candida) infection, provide treatment for the woman and the infant at the same time, to prevent re-infection. If the nipples are red and inflamed, prescribe hydrocortisone 1% cream in addition.
  • If nipple symptoms persist and are severe, continue topical treatment and consider treating for bacterial or candida ductal infection, depending on clinical judgement.

See NICE Clinical Knowledge Summary (CKS) topic on Breastfeeding problems for detailed information on management.

Thrush infection usually presents after a period of pain free breastfeeing and is very painful. Symptoms include pain that increases during a feed and persists afterwards, itching and sensitivity of the nipples is often apparent. Baby often has creamy/white lesions in their mouth caused by Thrush. It is most important to treat the mother and the baby concurrently. Miconazole cream is recommended for the mother's nipples and miconazole gel for baby's mouth (after 4 months of age) or nystatin drops for babies under 4 months.

Further information is available on the Breastfeeding Network Website.

Please see the Thrush in Breastfeeding Mother and Babies Pathway.

It is normal for breasts to feel tender, fully and heavy around days 3-4 when breastmilk 'comes in'. All that is necessary is frequent breastfeeding. A supportive, well fitting, non-wired bra will help the mother feel more comfortable.

Breast engorgement differs from full breasts and occurs when breasts get overly full. Engorgement can be prevented by frequent breastfeeding and expression of milk if baby is not able to feed.

Engorged breasts feel hard and looks shiny and breastmilk does not flow easily. Before baby can attach it may be necessary to express some breastmilk (preferably by hand) until the breast softens and baby can attach correctly. Warm bathing and a little breast massage will help the milk flow and frequent unlimited feeds will help remove the breastmilk. Mother can take some analgesia like paracetamol if necessary.

Women should be advised to report any signs and symptoms of mastitis including flu like symptoms, red, tender and painful breasts to their healthcare professional urgently.

Women with signs and symptoms of mastitis should be offered assistance with positioning and attachment and advised to:

  • continue to breastfeed frequently and/or use hand expression targeted to ensure effective milk removal from the affected lobes. This can be combined with gentle massaging of the breast and a warm compress to aid milk to flow.
  • start each feed on the affected side for up to 3 feeds, taking care not to allow the other breast to become overfull
  • take analgesia compatible with breastfeeding, for example paracetamol
  • increase fluid intake

If signs and symptoms of mastitis continue for more than a few hours of self-management please follow mastitis pathway.

Women with inverted nipples should receive extra support and care to ensure successful breastfeeding. Please see the La Leche website for further helpful information.

Tongue-tie is a condition when a tight piece of skin between the underside of the tongue and the floor of the mouth affects the baby's ability to attach properly to their mother's breast. Treatment is not always necessary, and should only be considered when the baby has difficulty feeding. This is covered by the local IFR policy and is only commissioned if the baby is less than 16 weeks old.

Please view the criteria based access policy here. 

Tongue-tie causes more difficulty in breast feeding babies than bottle fed babies as the breastfeeding baby needs to scoop breast tissues into the mouth with their tongue to ensure effective feeding, and their tongue needs to cover the lower gum so the nipple is protected from damage. A baby is unable to do this if their tongue is unable to function in the desired manner due to tongue-tie. The teat of a bottle does not require this scooping action, and so tongue-tied bottle fed babies are usually able to feed without difficulty and treatment is not therefore necessary.

Breast feeding babies with a significant tongue-tie tend to slide off the breast and chomp on the nipple with their gums, this is painful for the  mother, and leads to sore, often ulcerated and bleeding nipples. Baby will feed very frequently but is not satisfied for long as the transfer of breastmilk is poor due to an ineffective attachment at the breast. A slow weight gain is often apparent and a mother's breastmilk supply will decrease rapidly due to inadequate breast stimulation and milk removal.

If difficulty is experienced by a mother and baby is suspected to have a possible tongue tie, the mother should be referred to either the midwife (if baby is under a month old) or to the health visitor for help with positioning and attachment. If the midwife/health visitor is unable to resolve the issue they may refer to the infant feeding specialist midwife or health visitor or directly to the hospital for a frenulotomy. This is covered by the the local IFR policy and is only commissioned if the baby is less than 16 weeks old. Please view the criteria based access policy here.

Following a feeding assessment, a baby under 12 weeks can be referred to the maternity unit in Gloucester or Cheltenham where their suitability for a frenulotomy will be further assessed. This assessment may be followed by a frenulotomy. Babies over 12 weeks requiring a frenulotomy need to be referred to an ENT surgeon.There is a 16 week cut off a per the local IFR policy.

Information on Gloucestershire's frenulotomy service can be found here.

Please also see the criteria based access requirements within the local IFR policy here.

Women should be advised that babies need to feed at least 8-12 times in 24 hours. If a baby is not waking to feed, or falls asleep during a feed it is necessary to wake them up in the early days. To wake the baby it is helpful to remove their clothes and change their nappy. If this is not sufficient try gently wiping their face with damp cotton wool. Sometimes massaging a baby's feet can help, and gently movement of their limbs. Jaundice can cause a baby to be sleepy and needs to be monitored. The baby's general health should be assessed if there is no improvement.


Signpost to Community and National Resources:

Guidelines for the Identification and Management of Slow Weight Gain in the Breastfed Baby - Gloucestershire Health and Care NHSFT (GHC)

These guidelines aim to assist practitioners with the identification of the causes of slow weight gain, and the best ways in which to manage slow weight gain in breastfed babies.

Please follow the resource link below to view.

Guidelines for Growth Monitoring for Babies, Children and Young People - Gloucestershire Health and Care Services (GHC)

These guidelines aim to ensure that there is consistent practice within Gloucestershire Care Services NHS Trust in line with the latest evidence. They will assist staff in identifying and managing unusual growth patterns.

Please follow the resource link below to view.

When to Refer

If baby is less than 28 days old with exceptional or ongoing feeding problems contact Specialist Infant Feeding Midwife on 07799341200 (please do not give this number to the patient).

Unresolved feeding concerns for babies more than 28 days old can be discussed with Health Visiting Infant Feeding Lead on 07798534298 (please do not give this number to the patient).

Please follow the Infant Feeding Countrywide Referral Pathway.

If breast feeding support has been given and a tongue-tie is affecting feeding please refer to frenulotomy service. The criteria based access requirements within the local IFR policy can be found here.

If other suspected medical condition refer to Paediatrics or contact the paediatricians via Advice and Guidance.

Secondary Care Management


If you think a baby may require a frenulotomy, please refer into the Health Visitor or Midwife who will assess the baby and refer to the frenulotomy clinics in Cheltenham or Gloucester if required.

The criteria based access requirements within the local IFR policy can be found here.

Please see the Frenulotomy leaflet from Gloucestershire Hospitals NHS Foundation Trust here for more information.

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