Appendix 3. Breastfeeding

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    Exclusive breastfeeding (no food or drink other than breast milk) for the first 6 months is the best choice for infants, regardless of the term or birth weight.


    For HIV-infected mothers, see Section 3.7.


    If the neonate is unable to suck effectively or at all:

    • Breast milk can be expressed with a breast pump or by hand (Section 3.2).
    • If the neonate has a good swallowing reflex: the milk can then be given by cup, spoon or syringe (Section 3.3).
    • If the neonate cannot swallow effectively or at all: the milk is given with a nasogastric tube (Section 3.4) to prevent aspiration and exhausting the neonate.


    If sucking is ineffective, check for hypoglycaemia (Chapter 10, Section 10.3.4) and danger signs (Chapter 10, Section 10.3.1).


    If the neonate is able to suckle but the quantity of maternal milk is not sufficient, the supplemental suckling technique offers the possibility to feed her/him with infant milk while stimulating milk production (Section 3.5).


    Always make sure that any medications being taken by the mother are compatible with breastfeeding, and if necessary, adjust the treatment accordingly.

    3.1 Breastfeeding success factors

    The factors for success in breastfeeding are:

    • Informing pregnant women about breastfeeding benefits and implementation.
    • Putting the neonate to the breast early, within an hour of birth.
    • Correct and comfortable positioning of mother and neonate. Proper latch-on allows effective sucking and reduces complications (cracks): the neonate should face the mother’s body, with the chin against her breast, the nose free and the nipple and most of the areola in the mouth.
    • For women with inverted or flat nipples: use techniques to help nipple protrude (nipple massage, use of breast pump just before the neonate feeds).
    • Maintaining exclusive breastfeeding (unless medically contra-indicated).
    • Breastfeeding on demand at least 8 times daily day (at least every 3 hours).
    • Good hydration (at least 3 litres daily) and a caloric intake > 2500 kcal daily for the mother, as these directly affect the amount of milk produced.
    • Nipple care, washing with clean water before nursing.
    • An organisation that allows the mother and neonate to stay together 24 hours a day.
    • Help with maintaining lactation even if the mother has to be separated from her neonate (preventing milk production from stopping due to lack of stimulation).


    Do not stop breastfeeding if:

    • The neonate has diarrhoea: explain to the mother that her milk is not causing the diarrhoea.
    • The mother is sick (unless serious condition): explain to the mother that her milk is not of poor quality because she is sick.

    3.2 Hand expression and storage of breast milk

    Hand expression is an alternative when a breast pump is not available. Milk is expressed every 2 to 3 hours.

    Show the mother the technique. Give her a clean cup or container for collecting the milk. The container should be washed, boiled and rinsed with boiled water and air-dried before each use.


    • Wash hands, sit comfortably and hold the container under the breast.
    • With the other hand, hold the breast up with four fingers, and place the thumb above the areola.
    • Squeeze the areola between the thumb and the fingers while pressing backward toward the rib cage.
    • Express each breast for at least 5 minutes, alternating, until the milk stops flowing.
    • If the milk fails to flow, check the technique and apply warm compresses to the breasts.


    Feed the neonate immediately after expressing the milk (by cup or nasogastric tube).


    If the neonate does not take all of the collected milk, it can be stored in a clean container in the refrigerator (2 to 8 °C) for a maximum of 24 hours a Citation a. Managing newborn problems: a guide for doctors, nurses, and midwives. World Health Organization. 2003.

    Warm the milk (water bath) to body temperature for the next feeding.
    If no refrigerator is available, the milk can be stored in a clean container (covered) at room temperature for up to 4 hours if the ambient temperature is ≤ 22 °C or up to 1 hour if the ambient temperature is > 22 °C. 

    3.3 Administering the milk by cup or other utensil

    The milk can be administered using a cup, spoon or syringe.
    Use a clean (washed, boiled or rinsed with boiled water and air-dried) container/utensil for each feed.


    The mother should (with help from a carer):

    • Measure out the volume of milk needed according to the neonate’s age and weight (Appendix 4).
    • Hold the neonate in a half-seated or upright position on her lap.
    • Place the cup/spoon gently against the neonate’s lower lip and touch the outside of the upper lip with the edge of the cup.
    • Tilt the cup/spoon so that the milk just reaches the neonate’s lips.
    • Let the neonate take the milk at his own pace; never pour the milk into the mouth.
    • Stop feeding when the neonate closes the mouth and is no longer interested in feeding.


    If the neonate coughs or regurgitates multiple times, or is not able to take a sufficient quantity it means he/she does not yet have a sufficient swallow reflex. In this case, the neonate should be fed using a nasogastric tube until a later time.

    3.4 Administering the milk by nasogastric tube


    • Preterm or birth weight < 1500 g: poor sucking, limited or no coordination between sucking and swallowing, tire rapidly.
    • Neonates with respiratory distress: risk of aspiration, tire rapidly.
    • Sick neonates with little or no sucking and/or hypotonia. 
    • Neonates with cleft palate, particularly when the cleft is very wide.


    Before each feed:

    • Aspirate the gastric contents and use pH test to verify that the gastric tube is in the correct position.
    • Check for signs of feed intolerance (vomiting, distended or tender abdomen, bloody stools). If present, assess gastric aspirate appearance and volume:
      • If the aspirate is clear or milky and < 3 ml/kg: re-inject the aspirate slowly and feed the planned amount. Re-evaluate aspirate before next feed.
      • If the aspirate is clear or milky and ≥ 3 ml/kg: reinject the aspirate slowly and feed planned amount minus the volume of the residual. Re-evaluate aspirate before next feed. Continue feeds but do not increase feed volume until aspirate volume is < 3 ml/kg. 
      • If the aspirate is green, bloody, or fetid: do not re-inject the aspirate; stop the feeding, look for danger signs (Chapter 10, Section 10.3.1) and necrotizing enterocolitis (blood in stools and painful abdominal distension). Insert an IV line for maintenance fluid therapy (Appendix 5), start antibiotic therapy before transferring the neonate to a neonatal care unit.


    Administering the milk:

    • Take a sterile or clean (washed, rinsed with boiled water and air-dried) syringe, large enough to hold the total amount of the feeding. Remove the plunger and connect the syringe to the conic end of the tube.
    • Pour the milk into the syringe, which should be held vertically.
    • Ask the mother to hold the syringe 10 cm above the neonate and let the milk flow through the tube by gravity.
    • Do not use the plunger of the syringe to force the milk down faster.
    • Each feeding should last 10 to 15 minutes.


    For the daily amounts required for feeding, see Appendix 4.

    3.5 “Supplementary nursing” technique

    This technique is used to:

    • Maintain breast-feeding when milk production is less than the daily amount needed by the neonate,


    • In neonates who have difficulty suckling at the breast.


    It consists of giving expressed breast milk or infant formula through a feeding tube while stimulating milk production.


    • Cut off the end of a CH8 gastric tube (1 cm from the holes) and remove the cap from the other end.
    • Attach the first end to the nipple using adhesive tape. Place the other end in the cup. The neonate should have both the nipple and the tube in the mouth while nursing (Figure 1).
    • The mother should hold the cup 10 cm below breast-level, so that the milk is not sucked up too quickly.


    The neonate may need 2 or 3 days to adjust to the technique. If, for the first few days, the neonate does not take all of the milk in the cup, give him the rest with a cup, spoon or syringe.


    Figure 1 - "Supplementary nursing" technique


    3.6 Management of feeding problems (summary)



    Problem with breastfeeding, but breastfeeding seems possible (milk production, sucking and swallowing are all adequate)

    Give mother more advice, build her confidence, always have a member of the medical team present during breastfeeding, recording observations in the neonate’s chart.

    Breastfeeding with inadequate amount of breast milk (amount of milk produced less than neonate’s daily requirements)

    • Stimulate milk production by frequent breastfeeding (8 times daily).
    • Use a breast pump and the “supplementary nursing” technique.

    Ineffective sucking but good swallowing reflex

    • Express the milk with a breast pump or by hand.
    • Administer the milk using a cup, spoon or syringe.

    Ineffective sucking and poor or no swallowing reflex

    • Express the milk with a breast pump or by hand.
    • Feed breast milk via a nasogastric tube.


    3.7 Breastfeeding in HIV-infected women

    To reduce the risk of HIV transmission, mothers should receive long-term antiretroviral therapy.


    Exclusive breastfeeding is recommended for the first 6 months of life, with gradual weaning over one month starting at age 6 months. Stopping breastfeeding abruptly is not recommended.


    Breast milk substitutes can be used as an alternative to exclusive breastfeeding only under the following conditions:

    • There is enough infant formula available for exclusive use to age 6 months.
    • The mother (or the person in charge) is able to prepare the formula under good hygiene conditions and frequently enough to limit the risk of diarrhoea or malnutrition.
    • There is access to a health care facility offering a full range of paediatric care.