Prince of Wales Hospital Policy on Infant Feeding

Have a written infant feeding policy that is routinely communicated to all healthcare staff and parents.

1.1 The policy is written in both English and Chinese and made accessible to all staff of PWH.

1.2 All staff members caring for pregnant women, infants, young children and their mothers are oriented to the infant feeding policy of the hospital when they start work.

1.3 The policy summary in both English and Chinese is displayed in areas where pregnant women, infants, young children and their mothers are served.

1.4 The policy is available to pregnant women, mothers and their partners at their requests.

1.5 The main points of the policy are interpreted for mothers and their partners if needed.
Establish ongoing monitoring and data management systems on implementation of the Policy.

2.1 Develop ongoing monitoring and evaluation systems for the Policy implementation.

2.2 Audit mothers’ experiences of care regularly and review the outcomes to examine the effectiveness.

2.3 Monitor staff training and assess their knowledge and skills to ensure their competence in supporting infant feeding.

2.4 Record and monitor breastfeeding indicators to review progress and facilitate continuous quality improvements.

2.5 Regularly update all infant feeding related protocols to keep abreast with current evidence-based standards.
Ensure that staff who provide infant feeding services have sufficient knowledge, competence and skills to support breastfeeding.

3.1 The healthcare professionals are responsible for educating, supporting and evaluating the mothers on infant feeding including breastfeeding. They are to help the mothers to overcome their infant feeding challenges or make referrals to appropriate personnel if necessary.

3.2 All professional and supporting staff who take care of pregnant women, mothers, infants and young children would be trained in breastfeeding management at a level appropriate to their professional group. Training should also be provided for these staff on the care for women and infants who are not breastfed as an informed choice. New staff will receive training within six months of commencing their work.

3.3 All non-clinical staff such as clerical and housekeeping staff are orientated to the policy and should be able to refer infant feeding queries appropriately.

3.4 Training curricula are available for staff training according to the roles and responsibilities of the professional groups. The curricula would cover WHO’s ‘The Ten Steps to Successful Breastfeeding’ and ‘the International Code of Marketing of Breastmilk Substitutes’ and subsequent relevant World Health Assembly resolutions.

3.5 The training records are kept by designated personnel.
Discuss the importance and management of breastfeeding with pregnant women and their families.

4.1 The responsible professional staff will ensure that all pregnant women are given verbal and non-commercial written information of the benefits and management of breastfeeding and the potential health risks related to not breastfeeding or supplementing with formula in their antenatal visits to PWH or the shared care organisations (Maternal & Child Health Centres of the Department of Health). The information given is documented in the mothers’ hospital notes.

4.2 Breastfeeding classes are to be organised routinely for the pregnant women. All pregnant women are encouraged to participate in the breastfeeding classes.

4.3 Apart from discussing with the pregnant women and families the importance of breastfeeding and the risks of not breastfeeding or supplementing with other breastmilk substitutes, the global recommendations on exclusive breastfeeding and continue breastfeeding after 6 months, discuss with them the value of building relationship with their fetus in utero and the immediate and sustained skin contact with their infants after birth. Equip mothers with knowledge on the importance of early initiation of breastfeeding and the basics of good positioning and attachment. In supporting infants’ health and development, educate mothers about the importance of closeness, touch, and responding to infants’ needs through the practices of 24 hours rooming-in, recognising feeding cues and responsive feeding.

4.4 Healthcare professionals should also discuss with pregnant women their concerns on breastfeeding in their antenatal visits and if necessary, refer them to the lactation consultants.
Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth.

5.1 All mothers who delivered vaginally or by Caesarean section without general anaesthesia are encouraged to start skin-to-skin contact with their infants immediately after birth in an unhurried environment if the mothers and their infants are physically fit.

5.2 For mothers who have undergone general anaesthesia, skin-to-skin contact with their infants should be performed as soon as they are responsive and alert.

5.3 Skin-to-skin contact should last for at least one hour without interruption except due to clinical reasons. If skin-to-skin contact is interrupted under such circumstances, it should be resumed as soon as the mothers and infants are fit to continue.

5.4 During skin-to-skin contact, safety precautions should be taken. Educate mothers to observe infants’ face and keep them in a safe position during the contact. Observe for, assess and manage any signs of distress among healthy and sick infants, especially in their first few hours of birth.

5.5 All women are encouraged to recognise the feeding cues and to offer the first infant feeding uninterruptedly in skin-to-skin contact when they and their infants are ready, with the help from a midwife.

5.6 Mothers who are unable or do not wish to have skin contact immediately after birth are encouraged to commence skin contact as soon as they are able, or so wish.

5.7 Encourage mothers to practise skin-to-skin contact throughout the postnatal period.

5.8 Support infants who are cared in the neonatal unit to be held by their mothers skin-to-skin or have kangaroo mother care as soon as they are physically fit. Encourage the mothers to provide touch, comfort and emotional support to their infants throughout their stay in the neonatal unit.
Support mothers to initiate and maintain breastfeeding and manage common difficulties.

6.1 All breastfeeding mothers are offered further help with breastfeeding within the subsequent six hours of delivery.

6.2 The breastfeeding mothers should be assessed, taught and observed on their breastfeeding to ensure that they have acquired the skills of positioning, attachment and recognition of effective feeding. They should be encouraged to understand the needs of their infants that include comforting, verbal and visual communication, responsive feeding, the signs of having enough breastmilk and safe sleeping practice.

6.3 All mothers will be shown how to hand express their milk.

6.4 Breastfeeding mothers are encouraged to maintain lactation if their infants are separated from them or have to stop direct breastfeeding temporarily. Mothers are taught the use of milk pumps as necessary.

6.5 For mothers whose infants are preterm or sick, discuss with them the importance of their breastmilk for their infants as soon as is appropriate. Offer them help to express milk as early as possible and within six hours of delivery. To optimise long-term milk supply, encourage them to continue to express at least eight times in a 24-hour period especially in the first two to three weeks following delivery.

6.6 For those who have to prepare expressed breastmilk for their infants, the healthcare professionals should provide them the necessary education that includes breastmilk expression by hand and by pump, sterilisation technique, labeling of milk bottles and storage.

6.7 Create a suitable environment conducive to effective expression such as mothers having access to breast pumps and equipment, staying close to their infants when expressing whenever possible. Support mothers’ access any time for breastfeeding during their infants’ stay.

6.8 When an infant is not tolerating oral feeds, use their mothers’ colostrum for mouth care.

6.9 Assess mothers on their expressing especially in the first two weeks to support optimum expression and milk supply. Help them to overcome expressing difficulties where necessary.

6.10 Provide care to mothers to support the transition to direct breastfeeding and encourage them to tempt their infants to breastfeed later. Assess and educate mothers on feeding cues, proper positioning, attachment and recognition of effective feeding.

6.11 For infants who have clinical indications for a short term modified feeding regime in the early days after birth, such as in infants who are preterm, small for gestational age or excessively sleepy after birth, frequent feeding including a minimum number of feeds in 24 hours should be offered to ensure safety.

6.12 Mothers are supported through the transition to discharge home from hospital, including having the opportunity to stay overnight / for extended periods to support the development of mothers’ confidence and modified responsive feeding.

6.13 Mothers who have decided not to breastfeed are to have individual discussions on various feeding options and helped to decide what is suitable in their circumstances. Explain the importance of and encourage them to practice responsive feeding. To help enhance bonding, educate the mothers to hold their infants close during bottle feeds and offer the majority of feeds to their infants themselves.

6.14 Show mothers the safe preparation of their infants’ feeds with return demonstrations. Breast care should also be advised.

6.15 A referral to the lactation consultant service is made for mothers who have more complex breastfeeding problems.
Do not provide breastfed newborns any food or fluids other than breastmilk unless medically indicated.

7.1 In the first six months, breastfed infants should receive no other food or fluids except in cases of medical indication or fully informed mothers’ choice.

7.2 Breastfeeding mothers will be provided with information about the importance of exclusive breastfeeding in the first six months. They should receive the information that giving newborns any food or fluids other than breastmilk interferes with the establishment of their breastmilk production.

7.3 The breastfeeding mothers must be consulted and engaged in a full discussion if formula is prescribed as supplement for medical reasons. Any formula prescribed must be documented in infants’ hospital notes.

7.4 Breastfeeding mothers who request formula supplement are counselled to make aware of the possible health implications and the negative effects so that they can make a fully informed choice.

7.5 Prior to introducing formula, mothers are encouraged to express breastmilk to give to their infants via supplementary aids, such as cups, syringes and spoons.

7.6 Supplementation should be regularly reviewed and discussed with the mothers. These discussions and procedures are to be documented in the mothers’ and infants’ hospital notes.

7.7 All mothers are encouraged to breastfeed exclusively for six months and continue breastfeeding for two years or more. All weaning information should reflect this recommendation. When exclusive breastfeeding is not possible, the value of continuing partial breastfeeding should be emphasised. Mothers should also be supported to maximise the amount of breastmilk their infants receive.

7.8 Data of infant feeding on discharge are transferred to the shared care organisation (Maternal & Child Health Centres of the Department of Health) or the private sector.
Enable mothers and their infants to remain together and to practice rooming-in 24 hours a day.

8.1 Mothers and their infants are to stay together immediately after birth in postnatal wards. This practice applies to both breastfed and formula fed infants.

8.2 Mothers who have delivered by Caesarean sections should be given appropriate care but the policy of keeping mothers and infants together will apply.

8.3 Separation of mothers and infants in postnatal wards occurs only due to justifiable reasons.

8.4 Mothers are encouraged to learn how to interpret their infants’ needs and feeding cues.

8.5 For mothers who choose not to practise room-in of infants 24 hours a day as an informed choice, they are advised on the risks and the discussions are documented in the mothers’ hospital notes.

8.6 Mothers whose infants are cared in the neonatal unit are encouraged visitation with no restrictions unless the situation does not allow due to the infants’ best interest. They are also encouraged to hold their infants and participate in their care if conditions allow. Make mothers comfortable when in the unit so as to enable them to spend as much time as possible with their infants.

8.7 Value the parents as partners in care and consider them as the primary carers through entrusting them with all care possible and providing them with full information regarding their infants’ condition and treatment to enable informed decision-making.
Support mothers to recognise and respond to their infants’ cues for feeding.

9.1 Feeding according to need and with no restriction on frequency or duration is encouraged for all infants unless clinically contraindicated.

9.2 Regardless of their infant feeding modes, all mothers are to be educated on the feeding cues and encouraged to practise responsive feeding as part of nurturing care. Apart from feeding, support them to recognise and respond to infants’ cues for closeness and comfort to increase their confidence in their infants’ growth and development.

9.3 Mothers should be taught how to recognise that their infants are getting enough milk.

9.4 The importance of night-time feeding for milk production should be explained to the mothers. Mothers can also be advised that if their breasts become overfull they could try to breastfeed or express breastmilk if separated from their infants.

9.5 For mothers who are separated from their infants due to medical indications, encourage visitation as often as possible so that they can recognise feeding cues.

9.6 Support is to be given in the neonatal unit to mothers whose infants are in transition to responsive feeding and showing signs of interest in suckling.
Counsel mothers on the use and risks of feeding bottles, teats and pacifiers.

10.1 If expressed breastmilk or formula feeds are medically indicated, the use of feeding methods such as cups and spoons are preferred during the establishment of breastfeeding, in particular among preterm infants. Support mothers on the techniques and educate them on the rationale behind using these methods.

10.2 Mothers wishing to use bottles, teats and pacifiers should be counselled on the possible detrimental effects of introducing them when an infant is learning to breastfeed so that they can make a fully informed choice. Educate mothers on their choice of feeding after counselling. This includes the appropriate hygiene in the cleaning of utensils, bottles and teats used.

10.3 The information and support given and the mothers’ decisions should be documented in the appropriate health record.
Coordinate discharge so that parents and their families have timely access to ongoing support and care.

11.1 Before discharge from the hospital, mothers will be provided with postnatal education and communicated on their infant feeding planning.

11.2 PWH will regularly liaise with the Maternal & Child Health Centres (MCHCs) of the Department of Health on breastfeeding support and refer mothers to them on discharge from the hospital. Mothers are advised to access healthcare support, whether public or private, within 2-4 days after birth and again in the second week to ensure effective feeding and the well-being of mothers and infants. Infants who are admitted to the neonatal unit should also be referred to MCHCs for support on discharge.

11.3 All mothers will be provided with the contact details of healthcare professionals who can support them with breastfeeding. These include lactation consultants, Maternal & Child Health Centres, telephone helplines for breastfeeding support and peer support groups.

11.4 For mothers who require additional support for their complex breastfeeding challenges, a referral to lactation consultants or breastfeeding clinics should be made.

11.5 Mothers who choose not to breastfeed as an informed choice will be provided with the contact details of the supporting healthcare professionals including Maternal & Child Health Centres and telephone helpline of the hospital.
Support mother-friendly childbirth practices and procedures.

12.1 Support the women and families according to the current ‘Ten Steps to Successful Breastfeeding’ of the Baby-Friendly Hospital Initiative.

12.2 Provide birthing information to the pregnant women and introduce to them the use of birth plans. Discuss their plans with them at delivery admissions. Respect and support their choices for care options.

12.3 Encourage them to have the companionship of their significant others to provide constant or continuous physical and/or emotional support during labour and birth.

12.4 Allow women with low risk labour to drink during labour, except those who develop complications in their labour process.

12.5 Explain and encourage women to consider the use of non-pharmacological methods of pain relief unless analgesic or anaesthetic drugs are necessary because of complications. Respect and support them according to their personal preferences and what is better for the mother-infant dyads.

12.6 Encourage women to walk and move about during labour. To encourage natural births, offer preferred labouring and birth position choices suitable for the women, unless a restriction is specifically required for a complication and the reason is explained to the mother.

12.7 Avoid invasive procedures, such as rupture of the membranes, episiotomies, inductions or augmentations of labour, instrumental deliveries and Caesarean sections, unless specifically required due to complications and explain the reasons to the mothers.

12.8 All obstetric staff are informed of the mother-friendly labour and birthing policies and procedures.
Support breastfeeding friendly workplace practices.

13.1 PWH supports employees to continue breastfeeding after returning to work.

13.2 Breastfeeding rooms with facilities for expression and storage of breastmilk are set up for staff. Departmental breastfeeding areas are encouraged to be identified to facilitate staff in expressing breastmilk to maintain lactation.

13.3 Employees who need to express breastmilk during working hours could approach their supervisors to work out an appropriate arrangement for lactation breaks.

13.4 All other staff members are requested to support their colleagues to breastfeed by adopting a positive and accepting attitude.
Comply fully with the ‘International Code of Marketing of Breastmilk Substitutes’ and Subsequent Relevant WHA Resolutions (adopted from the Annex 2 of the Hospital Authority Breastfeeding Promotion Policy, 2010 & WHO/UNICEF (2009) Baby-Friendly Hospital Initiative Revised Updated and Expanded for integrated Care, Section 4, Hospital Self-Appraisal And Monitoring).

14.1 No advertising of all breastmilk substitutes, feeding bottles and teats.

14.2 No free samples to mothers.

14.3 No free or low cost supplies of breastmilk substitutes.

14.4 No promotion of products in or through health care facilities.

14.5 No company personnel to contact mothers.

14.6 No gifts or personal samples to healthcare workers. Healthcare workers should never pass samples on to mothers.

14.7 No use of space, equipment or educational materials sponsored or produced by companies when teaching mothers about infant feeding.

14.8 Labels should be in an appropriate language and have no words or pictures idealizing artificial feeding e.g. pictures of infants on the labels.

14.9 All information on artificial infant feeding should clearly explain the benefits of breastfeeding, warn of the costs and hazards associated with artificial feeding.

14.10 Information to health workers should be scientific and factual.