Breastfeeding

Key Messages

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These are the main health messages that should be conveyed to all future and new parents. They have been written in second person and at a reading level appropriate for the general public so that they can be shared with them directly. They are based on a consensus founded in scientific research and professional practice. Clicking an underlined word or group of words in the text will redirect you to the section in Supporting Evidence that deals with that topic.

These key messages are based on the WHO/UNICEF Baby-Friendly Hospital Initiative (BFHI) and the Breastfeeding Committee for Canada (BCC) Baby-Friendly Initiative (BFI) Practice Outcomes Indicators for Hospitals and Community Health Services. These strategies have been shown to be based on best practices for all mothers and babies, to protect, promote and support breastfeeding.

key message

Breastfeeding is the normal, unequalled way to feed your baby. Babies need just your milk for the first six months. Breastfeeding for up to two years or longer is healthy for babies and is encouraged.

Health Canada recommends that babies be fed only human milk for the first six months. Babies do not need any other liquids or foods during that time. After six months, gradually introduce solid foods starting with those rich in iron. You can keep breastfeeding for two years or longer.

Breast milk contains over 200 components that change depending on the age and needs of your baby and young child. It is the only food your baby needs for the first six months.

The longer you breastfeed, the greater the health benefits for you and your baby. This is why breastfeeding for as long as possible is recommended. Regardless of the length of time you nurse your baby, it is better to breastfeed for a short time than not at all.


key message

Breastfeeding is important for your baby and you.

Breastfeeding:

  • Protects your baby from many infections and illnesses.
  • Promotes healthy brain development.
  • Is convenient, since breastmilk is at the right temperature and available anytime.
  • Is cost-effective and environmentally friendly.
  • Protects you from breast cancer, ovarian cancer and diabetes.
  • Helps your body return to normal.


key message

Place your baby skin-to-skin right after birth for at least one hour or until your baby has finished breastfeeding for the first time.

Your baby will be placed on your abdomen right after birth because it is the best way to keep your baby warm and stable at this time. Your baby will be dried off, and a warm blanket will be placed around both of you. Your baby will look at you, start to look for your breast, and may start to breastfeed. Skin-to-skin has many benefits for a mother and baby and promotes breastfeeding success. It is best to wait and weigh your baby after this first feed.

To hold your baby skin-to-skin, place your baby wearing only a diaper in an upright position on your chest. When your baby is skin-to-skin, he is more likely to:

  • Latch on.
  • Latch on well.
  • Maintain his body temperature.
  • Maintain his heart rate, respiratory rate, and blood pressure.
  • Have a normal blood sugar.
  • Cry less.
  • Breastfeed exclusively and breastfeed longer.
  • Indicate to you when he is ready to feed.

Holding your baby skin-to-skin also promotes:

  • Better milk flow and production.
  • Bonding (the process of developing an emotional connection to your baby).

Skin-to-skin contact at any time has benefits for both you and your baby. Fathers, partners, and support persons can also hold baby skin-to-skin. Skin-to-skin cuddling and breastfeeding also help if your baby has to have a blood test or other painful procedure.


key message

Keep your baby close to you during the early days and weeks.

Sharing a room with your baby in a hospital, birthing centre, and/or at home can:

  • Help you learn about and respond to your baby’s cues.
  • Help you make more milk.
  • Help you feel close to your baby.
  • Help your baby adjust to life outside the womb.

If you are separated from your baby for any reason, ask for help with breastfeeding and how to keep your breast milk supply.


key message

Breastfeed your baby as often and for as long as your baby wants.

Your baby will give you cues to tell you when she is ready to feed and when she is finished. Babies will vary in how often they want to feed. Cluster feeding (frequent short feeds) is common in the first few weeks.

You do not need to time your feeds as long as your baby:

key message

All your baby needs is your milk for the first six months. Giving your baby other fluids can create some problems for you and your baby.

Unless there is a medical reason, babies should not receive any other food or drink in the first six months (including in the first few days after birth). Other foods or drinks interfere with the mother’s milk supply and may affect the baby’s interest in breastfeeding.

As your baby is learning to breastfeed, it may be difficult for your baby to go from breast to bottle to breast again. If your baby needs additional milk, ask your nurse or midwife to show you how to give small amounts of your milk with a spoon or a cup rather than using a bottle.


key message

There are many ways to calm your baby without using a soother or pacifier.

Using a soother instead of watching for your baby’s feeding cues may cause you to make less milk. Carrying, rocking, and skin-to-skin cuddling are other good ways to calm your baby instead of using a soother. If you make an informed decision to use a soother, it is best to wait until your baby is breastfeeding well (usually around 4 – 6 weeks of age).

key message

Ask for help as you are learning to breastfeed. You can do this!

The early days of parenting and breastfeeding are not always easy for new parents. Although it is natural for mothers to produce milk, breastfeeding is a learned skill. It may take a few weeks for you to feel comfortable with breastfeeding. It is normal for this to take time. Get help right away if your baby is not showing signs of breastfeeding well.

There are many people who can help you with breastfeeding:

  • Nurses and midwives can help you right after your baby is born.
  • Your partner, family, and friends can provide emotional support.
  • Peer support groups and postpartum doulas can provide support in your community.
  • Other breastfeeding mothers can provide support and encouragement.
  • Public health nurses or other breastfeeding experts can provide support in your community.
  • If breastfeeding issues persist, lactation consultants may be available in your hospital or the community (once you are home).

For breastfeeding support and information:

  • Call the Telehealth Ontario Breastfeeding Hotline at 1-866-797-0000. This helpline provides free, confidential advice and support. This service is available in English and French with translators available for other languages. It is available 24 hours a day and seven days a week.
  • Search for breastfeeding services near you at ontariobreastfeeds.ca.
  • Look for health services that practice all or most of the 10 steps of the WHO/UNICEF Baby-Friendly Initiative.

key message

Learn more about breastfeeding.

You can find out more about breastfeeding from the following resources. More suggestions can be found in the Resources and Links section.

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Supporting Evidence

The supporting evidence is written in third person and is aimed at prenatal education providers. It is not intended to be shared directly with new and expectant families; it is meant to provide the background information and evidence for the key message.

About Breastfeeding

Defining breastfeeding

From a biological perspective, breastfeeding is defined as a child being fed the milk naturally produced by the mother’s breasts. Breastfeeding is recognized worldwide as the normal and unequalled way to feed infants1,2 Breastfeeding practices vary widely depending on the culture in which families live.

National and international breastfeeding guidelines

Health Canada, the Public Health Agency of Canada, and the Baby-Friendly Initiative Ontario support the same guidelines as the WHO and UNICEF.1,2,3 See Appendix A for more information on the Baby-Friendly Initiative.

The Nutrition for Healthy Term Infants (2012) guidelines recommend that babies be exclusively breastfed for the first 6 months of age and that, thereafter, breastfeeding be continued with the addition of complementary foods until the age of 2 or beyond.2,4

Exclusive breastfeeding is defined as the baby receiving only human milk (from the breast or expressed). Vitamins, minerals, and most medications do not interfere with the nature of exclusive breastfeeding.2 Breastfeeding is no longer considered to be “exclusive” when a baby is given other liquids (e.g., commercial infant formulas, water, cow’s milk, goat’s milk, soy milk, juice, herbal tea) or foods.2

Breastfeeding: A biological standard

Breastfeeding is a biological process that allows human beings (like all mammals) to feed their babies by producing milk especially suited to their babies’ needs. The human baby is vulnerable at birth and requires constant care for several months. Breastfeeding, the act of nursing, skin-to-skin contact, and carrying the baby help to meet the baby’s nutritional, proximity, warmth, and safety needs.

During pregnancy, a woman’s body produces hormones that lead to continuing mammary gland (breast) development, called mammogenesis. These breast changes allow mothers to produce colostrum (mother’s first milk, rich in protein and antibodies) from approximately the 16th week of pregnancy, called lactogenesis I.

After birth, the drop in hormone levels caused by separation of the placenta from the uterine wall triggers a rapid increase in milk production, called lactogenesis II. Milk production then continues as long as the breast is stimulated and the milk is removed. The maintenance of milk production is called galactopoiesis. When that stimulation stops, the mammary gland goes “dormant” again until the next pregnancy.5,6

Milk like no other

Human milk contains over 200 components that work synergistically and change constantly to suit the baby’s age and specific needs.3 For the first six months, human milk provides everything the baby needs for optimal development with the exception of the full requirement of Vitamin D and K. After six months, human milk continues to be a vital component of the baby’s diet and provides ongoing immune protection.

Human milk contains a number of components that:

  • Meet the baby’s nutritional needs (e.g., lactose to fuel the brain; long-chain fatty acids for neuron and vision development; protein for digestion, growth, and development, etc.).
  • Give the baby early immune protection. An infant’s immune system is immature at birth and cannot produce certain antibodies for several months. Human milk contains antibodies, white blood cells, and other bioactive components that coat the baby’s intestinal and respiratory mucous membranes and help protect the baby from infection. This immune protection continues throughout the breastfeeding period.

See Appendix B for the principal components of breast milk.

National and provincial statistics

Breastfeeding rates across Canada have increased since the 1970s.7,8,9 However, for a variety of reasons, many women stop breastfeeding in the first few weeks of their child’s life. The cessation rate is twice as high in the first month than at any other time. A drop in the exclusive breastfeeding rate in the following months is also being observed.10 Early supplementation with commercial infant formulas (CIF) in the hospital has been documented as one of the best predictors of early breastfeeding cessation.11,12 Table 1 demonstrates and compares Canadian breastfeeding initiation rates and exclusivity by six months with Ontario statistics.

Table 1: Breastfeeding statistics across Canada and Ontario13

2010 2012 2013
Initiation rate Canada 87 percent 90.3 percent __
Initiation rate Ontario 89.6 percent 90.4 percent 91.8 percent
Exclusivity by six months rate in Canada 27.7 percent 24.2 percent __
Exclusivity by six months in Ontario 28.9 percent 22.4 percent 33.3 percent

The most current statistics reveal that Ontario’s breastfeeding rates are higher than the national average.

Presently a province-wide data collection agency (Better Outcomes Registry & Network) is collecting, interpreting, sharing, and rigorously protecting critical data about each birth in the province. This report will no doubt highlight areas for change to improve breastfeeding outcomes.7

Deciding to Breastfeed

Variables affecting breastfeeding

Despite the presence of breastfeeding guidelines, research indicates that many women have difficulty reaching the goals set by the guidelines or, in fact, their own breastfeeding goals. Exclusively breastfeeding for the first six months of their baby’s life is particularly challenging for first-time mothers.14 Studies reveal that factors exist that affect a woman’s decision to breastfeed and the duration that she breastfeeds.15,16

A woman’s decision to breastfeed is often made within a broader context, based on her interpersonal relationships, the community in which she lives, or sociocultural norms.17 Table 2 highlights different factors that may affect the decision to initiate or continue breastfeeding. These various factors should ideally be considered as part of activities to promote breastfeeding.

Table 2: Factors that affect breastfeeding initiation or duration

Positive Influences on Breastfeeding Negative influences on Breastfeeding
Individual Factors
  • Intention to breastfeed during pregnancy.18
  • Knowledge/belief of the benefits of breastfeeding.14,19
  • Strong sense of breastfeeding self-efficacy.14,18,20
  • Prior positive experience of breastfeeding.14
  • More advanced age (e.g., over 25).10,18
  • Higher education or income level.10,18
  • Partner in her life when baby is born.10
  • Perception of physical discomfort or pain associated with breastfeeding.18
  • Lack of prenatal information about breastfeeding.14
  • Belief that human milk is not enough nourishment for the baby.19,20,21
  • Introduction of commercial infant formulas in the first few days’ postpartum.18
  • Introduction of a pacifier in the first few months’ postpartum.14
  • Introduction of solid foods prior to 6 months of age.14
  • Smoking.14,18
Interpersonal Factors
  • Partner’s support.18,20
  • Maternal support of breastfeeding by family and friends (role models).14,18,21
  • Support by professionals.18,22,23,24
  • Inconsistent, inaccurate, or insufficient information and recommendations from family, friends, and professionals.18
Community Factors
  • Procedures and practices used in hospital or birthing centres (e.g., BFI protocol, skin-to-skin contact, rooming-in day and night).20,23
  • Access to resources (e.g., organizations, peer or mother-to-mother support groups, knowledgeable health care providers.20,23,25
  • Return to work.18,19,23
  • Nature of the job10 (e.g., inflexible schedule, high number of working hours).22
  • Working environment not conducive to initiating breastfeeding (e.g., negative attitude of the employer or co-workers).22,23
Sociocultural Factors
  • Government guidelines and public policies conducive to breastfeeding (e.g., paid maternity leave, right to breastfeed in public).17,23
  • Societal values (e.g., sexualization of breasts).17
  • Cultural imperatives for discreet breastfeeding.
  • Lack of visible role models (breastfeeding is rarely seen).
  • Over-representation of bottle use in the media when the act of nursing or the benefits of breastfeeding are rarely shown.26


See Appendix C for information about fostering a sense of breastfeeding self-efficacy.

Health Effects of Breastfeeding

Why is it important to breastfeed?

Literature reports numerous beneficial health effects of breastfeeding for mother and child. The importance of breastfeeding comes from the unique properties of human milk as well as from the act of breastfeeding. Few studies can distinguish between the effects of human milk, and/or the effects of the act of nursing. It is understood that the properties of human milk have benefits, however, the act of breastfeeding also allows for physical intimacy between mother and baby. A child who is breastfed exclusively for six months receives approximately 1500 feedings or intimate moments with his/her mother.

There is conclusive evidence for the importance of breastfeeding.

Importance for the mother

Reduced risk of:

  • Ovarian cancer.27,28
  • Breast cancer.27,28,29
  • Type 2 diabetes.28,30
Importance for the child

Reduced risk of:

  • Acute otitis media.27,28
  • Gastroenteritis27,28
  • Lower respiratory tract infection.27,28
  • Childhood cancer (e.g., leukemia).27,28
  • Type 1 diabetes [sic].15
  • Type 2 diabetes in adulthood.27,28,34
  • Sudden Infant Death Syndrome (SIDS).27,28,34,35
  • Necrotizing enterocolitis (only in premature babies).27,28
  • Cardiovascular disease.36,37,38
  • Obesity39,40
  • Cognitive deficits.41

Some authors mention other advantages of breastfeeding such as:6,42

  • Food safety for the infant, irrespective of the mother’s circumstances or location.
  • Constant availability of easy-to-store, optimal milk.
  • Reduced waste and a smaller carbon footprint.
  • Reduction in the amount of medical care for the baby (e.g., doctor’s visits, hospitalization).43
  • Reduced maternal absenteeism from work.
  • Savings of approximately $500 – $2000 per six months of commercial infant formulas use.44

Exclusivity and duration of breastfeeding

The important health effects of breastfeeding for both mother and child are associated with the exclusivity and duration of breastfeeding.2 The effects are dose dependent, meaning that they depend on the amount of human milk the child receives45,46,47,48 and the duration of breastfeeding respective to the child’s age.47

Exclusive breastfeeding for the first six months, and continued breastfeeding thereafter, with the addition of complementary foods, up to the age of 2 or longer, offers the most benefits to mother and baby.4 Note, however, that breastfeeding briefly or only partially offers more benefits than not breastfeeding at all.

Commercial infant formulas (CIF) are not comparable to human milk and pose some risks. Unlike CIF, breast milk composition is unique and tailored to the needs of humans. The majority of the naturally-occurring components of breast milk such as amino acids, fatty acids, enzymes, antibodies, immunological factors, and hormones cannot be replicated in CIF. Some other components may be inferior or lacking in CIF. Therefore, CIF can leave a baby vulnerable to illness, infections, or allergies.2,42

Commercial infant formulas are also vulnerable to manufacturing errors (e.g., ingredient, measurement, and labeling errors), chemical or bacterial contamination, dilution errors, or improper storage.1,42

Promoting and Supporting Breastfeeding: What You Need to Know

The role of health care professionals

Messages conveyed by health care professionals can influence parental decisions about initiation and duration of breastfeeding. Literature suggests that women have a greater tendency to initiate and continue breastfeeding if they are supported and encouraged by their doctor.49,50

It has also been documented that women often interpret a professional’s neutrality on the issue of breastfeeding negatively. Those who perceive professionals as having a neutral attitude toward breastfeeding are more likely to discontinue breastfeeding after approximately six weeks [sic].51

The health care professional’s role during the perinatal period is to:

  • Recommend breastfeeding in accordance with national and international breastfeeding guidelines.
  • Provide parents with scientifically accurate and credible information supporting them to make informed decisions.
  • Respectfully provide new information where appropriate while being receptive to each family’s circumstances and cultural differences.
  • Offer support, especially upon the initiation of breastfeeding, as cessation is high in the first month.

The following Canadian associations or organizations are committed to promoting, supporting, and protecting breastfeeding and have developed guidelines and/or position papers regarding breastfeeding:

  • Breastfeeding Committee for Canada (BCC).
  • Canadian Association of Midwives (CAM).
  • Canadian College of Family Physicians (CFPC).
  • Canadian Paediatric Society (CPS).
  • Canadian Pharmacists Association.
  • Dietitians of Canada.
  • Health Canada.
  • Ministry of Health and Long-Term Care in Ontario.
  • Ontario Association of Public Health Dentistry (OAPHD).
  • Ontario Public Health Association (OPHA).
  • Public Health Agency of Canada.
  • Registered Nurses’ Association of Ontario (RNAO).
  • Society of Obstetricians and Gynaecologists of Canada (SOGC).

The importance of the father/partner in breastfeeding

Numerous studies reveal that the father is very influential in a woman’s decision to initiate and continue breastfeeding. The chance of a woman initiating breastfeeding is increased by nearly 80 percent if the baby’s father is supportive of breastfeeding.43 The father’s attitude seems to be more influential than that of health care professionals.52,53

Furthermore, a pregnant woman’s perception of her partner’s attitude toward breastfeeding appears to be more influential than the partner’s actual attitude. Women generally tend to perceive their partners as being less favourable toward breastfeeding than they actually are.54 Women are 10 times more likely to initiate breastfeeding if they perceive their partners as having a positive attitude than if they believe their partner is ambivalent or prefers bottle feeding.55

The inclusion of expectant fathers/partners in breastfeeding-related training is worthwhile.56 Evidence shows that mothers whose partners receive information about overcoming breastfeeding challenges have greater breastfeeding rates than mothers whose partners do not receive that information.57

Additionally, other significant family members and support persons play a role. It is worthwhile including these individuals in the education process.

More information regarding fathers’/partners’ experiences with breastfeeding can be found in the Transition to Parenthood file.

Breastfeeding promotion strategies

The success of breastfeeding initiation and duration is dependent on a variety of strategies, some of which are more effective than others.

Effective strategies:

  • WHO Baby-Friendly Initiative (BFI) initiative.11,58,59,60,61,62,63,64 This global initiative includes the best practices from the scientific literature to promote breastfeeding.2 (See Appendix A for more information.)
  • Approaches that combine individual or group meetings and peer support.59
  • Interventions to foster a sense of breastfeeding self-efficacy.65,66 (See Appendix C for more information.)
  • Group classes for women who plan to breastfeed and individual education for women who do not.49
  • Peer support: Contact with women who have breastfed (e.g., telephone calls, presence of community organizations at regular prenatal information sessions).59,67,68
  • Participation of expectant fathers/partners in breastfeeding classes.57

Ineffective strategies

  • Distribution of written literature about breastfeeding with no follow-up intervention (e.g., counselling, discussion).59,68

Harmful strategies

  • Preparation of the nipples during pregnancy, or wearing Woolwich shields, for flat or inverted nipples.69
  • Distribution of samples or educational materials (e.g., DVDs or brochures) produced by commercial-infant-formula manufacturers.70

Appendix A provides more information about strategies that promote successful breastfeeding as set out by the Baby-Friendly Initiative.

Discussing breastfeeding during the prenatal period

There is little scientific information that determines the optimal time in the prenatal period in which to discuss breastfeeding. However, issues can be addressed by each trimester of pregnancy as suggested by the Academy of Breastfeeding Medicine (2009) and National Institute for Health and Care Excellence (2008) guidelines.

Prior to pregnancy, the majority of women will have already decided how they plan to nourish their babies. Evidence shows that the earlier the decision to breastfeed is made (during pregnancy or before), the more likely a woman is to breastfeed.43 Addressing the importance of breastfeeding and providing national and international breastfeeding guidelines to women and partners in the first trimester of pregnancy is supportive of breastfeeding.

In the first trimester:

  • Discuss the importance of breastfeeding for both the mother and her baby.
  • Address concerns identified by the mother or her family. Common concerns include potential challenges such as a lack of confidence or support; discomfort with breastfeeding in public; the mother’s diet while she is breastfeeding; baby care; fear of having sore nipples; effect on the breasts; and the impact of breastfeeding on the couple.
  • Emphasize that, though a natural process, breastfeeding takes time to learn.
  • Ask open-ended questions to explore a couple’s beliefs and knowledge; reframe their statements if necessary.
  • Include the expectant father/partner and relatives in the process.

In the second trimester:

  • Encourage the woman to find role models among the women in her life (e.g., family members, friends, and co-workers) who have breastfed successfully.
  • Encourage future parents to attend a breastfeeding class, or to take part in a breastfeeding support group, by providing a list of available resources.
  • Provide future parents with breastfeeding-related materials such as “Breastfeeding Matters” (Best Start Resource Centre, 2014).or the lower-literature booklet “My Breastfeeding Guide” (Best Start Resource Centre, 2015). At their next appointment, ask if they have any questions. If there is a lack of interest in the material, or they are unable to read the material, address the importance of exclusive breastfeeding; the principle of supply and demand; how to recognize if the baby is getting enough milk; and the importance of a good latch.

In the third trimester:

  • Address the breastfeeding process in the immediate postpartum period such as:
    • Skin-to-skin contact.
    • Uninterrupted first feeding.
    • Breastfeeding on cue.
    • Importance of avoiding supplements (except if they are medically indicated).
    • Alternative feeding methods (spoon/cup) if supplements are required.
    • Involvement of the expectant father/partner, etc.
  • Encourage future parents to contact a breastfeeding support group (if they have not already done so).
  • Provide anticipatory guidance about normal, newborn behaviours (including very frequent nighttime feeding in the first week) and management of normal postpartum fatigue (e.g., sleep when the baby sleeps).
  • Discuss preparation for breastfeeding such as simplify expectations; freeze food; make arrangements with family/friends to bring prepared meals; etc.
  • Ensure future parents have proper support during the postpartum period.

Learning to breastfeed

Although it is natural for the breasts to produce milk, breastfeeding itself takes time to learn for both mothers and babies. Breastfeeding is a learned skill and requires practice as well as flexibility in the early days. Many mothers find that it can take approximately four to six weeks to feel comfortable breastfeeding and establish a milk supply.

Preparing parents prenatally for a steep learning curve will help increase their success with breastfeeding. For example, many future parents do not know that babies often have an intense need to nurse (especially during the second day of life) and that skin-to-skin contact helps the baby to feed. The support of family and friends should also not be underestimated in the first few weeks postpartum. This support will further enhance the mother’s confidence in her ability to breastfeed.

For more information about the process of learning to breastfeed and strategies to overcome breastfeeding challenges, see Breastfeeding Matters (Best Start Resource Centre, 2014). This booklet contains information about breastfeeding in the immediate postnatal period, including skin-to-skin contact immediately after the baby is born; feeding in the first hour after birth; rooming-in with the baby day and night; breastfeeding on demand; and effective breastfeeding positions and latching. For more information about breast changes in the postpartum period, see the Recovery after Birth file.

Skin-to-skin

There are advantages to offering babies skin-to-skin immediately following the birth of all babies.73

These advantages include:

  • Relaxed state of mother and baby.74
  • Decreased stress hormone levels.74,75
  • Decreased experiences of spousal relationship stress by fathers.74
  • Homeostasis for baby.73
  • Cardiorespiratory stability of the late preterm baby.73
  • Blood glucose stability.73
  • Increased breastfeeding duration.73
  • The benefits of skin-to-skin are not only limited to the early postpartum period.

Having a baby by caesarean birth does not exclude a mother or the father/partner from providing early skin-to-skin with their baby.76 It is in the best interest of mothers and babies to remain together in the newborn period whenever possible. Mother/baby rooming-in enhances bonding and optimizes breastfeeding initiation.77

Caesarean birth and breastfeeding

Ideally, most babies should go skin-to-skin immediately after birth, even after a caesarean birth. If the mother is unwell or unable to have the baby skin-to-skin, the father or partner can do so to help the stability of the newborn. Maternal skin-to-skin and breastfeeding can also occur in the recovery room as soon as the mother is able. Families need to be supported to work with their health care provider to include skin-to-skin care in the caesarean birth to assist both mother and baby. It is recommended that the separation of the mother and infant should be minimized, and breastfeeding should be initiated as soon as it is safe and possible.78

Feeding cues

Babies need to feed frequently. Most babies feed at least eight times in 24 hours. Feeding cues will indicate to the mother that the baby is ready to feed.

  • Early cues: “I’m hungry.”
    • Stirring, moving arms.
    • Mouth opening, yawning, or licking.
    • Hand-to-mouth movements.
    • Turning head from side-to-side.
    • Rooting, seeking to reach things with his or her mouth.
  • Mid cues: “I’m really hungry.”
    • Stretching.
    • Moving more and more.
    • Hand-to-mouth movements.
    • Sucking, cooing, or sighing sounds.
  • Late cues: “Calm me, then feed me.”
    • Crying.
    • Agitated body movements.
    • Colour turning red.

If a baby demonstrates late feeding cues, the baby can be calmed before feeding by:

  • Cuddling.
  • Skin-to-skin holding.
  • Talking or singing.
  • Stroking or rocking.79

To see what feeding cues look like, watch the Baby’s Feeding Cues and Behaviours video.77

Signs a baby is getting enough milk
  • Feeds often, at least eight times in 24 hours.
  • Feeds with strong sucking and active jaw movements (not just flutter sucks).
  • Has plenty of wet and dirty diapers.
  • Gains weight consistently.

When discussing feeding patterns and how to know if the baby is getting enough milk, the Breastfeeding Your Baby (Best Start Resource Centre) resource can be helpful.

Discussing commercial infant formulas

During the prenatal period, it is important for pregnant women to develop confidence in their ability to breastfeed their baby. Discussing commercial infant formulas (CIF) in a group setting may undermine a mother’s confidence and imply that CIF and breastfeeding are equal choices; this may further contribute to the normalization of bottle feeding.80 The discussion of CIF may also lead new mothers to believe that they are likely to need to use CIF while breastfeeding.

The Baby-Friendly Initiative suggests providing information about commercial infant formulas on an individual basis to future parents who request it (and to families who choose to use it).81 The WHO code, however, discourages providing free samples of formula and advertisements for formula.

It is important to ensure that all future parents receive appropriate information about feeding their infant and that they are supported through the feeding process.81

Individual consultations with parents who have made the decision to feed their baby CIF are more supportive than group settings. Parents can be provided with feeding information regarding safety and types of CIF available today (powder, liquid concentrate, or ready-to-serve).80 This customized instruction can be shared on the maternity ward or birthing centre, during a postnatal home visit, or during a baby’s follow-up appointments. Parents should then be taught how to safely prepare, use, and store CIF as well as the principles of responsive infant feeding.

If parents inquire about CIF in a group setting, health care professionals are encouraged to answer their questions briefly. If the discussion continues, they can offer to answer those questions individually at the end of the class. Parents can also be directed to the Public Health Agency of Canada for more information on feeding practices.

Reasons to use CIF

Some families will decide to use CIF on a temporary basis (often if they fear the mother has no milk during the colostral phase), as a regular part of their breastfeeding plan, or as a complete replacement for breastfeeding. There is a difference between social reasons for choosing CIF and medical reasons. Medical indications for supplementation include infant and maternal conditions. Many of these are temporary, but some may be ongoing. For a complete list of medical indications for supplementation review Appendix 6.2 of the BFI Integrated 10 Steps Practice Outcome Indicators for Hospitals and Community Health Services. Good counselling skills and accurate breastfeeding assessments by health care providers can help ensure families make informed decisions about the use of CIF. Health care professionals are required to ensure that mothers receive the information they need to make informed decisions and then to respect a woman’s decision not to breastfeed.

Situational Precautions

Contraindications to breastfeeding

Few situations exist when breastfeeding is not recommended.12 Most maternal illnesses or conditions have no adverse effect on human milk quality. It should be noted that in circumstances where there is not enough human milk, the mother is too ill, or the baby is unable to feed at the breast, a mother is encouraged to nourish her child by supplementing with her own expressed milk or pasteurized human milk from a milk bank if available and then CIF as required to meet the needs of the baby.

Very few medications are contraindicated in breastfeeding mothers.82 Medications prescribed to lactating women should be assessed for lactation risk to ensure the well-being of the baby. There are circumstances when a mother should consult a professional to ensure she is getting the most accurate information related to breastfeeding and medication use. If a breastfeeding mother requires any medication, she should discuss the possible drug effects on her and her baby with her doctor or pharmacist. If a mother is required to take a drug that is contraindicated, then it is possible that another drug option may exist which would be safe for her to continue breastfeeding. Mothers can also contact Motherisk to gain current and reliable information on lactation risk. Alcohol consumption and smoking are not contraindications to breastfeeding, provided that certain precautions are taken. This is discussed in more detail in the Alcohol and Smoking files of this tool.

Exceptional situations exist that are incompatible with breastfeeding including:

  • A mother using illicit drugs (see the Medications and Drugs file).
  • A mother with HIV/AIDS.
  • A baby with a diagnosis of certain metabolic disorders such as galactosemia or PKU. Note that with PKU, a special formula with some breastfeeding is usually permitted, but levels of phenylalanine must be monitored.12,81

Special situations – the preterm baby

Scenarios exist that may require special arrangements for mothers such as expressing milk for a preterm baby. If babies cannot feed well directly at the breast, mothers should be given information and support to establish their milk supply by early, frequent hand expression, use of a breast pump, and skin-to-skin care. The use of human milk, especially for the very preterm infant, is essential to decrease the risk of life-threatening illness (sepsis and necrotizing enterocolitis)83. Human milk is invaluable to very preterm infants. Mothers who are unable to or do not plan to breastfeed are encouraged to express their milk for a very preterm infant. Pasteurized donor human milk (DHM) from a milk bank may also be an option for compromised newborns.

Milk banks and sharing of human milk

As our understanding of the importance of human milk increases so has the development of human milk banks in Canada and around the world. Milk banking started in the early 1900s formalizing the traditional practice where mothers shared milk by nursing each other’s babies or wet nursing. Today’s milk banks include multi-step donor-screening and milk-screening processes in the provision of pasteurization of donor human milk. Increasingly, pasteurized donor human milk is becoming an option, particularly for premature or health compromised infants when a mother’s milk is not available. Canadian Milk Banks operate under stringent guidelines from the Human Milk Banking Association of North America (HMBANA).

Again, with increased public awareness of the importance of human milk, some mothers are attempting to get milk from other mothers (a process often referred to as milk sharing). With Internet access, in addition to informal milk sharing between family and close friends, milk sharing can occur between strangers using the Internet to establish connections. Internet sites include options of sharing and selling/purchasing milk. Using unpasteurized milk is not without risk as milk can be contaminated with illness-causing viruses and bacteria either within the milk or as a result of improper storage and handling.

Health Canada recommends against the consumption of unprocessed donor human milk obtained from private sources.84,85

For more information about the risks of using human milk purchased online or from another person, see the Health Canada website.

Referrals

When to refer

Certain factors have been associated with lower breastfeeding initiation and/or duration rates.86

Women may benefit from additional breastfeeding support if they:

  • Are of a younger maternal age.
  • Are of aboriginal descent.15,87
  • Have a lower income.
  • Have limited education.
  • Are single or lack social support.
  • Have a medical concern such as poor maternal health, obesity, mental illness.
  • Use substances such as illicit drugs or smoke.
  • Have had a cesarean birth or medical issues during labour.
  • Have a physical disability (e.g., visual impairment).
  • Have a history of breast surgery.
  • Have had previous breastfeeding challenges.
  • Have multiples.
  • Have a preterm baby.
  • Have a pregnancy-related illness (e.g., gestational diabetes).
  • Have an infant with health concerns.

Where to refer

Refer women to appropriate community resources including:

  • Community health programs and community health nurses.
  • Peer-to-peer support groups (e.g., La Leche League).
  • Hospital and community breastfeeding clinics.
  • Telehealth Ontario breastfeeding advice and support 1-866-797-0000.

See the Resources and Links section for further information.

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Resources & Links

Please note this is not an exhaustive list of available resources, nor should any of these resources be used in place of seeking professional advice. The resources cited throughout this resource are not necessarily endorsed by the Best Start Resource Centre or the Government of Ontario. When in doubt, professionals should contact the organization responsible for issuing a specific recommendation/practice guideline.

Professional Guidelines

Professional Associations

Reports/Publications

Websites

Helplines

  • Telehealth Ontario 1-866-797-0000

Prenatal Education Provider Tools

Client Resources and Handouts

Books for Parents

  • Huggins, K. (2007). The Nursing Mother’s Companion. (6th ed.). Harvard Common Press.
  • The Womanly Art of Breastfeeding. (2010). (8th ed.) La Leche League International
  • Newman, J. & Pitman, T. (2014). Dr. Jack Newman’s Guide to Breastfeeding. (Revised Edition). Harper Collins, Canada.

Books for Health Care Professionals

  • Medications and Mothers’ Milk, (2014). Hale, T.W. and Rowe, T. Hale Publishing, Plano Texas.

Videos

Apps

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Appendices

Appendix A: The Baby-Friendly Initiative

The Baby-Friendly Initiative (BFI) in Canada is based on an international program (the Baby-Friendly Hospital Initiative) launched in 1991 by the WHO and UNICEF to optimize breastfeeding results. BFI Ontario serves to implement the BFI through ongoing partnership with health care professionals, service providers, and consumers in Ontario.

The BFI Ontario and the Breastfeeding Committee for Canada endorse the WHO and UNICEF guidelines, which recommend exclusive breastfeeding for the first six months of a child’s life and continued breastfeeding along with complementary foods until the age of two and beyond. This allows a mother and her child to continue to benefit from the many immunological, developmental, and nutritional benefits of breastfeeding. To understand how BFI applies to prenatal education, it is helpful to understand the background information that guides BFI practice in Canada

The Ten Steps to Successful Breastfeeding: A Joint WHO/U88

  1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
  2. Train all health care staff in skills necessary to implement this policy.
  3. Inform all pregnant women about the benefits and management of breastfeeding.
  4. Help mothers initiate breastfeeding within a half-hour of birth.
  5. Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants.
  6. Give newborn infants no food or drink other than breast milk unless medically indicated.
  7. Practice rooming-in – allow mothers and infants to remain together – 24 hours a day.
  8. Encourage breastfeeding on demand.
  9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
  10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

The interpretations for Canadian practice89

Every facility or agency providing maternity services and care of newborn infants should:

  1. Have a written breastfeeding policy that is routinely communicated to all health care providers and volunteers.
  2. Ensure all health care providers have the knowledge and skills necessary to implement the breastfeeding policy.
  3. Inform pregnant women and their families about the importance and process of breastfeeding.
  4. Place babies in uninterrupted skin-to-skin contact with their mothers immediately following birth for at least an hour or until completion of the first feeding or as long as the mother wishes: Encourage mothers to recognize when their babies are ready to feed, offering help as needed.
  5. Assist mothers to breastfeed and maintain lactation should they face challenges including separation from their infants.
  6. Support mothers to exclusively breastfeed for the first six months, unless supplements are medically indicated.
  7. Facilitate 24-hour rooming-in for all mother-infant dyads: mothers and infants remain together.
  8. Encourage baby-led or cue-based breastfeeding. Encourage sustained breastfeeding beyond six months with appropriate introduction of complementary foods.
  9. Support mothers to feed and care for their breastfeeding babies without the use of artificial teats or pacifiers (dummies or soothers).
  10. Provide a seamless transition between the services provided by the hospital, community health services and peer support programs. Apply principles of Primary Health Care and Population Health to support the continuum of care and implement strategies that affect the broad determinants that will improve breastfeeding outcomes.

The WHO Code: Compliance with the International Code of Marketing of Breastmilk Substitutes90

The WHO Code is a health policy framework for breastfeeding promotion adopted by the World Health Assembly and the World Health Organization in 1981. The WHO Code recommends restrictions on the marketing of breast milk substitutes, such as infant formula, to ensure that mothers are not discouraged from breastfeeding.

Optimizing breastfeeding: Steps to Success

Recommendations Benefits
Uninterrupted skin-to-skin contact for an hour or more after birth1,70,80,91 whether or not the babies are breastfed (step 4). Skin-to-skin contact provides the context enabling a sequence of behaviours observed in most babies. A series of innate reflexes enables the baby to search for and find the breast. These behaviours include signs of readiness to feed. Mothers often intuitively help the baby as needed, contributing to an effective first feeding.
Most hospitals actively support skin-to-skin contact, even after a caesarean birth. If mother or baby are unwell, skin-to-skin care may be delayed. Support persons can also provide skin-to-skin contact. This practice is an essential component of stability of the new baby as they make the transition from birth.
Skin-to-skin care:

  • Improves the baby’s temperature and oxygenation and stabilizes the baby’s heart rate.
  • Reduces crying and quickly calms the baby.
  • Decreases stress of the newborn.
  • Allows bacteria from the mother to colonize the baby and decreases the risk of hospital-acquired infection.
  • Enables mother and child to get to know one another.
  • Strengthens the mother-baby bond.
  • Promotes the secretion of oxytocin that helps the mother’s uterus contract decreasing the risk of postpartum hemorrhage.
Breastfeeding in the first hour after birth1,80 (step 4).
  • Provides antibody-rich colostrum.
  • Helps stabilize the baby’s blood sugar.
  • Is associated with longer breastfeeding duration and less risk of unnecessary supplementation.
  • Reduces the risk of postpartum hemorrhage (breastfeeding promotes the secretion of oxytocin).
Rooming-in day and night1,80 (step 7).
  • A mother can learn to recognize her baby’s hunger cues and offer her breasts in response to the cues.
  • Allows parents to familiarize themselves with their newborn’s sleep-wake cycles and enables them to rest at the same time as their baby. Mothers who room-in feel more rested than mothers who do not room-in.
  • Reinforces the parents’ confidence in their ability to meet the needs of their baby.
Breastfeeding positions and latching92
See the BSRC Breastfeeding Matters booklet for breastfeeding positions.
  • Increases maternal comfort.
  • Contributes to adequate breast stimulation and milk production.
  • A better latch allows a better flow of milk from breast to baby.
Breastfeeding on cue.1,80,92
  • Frequent, untimed feedings help to establish and maintain a milk supply.
  • The frequency and duration of feedings vary from one baby to the next.
  • Most breastfed babies nurse eight or more times every 24 hours, generally with at least one episode of “cluster feeding.”
  • Frequent feedings establish milk supply, so the baby loses less weight. Frequent feedings promote meconium elimination and reduce the risk of jaundice.
  • On occasion, babies have to be stimulated to feed more often in the first few days of life, especially if they are drowsy (e.g., have had a difficult birth, preterm birth).
  • The signs that the baby is drinking enough, including bowel movements (frequency and change of appearance from black to yellow for newborns), are key points for parents to remember and are listed in the BSRC Breastfeeding Matters booklet.
Exclusive breastfeeding (avoiding supplements).80
  • Exclusive breastfeeding contributes to longer breastfeeding duration.
  • Nutritionally, human milk is the only food a baby needs in the first six months of life.
  • The addition of CIF may jeopardize breastfeeding because it reduces breast stimulation and, therefore, interferes with the establishment and maintenance of milk supply.
  • Reducing the amount of human milk reduces its benefits (i.e., dose-dependent effect).
  • The addition of CIF changes the baby’s intestinal flora and prematurely exposes the baby to cow-milk protein and pathogens.
  • There are medical reasons to give additional milk to babies. Careful assessment by the health care provider can help parents make this decision. The first choice is a mother’s own expressed milk. If this is not available, pasteurized donor human milk followed by CIF.
Avoiding soothers and bottles1,80,93 (step 9). The introduction of a soother may mask the signs of hunger and increase the interval between feedings, resulting in:

  • The child drinking less milk overall.
  • Reduced breast stimulation and, therefore, reduced milk production.

The introduction of a bottle may:

  • Lead to decreased breast stimulation, especially if the bottle replaces the mother’s milk thus resulting in less milk production.

The general recommendation is to ensure that the baby is drinking properly from the breast and that breastfeeding is well established before using a soother or bottle. This may take four to six weeks.

Resources available to breastfeeding mothers. See Resources and Links section.

Appendix B: Principal components of human milk94,95

Principal components of human milk Benefits
PROTEINS: Whey Assists in digestion, growth, and development.
Casein Balanced with whey to assist in digestion, growth, and development.
Lactoferrin Protects the gut from bacteria.
Lactoferrin is an iron-binding glycoprotein.94
Secretory IgA Protects baby from viruses and bacteria.
Lysozyme Protects baby against E. coli and Salmonella.
FATS: Numerous essential fatty acids Necessary for healthy brain development.
VITAMINS: Fat-soluble vitamins A, D, E, K Necessary for babies’ health and development.
Water-soluble vitamin C, riboflavin, niacin, pantothenic acid Necessary for babies’ health and development.
CARBOHYDRATES: Lactose Accounts for approximately 40 percent of the required caloric needs.
Assists in the absorption of calcium, phosphorus, and magnesium.
Bifidus factor Supports the growth of beneficial bacteria in a baby’s gut.

Other human milk components include, but are not limited to:96

  • Other immunoglobulins include SIgG, SIgM.
  • Macrophages.
  • Neutrophils.
  • Lymphocytes.
  • Mucins.
  • Haptocorrin.
  • Lactoperoxidase.
  • Nucleotides.
  • Cytokines.
  • Hormones and growth factors.
  • Oligosaccharides and prebiotics.

Appendix C: Fostering a sense of breastfeeding self-efficacy

When it comes to breastfeeding, the sense of self-efficacy refers to a woman’s perception of her ability to breastfeed her baby.97,98 If she believes that she can breastfeed successfully, she will be more likely to choose to breastfeed and to continue doing so. On the other hand, if her confidence in her ability to breastfeed is low, she will be two to three times more likely to quit before she achieves her goals.99,100,101,102

Having a strong sense of breastfeeding self-efficacy during the prenatal period is associated with a higher rate of breastfeeding initiation and continuation among women from different socio-demographic backgrounds. It has also been shown that a woman’s sense of self-efficacy can be enhanced, contributing to breastfeeding duration and exclusivity.66

Breastfeeding self-efficacy may be affected by the following experiences:

  • Personal experiences of breastfeeding:
    This is the most influential factor.A breastfeeding experience that is perceived as successful enhances the sense of self-efficacy, whereas a negative experience can adversely affect that feeling. It has been shown that women who have given birth before have a stronger sense of self-efficacy than those who are pregnant for the first time.103
  • Observing others (modeling):
    Knowing and observing a woman who has breastfed successfully contributes to the sense of self-efficacy. Viewing audiovisual documents depicting breastfeeding women also seems to have this effect.65 Women who have received support from a peer group report that it increased their confidence.98
  • Verbal persuasion:
    Encouragement to continue breastfeeding does not appear to enhance the sense of self-efficacy, whereas complimenting the woman on her breastfeeding efforts seems to be effective when the compliments come from the woman’s partner or the maternal grandmother.65
  • Physiological and psychological factors:
    Nipple pain, for example, is associated with a lower sense of self-efficacy in the first few days.65 A low sense of self-efficacy in the immediate postnatal period is also associated with the perception of not having enough milk at four weeks.104

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Health Before Pregnancy

Health Before Pregnancy

Routine Prenatal Care

Routine Prenatal Care

Physical Changes

Physical Changes

Healthy Eating & Weight Gain

Healthy Eating & Weight Gain

Active Living

Active Living

Alcohol

Alcohol

Smoking

Smoking

Medications & Drugs

Medications & Drugs

Safety During Pregnancy

Safety During Pregnancy

Abuse

Abuse

Mental Health

Mental Health

Pregnancy & Infant Loss

Pregnancy & Infant Loss

Preterm Labour

Preterm Labour

Labour Progress

Labour Progress

Labour Support

Labour Support

Interventions in Labour

Interventions in Labour

Pain Medications in Labour

Pain Medications in Labour

Caesarean Birth

Caesarean Birth

Vaginal Birth After Caesarean

Vaginal Birth After Caesarean

Breech Birth

Breech Birth

Newborn Care

Newborn Care

Newborn Safety

Newborn Safety

Breastfeeding

Breastfeeding

Recovery After Birth

Recovery After Birth

Transition to Parenthood

Transition to Parenthood