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South Australian Perinatal Practice Guidelines 

Breastfeeding  
  Department for Health and Ageing, Government of South Australia. All rights reserved.  

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Note:
This guideline provides advice of a general nature.  This statewide guideline has been prepared to 
promote and facilitate standardisation and consistency of practice, using a multidisciplinary approach.  
The guideline is based on a review of published evidence and expert opinion.  
Information in this statewide guideline is current at the time of publication.  
SA Health does not accept responsibility for the quality or accuracy of material on websites linked from 
this site and does not sponsor, approve or endorse materials on such links. 
Health practitioners in the South Australian public health sector are expected to review specific details of 
each patient and professionally assess the applicability of the relevant guideline to that clinical situation. 
If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician 
must document in the patient s medical record, the decision made, by whom, and detailed reasons for 
the departure from the guideline. 
This statewide guideline does not address all the elements of clinical practice and assumes that the 
individual clinicians are responsible for discussing care with consumers in an environment that is 
culturally appropriate and which enables respectful confidential discussion. This includes: 

  The use of interpreter services where necessary, 
  Advising consumers of their choice and ensuring informed consent is obtained, 
  Providing care within scope of practice, meeting all legislative requirements and 

maintaining standards of professional conduct, and  
  Documenting all care in accordance with mandatory and local requirements 

 
Explanation of the aboriginal artwork: 
The aboriginal artwork used symbolises the connection to country and the circle shape shows the strong relationships amongst families and the aboriginal 
culture. The horse shoe shape design shown in front of the generic statement symbolises a woman and those enclosing a smaller horse shoe shape depicts 
a pregnant women. The smaller horse shoe shape in this instance represents the unborn child. The artwork shown before the specific statements within the 
document symbolises a footprint and demonstrates the need to move forward together in unison. 
 

     

 

 

 

 

 

 

Purpose and Scope of PPG 
This guideline provides clinicians with information to support women with the initiation and 
management of breastfeeding for the healthy term infant up to the age of four (4) weeks after 
birth. This PPG is intended for use in the antenatal, intrapartum and postnatal period. 

 

Australian Aboriginal Culture is the oldest living culture in the world yet 
Aboriginal people continue to experience the poorest health outcomes when 
compared to non-Aboriginal Australians. In South Australia, Aboriginal women are 
2-5 times more likely to die in childbirth and their babies are 2-3 times more likely to 
be of low birth weight.  The accumulative effects of stress, low socio economic 
status, exposure to violence, historical trauma, culturally unsafe and discriminatory 
health services and health systems are all major contributors to the disparities in 
Aboriginal maternal and birthing outcomes. Despite these unacceptable statistics 
the birth of an Aboriginal baby is a celebration of life and an important cultural 
event bringing family together in celebration, obligation and responsibility. The 
diversity between Aboriginal cultures, language and practices differ greatly and so 
it is imperative that perinatal services prepare to respectively manage Aboriginal 
protocol and provide a culturally positive health care experience for Aboriginal 
people to ensure the best maternal, neonatal and child health outcomes. 

 



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Flowchart 1: Breastfeeding the Healthy Term Infant in the First 24 
Hours Following Birth 
 

 

 
  



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Flowchart 2: Management of Infants with more than 10% weight 
loss below birth weight from day 3-5 
 

 

  



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Table of Contents 
Purpose and Scope of PPG ....................................................................................................... 1 
Flowchart 1: Breastfeeding the Healthy Term Infant in the First 24 Hours Following Birth ....... 2 
Flowchart 2: Management of Infants with more than 10% weight loss below birth weight from 
day 3-5 ....................................................................................................................................... 3 
Summary of Practice Recommendations .................................................................................. 5 
Abbreviations ............................................................................................................................. 5 
Introduction ................................................................................................................................ 6 
Antenatal .................................................................................................................................... 7 

First antenatal visit (or at first opportunity) ............................................................................ 7 
Discuss .............................................................................................................................. 7 
Obtain clinical history ......................................................................................................... 7 
Physical examination: ........................................................................................................ 7 
Document ........................................................................................................................... 7 

Subsequent visits: .................................................................................................................. 7 
Antenatal Expressing ............................................................................................................. 8 

Antenatal Expression ......................................................................................................... 8 
Labour and Birth ........................................................................................................................ 9 
Postnatal .................................................................................................................................. 10 

Feeding Cues ....................................................................................................................... 10 
Positioning and Attachment ................................................................................................. 10 
Correct Attachment .............................................................................................................. 10 

Signs of correct attachment ............................................................................................. 10 
Pain with attachment........................................................................................................ 11 
Sucking pattern ................................................................................................................ 11 
General ............................................................................................................................ 11 

Feeding Frequency: ............................................................................................................. 12 
First 24 hours following birth  ........................................................................................... 12 
24-72 Hours Post Birth..................................................................................................... 12 
General ............................................................................................................................ 13 

Indication of and Assessment of Effective Feeding: ............................................................ 13 
Signs of effective breastfeeding: ...................................................................................... 13 
Infant weight ..................................................................................................................... 14 

Maternal Supplements ......................................................................................................... 14 
Iron ................................................................................................................................... 14 
Vitamin D ......................................................................................................................... 14 

Maternal Medications and Breastfeeding ................................................................................ 15 
Contraception ................................................................................................................... 15 

Impact of Introduction of Supplementary Feeds ...................................................................... 15 
Use of Bottles, Teats, Dummies .............................................................................................. 15 
Expression of Breastmilk ......................................................................................................... 16 
After Discharge/Community Services ...................................................................................... 16 
Resources ................................................................................................................................ 17 

Useful Websites for Health Professionals ........................................................................... 17 
Useful Websites for Women ................................................................................................ 17 
Phone resources for women ................................................................................................ 17 

Appendix 1: Antenatal hand expressing .................................................................................. 20 
Appendix 2: Postnatal hand expressing .................................................................................. 21 
Appendix 3: Safe Storage of EBM ........................................................................................... 22 
Appendix 4: WHO Acceptable Medical Reasons for the use of Breastmilk Substitutes34 ....... 23 

ADDENDUM FOR AUSTRALIA .......................................................................................... 24 
Acknowledgements .................................................................................................................. 25 
 



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Summary of Practice Recommendations 
Each interaction that a mother (and her infant) has with health practitioners needs to protect, 
promote and support breastfeeding. 
Health practitioners need to be aware of the Baby Friendly Health Initiative (BFHI)  10 Steps 
to Successful Breastfeeding  and the BFHI  7 Point Plan for Community Health Services  and 
strive to achieve this in their practice. 
Provide pregnant women with information about the benefits, initiation and management of 
breastfeeding. 
Assess factors which may impact on the establishment of breastfeeding throughout the 
perinatal period. 
Where possible skin to skin contact should be initiated within 10 minutes of birth and be 
uninterrupted for at least 1 hour irrespective of type of birth or mother s feeding intentions. 
Provide women with information, assistance and support to enable establishment of 
breastfeeding. 
If the woman has delayed contact with her baby, offer additional support. 
Inform women about post-discharge services and community supports to facilitate ongoing 
breastfeeding. 
Comply with the World Health Organisation International Code of Marketing of Breast milk 
Substitutes. 

Abbreviations 
ABA Australian Breastfeeding Association 
ANRQ Antenatal Risk Questionnaire 
BFHI Baby Friendly Health Initiative  
BGL Blood Glucose Level 
BMI Body Mass Index 
CaFHS Child and Family Health Services 
CALD Culturally and Linguistically Diverse 
DAME Diabetes and Antenatal Milk Expressing Trial 
EBM Expressed Breast Milk 
GP General Practitioner 
IUGR Intrauterine Growth Restriction 
kg Kilogram(s) 
LSCS Lower Segment Caesarean Section  
MER Milk Ejection Reflex 
MO Medical Officer 
NHMRC National Health and Medical Research Council 
PCOS Poly Cystic Ovarian Syndrome 
PIF Priority Information Form 
PPG Perinatal Practice Guidelines 
PPH Postpartum Haemorrhage 
RDR Rapid Detection Response 
REM Rapid Eye Movement 
RPOC Retained Products of Conception 
SAPR South Australian Patient Record 
WHO World Health Organisation 
 

  



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Introduction 
Breastfeeding is the biologically normal way to feed an infant for healthy growth and 
development. It provides a protective effect for infants against many illnesses, including 
gastro-intestinal, respiratory and urinary tract infections, otitis media (until 2 years), Sudden 
Infant Death Syndrome (SIDS), malocclusion, dental caries, childhood leukaemia and chronic 
conditions which may occur in later life, such as type 2 diabetes, coeliac disease, asthma and 
obesity. 
For mothers, breastfeeding has many positive effects, including reduced risk of osteoporosis, 
pre-menopausal breast cancer, ovarian cancer, type 2 diabetes and post-menopausal 
obesity. Mother-infant bonding is enhanced, and the incidence of postnatal depression has 
been demonstrated to reduce1.  
In Australia, breastfeeding is initiated for almost 96% of infants, with an approximate 90% 
initiation rate for exclusive breastfeeding. By 3 months, the percentage of infants in Australia 
who are exclusively breastfeeding reduces significantly.  
In South Australia in 2010, the exclusive breastfeeding initiation rate was 89.6%. By the age 
of 1 month, less than 60% of South Australian infants were exclusively breastfeeding. By the 
age of 6 months, only 14.6% of South Australian infants were exclusively breastfeed 
(consistent with the National data)2. 
These figures fall well below the World Health Organisation (WHO) recommended duration 
for exclusive breastfeeding for 6 months 3. 
In Australia, the recommendation of the National Health and Medical Research Council 
(NHMRC) is that exclusive breastfeeding is maintained to around 6 months of age, with the 
introduction of appropriate complementary foods and continued breastfeeding until 12 months 
of age, or longer as the mother and child wish4.   
The BFHI was developed by the World Health Organisation and UNICEF to protect, promote 
and support breastfeeding. It provides a framework for hospitals and health services to 
implement evidence based practices which optimise infant feeding. The BFHI standards 
require that all mothers receive appropriate information and support with initiating and 
maintaining breastfeeding. 
In Australia, BFHI has been expanded to include health and community services, and is now 
known as the Baby Friendly Health Initiative. It is governed through the Australian College of 
Midwives5. 
This guideline is based on the 10 Steps to Successful Breastfeeding and the 7 Point Plan for 
the Protection, Promotion and Support of Breastfeeding, as per the BFHI criteria for Maternity 
Services and for Community Services. 
All staff are required to comply with the SA Health Breastfeeding Policy Directive (available 
at www.sahealth.sa.gov.au/perinatal), including the WHO International Code of Marketing 
Breastmilk Substitutes (http://www.who.int/nutrition/publications/code_english.pdf),  the World 
Health Assembly Resolutions (http://www.who.int/nutrition/topics/wha_nutrition/en/) and the 
Marketing in Australia of Infant Formula Agreement  

(http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-strateg-
foodpolicy-apmaif.htm). 

  








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Antenatal 
In the antenatal period, the majority of women intend to breastfeed, either  exclusively or 
combining breast and artificial formula feeding6.  Most women are aware that breastfeeding 
conveys health benefits. 
Less than 5% of women plan to fully artificially feed.  The most commonly stated reason for 
not initiating breastfeeding is unsuccessful previous breastfeeding experience7.  Antenatal 
education and anticipatory guidance about actions that support breastfeeding appear to 
increase the duration of breastfeeding8.  

First antenatal visit (or at first opportunity) 
Discuss  
Woman s intentions, knowledge and expectations re infant feeding.  
Previous breastfeeding experiences including duration, previous problems encountered, 
supply adequacy, mastitis. 
Psycho-social: factors which may impact on breastfeeding (e.g. increased maternal anxiety or 
depression, as indicated through high Edinburgh Postnatal Depression or ANRQ scores, 
partner support, plans to return to employment or study, intended duration of breastfeeding); 
 
Obtain clinical history 
Surgical: particularly history of breast surgery (reduction, enlargement, nipple relocation, 
cystectomy, mastectomy) or gynaecological surgery. 
Medical: history of hormonal imbalances, diabetes, thyroid dysfunction, Poly Cystic Ovarian 
Syndrome (PCOS), luteal cysts, fertility difficulties, IVF pregnancy, severe anaemia. 
Obstetric: gestational diabetes, pre-eclampsia, prematurity, Intrauterine Growth Restriction 
(IUGR), prolonged labour, previous birth type, postpartum haemorrhage, weight and gestation 
of previous infants. 
 
Physical examination:  
Consider visual inspection of breasts   Note symmetry, size and changes during pregnancy, 
nipple appearance, surgical/trauma scars, nipple piercing. Note: Breast examination may be 
deferred to a subsequent antenatal visit, depending on rapport / relationship between woman 
and health care provider and cultural considerations. 
 
Document  
Woman s intention re infant feeding in SAPR and/or case notes. 
Findings from assessment. 
Plan to support breastfeeding if required. 

Subsequent visits:  

Provide information re: 

&gt; Breast and nipple changes during pregnancy 
&gt; Importance of breastfeeding and risks of not breastfeeding 
&gt; Care and analgesia during labour (importance of support person, comfort and use of 

non-pharmacological pain relief during labour, potential impact of pharmacological 
analgesia during labour on breastfeeding initiation); 

&gt; Importance of early, uninterrupted skin to skin contact after birth 
&gt; Early initiation of breastfeeding 



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&gt; Feeding cues  
&gt; Basic attachment and positioning 
&gt; Normal infant behaviours in first 1-2 days  
&gt; Rooming in 
&gt; Feeding frequency and night feeds 
&gt; Discouragement of use of bottles, teats and dummies while breastfeeding is being 

established 
&gt; Exclusive breastfeeding and avoidance of artificial formula supplementation unless 

medically necessary 
&gt; Postnatal and community assistance and support services available (e.g. Domiciliary 

Midwifery Services, Australian Breastfeeding Association, CaFHS, private lactation 
consultant, General Practitioner) 

&gt; Importance of a well-balanced diet, adequate nutrition and rest 
&gt; Specific breast preparation is not necessary. No benefits or long term effects from 

exercises, massage or  nipple toughening  practices have been found 
Document breastfeeding education progressively during pregnancy. 

Antenatal Expressing  
Some women may wish to consider antenatal expressing of breastmilk.  
The aim of antenatal expressing is to have a ready supply of colostrum available for the 
newborn infant after birth, avoiding the need for use of artificial formula if stabilisation of 
neonatal blood glucose level (BGL) or supplementation of breastfeeding is required. The 
availability of colostrum may reduce the need for admission to or the duration of stay in a 
Special Care nursery.  
Colostrum may be expressible from mid-pregnancy (starts to form from 16 weeks gestation). 
It has been hypothesised that lactogenesis II may commence earlier in women who have 
undertaken antenatal expressing9. 
Some controversy exists around antenatal expressing possibly causing early onset of labour, 
with a limited number of high quality research studies available. Evidence from the Diabetes 
and Antenatal milk expressing trial (DAME) demonstrated safety when commenced from 36 
weeks gestation10. 
 
However, there is general acceptance of the following principles: 
Antenatal Expression 
Indications: 

&gt; Previous supply issues 
&gt; Planned caesarean section 
&gt; Maternal gestational diabetes mellitus (GDM) or diabetes mellitus 
&gt; Known fetal condition that will interfere with early initiation of breastfeeding 
&gt; Maternal reassurance 

Caution should be used in the following circumstances: 

&gt; History of classical caesarean section or more than one caesarean section 
&gt; History of preterm labour, cervical incompetence or cervical suture in situ 
&gt; Threatened preterm labour in current pregnancy (unless there is agreement to allow 

labour and birth to proceed after this time) 
&gt; Antepartum haemorrhage, oligohydramnios, polyhydramnios, pre-eclampsia, placental 

insufficiency, intrauterine growth restriction, fetal macrosomia or decreased fetal 
movements in current pregnancy 

&gt; Placenta praevia or other abnormal placentation (e.g. accreta) 
&gt; Multiple pregnancy 



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&gt; Substance misuse or methadone use in current pregnancy 
&gt; Current anticoagulation therapy 

Aim: 

&gt; Undertake brief periods of gentle expressing only once or twice daily from 36 weeks 
gestation 

&gt; Collect small volumes of colostrum at each expression 
&gt; Store (and transport) expressed breastmilk (EBM) safely 
&gt; Avoid/delay introduction of cow s milk protein into infant s diet 

 
See appendix 1 for Antenatal Expressing Protocol11.  

Each health service will need to develop a pathway for women to bring EBM at time of 
admission in labour or elective caesarean section for use as needed. See Expressed Breast 
Milk. Safe Management and Administration in SA 2018 Clinical Directive available 
at: https://extapps2.sahealth.sa.gov.au/PracticeGuidelines/. 

Labour and Birth 
Clinical practices during labour and birth impact initiation of breastfeeding.  
During labour, practices which are supportive of breastfeeding include the presence of a 
support person, use of non-pharmacological methods of pain relief and allowing the woman to 
eat and drink as tolerated. 
All medications administered to the mother will cross the placenta, and may affect the infant, 
resulting in delayed eye opening and decreased suckling at the breast. The effects will vary, 
depending on maternal metabolism, time interval between drug administration and time of 
birth, dose, and method of administration13. 
Skin to skin contact assists the infant to maintain body temperature, stabilise blood glucose 
level and enable colonization with harmless bacteria, protecting the infant from pathogenic 
bacteria14, 15. Immediate and uninterrupted skin to skin has also been demonstrated to have 
maternal benefits, reducing oxidative stress, thereby promoting wound healing and decreased 
emotional stress16. 
Following birth, immediately place infant in skin to skin contact with its mother and facilitate 
uninterrupted skin to skin contact for at least 1 hour or until the baby s first breastfeed.  
Following caesarean section with spinal or epidural analgesia, initiate skin to skin contact in 
theatre (if safe to do so) or within 10 minutes of arriving in recovery. Following caesarean 
section with general anaesthesia, facilitate skin to skin contact with the mother within 10 
minutes of her being able to respond to her baby. 
During skin to skin contact, ensure the infant is able to breathe without restriction, maintains a 
healthy colour, and can be easily observed.   To enable unrestricted breathing, the infant s 
face must be visible, and there must be no cover over the mouth or nose.  
Avoid weighing and measuring the infant immediately after birth unless there is a medical 
reason or mother requests this;  
In the initial post-birth period, the infant may be alert for up to two hours, which provides an 
ideal time for skin to skin contact and to initiate breastfeeding. 
Facilitate uninterrupted skin to skin contact for at least an hour. This should enable the infant 
to initiate breastfeeding when ready following a sequence of reflex behaviours. 
Early feeding stimulates the passage of meconium, increases stimulation of the breast and 
synthesis of breastmilk, enhances mother-infant bonding and attachment, and has been 
shown to increase the duration of breastfeeding17. 




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Postnatal 
Feeding Cues 

Early feeding cues: Increased restlessness, yawning, stretching, turning movements of the 
head towards the mother (rooting), tongue extensions and mouth opening. 
Moderate feeding cues: Increased physical movements, infant brings hands and fingers to the 
mouth, spontaneous sucking movements, intermittent crying. 
Late feeding cues: Crying, infant becomes distraught if feeding not initiated. 
See http://www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&amp;np=302&amp;id=1810#5 
for visual examples of feeding cues18. 
Encourage mothers to initiate feeding when early or moderate feeding cues are noted. If the 
infant is distressed and crying, he/ she will need to be calmed and settled prior to attempting 
to breastfeed.  
Initiate first breastfeed during skin to skin time following birth. 

Positioning and Attachment 

Encourage woman to optimise comfort prior to feeding (i.e. adequate analgesia, drink 
available, comfortable position either sitting or lying). During feed ensure posture is 
appropriate for mother. 
See http://www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&amp;np=302&amp;id=1810#319 
for visual examples of positioning for mother. 
Unwrap infant to maximize contact between mother and baby. Allow the infant s body to be 
positioned in close contact directly opposite the mother s body, with infant s shoulders and 
neck supported. Ensure baby s head gently tilts back which enables the chin to make first 
contact with the breast. 
Mother may utilise cross-cradle or cradle hold, in side-lying or laid back  (biological) position, 
to support the infant s body, stabilizing the position and enabling the infant to instinctively 
search for and attach to the breast8. 
See http://www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&amp;np=302&amp;id=1810#420 
for attachment pictures and information for women. 
Position infant so that nose is opposite mother s nipple allowing baby to smell and search. 
Using hands-off technique, allow infant to self-attach onto the breast, as this promotes 
effective feeding. 
If necessary, the mother may assist by shaping or supporting her breast. 
The infant can be encouraged to open mouth widely by gently brushing nipple onto top of 
his/her mouth. 
When mouth is wide open, quickly bring infant forward onto breast, with chin touching breast, 
so that infant can take a large mouthful of breast tissue into mouth, and the mother s nipple 
extends deeply into the infant s mouth. 

Correct Attachment 
Signs of correct attachment 
Mouth wide open, with cheeks full, and lips well sealed around the areola or breast tissue. 
(Note: the lower lip will not be visible while the infant is breastfeeding). 
No evidence of hollowing of the cheeks during sucking 
Nose is clear of the breast, enabling infant to breathe without restriction 
Chin pushed deeply into breast tissue 
No audible clicking sounds 






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Pain with attachment 
The mother may note some initial nipple discomfort during attachment as the nipple elongates 
inside the infant s mouth, but this should settle rapidly. The mother may report a tugging or 
pulling sensation during feeds, but minimal discomfort.  
If attachment is painful suggest she move baby gently to improve attachment. If there is no 
improvement, advise the mother to gently detach infant from the breast by inserting her clean 
finger into the corner of the infant s mouth to release the vacuum. Attempt correct attachment. 
 
Sucking pattern 
Prior to lactogenesis, sucking may be frequent and short, with few or no sustained sucking 
periods. 
After lactogenesis II has commenced, the sucking pattern changes, so that breast feeds are 
initiated with short, rapid sucks to initiate the milk ejection reflex (MER). When the MER 
occurs, sucking frequency slows, resulting in periods of rhythmic sucking with audible 
swallowing and short resting periods or pauses21. 
 
General 
As the infant becomes satisfied during the feed, the sucking rate slows, and the infant may let 
go of the breast spontaneously when satisfied. 
The infant may feed from one or both breasts at each feed. 
After feeding, the nipple should appear normal in colour and shape, with no evidence of 
damage or ridging (e.g. grazes or bruising). 
After feeding, the mother s breasts should feel softer, with reduced tightness or heaviness, 
and any lumps which may have been present prior to the feed should have resolved or 
reduced. 

Rooming In: 

Allow mothers and infants to remain together 24 hours per day. The infant should sleep in the 
same room or area as the mother, but not co-sleep with the mother on any surface as co-
sleeping increases the risk of SIDS. 
Benefits of rooming in include:  

&gt; Mother learns to read baby feeding cues and develop settling techniques, thereby 
increasing her confidence and skills in achieving breastfeeding;  

&gt; Increased opportunities for skin to skin contact 
&gt; Increased likelihood that infant will be exclusively breastfed 
&gt; Longer duration of breastfeeding when compared to mother- baby dyads where the baby 

sleeps in a separate room22 
&gt; Reduction in infection risk due to reduced exposure to foreign bacteria 
&gt; Reduced risk of incorrect identification of mother and infant (in the hospital/ healthcare 

facility setting) 
&gt; Enhanced emotional development of the infant; 
&gt; Reduced Sudden and Unexpected Infant Death (see Safe Infant Sleeping 

Standards: http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+in
ternet/clinical+resources/clinical+topics/child+health/safe+infant+sleeping+standards23  

 





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Feeding Frequency: 
First 24 hours following birth (see flowchart 1)  
The initial post-birth alert period is usually followed by a sleepy period, which may last 6-10 
hours or more24.  
 
Successful breastfeed around time of birth 
If the infant had an adequate breastfeed following birth, allow the infant to sleep until it wakes 
and  demands  (up to 8 hours following birth feed).  

&gt; If the infant has another adequate breastfeed at this point, he/she can be left to wake 
and  demand  their next feed. Frequency of feeds should increase in the next 24 hour 
period. 

&gt; If the infant does not have another adequate breastfeed at this time, he/she can be left 
for a further 2 hours if not ready to feed. Check observations and encourage mother to 
express. 

&gt; At 10 hours post birth feed, facilitate skin to skin contact and attempt breastfeed again. 
o If the infant has another adequate breastfeed at this point, he/she can be 

left to wake and  demand  their next feed. Frequency of feeds should 
increase in the next 24 hour period. 

o If the infant does not have a successful breastfeed but is vigorous, 
express and give EBM. If no EBM is available, consider obtaining infant 
blood glucose level (BGL) and make ongoing plan. 

o If the infant does not have a successful breastfeed and is not vigorous or 
not making attempts to feed, obtain BGL and check temperature. If 
temperature &lt; 36 celsius and/or BGL &lt;2mmo/L and/or infant is clammy, 
jittery or hypotonic, immediately contact neonatologist, pediatrician or GP 
(as per unit protocol). 

 
Infant did not have successful breastfeed around the time of birth 
If the infant has not breastfed by 6 hours following birth: 

&gt; Wake the infant 
&gt; Initiate skin to skin contact again and watch for feeding cues.  
&gt; Check infant temperature. If 36-36.6 Celsius, place warm blankets over mother and 

infant. 
&gt; If the infant has an adequate breastfeed at this point, allow the infant to sleep until it 

wakes and  demands  (up to 8 hours following this first feed). Monitoring of breastfeeding 
frequency and success would then follow the guidelines as above for the first 24 hours. 

&gt; If the baby does not have a successful breastfeed at 6 hours following birth either, but 
is vigorous, express and give EBM. If no EBM is available, consider obtaining infant BGL 
and make ongoing plan. 

&gt; If the infant does not have a successful breastfeed and is not vigorous, consider BGL, 
check observations and obtain review. 

 
24-72 Hours Post Birth  
Infants should breastfeed a minimum of 8 feeds, have at least 2 wet nappies and 3 soft 
green/black stools in every 24 hour period between 24 and 72 hours of age. If these criteria 
are not met, undertake the following assessments: 

&gt; Infant temperature 
&gt; Breastfeeding vigour 
&gt; Breast attachment 



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&gt; Establishment of milk supply 
&gt; Condition of mother s breasts/nipples 
&gt; Infant s oral anatomy 
&gt; Mother s breastfeeding knowledge and history 
&gt; Infant s weight  

 
Undertake infant BGL and refer to the neonatologist, paediatrician or GP if the infant displays 
any of the following: 

&gt; Hypothermia (&lt; 36 celsius) 
&gt; Poor feeding for longer than 6-8 hours 
&gt; Hypotonia 
&gt; Lethargy 
&gt; Clamminess 
&gt; Jitteriness 

 
General 
Immediately after birth, the onset of lactation is initiated due to the sudden decrease in serum 
oestrogen and progesterone levels at the time of placental delivery. The infant will have 
variable sleep-wake cycles, and may feed frequently as lactogenesis starts. 
From 38-96 hours postpartum, cellular metabolism changes, and milk volume increases 
rapidly. Ongoing maintenance of lactation requires frequent removal of milk from the breast, 
either by breastfeeding or expression.  
Healthy term infants will feed at irregular intervals, requiring a minimum of 8-12 feeds in a 24 
hour period1. Feeding frequency depends on effective milk transfer and according to need. 
Feeds should therefore not be timed or restricted unless there is a clinical indication which 
may necessitate additional feeding strategies to ensure adequate intake.  
Infants are mostly settled and content between feeds, although all infants will have some 
unsettled periods. 
Serum prolactin levels are higher during REM sleep, and increased prolactin surges in 
response to suckling are greater during night feeds, therefore contributing to establishment of 
adequate lactation25.  
Exclusive breastfeeding is recommended for the first 6 months, after which other foods need 
to be introduced. Breastfeeding can continue for 12 months and beyond, depending on 
mother   infant preferences. 

Indication of and Assessment of Effective Feeding: 

In the absence of specific relevant medical conditions or surgical history, with frequent 
opportunities to initiate breastfeeds, and with adequate support, most mothers are able to 
produce adequate milk supply for their infant(s). 
 
Signs of effective breastfeeding: 
&gt; Baby wakes and demands feeds and looks comfortable and calm during feed. 
&gt; Good muscle tone is evident. 
&gt; Lower jaw rhythmically moving during sucking with audible swallowing during feeds  
&gt; Healthy skin: Physiological jaundice is common, but usually resolves rapidly with 

adequate breastmilk intake. Other causes of jaundice, especially if persistent or 
increasing in severity, should be investigated and managed (see Neonatal Jaundice 
PPG available at www.sahealth.sa.gov.au/perinatal)26.  

 




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&gt; Urine output: there may be 1 2 wet nappies in the first 24 hours. As breastmilk intake 
increases, urine output increases to 5-6 heavily wet nappies within a 24 hour period after 
approximately 5 days. 

&gt; Bowel actions change from meconium (in the first 24-36 hours) to transitional stool (36-
72 hours) then there is a gradual change to soft, semi-formed mustard yellow stools. 
Mature milk stools are yellow, in colour, and may be quite fluid / runny. In the first 3-4 
weeks, bowel actions are expected at least daily, and may be more frequent. 

&gt; After 3-4 weeks, breastfed infants may have less bowel actions   e.g. every few days. 
&gt; From 6 months onwards, the stools will change in colour and smell as other foods are 

introduced into the diet. 
 
Relevant medical or surgical conditions which may delay or impact on adequacy of breastmilk 
supply include hypothyroidism, obesity, type 1 diabetes, breast reduction surgery (especially if 
there has been nipple relocation), PCOS, prolonged labour, emergency LSCS, retained 
products of conception.  
 
Infant weight 
There is no consensus about acceptable initial weight loss, but ranges of acceptability are 
from 7-10% below birth weight. Maternal intravenous therapy during labour has been 
demonstrated to correlate with infant weight loss in the first 24 hours12. 
As breastmilk intake increases, weight gain occurs. 

&gt; Return to birth weight by approximately 14 days after birth. 
&gt; Weight gain 150   200 gm per week for first 3 months 
&gt; Weight gain 100   150 gm per week for 3-6 months 
&gt; Weight gain 70   90 gm per week from 6   12 months28  
&gt; Weight is doubled from birth weight by 5-6 months 
&gt; Weight is tripled from birthweight by 12 months29  

 
If the infant loses more than 10% of birth weight from day 3 (or 5 depending on local 
guidelines for weighing babies), further assessment of mother, infant and breastfeeding need 
to occur (see flowchart 2) 
Depending on assessment, a number of management strategies may need to be employed. 
Examples include breast expression and offering the infant EBM, professional observation 
and support of breastfeed, assessment of infant by medical officer and medication 
(see flowchart 2) 

Maternal Supplements 
There are supplements available to support breastfeeding but are not routinely recommended 
in the presence of an adequate diet. 
Iron 
See Anaemia in Pregnancy PPG (www.sahealth.sa.gov.au/perinatal)30  

Vitamin D 
See Vitamin D Status in Pregnancy PPG (www.sahealth.sa.gov.au/perinatal)31 

  





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Maternal Medications and Breastfeeding 
A small number of medications and some complementary medicines are contraindicated with 
breastfeeding.  
Individual risk-benefit analysis must be undertaken when considering the use of these 
medications32. 
Telephone referral can be made to the Drug Information Service at the Women s and 
Children s Hospital (Phone 8161 7222), for discussion of appropriate medication options. 
(This service has the most up-to-date information available.)  
 
Contraception 
Provide appropriate contraceptive advice as indicated, allowing informed choice by the 
woman. Progesterone only contraceptives have not been shown to have a negative impact on 
breastfeeding, including duration of breastfeeding or timing of introduction of supplementary 
feeds.  
The use of combined hormonal contraception has been demonstrated to adversely affect 
breastfeeding, with some studies showing reduced duration of breastfeeding and increased 
supplementation33. 

Impact of Introduction of Supplementary Feeds 
There are a number of medical conditions in which it is acceptable to initiate supplementary 
feeding, either temporarily or on an ongoing long-term basis. 
See http://apps.who.int/iris/bitstream/handle/10665/69938/WHO_FCH_CAH_09.01_eng.pdf;js
essionid=619468C123398BEB05C8E73F13BE6386?sequence=134 

 
Introduction of supplementary feeds in the absence of legitimate clinical indication can lead 
to: 

&gt; Decreased exclusive breastfeeding and overall reduced duration of breastfeeding35, 36 
&gt; Reduced maternal milk supply, due to reduced opportunities or time feeding at the breast 
&gt; Breast refusal, especially if supplementary feeds have been given by early introduction 

of bottle and teat 
&gt; Inadequate infant nutrition, due to incorrect preparation of artificial formula 
&gt; Increased risk of gastro-intestinal infection, due to poor hygiene practices or the use of 

incorrectly prepared/stored/collected artificial formula or donor expressed breastmilk 
Where supplementary feeds are clinically indicated, consideration should be given to 
administration by spoon, cup, supply line, syringe/finger or gavage feeding. Ensure mother 
receives individual instruction in the safe preparation of infant formula. 

Use of Bottles, Teats, Dummies 
Bottles, teats and dummies are not recommended during the early weeks of establishing 
breastfeeding (approximately 4-6 weeks). 
Risks associated with use of bottles and teats in the neonatal period include reduced 
lactation, difficulty in resuming breastfeeding (due to different sucking technique required for 
bottle feeding) and breast refusal. 
Dummy use has been associated with reduced exclusive breastfeeding duration, dental 
malocclusion, increased oral infection risk and low milk supply37.  
If, following discussion, the mother makes an informed decision to use bottles, teats or 
dummies; her decision will be respected and supported.  





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Expression of Breastmilk 
Expressing is defined as the removal of milk from the breast(s) by either manual technique or 
through use of a specifically designed pump. 
Indications: 

&gt; Preterm or hospitalised infant; 
&gt; Hypolactation (low milk supply); 
&gt; Blocked duct / Mastitis 
&gt; Maternal medications for which breastfeeding is contra-indicated, but for which there is 

no safe, effective, alternative option; 
&gt; Mother returning to work or planning to leave infant with carer; 
&gt; Maternal illness in which breastfeeding is temporarily not recommended. In Australia, 

women with Human Immunodeficiency Virus (HIV) are recommended not to breastfeed, 
In other areas of the world, the recommendations re breastfeeding may differ, depending 
on individual assessment of the situation, viral load, and clinical status of the woman.  

 
Expressing for premature infants or those infants requiring increased level of care in the early 
newborn period and who are unable to breastfeed should be initiated within the first 6 hours 
after birth. 
Initiation of expressing within the first hour after birth has been shown to increase milk 
volumes12.  
Frequency of expressing will be individually assessed, depending on the indication, for 
mothers whose infants are premature or requiring high level care.  
Expressing should be undertaken at least 7-8 times within a 24 hour period, including at night, 
until lactation is well established. 
See Appendices for Hand Expression Technique and information on EBM management. 

After Discharge/Community Services  
Provide referral for ongoing care via Midwifery Group Practice midwife, domiciliary midwifery 
service or other follow-up support service such as CaFHS, GP, etc. as per local guidelines. 
Provide referral to CaFHS if early breastfeeding review is recommended and mother 
consents. 
Inform woman of availability and access to community infant feeding support services. (E.g. 
Local Community Health Centre, CaFHS, Australian Breastfeeding Association, International 
Board Certified Lactation Consultant). The My Health and Development Record (the Blue 
Book) should be referred to when promoting these supports and services. 
Advise women with culturally and linguistically diverse backgrounds of information available in 
other languages available from the ABA website 
and/or. https://medlineplus.gov/languages/breastfeeding.html38 
Document clinical details, including weight and feeding management in infant s Health Record 
booklet. 
Provide information to father of baby or significant others of their crucial role in supporting the 
breastfeeding mother. This support can include (but is not limited to) adequate rest for mother 
when infant rests, fluids and nutrition, support with household chores and other children in the 
family during the early weeks of infant being home. 
Advise women of when to seek additional support: maternal health issues; e.g. heavy PV 
loss, fever, pain, breast or nipple issues or for infant issues such as not waking for feeds, 
reduced urine output or infrequent stooling. 
 




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Resources 
Useful Websites for Health Professionals 

Guidance for health facilities on implementing the 10 Steps to Successful Breastfeeding 
https://www.unicef.org/media/media_102787.html 
http://www.who.int/nutrition/publications/infantfeeding/bfhi-implementation/en/  
 
Baby Friendly Health Initiative Australia 
https://www.midwives.org.au/sites/default/files/uploaded-content/website-
content/BFHI/bfhi_handbook_for_maternity_facilities_20160804.pdf 
 
BFHI 7 Point Plan for Community Health Services 
https://www.midwives.org.au/resources/bfhi-information-pack-community-facilities 
 
Global Health Media 
https://globalhealthmedia.org/portfolio-items/breastfeeding-attachment/ 
 
Recommendations for common breastfeeding concerns: Queensland Clinical Guideline: 
Establishing Breastfeeding 
https://www.health.qld.gov.au/__data/assets/pdf_file/0033/139965/g-bf.pdf 

Useful Websites for Women 
For extensive information and pictures on establishing breastfeeding, feeding cues, 
expression and storage of breastmilk etc. 
Child and Youth Health 
http://www.cyh.com   
Raising Children Network 
http://raisingchildren.net.au/  
 
Expression and Storage of Breastmilk (Policy and Information Leaflet for women) 
www.sahealth.sa.gov.au/perinatal  
 
Australian Breastfeeding Association (including email counselling and live chat) 
https://www.breastfeeding.asn.au/ 
 
Videos for: 
Attaching Your Baby at the Breast 
https://globalhealthmedia.org/portfolio-items/attaching-your-baby-at-the-breast/ 
How to Express Breastmilk 
https://globalhealthmedia.org/portfolio-items/how-to-express-your-first-milk/ 
https://globalhealthmedia.org/portfolio-items/how-to-express-breastmilk/ 

Phone resources for women 
CaFHS 1300 733 606 
CaFHS Parent Help Line 1300 364 100 
ABA telephone support line 1800 mum 2 mum (1800 686 268) 

Other  
CaFHS Breastfeeding Clinics 
CaFHS Torrens House 
ABA local support group 
Private midwives and lactation consultants 

















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References 
1. Queensland Clinical Guidelines, Maternity and Neonatal Clinical Guideline 

 Establishing breastfeeding  Queensland Health, 2016 
2. Australian National Infant Feeding Survey 2010 (Australian Institute of Health and 

Welfare, Canberra. Published 2011) 
3. World Health Organisation Dept of Nutrition for Health and Development (e-Library of 

Evidence for Nutrition Actions), October 2018 
4. National Health and Medical Research council  Infant Feeding Guidelines   

Information for Health Workers, Australian Government 2012, Minor update 2013 
5. BFHI Handbook for Maternity Facilities (Australian College of Midwives, 2016) 
6. Draft Australian National Breastfeeding Strategy (Australian Government, Australian 

Health Ministers Advisory Council) May 2018 
7. Australian National Infant Feeding Survey 2010 (Australian Institute of Health and 

Welfare, Canberra. Published 2011) 
8.  Antenatal breastfeeding education for increasing breastfeeding duration (Review) 

Cochrane Library, 2012 Lumbiganon P., Martis R., Laopaiboon M., Festin MR., Ho 
JJ., Hakimi M.  

9. Chapman T, Pincombe J, Harris M.  Antenatal breast expression: A critical review of 
the literature  Midwifery  2012 

10. Forster D, Moorhead A, Jacobs S, Davis P, Walker S, McEgan K et al  Advising 
women with diabetes in pregnancy to express breastmilk in late pregnancy (Diabetes 
and Antenatal Milk Expressing [DAME]): a multicentre, unblended, randomised 
controlled trial. The Lancet, Vol 389, Issue 10085, Pg2204-2213, June 03, 2017 

11. Lyell McEwin Health Service Fact Sheet  Expressing Colostrum  
12. Expressed Breast Milk. Safe Management and Administration in SA 2018 Clinical 

Directive available at: https://extapps2.sahealth.sa.gov.au/PracticeGuidelines/   
13. Ransjo-Arvidson A-B, Matthiesen A-S, Lilija G., Nissen E., Widstrom A-M., Uvnas-

Moberg K.  Maternal Analgesia During Labour Disturbs Newborn Behaviours: Effects 
on Breastfeeding, Temperature and Crying  2001 

14. Feldman-Winter L., Goldsmith J.,  Safe Sleep and Skin-to-Skin Care in the Neonatal 
Period for Healthy Term Newborns  American Academy of Pediatrics Clinical Report, 
Sept 2016, Vol 138, Issue 3 

15. Yuksel B., Ital I., Balaban O., Kocak E., Seven A., Kucur SK., Bakirci M., Keskin N 
 Immediate breastfeeding and skin to skin contact during cesarian section decreases 
maternal oxidative stress, a prospective randomized case-controlled study  Journal of 
Maternal-Fetal &amp; Neonatal Medicine. Oct 2015 

16. Feldman-Winter L., Goldsmith J., Safe Sleep and Skin-to-Skin Care in the Neonatal 
Period for Healthy Term Newborns  American Academy of Pediatrics Clinical Report, 
Sept 2016, Vol 138, Issue 3 

17. Riordan J., and Wambach K.  Breastfeeding and Human Lactation  4th edition, 2010, 
pages 216-217 

18. Women s and Children s Health Network. Parenting and Child Health. Child and 
Youth Health. Health Topics: Feeding Cues available 
at: http://www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&amp;np=302&amp;id=18
10#5  

19. Women s and Children s Health Network. Parenting and Child Health. Child and 
Youth Health. Health Topics: Positioning for Mother available 
at: http://www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&amp;np=302&amp;id=18
10#3 

20. Women s and Children s Health Network. Parenting and Child Health. Child and 
Youth Health. Health Topics: Positioning and Attaching Your Baby available 
at: http://www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&amp;np=302&amp;id=18
10#4 

21. Riordan J. and Wambach K.  Breastfeeding and Human Lactation  4th edition, 2010, 
pages 90-91, 100-101 

22. Doan T., Gay CL, Kennedy HP, Newman J, Lee KA.  Nighttime Breastfeeding 
Behaviour is Associated with More Nocturnal Sleep among First-Time Mothers at 
One Month Postpartum  Journal of Clinical Sleep Medicine. 2014; 10(12) 










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23. SA Health. South Australian Safe Infant Sleeping Standards available 
at:   http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+inter
net/clinical+resources/clinical+topics/child+health/safe+infant+sleeping+standards 

24. Riordan J. and Wambach K.  Breastfeeding and Human Lactation  4th edition, 2010, 
page 583 

25. West D.  Maximising a Mother s Milk Production Capability  2016 
26. SA Health. Perinatal Practice Guideline. Neonatal Jaundice. Available 

at: www.sahealth.sa.gov.au/perinatal  
27. Tawia S., McGuire L.  Early weight loss and weight gain in healthy, full term, 

exclusively breastfed infants  in Breastfeeding Review, Vol 22, No 1, March 2014 
28. National Health and Medical Research Council  Infant Feeding Guidelines- 

Information for Health Workers , Australian Government 2012, minor update 2013 
Page 36 

29. Riordan J. and Wambach K.  Breastfeeding and Human Lactation  4th edition, 2010, 
Page 583 

30. SA Health. Perinatal Practice Guideline. Anaemia in Pregnancy. Available 
at: www.sahealth.sa.gov.au/perinatal   

31. SA Health. Perinatal Practice Guideline. Vitamin D Status in Pregnancy. Available 
at: www.sahealth.sa.gov.au/perinatal  

32. Amir L., Pirotta M., Raval M. Breastfeeding   Evidence-based guidelines for the use 
of medicines  in Australian Family Physician, Vol 40, No 9, Sept 2011 

33. Tawia S.  Breastfeeding and Contraception  Australian Breastfeeding Association 
Professional Newsletter, October 2016 

34. World Health Organisation and UNICEF, Acceptable Medical Reasons for use of 
Breast-Milk Substitutes, WHO, Geneva, 2009 available 
at: http://apps.who.int/iris/bitstream/handle/10665/69938/WHO_FCH_CAH_09.01_en
g.pdf;jsessionid=619468C123398BEB05C8E73F13BE6386?sequence=1 

35. National Health and Medical Research Council  Infant Feeding Guidelines   
Information for Health Workers , Australian Government 2012, minor update 2013. 
Page 34 

36. Academy of Breastfeeding Medicine Clinical Protocol #3: Supplementary Feedings in 
the Healthy Term Breastfed Neonate, Revised 2017  Breastfeeding Medicine, Vol 12, 
No 3, 2017 

37. National Health and Medical Research Council,  Infant Feeding Guidelines   
Information for Health Workers  Australian Government 2012, minor update 2013, 
Page 33 

38. https://medlineplus.gov/languages/breastfeeding.html 
39. Expressed Breast Milk. Safe Management and Administration in SA 2018 Clinical 

Directive Patient Information Brochure available 
at: https://extapps2.sahealth.sa.gov.au/Practice Guidelines/ 

40. Australian College of Midwives  Baby Friendly Health Initiative Handbook for 
Maternity Facilities  August 2016, Pages 38-40 

 
 
 

  












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Appendix 1: Antenatal hand expressing11 

 
Equipment: 
Syringes with closing cap 
Ziplock bags 
Information sheet about Expressed Breastmilk Storage and Management 
Stickers with name/date/time information 
 
Process: 
Start at 36 weeks gestation (using caution with specific clinical presentations) 
Instruct woman re hand expression technique 
Advise woman to prepare equipment first, and to express in a comfortable, relaxed position; 
Instruct woman to thoroughly wash hands with soap and water, and dry before handling 
colostrum and equipment 
Recommend starting after a shower, while the breasts are warm 
Instruct woman to gently massage breasts prior to expressing 
Instruct the woman to express for a few minutes on each breast once or twice each day 
Instruct the woman to stop expressing if she experiences cramping uterine pain, vaginal 
bleeding or symptoms of hypoglycaemia and to seek health professional advice 
Instruct the woman in use of a syringe to draw up drops of colostrum, and to cap syringe 
when finished 
Instruct the woman to use a new syringe each day. If expressing twice per day, it is 
recommended to use a new syringe for each expression. Capped syringes are available for 
sale at most pharmacies 
Instruct woman to complete the details on the identification sticker, attach it to the syringe and 
store it in the freezer in the ziplock bag. Colostrum can be stored in the coldest part of the 
fridge (at the back) for three days before being frozen 
Advise the woman to inform her health professional that she will be bringing frozen colostrum 
into the hospital at time of admission (she may also include this on her birth plan) 
 
For EBM storage information see Appendix 3: 

  



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Appendix 2: Postnatal hand expressing 
 
Hand Expressing Process: 
Wash hands first;  
Use clean, sterilised container, spoon or cup. (In the hospital healthcare facility use sterile 
containers provided); 
Initiate the MER by gentle massage and warmth over the breast. Warmth may also assist the 
MER; 
Breast and nipple massage stimulate oxytocin release, which shortens and widens the 
lactiferous ducts, increases pressure inside the breast, and maximises milk removal;  
After massage, position the thumb and forefinger on the edge of the areola; 
Gently press back into the breast tissue; 
Using a rhythmical compression and release, with the forefinger and thumb in a C shape, 2 
finger widths away from the nipple, top and bottom, press and relax as the finger pads of the 
thumbs and forefinger come together. Rotate fingers around the radius of the nipple to 
effectively hand express from the milk ducts. The lactiferous ducts may be palpable under the 
skin surface; 
Continue the process for approximately 10-15 minutes, or while milk can be expressed 
comfortably. To effectively express from all areas of the breast, the fingers can be moved to 
different positions during expressing.  For example, the woman may wish to start with her 
fingers at the 6 o clock and 12 o clock position, then move to 3 o clock and 9 o clock  
If a breast pump is used for expressing, follow the manufacturer s instructions for preparation, 
use and cleaning of the equipment. 
Hand expressing has been shown to be more effective to express colostrum. Breast pump 
use has been demonstrated to increase milk volumes after lactogenesis II has occurred17. 
 
For more information on postnatal breast expression technique see: 
http://www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&amp;np=302&amp;id=2141 
or the video hyperlink: https://med.stanford.edu/newborns/professional-
education/breastfeeding/hand-expressing-milk.html 
 

  






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Appendix 3: Safe Storage of EBM12 

 
 

For EBM storage information see: 
Expressed Breast Milk. Safe Management and Administration in SA 2018 Clinical Directive12 
and Patient Information Brochure39 available 
at: https://extapps2.sahealth.sa.gov.au/PracticeGuidelines/ 
 

  

Length of time breast milk can be stored 

Breast milk 
status 

Storage at room 
temperature (26 C 

or lower) 

Storage in 
refrigerator  

(5 C or lower) 
Storage in freezer 

Freshly 
expressed into 
sterile container 

6-8 hours  
If refrigeration is 
available store 
milk there 

No more than 72 
hours 
Store at back, 
where it is coldest 

2 weeks in freezer 
compartment inside 
refrigerator (-15 C) 
3 months in freezer section of 
refrigerator with separate door 
(minus 18 C) 
6-12 months in deep freeze 
(minus 20 C) 

Previously 
frozen (thawed) 

4 hours or less   
that is, the next 
feeding 

24 hours Do not refreeze 

Thawed outside 
refrigerator in 
warm water 

For completion of 
feeding 

4 hours or until next 
feeding 

Do not refreeze  

Infant has 
begun feeding  

Only for 
completion of 
feeding 
Discard after feed 

Discard Discard 




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Appendix 4: WHO Acceptable Medical Reasons for the use of 
Breastmilk Substitutes34 

 
INFANT CONDITIONS: 
Infants with the following conditions should not receive breast milk or any other milk 
except specialised formula: 

  Classic galactosaemia: a special galactose-free formula is needed 
  Maple Syrup Urine Disease: a special formula free of leucine, isoleucine and valine is 

needed 
  Phenylketonuria: a special phenylalanine-free formula is needed, though some 

breastfeeding is possible under careful monitoring. 
 
Infants with the following conditions for whom breast milk remains the best feeding 
option, but who may need other food in addition to breast milk for a limited period: 

  Very low birth weight infants  (those born weighing less than 1500g) 
  Very preterm infants (i.e. those born less than 32 weeks gestational age) 
  Newborn infants who are at risk of hypoglycaemia due to impaired metabolic 

adaptation or increase glucose demand. This includes those who are preterm, small 
for gestational age, or who have experienced significant intrapartum hypoxic/ 
ischaemic stress, as well as those who are ill and those whose mothers are diabetic if 
their blood sugar fails to respond to optimal breastfeeding or breast milk feeding. 

 
MATERNAL CONDITIONS: 
Mothers who are affected by any of the conditions mentioned below should receive 
treatment according to standard guidelines: 
Mothers who may need to avoid breastfeeding: 

  HIV infection: if replacement feeding is acceptable, feasible, affordable, sustainable 
and safe (AFASS) 

The most appropriate infant feeding option for a HIV-infected mother depends on the 
individual circumstances of the mother and baby, including the mother s health status, but 
should also take into consideration the health services available and the counselling and 
support the mother is likely to receive. When replacement feeding is acceptable, feasible, 
affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected women is 
recommended. Mixed feeding in the first 6 months of life (ie breastfeeding while also giving 
other fluids, formula or foods) should always be avoided by HIV-infected mothers. 
 
Mothers with the following conditions or situations may need to avoid breastfeeding 
temporarily: 

  Severe illness that prevents a mother from caring for her infant (eg sepsis) 
  Herpes simplex virus type 1 (HSV-1): Direct contact between lesions on the mother s 

breasts and the infant s mouth should be avoided until all active lesions have 
resolved. 

  Maternal medication including 
? Sedating psychotherapeutic drugs, anti-epileptic drugs and opioids and their 

combinations, which may cause side effects such as drowsiness and respiratory 
depression. These drugs should be avoided if a safer alternative is available. 

? Radioactive iodine-131. If possible, a safer alternative may be used. A mother 
can resume breastfeeding about 2 months after receiving this substance. 

? Excessive use of topical iodine or iodophors (e.g. povidone-iodine) especially on 
open wounds or mucous membranes, which can lead to thyroid suppression or 
electrolyte abnormalities in the breastfed infant. 

? Cytotoxic chemotherapy. 



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Mother with the following conditions can continue breastfeeding, although health 
problems may be of concern: 

  Breast abscess: breastfeeding should continue on the unaffected breast; feeding from 
the affected breast can resume once treatment has started. 

  Hepatitis B: infants should be given Hepatitis B vaccine within the first 48 hours or as 
soon as possible thereafter. 

  Hepatitis C 
  Mastitis: if breastfeeding is very painful, milk will need to be removed by expression, 

to avoid progression of the condition. 
  Tuberculosis: mother and baby should be managed according to national tuberculosis 

guidelines. 
  Substance use: Mothers should be encouraged not to use these substances, and 

should be offered opportunities and support to abstain from use. Mothers who choose 
not to cease their use of these substances or who are unable to do so should seek 
individual advice on the risks and benefits of breastfeeding depending on their 
individual circumstances. For mothers who use these substances in short episodes, 
consideration may be given to avoiding breastfeeding temporarily during this time. 
? Nicotine, alcohol, ecstasy, amphetamines, cocaine and related stimulants have 

been demonstrated to have harmful effects on breastfed babies. 
? Alcohol, opioids, benzodiazepines and cannabis can cause sedation in both 

mother and baby. 
 

ADDENDUM FOR AUSTRALIA40 

The Baby Friendly Health Initiative Australia also considers the following conditions to be 
acceptable medical reasons for the use of breastmilk substitutes in Australia. 

  Primary Inadequate Breastmilk Supply 
  Breast surgery: Women who have had breast surgery such as breast reduction with 

nipple relocation may find it necessary to use a breastmilk substitute, to ensure that 
their baby receives adequate intake and nutrition. 

  Bilateral breast hypoplasia: Every attempt should be made to stimulate an adequate 
milk supply, but if unsuccessful, the baby may need a breastmilk substitute to receive 
adequate nutrition and intake. 

 
HIV infections: The World Health Organisation released updated guidelines in 2010, 
indicating that if a decision is made to use replacement feeding it must be acceptable, 
feasible, affordable, sustainable and safe. An individual decision should be made in 
consultation with each mother, taking into account her circumstances and viral load. 
Hepatitis B: Under the current Hepatitis B recommended prophylaxis, breastfeeding is not a 
risk factor for mother-to-child transmission. 
  



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Acknowledgements 
The South Australian Perinatal Practice Guidelines gratefully acknowledge the contribution of 
clinicians and other stakeholders who participated throughout the guideline development 
process particularly:  

Write Group Lead 
Marianne Sturm 
 
Write Group Members 
Kathy Mattner 
Chrissy Mackinnon 
Colleen Panario 
Tracey McPhee 
 
Other major contributors 
Rebecca Smith 
 
SAPPG Management Group Members 
Sonia Angus 
Dr Kris Bascomb 
Lyn Bastian 
Dr Feisal Chenia 
John Coomblas 
A/Prof Rosalie Grivell 
Dr Amy Keir 
Dr Sue Kennedy-Andrews 
Jackie Kitschke 
Catherine Leggett 
Dr Anupam Parange 
Dr Andrew McPhee 
Rebecca Smith 
Dr Laura Willington 
  



Breastfeeding 
  
 

 
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Document Ownership &amp; History 
Developed by: SA Maternal, Neonatal &amp; Gynaecology Community of Practice 
Contact: HealthCYWHSPerinatalProtocol@sa.gov.au 
Endorsed by: SA Safety and Quality Strategic Governance Committee 
Next review due:  28/06/2024    
ISBN number:  978-1-76083-162-2 
PDS reference:  CG317 
Policy history: Is this a new policy (V1)?  Y 
 Does this policy amend or update and existing policy?   N 
 If so, which version?  
 Does this policy replace another policy with a different title?  N 
 
 
 
 

Approval 
Date 

Version Who approved New/Revised Version Reason for Change 

28/06/2019 V1 SA Health Safety and Quality Strategic Governance Committee 

Original SA Health Safety and 
Quality Strategic Governance 
Committee approved version. 

 



	Purpose and Scope of PPG
	Flowchart 1: Breastfeeding the Healthy Term Infant in the First 24 Hours Following Birth
	Flowchart 2: Management of Infants with more than 10% weight loss below birth weight from day 3-5
	Summary of Practice Recommendations
	Abbreviations
	Introduction
	Antenatal
	First antenatal visit (or at first opportunity)
	Discuss
	Obtain clinical history
	Physical examination:
	Document

	Subsequent visits:
	Antenatal Expressing
	Antenatal Expression


	Labour and Birth
	Postnatal
	Feeding Cues
	Positioning and Attachment
	Correct Attachment
	Signs of correct attachment
	Pain with attachment
	Sucking pattern
	General

	Feeding Frequency:
	First 24 hours following birth (see flowchart 1)
	24-72 Hours Post Birth
	General

	Indication of and Assessment of Effective Feeding:
	Signs of effective breastfeeding:
	Infant weight

	Maternal Supplements
	Iron
	Vitamin D


	Maternal Medications and Breastfeeding
	Contraception

	Impact of Introduction of Supplementary Feeds
	Use of Bottles, Teats, Dummies
	Expression of Breastmilk
	After Discharge/Community Services
	Resources
	Useful Websites for Health Professionals
	Useful Websites for Women
	Phone resources for women

	Appendix 1: Antenatal hand expressing11
	Appendix 2: Postnatal hand expressing
	Appendix 3: Safe Storage of EBM12
	Appendix 4: WHO Acceptable Medical Reasons for the use of Breastmilk Substitutes34
	ADDENDUM FOR AUSTRALIA40

	Acknowledgements

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