Infant feeding and maternal

nutrition in postnatal care

A NICE pathway brings together all NICE guidance, quality
standards and materials to support implementation on a specific
topic area. The pathways are interactive and designed to be used
online. This pdf version gives you a single pathway diagram and
uses numbering to link the boxes in the diagram to the associated
recommendations.
To view the online version of this pathway visit:
http://pathways.nice.org.uk/pathways/postnatal-care
Pathway last updated: 29 July 2015. To see details of any updates to this pathway since its launch,
visit: About this Pathway. For information on the NICE guidance used to create this path, see:
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Infant feeding and maternal nutrition in postnatal care

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Women and babies

No additional information

Maternal health and nutrition

A healthy diet
Advise mothers that a healthy diet is important for everyone and that they do not need to modify
their diet to breastfeed.
Vitamin D
Ensure health professionals recommend vitamin D supplements
Local authorities, primary care and clinical commissioning groups should:
Ensure computerised prompts on vitamin D are integrated into health and social care
systems.
Ensure health professionals recommend and record vitamin D supplement use among atrisk groups [See page 11] (and other family members, as appropriate) whenever possible.
This could take place during registration appointments with new patients in general
practice, flu, other vaccine and screening appointments. It could also take place during
routine appointments and health checks including, for example:
NHS Health Check
diabetes check-ups
falls appointments and check-ups
health assessments for looked-after children
the first contact with someone who is pregnant
antenatal and postnatal appointments
medicine use and prescription reviews
health visitor appointments
developmental checks for infants and children.
Developers of standardised electronic and handheld maternity notes and developers of
personal child health records (the 'red book') should add specific questions about the use of
vitamin D supplements.

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Testing vitamin D levels

Health professionals should not routinely test people's vitamin D status unless:
they have symptoms of deficiency
they are considered to be at particularly high risk of deficiency (for example, they have very
low exposure to sunlight)
there is a clinical reason to do so (for example, they have osteomalacia or have had a fall).
Increase availability of vitamin D supplements for at-risk groups
Local authorities should ensure vitamin D supplements containing the recommended reference
nutrient intake are widely available for all at-risk groups by:
Establishing arrangements with a range of settings to promote and distribute them. This
could include local pharmacies, children's centres, midwifery and health visiting services
and GP reception areas.
Considering providing free supplements for at-risk groups.
Encouraging pharmacies and other outlets selling food supplements (such as
supermarkets) to stock the lowest cost vitamin D supplements and promote them to at-risk
groups.
Ensure improvements in the availability of vitamin D supplements are supported by local
awareness-raising activities (see raise awareness of the importance of vitamin D
supplements and training and professional development in the NICE pathway on increasing
vitamin D supplement use among at-risk groups).
Prescribing medication
Health professionals should discuss the benefits and risks associated with any prescribed
medication and encourage the mother to continue breastfeeding, if reasonable to do so. In most
cases, it should be possible to identify a suitable medication which is safe to take during
breastfeeding by analysing pharmokinetic and study data. Appendix 5 of the 'British national
formulary' (BNF) should only be used as a guide as it does not contain quantitative data on
which to base individual decisions.
Health professionals should recognise that there may be adverse health consequences for both
mother and baby if the mother does not breastfeed. They should also recognise that it may not
be easy for the mother to stop breastfeeding abruptly and that it is difficult to reverse.

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Formula feeding

Commissioners and managers should ensure mothers have access to independent advice from
a qualified health professional on the use of infant formula. This should include information on
the potential risks associated with formula feeding and how to obtain ongoing advice at home.
Midwives should ensure mothers who choose to use infant formula are shown how to make up
a feed, store and warm formula and how to clean and sterilise bottles and teats before leaving
hospital or the birth centre, or before the mother is left after a home birth. This advice should
follow the most recent guidance from the Department of Health about bottle feeding.
Encourage parents and carers to use a bottle for expressed breast milk, infant formula or cooled
boiled water only.
Discourage parents and carers from adding sugar or any solid food to bottle feeds.
Advise mothers who choose not to breastfeed that there is insufficient evidence to suggest that
infant formula based on partially or extensively hydrolysed cow's milk protein helps to prevent
allergies.

Quality standards
The following quality statement is relevant to this part of the pathway.
Postnatal care quality standard
6.

Formula feeding

Breastfeeding

Attachment and positioning

Advise women of the following signs of good attachment and positioning:
the baby's mouth is wide open
there is less areola visible underneath the chin than above the nipple
the baby's chin is touching the breast, the lower lip is rolled down and the nose is free
there is no pain.

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If the baby is not attaching effectively, advise teasing the baby's lips with the nipple to open the
mouth.
Review attachment and positioning if breastfeeding causes pain or discomfort.
Successful feeding
Encourage unrestricted breastfeeding frequency and duration.
Reassure women about breast milk supply and help them gain confidence.
Advise women that babies will stop feeding when satisfied.
Advise women of the signs that a baby is successfully feeding:
swallowing is audible and visible
there is a sustained rhythmic suck
the arms and hands are relaxed
the mouth is moist
regular soaked/heavy nappies.
Ensure a mother can demonstrate how to position and attach the baby to the breast and can
identify signs that the baby is feeding well. This should be achieved (and be documented)
before she leaves hospital or the birth centre (or before the midwife leaves the mother after a
home birth).
Offer additional breastfeeding support to women who have had a narcotic/general anaesthetic,
a caesarean or delayed contact with their baby.
Ensure breast pumps are available for women who have been separated from their babies and
give instruction on how to use them.
Advise mothers with a family history of allergy to feed the baby only on breast milk. For current
dietary advice see NHS Choices.
Reassure women that they may feel:
brief discomfort at the start of feeds in the first few days; this is not uncommon but should
not persist
softening of their breast during the feed
no compression of the nipple at the end of the feed
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relaxed and sleepy.

Expressing and storing breast milk
Show all breastfeeding mothers how to hand-express breast milk. Advise mothers that
expressed milk can be stored for:
up to 5 days in the main part of a fridge, at 4C or lower
up to 2 weeks in the freezer compartment of a fridge
up to 6 months in a domestic freezer, at minus 18C or lower.
Advise mothers who wish to store expressed breast milk for less than 5 days that the fridge
preserves its properties more effectively than freezing.
Advise mothers who freeze their expressed breast milk to defrost it in the fridge and not to refreeze it once thawed. Advise them never to use a microwave oven to warm or defrost breast
milk.

Quality standards
The following quality statement is relevant to this part of the pathway.
Postnatal care quality standard
5.

Breastfeeding

Common breastfeeding concerns

Concern

Action

Cracked or painful
Assess attachment and positioning. If pain persists, consider thrush.
nipples

Engorged breasts

Advise frequent unlimited feeding, breast massage, hand expression,

analgesia and that the woman has a well-fitting bra.

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Mastitis

Offer assistance with attachment and positioning and advise woman to

continue breastfeeding/hand expression, gently massage affected
breast(s), take paracetamol and increase fluid intake. Advise woman to
contact you urgently if it lasts more than a few hours.

Mastitis lasting
more than a few
hours

Consider antibiotics (urgent action).

Inverted nipples

Give extra breastfeeding support.

Breastfeeding
concerns despite
review of
attachment and
positioning

Evaluate for ankyloglossia (urgent action).

Perceived
breastmilk
insufficiency

Reassure woman, review attachment and positioning and evaluate baby's

health.

Sleepy baby

Advise skin-to-skin contact or massage of baby's feet. If no improvement,

assess general health.

Ankyloglossia
NICE interventional procedures guidance
NICE interventional procedures guidance makes recommendations on whether interventional
procedures used for diagnosis or treatment are safe enough and work well enough for routine
use, and whether special arrangements are needed for patient consent. The interventional
procedures NICE considers are usually new, but NICE also issues guidance for established
procedures when there is uncertainty about their safety or how well they work. The following
NICE interventional procedure guidance is relevant to this part of the pathway.

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Division of ankyloglossia (tongue-tie) for breastfeeding

Current evidence suggests that there are no major safety concerns about division of
ankyloglossia (tongue-tie) and limited evidence suggests that this procedure can improve
breastfeeding. This evidence is adequate to support the use of the procedure provided that
normal arrangements are in place for consent, audit and clinical governance.
Division of ankyloglossia (tongue-tie) for breastfeeding should only be performed by registered
healthcare professionals who are properly trained.
Publication of further controlled trials on the effect of the procedure on successful long-term
breastfeeding will be useful.
These recommendations are from Division of ankyloglossia (tongue-tie) for breastfeeding (NICE
interventional procedure guidance 149).
NICE has written information for parents and the public explaining the guidance on division of
ankyloglossia (tongue-tie) for breastfeeding.

Quality standards
The following quality statement is relevant to this part of the pathway.
Postnatal care quality standard
5.

Breastfeeding

Ongoing breastfeeding support

Ensure breastfeeding peer supporters:

contact new mothers directly within 48 hours of their transfer home (or within 48 hours of a
home birth)
offer mothers ongoing support according to their individual needs. This could be delivered
face-to-face, via telephone or through local groups.
Provide continuing and proactive breastfeeding support at home, recording all advice in the
mother's hand-held records.

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Do not provide written materials in isolation but use them to reinforce face-to-face advice about
breastfeeding.
Health visitors and the child health promotion programme team should support mothers to
continue breastfeeding for as long as they choose.
Provide contact details for local voluntary organisations that can offer ongoing support to
complement NHS breastfeeding services.

Quality standards
The following quality statement is relevant to this part of the pathway.
Postnatal care quality standard
5.

Breastfeeding

Resources
The following implementation tool is relevant to this part of the pathway.
A peer support programme for women who breastfeed: commissioning guide

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Population groups at higher risk of having a low vitamin D status include:

All pregnant and breastfeeding women, particularly teenagers and young women
Infants and children under 5 years
People over 65
People who have low or no exposure to the sun. For example, those who cover their skin
for cultural reasons, who are housebound or confined indoors for long periods
People who have darker skin, for example, people of African, African-Caribbean and South
Asian origin.

Glossary
Diet
in this pathway, the term 'diet' refers to the habitual eating patterns of individuals and groups of
people who are not slimming or eating to manage or treat a medical condition
Emergency
life-threatening or potential life-threatening situation
Follow-on formula
under UK law, follow-on formula may provide the liquid component of a progressively varied diet
for healthy infants aged over 6 months
Healthy eating
there is no standard definition. However it is widely accepted that 'healthy eating' means
following a diet which is low in fat (particularly saturated fat), sugar and salt, and high in fruit,
vegetables and fibre-rich starchy foods. More details are available from NHS Choices
Infant formula
under UK law, infant formula is the term used to describe a food intended to satisfy, by itself, the
nutritional needs of infants during the first months of life. The Department of Health advises that
infant formula may be used on its own for the first 6 months

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Non-urgent
continue to monitor and assess
Reference nutrient intake
The amount of a nutrient needed to meet the needs of around 97% of individuals in a group
Significant hyperbilirubinaemia
an elevation of the serum bilirubin to a level requiring treatment
Urgent
potentially serious situation, which needs appropriate action
Visible jaundice
jaundice detected by visual inspection
Weaning
weaning or 'complementary feeding' is the transition from an exclusively milk-based diet to a
diet based on solid foods
Co-sleeping
parents or carers sleeping on a bed or sofa or chair with an infant
SIDS
sudden infant death syndrome

Sources
Postnatal care (2006 updated 2014) NICE guideline CG37
Vitamin D: increasing supplement use among at-risk groups (2014) NICE public health guidance
56

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Maternal and child nutrition (2008) NICE public health guidance 11

Division of ankyloglossia (tongue-tie) for breastfeeding (2005) NICE interventional procedure
guidance 149

Your responsibility
The guidance in this pathway represents the view of NICE, which was arrived at after careful
consideration of the evidence available. Those working in the NHS, local authorities, the wider
public, voluntary and community sectors and the private sector should take it into account when
carrying out their professional, managerial or voluntary duties. Implementation of this guidance
is the responsibility of local commissioners and/or providers. Commissioners and providers are
reminded that it is their responsibility to implement the guidance, in their local context, in light of
their duties to avoid unlawful discrimination and to have regard to promoting equality of
opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent
with compliance with those duties.

Copyright
Copyright National Institute for Health and Care Excellence 2015. All rights reserved. NICE
copyright material can be downloaded for private research and study, and may be reproduced
for educational and not-for-profit purposes. No reproduction by or for commercial organisations,
or for commercial purposes, is allowed without the written permission of NICE.

Contact NICE
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www.nice.org.uk
nice@nice.org.uk
0845 003 7781

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