This Guidelines summary covers planning and supporting babies’ feeding in the first 8 weeks after the birth. Breastfeeding is known to have some benefits on mothers and babies, when compared with formula feeding, including rates of infection in babies and reduced risk of breast cancer in mothers. However, some mothers choose bottle feeding while others struggle to establish satisfactory breastfeeding. This summary aims to determine what information and support on formula feeding parents find helpful antenatally, and within the first 8 weeks after birth.
The recommendations in this summary are taken from NICE guideline 194: Postnatal care. For more information on routine postnatal care, read our Guidelines for Nurses summary on postnatal care.
The guideline uses the terms ‘woman’ or ‘mother’ throughout. These should be taken to include people who do not identify as women, but are pregnant or have given birth. Similarly, where the term ‘parents’ is used, this should be taken to include anyone who has main responsibility for caring for a baby.
Reflecting on Your Learnings
Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.
General Principles About Babies’ Feeding
- When discussing babies’ feeding, follow the recommendations in the section on principles of care in the NICE guideline on postnatal care, and:
- acknowledge the parents’ emotional, social, financial, and environmental concerns about feeding options
- be respectful of parents’ choices.
- Before and after the birth, discuss breastfeeding and provide information and breastfeeding support (see the section on supporting women to breastfeed). Topics to discuss may include:
- nutritional benefits for the baby
- health benefits for both the baby and the woman
- how it can have benefits even if only done for a short time
- how it can soothe and comfort the baby
- Give information about how the partner can support the woman to breastfeed, including:
- the value of their involvement and support
- how they can comfort and bond with the baby
- Inform women that vitamin D supplements are recommended for all breastfeeding women (see the NICE guideline on vitamin D)
- Inform women and their partners that under the Equality Act 2010, women have the right to breastfeed in ‘any public space’.
Role of the Healthcare Professional Supporting Breastfeeding
- Healthcare professionals caring for women and babies in the postnatal period should know about:
- breast milk production
- signs of good attachment at the breast
- effective milk transfer
- how to encourage and support women with common breastfeeding problems
- appropriate resources for safe medicine use and prescribing for breastfeeding women
- Encourage the woman to have early skin-to-skin contact with her baby so that breastfeeding can start when the baby and mother are ready
- Those providing breastfeeding support should:
- be respectful of women’s personal space, cultural influences, preferences, and previous experience of infant feeding
- balance the woman’s preference for privacy to breastfeed and express milk in hospital with the need to carry out routine observations
- obtain consent before offering physical assistance with breastfeeding
- recognise the emotional impact of breastfeeding
- give women the time, reassurance, and encouragement they need to gain confidence in breastfeeding.
Supporting Women to Breastfeed
- Give breastfeeding care that is tailored to the woman’s individual needs and provides:
- face-to-face support
- written, digital, or telephone information to supplement (but not replace) face-to-face support
- continuity of carer
- information about what to do and who to contact if she needs additional support
- information for partners about breastfeeding and how best to support breastfeeding women, taking into account the woman’s preferences about the partner’s involvement
- information about opportunities for peer support
- Make face-to-face breastfeeding support integral to the standard postnatal contacts for women who breastfeed. Continue this until breastfeeding is established and any problems have been addressed
- Be aware that younger women and women from a low income or disadvantaged background may need more support and encouragement to start and continue breastfeeding, and that continuity of carer is particularly important for these women
- Provide information, advice, and reassurance about breastfeeding, so women (and their partners) know what to expect, and when and how to seek help. Topics to discuss include:
- how milk is produced, how much is produced in the early stages, and the supply-and-demand nature of breastfeeding
- responsive breastfeeding
- how often babies typically need to feed and for how long, taking into account individual variation
- feeding positions and how to help the baby attach to the breast
- signs of effective feeding so the woman knows her baby is getting enough milk (it is not possible to overfeed a breastfed baby)
- expressing breast milk (by hand or with a breast pump) as part of breastfeeding and how it can be useful; safe storage and preparation of expressed breast milk; and the dangers of ‘prop’ feeding
- normal breast changes during pregnancy and after the birth
- pain when breastfeeding and when to seek help
- breastfeeding complications (for example, mastitis or breast abscess) and when to seek help
- strategies to manage fatigue when breastfeeding
- supplementary feeding with formula milk that is sometimes, but not commonly, clinically indicated (also see the NICE guideline on faltering growth)
- how breastfeeding can affect the woman’s body image and identity
- that the information given may change as the baby grows
- the possibility of relactation after a gap in breastfeeding
- safe medicine use when breastfeeding.
- A practitioner with skills and competencies in breastfeeding support should assess breastfeeding to identify and address any concerns
- As part of the breastfeeding assessment:
- ask about:
- any concerns the parents have about their baby’s feeding
- how often and how long the feeds are
- rhythmic sucking and audible swallowing
- if the baby is content after the feed
- if the baby is waking up for feeds
- the baby’s weight gain or weight loss
- the number of wet and dirty nappies
- the condition of the woman’s breasts and nipples
- observe a feed within the first 24 hours after the birth, and at least one other feed within the first week
- ask about:
- If there are ongoing concerns, consider:
- observing additional feeds
- other actions, such as:
- adjusting positioning and attachment to the breast
- giving expressed milk
- referring to additional support such as a lactation consultation or peer support
- assessing for tongue‑tie.
- Before and after the birth, discuss formula feeding with parents who are considering or who need to formula feed, taking into account that babies may be partially formula fed alongside breastfeeding or expressed breast milk
- Information about formula feeding should include:
- the differences between breast milk and formula milk
- that first infant formula is the only formula milk that babies need in the first year of life, unless there are specific medical needs
- how to sterilise feeding equipment and prepare formula feeds safely, including a practical demonstration if needed
- for women who are trying to establish breastfeeding and considering supplementing with formula feeding, the possible effects on breastfeeding success, and how to maintain adequate milk supply while supplementing
- For parents who formula feed:
- have a one-to-one discussion about safe formula feeding
- provide face-to-face support
- provide written, digital, or telephone information to supplement (but not replace) face-to-face support
- Face-to-face formula feeding support should include:
- advice about responsive bottle feeding and help to recognise feeding cues
- offering to observe a feed
- positions for holding a baby for bottle feeding and the dangers of ‘prop’ feeding
- advice about how to pace bottle feeding and how to recognise signs that a baby has had enough milk (because it is possible to overfeed a formula-fed baby), and advice about ways other than feeding that can comfort and soothe the baby
- how to bond with the baby when bottle feeding, through skin-to-skin contact, eye contact, and the potential benefit of minimising the number of people regularly feeding the baby
- For parents who are thinking about supplementing breastfeeding with formula, or changing from breastfeeding to formula feeding, support them to make an informed decision.
- Discuss lactation suppression with women if breastfeeding is not started or is stopped, breastfeeding is contraindicated for the baby or the woman, or in the event of the death of a baby. Follow the recommendations in the NICE guideline on postnatal care. Topics to discuss include:
- how the body produces milk, what happens when milk production stops, and how long it takes for milk production to stop
- self-help advice, such as:
- avoiding stimulating the breast
- wearing a supportive bra
- using ice packs
- over-the-counter pain relief
- sparingly expressing milk to ease engorgement
- when to seek help
- medicines that can be prescribed to suppress lactation
- the advantages and disadvantages of the different methods of lactation suppression
- the possibility of becoming a breast milk donor (also see the section on screening and selecting donors in the NICE guideline on donor milk banks).
Terms Used in This Summary
This section defines terms that have been used in a particular way for this guideline. For other definitions see the NICE glossary.
Bonding and Emotional Attachment
Bonding is the positive emotional and psychological connection that the parent develops with the baby.
Emotional attachment refers to the relationship between the baby and parent, driven by innate behaviour and which ensures the baby’s proximity to the parent and safety. Its development is a complex and dynamic process dependent on sensitive and emotionally attuned parent interactions supporting healthy infant psychological and social development and a secure attachment. Babies form attachments with a variety of caregivers but the first, and usually most significant of these, will be with the mother and/or father.
Continuity of Carer
Better Births, a report by the National Maternity Review, defines continuity of carer as consistency in the midwifery team (between four and eight individuals) that provides care for the woman and her baby throughout pregnancy, labour, and the postnatal period. A named midwife coordinates the care and takes responsibility for ensuring the needs of the woman and her baby are met throughout the antenatal, intrapartum, and postnatal periods.
For the purpose of this guideline, the definition of continuity of carer in the Better Births report has been adapted to include not just the midwifery team, but any healthcare team involved in the care of the woman and her baby, including the health visitor team. It emphasises the importance of effective information transfer between the individuals within the team. Having continuity of carer means that a trusting relationship can be developed between the woman and the healthcare professional(s) who cares for her. For more information, see the NHS Implementing Better Births: continuity of carer.
In general, effective feeding includes the baby showing readiness to feed, rhythmic sucking, calmness during the feed, and satisfactory weight gain. For a first feed at the breast, or with a bottle, effective feeding is shown by the baby latching to the breast, or drawing the teat into mouth when offered and showing some rhythmic sucking.
First Infant Formula
First infant formula or ‘first milk’ is the type of formula milk that is suitable for a baby from birth to 12 months.
Low Birth Weight
A birth weight of less than 2500 g regardless of gestational age.
Nominal Group Technique
This is a structured method that uses the opinions of individuals within a group to reach a consensus. It involves anonymous voting with an opportunity to provide comments. Options with low agreement are eliminated and options with high agreement are retained. Using the comments that individuals provide, options with medium agreement are revised and then considered in a second round. For more information, see supplement 1 on methods.
Parents are those with the main responsibility for the care of a baby. This will often be the mother and the father, but many other family arrangements exist, including single parents.
Partner refers to the woman’s chosen supporter. This could be the baby’s father, the woman’s partner, a family member or friend, or anyone who the woman feels supported by, or wishes to involve.
When a baby’s feeding bottle is propped against a pillow or other support, rather than the baby and the bottle being held when feeding.
Responsive feeding means feeding in response to the baby’s cues. It recognises that feeds are not just for nutrition, but also for love, comfort, and reassurance between the baby and mother (or parent in case of bottle feeding). Responsive breastfeeding also involves a mother responding to her own desire to feed for her comfort or convenience. Responsive bottle feeding involves holding the baby close, pacing the feeds, and avoiding forcing the baby to finish the feed by recognising signs that the baby has had enough milk, and to reduce the risk of overfeeding. For more information, see the UNICEF Baby Friendly Initiative information sheet on responsive feeding.