Postnatal care

Why the committee made the recommendations

The committee agreed that one of the key principles of care in the postnatal period is to listen to women and be responsive to their needs, in line with the findings of the Ockenden report on maternity services at the Shrewsbury and Telford hospital NHS trust. The NICE guideline on patient experience in adult NHS services gives comprehensive guidance on individualised and person-centred care.

The committee also agreed that healthcare professionals should be aware of the disproportionate maternal and neonatal mortality rates among women and babies from black, Asian and minority ethnic backgrounds and those living in deprived areas, as highlighted by the 2020 MBRRACE-UK reports on maternal and perinatal mortality. This increased risk of death indicates that closer monitoring and lower thresholds for further care or admission might be needed. Future research could help understand these disparities and what interventions could improve the outcomes.

The committee recognised that the home and family circumstances for women vary, and it is up to the woman who she may want to involve in her postnatal care. The committee also recognised the role of the baby's father or other parents (or whoever has parental responsibility) in the care of the baby.

There was evidence that information given in the postnatal period is often inconsistent, and this was supported by the committee's experience. There was some evidence that information may need to be repeated at different times by different healthcare professionals. The committee agreed that this is good practice given the number of healthcare professionals that new parents are likely to come into contact with. They discussed concerns about the wide range and varied quality of information available from healthcare professionals, the internet and social media.

The evidence showed that healthcare professionals are a trusted source of information, so the committee agreed that it is important for healthcare professionals to provide evidence-based and consistent information throughout the woman's care. It should also take into consideration the individual needs and preferences of the woman. The evidence suggested that it is helpful to deliver information in different formats, for example, face-to-face discussions and printed or digital materials. The NICE guideline on patient experience in adult NHS services gives more information. The committee discussed the importance of allowing sufficient time for discussions.

The NICE guideline on pregnancy and complex social factors provides guidance for the antenatal period for specific groups. The committee agreed that the principles of care that are not specific to the antenatal period can also be applied to the postnatal period for potentially vulnerable groups of women.

How the recommendations might affect practice

There is some variation in what information is provided, and the recommendations may result in a change in practice for some centres, involving more training for healthcare professionals, and more time in postnatal appointments. The recommendations are expected to have a positive effect on women's experience of the healthcare service by increasing their confidence in the information provided. This may result in parents being more likely to follow the advice given, which may enable them to react more appropriately to difficulties and thereby reduce morbidity and mortality.

Return to recommendations

Why the committee made the recommendations

The evidence highlighted issues that should be communicated between healthcare professionals at transfer of care, including the woman's history in relation to her pregnancy and birth experience, and any mental health problems or safeguarding issues. Based on this evidence and their knowledge and experience, the committee agreed the information that should be passed on when women transfer between services, so that healthcare professionals do not miss relevant information and the woman does not always have to repeat the same information to different healthcare professionals. What is relevant and the level of detail needed may vary depending on whether the healthcare professional is a GP, midwife or a health visitor.

The committee also emphasised the importance of seamless transfer of care from midwifery to health visitor care so that there is continuous care provision.

How the recommendations might affect practice

There is variation in practice regarding what information, if any, is transferred between the different teams. The recommendation should lead to clearer guidance, improve relevant transfer of information and improve care for women and babies.

Return to recommendations

Why the committee made the recommendations

Studies looking at varying transfer timings showed that there was no consistent evidence about the best time to transfer the care of women and their babies to community care. Based on their knowledge and experience, the committee agreed that the timing should depend on the health and wellbeing of the woman and the baby. This also applies to the departure of the midwife in the case of a home birth. This will help to safely manage potential complications, prevent readmissions in the immediate postnatal period, and take into account any safeguarding concerns so that the woman and the baby are not discharged to an unsafe environment.

Assessing the woman's bladder function to rule out urinary retention is important because undetected or unmanaged urinary retention can lead to serious long-term consequences such as urinary incontinence.

Not passing meconium (the baby's first bowel movement) within the first 24 hours can be a sign of bowel obstruction, so it is important that parents know to seek advice from a healthcare professional. This might be for example a midwife, a doctor or, if the baby is thought to be seriously unwell, the emergency services.

Observing at least 1 effective feed (regardless of the method of feeding) is important to establish feeding and lower the chance of feeding problems at home and the need for readmission.

The committee also agreed that in order to reassure women that they and their babies are being taken care of, they should be given information about what happens next, what support is available and who to contact in case of concerns. It is also important to highlight the importance of pelvic floor exercises soon after birth to prevent potentially long-term and serious conditions such as incontinence and pelvic organ prolapse.

No evidence on timing of transfer to home care was identified for twins or triplets, but the committee agreed that the same principles apply for multiple births as for singleton births.

Because of the lack of clear evidence, the committee made a recommendation for research on length of postpartum stay to assess how the length of the hospital stay after giving birth affects unplanned or emergency contacts with primary or secondary care.

How the recommendations might affect practice

There is wide variation in practice in how long women stay in hospital after giving birth. The committee noted that observing a feed before transfer is already current practice in settings that are UNICEF Baby Friendly Initiative (BFI)-accredited, but many providers in England do not have this accreditation. The recommendations should lead to more consistency. If potential problems are prevented or managed early, this could potentially lead to cost savings because of lower reattendance or readmission.

Return to recommendations

Why the committee made the recommendation

There was little evidence and the committee had low confidence in it, so the committee used their knowledge and experience to agree the timing of the first midwife visit. Having the first visit within 36 hours after transfer of care would usually mean that the visit is not left too long, so that any health or support needs can be identified early.

The committee agreed that the first postnatal visit by the midwifery team should be by a midwife (and not, for example, by a maternity support worker), face-to-face and, depending on the woman's circumstances and preferences, in the home. This should enable a comprehensive assessment of the health and support needs of the woman and her baby.

Because of the lack of evidence, the committee made a recommendation for research on the first midwife visit after discharge to assess how the timing of the first midwife visit after the transfer of care affects unplanned or emergency contacts with primary or secondary care.

How the recommendation might affect practice

The recommendation should reduce variation in practice and improve care for women. The recommendation might affect practice because a midwife should attend the first postnatal visit, and in current practice this might be a maternity support worker or a student midwife instead. However, no significant resource implications are expected.

Return to recommendations

Why the committee made the recommendations

No evidence was found about when the first postnatal health visitor visit should take place, so the committee used their knowledge and experience to agree the timing. The aim is to involve health visitors when they are most needed, and spread the visits evenly throughout the postnatal period.

According to the Department of Health and Social Care's Healthy Child Programme, there should be 2 health visitor visits in the postnatal period. The first visit is often very soon after transfer of care from midwifery care (which usually takes places 10 to 14 days after birth). This creates a gap of several weeks before the second health visitor visit at around 6 to 8 weeks. The first 2 weeks after birth may be overwhelming for some families, with several visits from both the midwifery team and health visitors. Having the first postnatal health visitor visit 1 to 2 weeks after transfer of care from midwifery care will mean that the visits are more evenly spread out.

Although the Healthy Child Programme includes an antenatal visit by the health visitor, the committee agreed that this does not always happen. If this is the case, an additional early postnatal visit by the health visitor to replace the missed antenatal visit could be considered to enable the health visitor to get to know the family and their circumstances early on.

Because of the lack of evidence, the committee made a recommendation for research on the most effective timing of the first postnatal visit by a health visitor.

How the recommendations might affect practice

There is variation in when the first postnatal health visitor visit takes place. However, 1 of the key performance indicators of the Healthy Child Programme is that the first postnatal health visitor visit takes place between 10 and 14 days after birth, so the recommendation would mean a change in practice. The recommendation aims to reduce variation in practice and improve care for women and their babies. Some additional resources may be needed to organise an additional early postnatal visit by a health visitor in the exceptional circumstance when a mandated antenatal health visitor visit has not taken place; however, the resource impact of this is not considered to be large, and is likely outweighed by the potential benefits.

Return to recommendations

Why the committee made the recommendations

The recommendations were not developed by the usual NICE guideline systematic review process because of the scale and complexity of the topic. Using the nominal group technique to vote on statements about the content of postnatal care contacts, the committee made recommendations through formal consensus because reaching consensus by committee discussion alone would be challenging. The statements were based on a review, including critical appraisal, of existing guidelines and systematic reviews. The committee based the recommendations on these and their knowledge and experience.

The committee agreed that at each postnatal contact, women's general health and wellbeing, including psychological and emotional health, should be assessed and women should be asked if they have any concerns. The committee also agreed the physical health areas that midwives should assess. In order to prevent serious outcomes, women should also be made aware of the signs and symptoms of potentially serious conditions so they can seek help. Women's physical health assessment is not in the remit of the health visitor but when there are concerns, either observed by the healthcare professional or expressed by the woman, all healthcare professionals, including health visitors, should refer or advise self-referral so that the woman can get appropriate assessment and care.

The committee acknowledged that some women may want to talk about their birth experience. In some cases, women might need additional support in coping with their experience.

No evidence was identified on the timing of the comprehensive routine postnatal check. Based on their knowledge and experience, the committee agreed this should ideally happen between 6 and 8 weeks after birth, as is current practice, to coincide with the Public Health England newborn and infant physical examination.

No evidence was identified about which tools are effective in the clinical postnatal review of women. A tool that has been tested and validated in an independent sample assessing postnatal physical and mental health problems could help identify those women who need additional care and support, so the committee made a recommendation for research on clinical tools to assess women's health.

References were made to NICE guidelines on different conditions that may affect women postnatally. A bacterial infection could be transmitted to the baby, so it is important to assess the baby if the mother has suspected or confirmed puerperal sepsis.

How the recommendations might affect practice

By ensuring that women's physical and psychological health and wellbeing is comprehensively assessed, and any problems are managed appropriately, there may be an increase in referrals if problems are identified. The committee agreed that any referrals would prevent delays in diagnosing and treating problems, and improve care.

Return to recommendations

Why the committee made the recommendations

No relevant evidence was identified about how to assess early symptoms and signs of postpartum haemorrhage, so the committee used their knowledge and experience to make the recommendations. Discussing with women what to expect after birth helps women to distinguish between a normal amount of lochia (vaginal discharge containing blood, mucus and uterine tissue) and signs and symptoms of postpartum haemorrhage. Women should be advised to seek medical advice if they observe these signs or symptoms because postpartum haemorrhage can have severe consequences.

The committee agreed that although all women are at risk of secondary postpartum haemorrhage, some factors increase this risk and these should be taken into account when assessing the severity of blood loss. The risk factors for postpartum haemorrhage are listed in the NICE guideline on intrapartum care. The committee used their knowledge and experience to list other factors that might worsen the consequences of postpartum bleeding so that appropriate action can be taken.

How the recommendations might affect practice

It is not routine practice to discuss what blood loss to expect postnatally, so the recommendations will involve a minor change to current practice but will potentially improve outcomes by early identification of secondary postpartum haemorrhage.

Return to recommendations

Why the committee made the recommendations

Perineal pain and its complications are often overlooked and falsely considered to be part of normal postnatal healing. However, early identification and management of perineal pain may prevent long-term consequences and improve the woman's overall experience of postnatal care. To help healthcare professionals identify women with perineal pain and to prompt appropriate care, healthcare professionals should ask women if they have any perineal concerns.

Practical advice about how to maintain good perineal hygiene can prevent infection or complications. In order to assess changes in the severity of perineal pain over time, a validated pain score might help to give a clearer view. Physical examination of the perineum could help determine the severity or cause of the pain, or whether further action is needed. In some cases, medication might be needed to alleviate the pain.

The committee emphasised that women with perineal wound breakdown should be urgently referred to appropriate maternity services for further management to prevent further complications and potential long-term adverse outcomes.

There was evidence that prolonged perineal pain and severity of pain is associated with depressive symptoms. There was no other relevant evidence about perineal pain, but the committee agreed, based on their knowledge and experience, that it can have negative long-term implications. To help healthcare professionals identify women with persistent or worsening perineal pain and to prompt appropriate care, they should be aware of the factors that can increase the risk of persistent postnatal perineal pain.

Because of the lack of evidence about what characteristics of perineal pain suggest the need for further evaluation, a recommendation for research on perineal pain was made.

How the recommendations might affect practice

In current practice, some women only receive treatment for perineal complications when the situation has become serious. By ensuring that perineal pain is identified early and treated without delay, then further complications and long-term consequences can be avoided. There may be an increase in referrals to secondary care for women who are usually seen by their GP, but the recommendations should improve care and outcomes.

Return to recommendations

Why the committee made the recommendations

Most of the recommendations in this section were not developed by the usual NICE guideline systematic review process because of the scale and complexity of the topic. Using the nominal group technique to vote on statements about the content of postnatal care contacts, the committee made recommendations through formal consensus because reaching consensus by committee discussion alone would be challenging. The statements were based on a review, including critical appraisal, of existing guidelines and systematic reviews. The committee based the recommendations on these, and their knowledge and experience.

The general wellbeing, feeding and development of the baby should be assessed at every postnatal contact so that any concerns can be identified early. Not passing meconium (the baby's first bowel movement) within the first 24 hours can be a sign of bowel obstruction, so it is important that healthcare professionals engaging with the family in the immediate postnatal period are aware of the need for advice from a doctor.

There was no reason for the committee to change the current recommended assessment criteria that healthcare professionals should use within 72 hours after the birth. The committee agreed that the same criteria could be used in the 6‑ to 8‑week assessment. The recommendation about weight and head circumference measurement is based on guidance from the UK-WHO (World Health Organization) growth charts.

The recommendations refer to other NICE guidelines for guidance on specific clinical situations, and relevant NHS screening programmes.

To help parents, healthcare professionals should also discuss and provide information about how to care for their baby. Established guidance exists on safer sleeping practices, and resources for these are available from, for example, UNICEF, Baby Sleep Information Source (Basis), and the Lullaby Trust.

Baby Check is a scoring system intended to help in the assessment of babies up to 6 months of age, taking into account the presence or absence of various symptoms and signs of illness. It gives an overall score to help in deciding whether the baby may need clinical assessment or care. Although the evidence base for the Baby Check was predominantly in relation to babies attending secondary care, there was evidence that in the community setting, it can identify babies who are likely to be well. Also, the studies included babies ranging from birth to 6 months and were not therefore specifically focused on those in the early weeks of life.

The Lullaby Trust has produced parent-friendly modified versions of the Baby Check scoring system, in the form of a mobile app and a downloadable booklet. Although the modifications are mostly related to the language used, the committee had some concerns because the modified versions have not been validated, and neither has the use of Baby Check by parents, as opposed to healthcare professionals. Finally, the committee noted that the Lullaby Trust's modified versions have adopted current practices regarding temperature measurement (armpit or ear), and this differs from the original Baby Check evaluations, which use rectal temperature.

Although Baby Check cannot therefore provide complete reassurance, the committee agreed that the Baby Check scoring system could be helpful to parents as a 'checklist' of symptoms and signs of possible illness when they are uncertain whether their baby might be unwell and deciding whether to seek advice from a healthcare professional. The committee agreed it would be best for parents to be given information about Baby Check in advance rather than when they are concerned about their baby's wellbeing.

How the recommendations might affect practice

The recommendations largely reflect current practice. There may be an increase in the use of Baby Check scoring system by parents. It is not known if this would have an impact on parents seeking advice from healthcare professionals, but the impact would not be expected to be large.

Return to recommendations

Why the committee made the recommendations

There was evidence of varying quality from multiple studies about the different risk factors associated with sudden unexpected death in infancy when bed sharing (up to 1 year of age). Based on the evidence and their knowledge and experience, the committee agreed the safe bed sharing practices that should be discussed with all parents and the circumstances in which bed sharing with a baby should be strongly advised against. The evidence also showed an association between bed sharing and breastfeeding although there is uncertainty about the causality. Preterm babies are outside the remit of this guideline and are therefore not mentioned in the recommendations; however, the committee were aware of evidence showing an increased risk of sudden unexpected death in infancy when bed sharing with a baby born preterm.

How the recommendations might affect practice

In current practice, there is confusion and mixed messages from both healthcare professionals and within the community on the best practice for safe sleeping, including advice about never sharing a bed with a baby. These recommendations should lead to clear guidance, reduce variation in practice, and improve care for women and babies.

Return to recommendations

Why the committee made the recommendations

There was limited evidence on how to promote attachment between the mother and baby, and it did not show any specific interventions to be effective, so the recommendations are based on the committee's knowledge and experience. The committee agreed to make the recommendations for parents, not just the mother, because discussing and recognising the issues related to developing emotional attachment are relevant for other parental caregivers as well.

The committee agreed that discussions about emotional attachment should begin antenatally and continue into the postnatal period. The committee highlighted that emotional attachment will usually happen naturally if the primary carer is able to spend quality time with their baby. The value of such quality time is not always recognised as important by the parent(s) when there are so many other demands on parents' time in the postnatal period.

The committee recognised that attachment can also be affected by the woman's wellbeing, recovery from birth and other demands that parenthood brings. Therefore, it is important to discuss these issues with the parents to support them in building a relationship with their baby. It was considered important for the woman's partner (if there is one) to understand the various challenging aspects that the mother might be experiencing in the postnatal period, which might affect bonding and emotional attachment.

Based on their knowledge and experience, the committee highlighted particular groups of parents who may be more vulnerable to difficulties in attachment and may need more support.

How the recommendations might affect practice

There is variation in practice regarding what women are offered in support relating to emotional attachment. The recommendations should lead to clear guidance, reduce variation in practice and improve care for women.

Return to recommendations

Why the committee made the recommendations

It is important to identify babies who are seriously ill early so that the condition can be managed and adverse outcomes can be avoided. In the committee's experience, parents' concern about 'something being not quite right' can sometimes be overlooked, but it can be an important sign of serious illness and should be taken seriously.

Baby Check is a scoring system intended to help in the assessment of babies up to 6 months of age, taking into account the presence or absence of various symptoms and signs of illness. It gives an overall score to help in deciding whether the baby may need clinical assessment or care. Based on the evidence in the secondary care setting, its sensitivity to identify those babies who are seriously ill varied. In the community setting, it was found to identify babies who are well suggesting that further assessment is not needed but the evidence regarding its accuracy in identifying seriously ill babies is lacking. Also, the studies in which it was being tested included babies ranging from birth to 6 months and were not therefore specifically focused on those in the early weeks of life as this guideline.

The Lullaby Trust has produced parent-friendly modified versions of the Baby Check scoring system, in the form of a mobile app and a downloadable booklet. Although the modifications are mostly related to the language used, the committee had some concerns because the modified versions have not been validated, and neither has the use of Baby Check by parents, as opposed to healthcare professionals. Finally, the committee noted that the Lullaby Trust's modified versions have adopted current practices regarding temperature measurement (armpit or ear), and this differs from the original Baby Check evaluations, which use rectal temperature.

For these reasons, the committee agreed that Baby Check should not be used in isolation to determine the need for further assessment or care but that it could be a helpful tool when used in addition to clinical judgement. Also, by focusing attention on important symptoms and signs, it could help during a remote assessment as a communication aid between healthcare professionals and parents.

The committee also noted that sometimes the presence of fever in young babies is not recognised as a serious concern. It is particularly important to note changes in the baby's wellbeing and behaviour.

There was evidence that single signs and symptoms are not necessarily useful predictors of serious illness on their own. However, based on various other NICE guidelines, there are some 'red flag' symptoms and signs that indicate a serious illness that needs immediate action.

How the recommendations might affect practice

The recommendations should reinforce current good practice and improve care for babies. There may be an increase in the use of the Baby Check scoring system as a supplemental tool for healthcare professionals, particularly during remote appointments.

Return to recommendations

Why the committee made the recommendation

Based on their knowledge and experience, the committee agreed that the choices parents make around feeding are not easy and sometimes their preferred choice might not be an option for them. Evidence among parents who bottle fed their babies showed that they sometimes felt judged by the healthcare professionals about their choices. Therefore, the committee agreed that as a general principle, discussions around feeding should be respectful and acknowledge the various consequences different feeding options may have.

How the recommendation might affect practice

There is some variation in practice, so the recommendation aims to improve the consistency of support given to parents about feeding their baby.

Return to recommendations

Why the committee made the recommendations

Based on their knowledge and experience, the committee agreed that discussion and support around breastfeeding should start in the antenatal period so that women are equipped to make decisions about feeding and are prepared to start breastfeeding when the baby is born. The discussions and support should continue in the postnatal period so that any questions and concerns can be addressed and women feel they are being supported.

There was good evidence about women being motivated by the many benefits of breastfeeding, so it is important to share these with the women. It is established knowledge that breastfeeding has nutritional and health benefits for the baby (such as lower rates of infection) and some health benefits for the woman (such as lower risk of breast cancer). There was evidence that women felt they were able to soothe and comfort the baby by breastfeeding.

The committee agreed that it is important to explain that breastfeeding can have benefits even if done for a short period of time. For example, colostrum (the breast milk that is produced in the first few days) is known to have various nutritional and health benefits for the baby.

The committee also agreed that parents should receive information about partners' involvement in supporting breastfeeding. The evidence showed that some women and their families believed that bottle feeding was a way for the baby to bond with their partner or other family members. The committee agreed that partners and family members should be given information about alternative ways to comfort and bond with the baby.

Because breastfeeding women may be at risk of vitamin D deficiency, they should be informed about the NICE recommendation about taking vitamin D supplementation.

There was evidence that some women thought that other people felt that breastfeeding in public is inappropriate or insensitive to other people's feelings, which can be a barrier for breastfeeding in public places. The committee agreed the importance of reassuring women and their partners that under the 2010 Equality Act, women have the right to breastfeed in 'any public space'.

How the recommendations might affect practice

The recommendations largely reflect current practice and should reinforce good practice across the country.

Return to recommendations

Why the committee made the recommendations

Feeding is an integral part of the postnatal period, so healthcare professionals should have the relevant knowledge to encourage breastfeeding and to support women to establish and continue breastfeeding. The BNF provides useful information on safe medicine use and prescribing for women who are breastfeeding. If needed, further advice is available from an NHS medicines information centre or other specialist sources.

The World Health Organization (WHO) recommends that breastfeeding is started early in order to facilitate establishment of breastfeeding, and the committee agreed that healthcare professionals caring for women and babies in the immediate postnatal period should encourage early skin-to-skin contact to help start breastfeeding when the baby and the mother feel ready.

The committee agreed that healthcare professionals should be sensitive to the individual preferences, experiences and values of the woman when supporting her with breastfeeding. There was evidence that after birth, women value having privacy in hospital, and a lack of privacy can be a barrier to breastfeeding and expressing breast milk. However, the committee noted that healthcare professionals also need to be able to carry out clinical observations of women easily, so recommended that these needs be balanced against each other.

The evidence also showed that varying experiences with breastfeeding can have an impact on the woman's emotional wellbeing, and women often need reassurance and encouragement to gain confidence.

How the recommendations might affect practice

In the committee's experience, some healthcare professionals caring for women and babies during the postnatal period may not have adequate knowledge to support women with breastfeeding and might need more training. The recommendations should reinforce best clinical practice and lead to better consistency of care.

Return to recommendations

Why the committee made the recommendations

There was evidence that women value breastfeeding care that provides individualised support and continuity of carer, and feel that 'remote' support (such as online or telephone support) can be a helpful addition but should not replace face-to-face support.

The evidence also showed that partners often feel that they lack knowledge and understanding of breastfeeding, and want to know how they can best support breastfeeding mothers.

There was evidence that women find peer support valuable. Through peer support, women can share their experiences and gain information and social contacts, which can provide ongoing support.

There was no evidence that extra interventions increase breastfeeding rates so the committee agreed that breastfeeding support should be an integral part of standard postnatal care contacts.

There was some evidence that younger women may have additional barriers to breastfeeding, such as feeling alone in the maternity unit, the feeling of needing to 'carry on with life' and therefore choosing to formula feed, and lack of peer support. Evidence also suggested that additional support may be beneficial for improving the rate of breastfeeding among women from low income or socially disadvantaged backgrounds.

The evidence showed that women value support and practical information about breastfeeding, as well as information about the underlying physiology of breastfeeding. This will help them to recognise what is or is not normal, and when to seek help. The evidence also showed that some common features of breastfeeding, such as sore nipples, can discourage women if they do not know in advance what to expect.

There was no evidence about breastfeeding support for parents of twins or triplets, so the committee made a recommendation for research.

How the recommendations might affect practice

There is significant variation in the provision of practical and professional breastfeeding support, so the recommendations will support best practice in some settings and improve practice in other settings. They will reduce variation in practice and improve care for women and babies. Providing continuity of carer may have an impact on how services are organised, but no significant resource impact is expected.

Return to recommendations

Why the committee made the recommendations

Assessing breastfeeding is an important part of postnatal contacts. None of the clinical tools identified in the evidence review were useful in identifying women who would not be breastfeeding (or exclusively breastfeeding) at follow up, which was considered an indication of breastfeeding difficulties, so the committee did not recommend any tools. The committee used their knowledge and experience to make the recommendations, in line with the principles in the UNICEF Baby Friendly Initiative (BFI) breastfeeding assessment tool, including asking the parents about any concerns and about indications of successful breastfeeding.

In addition, observing a feed twice in the first week can help establish good breastfeeding practice. Additional observations or interventions may be needed if there are ongoing concerns.

How the recommendations might affect practice

In current practice, observing a full feed in the first week might not always happen, so this may mean a change in practice and may have some impact on time needed at the postnatal contacts. The recommendations are based on the UNICEF BFI breastfeeding assessment tool, which is already widely used in practice. In places where it is not already used, the committee were aware that work is underway to reach that standard. The recommendations will improve and standardise practice.

Return to recommendations

Why the committee made the recommendations

The committee recognised that babies can be formula fed in combination with breastmilk or they can be fed with formula milk only. There was good evidence about what information and support parents who formula feed find helpful, so the committee used the evidence together with their knowledge and experience to make the recommendations. Common themes in the evidence were the lack of impartial information about formula feeding, women feeling that they were not supported in their feeding choices, and the emotional impact that feeding choices can have on parents. The committee agreed that, as for women who breastfeed, women who formula feed should be supported regardless of their feeding choices. The recommendations reflect the key features of formula feeding support and the information that should be given to women and their families if they are formula feeding or are considering to formula feed and who need to formula feed because of a medical or other reason.

The evidence showed that women value face-to-face feeding support but also feel that additional information to support feeding can be helpful. The evidence showed that women who are formula feeding feel that they are not given the information or support they need, for example, about how to interpret and respond to the baby's behaviours and cues, and how to formula feed safely. Based on the committee's experience, it is important to give information about how to hold the baby and how feeding can be used as an opportunity to bond with the baby, and also advise parents against using a 'propped up' bottle during a feed because it can be harmful for the baby.

The evidence also showed that women were unaware of the impact introducing formula feeding could have on breastfeeding and felt unsupported by healthcare professionals when considering this. Therefore, the committee agreed it was important that women were supported to make an informed, guilt-free decision by providing balanced and evidence-based information.

How the recommendations might affect practice

The committee noted that there is significant variation in practice in providing formula feeding support, so the recommendations will support best practice in some settings and improve practice in other settings. Overall, they will improve consistency.

Return to recommendations

Why the committee made the recommendation

No evidence was identified on the information and support that should be given to women about lactation suppression. The committee discussed when discussions about lactation suppression should happen and what should be discussed, and used their knowledge and experience to agree the recommendation. The committee agreed that discussions should be sensitive and individualised according to the woman's situation. Practical advice about how to ease the process of milk drying up can be helpful for women, and in some cases, medicine to suppress lactation might also be appropriate to make the process quicker, although for most this is not needed.

Donating breast milk to a local breast milk bank, depending on the local services, could be valuable to some women who cannot breastfeed their own baby.

How the recommendation might affect practice

The recommendation largely reflects current practice and should reinforce best practice. To ensure that women understand the information they are given, and that information is being provided at the most appropriate time, some extra time from healthcare professionals may be needed.

Return to recommendations