Rationale

• Breast milk feeding, even partial, reduces risk of necrotising enterocolitis (NEC), retinopathy of prematurity (ROP), sudden infant death (SIDS) and improves cognitive outcomes in preterm babies

• Human milk is important in establishing enteral nutrition

• Any amount of mother’s fresh breast milk is better than none

• Physician advocacy has a strong influence on intention to feed

Buccal colostrum

• Counsel all mothers anticipating delivery of sick/preterm baby about benefits of colostrum and show SWMN ODN film
• Early expressing and benefits of colostrum available at www.swmnodn.org.uk/media
• Advise mothers to hand express as soon after delivery as possible (ideally within 1 hr) 
• Initiate administration of buccal colostrum as soon as colostrum available (ideally within 2 hr of birth) 

Parent and staff information

• See www.unicef.org.uk/babyfriendly or www.bestbeginnings.org.uk/watch-small-wonders-online 

• In pregnancy at high risk of premature delivery, discuss feeding preferences, advantages of breastfeeding and how expression of breast milk can be supported
• If delivery is imminent (any gestational age) or high risk pregnancies >36 weeks consider antenatal colostrum collection
• Discuss value/benefits at birth and during mother’s first visit to NNU 
• Document discussion in maternal healthcare record
• Encourage mothers to practice ‘kangaroo care’ also known as skin-to-skin holding (see Kangaroo care guideline)
• Separate decision to provide a few weeks’ pumped breast milk from the commitment to long-term, exclusive breastfeeding 
• Praise all efforts to provide breast milk
• Ensure adequate discussion and provision of written information on hand expression, and on mode and frequency of pump use (see Breast milk expression guideline)  
• See Progression to oral feeding in preterm babies guideline regarding establishing breastfeeding and responsive feeding 

HIV in UK

• Always check maternal HIV status before breastfeeding
  
  • breastfeeding contraindicated in UK
  • if you are concerned that mother intends to breastfeed, ensure an HIV specialist explains risk to baby, allowing the mother to make an informed decision
  • if decision made by mother to breastfeed after advice, signpost to breastfeeding support 

HIV in developing countries

• If returning to a developing country where there is no access to clean water, exclusive breastfeeding is safer than mixed

Maternal medications

• Antimetabolites or cytotoxic drugs
• Radioisotope investigation (until isotope clears)
• See Neonatal Formulary, BNF, ‘Medications and mother’s milk’ by T W Hale, https://www.ncbi.nlm.nih.gov/books/NBK501922/?report=classic or https://www.sps.nhs.uk/home/guidance/safety-in-breastfeeding/

Tuberculosis (TB)

• Maternal sputum-positive TB is not a contraindication to breastfeeding
• If mother on isoniazid, give prophylactic pyridoxine to mother and baby
• Refer to Tuberculosis (investigation and management following exposure in pregnancy) guideline for further advice

Cytomegalovirus (CMV)

• Mothers who have a primary CMV infection or reactivation may be infective. Take senior microbiological advice on testing and feeding
• Pasteurisation of milk inactivates CMV

Hepatitis B

• Risk of transmission can be almost totally eliminated by a combination of active and passive immunisation 
• Breastfeeding not contraindicated 
• See Hepatitis B and C guidelines

Hepatitis C

• Transmission by breastfeeding theoretically possible but has not been documented
• Breastfeeding not contraindicated but inform mother risks unknown – consider avoiding breastfeeding if nipples cracked as increased risk of infection

Varicella-zoster virus (VZV)

• Babies of mothers with active VZV can reduce risk by avoiding breastfeeding until mother is no longer infectious (5 days from onset of rash)
  Premature babies born <1 kg or <28 weeks are considered high risk and should be given varicella-zoster immunoglobulin (VZIG) (see Varicella guideline)

Herpes simplex type 1

• Omit breastfeeding or feeding expressed breast milk (EBM) from affected side in women with herpetic lesions on breast
  • until lesions have healed
  • cover active lesions elsewhere
  • careful hand hygiene essential 
  • affected side: cover, pump and discard milk (no breastfeeding) until lesions are clear
  • unaffected side: can breastfeed and use EBM

Phenylketonuria (PKU)

• Breastfeeding not contraindicated in babies with PKU
• Screening service will contact paediatric dietitians directly
• Careful dietetic management necessary 
• All babies to be under the care of paediatric dietitians and inherited metabolic diseases team

Radioactive diagnostic agents

• Women receiving radioactive diagnostic agents to pump and discard although most agents have very short plasma half-lives, seek advice from hospital nuclear medicine department as to how long to discard milk for 

Medications

• For medications that require caution with breastfeeding, see Maternal medications 

Social drugs

Alcohol

• Discourage more than limited consumption

Nicotine

• Nicotine concentration in breast milk increases immediately after smoking
• Discourage mothers from smoking directly before breastfeeding or expressing breast milk