Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care. Parents and carers have the right to be involved in planning and making decisions about their baby's health and care, and to be given information and support to enable them to do this, as set out in the NHS Constitution and summarised in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off‑label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Please note that the Royal College of Obstetricians and Gynaecologists has produced guidance on COVID-19 infection and pregnancy for all midwifery and obstetric services.

This guideline uses the term 'woman' or 'mother' and includes all people who have given birth, even if they may not identify as women or mothers. 'Woman' is generally used but in some instances, 'mother' is used when referring to her in relation to her baby.

This guideline uses the term 'partner' to refer 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. The term 'parents' refers to 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.

1.1 Organisation and delivery of postnatal care

Principles of care

1.1.1 When caring for a woman who has recently given birth, listen to her and be responsive to her needs and preferences. Also see the NICE guideline on patient experience in adult NHS services.

1.1.2 Be aware that the 2020 MBRRACE-UK reports on maternal and perinatal mortality showed that women and babies from some minority ethnic backgrounds and those who live in deprived areas have an increased risk of death and may need closer monitoring. The reports showed that:

  • compared with white women (8 per 100,000), the risk of maternal death during pregnancy and up to 6 weeks after birth is:

    • 4 times higher in black women (34 per 100,000)

    • 3 times higher in mixed ethnicity women (25 per 100,000)

    • 2 times higher in Asian women (15 per 100,000; does not include Chinese women)

  • the neonatal mortality rate is around 50% higher in black and Asian babies compared with white babies (17 compared with 25 per 10,000)

  • women living in the most deprived areas are more than 2.5 times more likely to die compared with women living in the least deprived areas (6 compared with 15 per 100,000)

  • the neonatal mortality rate increases according to the level of deprivation in the area the mother lives in, with almost twice as many babies dying in the most deprived areas compared with the least deprived areas (12 compared with 22 per 10,000).

1.1.3 A woman may be supported by her partner in the postnatal period. Involve them according to the woman's wishes.

1.1.4 When caring for a baby, remember that those with parental responsibility have the right be involved in the baby's care, if they choose.

1.1.5 When giving information about postnatal care, use clear language and tailor the timing, content and delivery of information to the woman's needs and preferences. Information should support shared decision making and be:

  • provided face-to-face and supplemented by virtual discussions and written formats, for example, digital, printed, braille or Easy Read

  • offered throughout the woman's care

  • individualised and sensitive

  • supportive and respectful

  • evidence based and consistent

  • translated by an appropriate interpreter to overcome language barriers.

    For more guidance on communication, providing information (including different formats and languages) and shared decision making, see the NICE guideline on patient experience in adult NHS services and the NHS Accessible Information Standard.

1.1.6 Check that the woman understands the information she has been given, and how it relates to her. Provide regular opportunities for her to ask questions, and set aside enough time to discuss any concerns.

1.1.7 Follow the principles in the NICE guideline on pregnancy and complex social factors for women who may need additional support, for example:

  • women who misuse substances

  • recent migrants, asylum seekers or refugees, or women who have difficulty reading or speaking English

  • young women aged under 20

  • women who experience domestic abuse.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on principles of care.

Full details of the evidence and the committee's discussion are in evidence review G: provision of information about the postnatal health of women.

Communication between healthcare professionals at transfer of care

1.1.8 Ensure that there is effective and prompt communication between healthcare professionals when women transfer between services, for example, from secondary to primary care, and from midwifery to health visitor care. This should include sharing relevant information about:

  • the pregnancy, birth, postnatal period and any complications

  • the plan of ongoing care, including any condition that needs long-term management

  • problems related to previous pregnancies that may be relevant to current care

  • previous or current mental health concerns

  • female genital mutilation (mother or previous child)

  • who has parental responsibility for the baby, if known

  • the woman's next of kin

  • safeguarding issues (also see the NICE guideline on domestic violence and abuse and the NICE guideline on child abuse and neglect)

  • concerns about the woman's health and care, raised by her, her partner or a healthcare professional

  • concerns about the baby's health and care, raised by the parents or a healthcare professional

  • the baby's feeding.

1.1.9 Midwifery services should ensure that:

  • the transfer of care from midwife to health visitor is clearly communicated between healthcare professionals and

  • the woman or the parents are informed about the transfer of care from midwife to health visitor.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on communication between healthcare professionals at transfer of care.

Full details of the evidence and the committee's discussion are in evidence review B: information transfer.

Transfer to community care

1.1.10 Before transfer from the maternity unit to community care, or before the midwife leaves after a home birth:

  • assess the woman's health (see recommendations 1.2.2 and 1.2.3)

  • assess the woman's bladder function by measuring the volume of the first void after giving birth

  • assess the baby's health (including physical inspection and observation)

  • if the baby has not passed meconium, advise the parents that if the baby does not do so within 24 hours of birth, they should seek advice from a healthcare professional (also see recommendation 1.3.12)

  • make sure there is a plan for feeding the baby, which should include observing at least 1 effective feed.

1.1.11 Before transfer from the maternity unit to community care, discuss the timing of transfer to community care with the woman, and ask her about her needs, preferences and support available.

1.1.12 When deciding on the timing of the transfer to community care, take into account the woman's preferences, the factors in recommendations 1.1.10 and 1.1.11 and any concerns, including any safeguarding issues (also see the NICE guideline on domestic violence and abuse).

1.1.13 Before transfer from the maternity unit to community care, or before the midwife leaves after a home birth, give women information about:

  • the postnatal period and what to expect

  • the importance of pelvic floor exercises

  • what support is available (statutory and voluntary services)

  • who to contact if any concerns arise at different stages.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on transfer to community care.

Full details of the evidence and the committee's discussion are in evidence review A: length of postpartum stay.

First midwife visit after transfer of care from the place of birth or after a home birth

1.1.14 Ensure that the first postnatal visit by a midwife takes place within 36 hours after transfer of care from the place of birth or after a home birth. The visit should be face-to-face and usually at the woman's home, depending on her circumstances and preferences.

For a short explanation of why the committee made the recommendation and how it might affect practice, see the rationale and impact section on first midwife visit after transfer of care from the place of birth or after a home birth.

Full details of the evidence and the committee's discussion are in evidence review C: timing of first postnatal contact by midwife.

First health visitor visit

1.1.15 Consider arranging the first postnatal health visitor home visit to take place between 7 and 14 days after transfer of care from midwifery care so that the timing of postnatal contacts is evenly spread out.

1.1.16 If a woman did not receive an antenatal health visitor visit, consider arranging an additional early postnatal health visitor visit.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on first health visitor visit.

Full details of the evidence and the committee's discussion are in evidence review D: timing of first postnatal contact by health visitor.

1.2 Postnatal care of the woman

Assessment and care of the woman

1.2.1 At each postnatal contact, ask the woman about her general health and whether she has any concerns, and assess her general wellbeing. Discuss topics that may be affecting her daily life, and provide information, reassurance and further care as appropriate. Topics to discuss may include:

1.2.2 At each postnatal contact, assess the woman's psychological and emotional wellbeing. Follow the recommendations on recognising mental health problems in pregnancy and the postnatal period and referral in the NICE guideline on antenatal and postnatal mental health. If there are concerns, arrange for further assessment and follow up.

1.2.3 At each postnatal contact by a midwife, assess the woman's physical health, including the following:

  • for all women:

    • symptoms and signs of infection

    • pain

    • vaginal discharge and bleeding (see the section on postpartum bleeding)

    • bladder function

    • bowel function

    • nipple and breast discomfort and symptoms of inflammation

    • symptoms and signs of thromboembolism

    • symptoms and signs of anaemia

    • symptoms and signs of pre‑eclampsia

  • for women who have had a vaginal birth:

  • for women who have had a caesarean section (also see the NICE guideline on caesarean section):

    • wound healing

    • symptoms of wound infection.

1.2.4 At the first postnatal midwife contact, inform the woman that the following are symptoms or signs of potentially serious conditions, and she should seek medical advice without delay if any of these occur:

  • sudden or very heavy vaginal bleeding, or persistent or increased vaginal bleeding, which could indicate retained placental tissue or endometritis

  • abdominal, pelvic or perineal pain, fever, shivering, or vaginal discharge with an unpleasant smell, which could indicate infection

  • leg swelling and tenderness, or shortness of breath, which could indicate venous thromboembolism

  • chest pain, which could indicate venous thromboembolism or cardiac problems

  • persistent or severe headache, which could indicate hypertension, pre‑eclampsia, postdural-puncture headache, migraine, intracranial pathology or infection

  • worsening reddening and swelling of breasts persisting for more than 24 hours despite self-management, which could indicate mastitis

  • symptoms or signs of potentially serious conditions that do not respond to treatment.

1.2.5 At each postnatal contact, give the woman the opportunity to talk about her birth experience, and provide information about relevant support and birth reflection services, if appropriate. See the section on traumatic birth, stillbirth and miscarriage in the NICE guideline on antenatal and postnatal mental health and the NICE guideline on post-traumatic stress disorder.

1.2.6 All healthcare professionals should ensure appropriate referral if there are concerns about the woman's health.

1.2.7 At 6 to 8 weeks after the birth, a GP should:

  • carry out an assessment including the points in recommendations 1.2.1 to 1.2.5 and taking into account the time since the birth

  • respond to any concerns, which may include referral to specialist services in either secondary care or other healthcare services such as physiotherapy.

1.2.8 For guidance on care for women with symptoms or signs of sepsis, see the NICE guideline on sepsis. If the woman has confirmed or suspected puerperal sepsis, assess the baby for symptoms or signs of infection.

1.2.10 For postnatal care of women with pre-existing diabetes or who had gestational diabetes, see the recommendations on postnatal care in the NICE guideline on diabetes in pregnancy.

1.2.11 For guidance on assessing the risk and preventing venous thromboembolism in women who have given birth, see the NICE guideline on venous thromboembolism and the Royal College of Obstetricians and Gynaecologists' guideline on reducing the risk of venous thromboembolism during pregnancy and the puerperium.

1.2.12 For guidance on assessing and managing urinary incontinence and pelvic organ prolapse in women who have given birth, see the NICE guideline on urinary incontinence and pelvic organ prolapse in women.

Postpartum bleeding

1.2.13 Discuss with women what vaginal bleeding to expect after the birth (lochia), and advise women to seek medical advice if:

  • the vaginal bleeding is sudden or very heavy

  • the bleeding increases

  • they pass clots, placental tissue or membranes

  • they have symptoms of possible infection, such as abdominal, pelvic or perineal pain, fever, shivering, or vaginal bleeding or discharge has an unpleasant smell

  • they have concerns about vaginal bleeding after the birth.

1.2.14 If a women seeks medical advice about vaginal bleeding after the birth, assess the severity, and be aware of the risk factors for postpartum haemorrhage in the NICE guideline on intrapartum care for healthy women and babies. Also be aware of the following factors, which may worsen the consequences of secondary postpartum haemorrhage:

  • anaemia

  • weight of less than 50 kg at the first appointment with the midwife during pregnancy (booking appointment).

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on postpartum bleeding.

Full details of the evidence and the committee's discussion are in evidence review I: assessment of secondary postpartum haemorrhage.

Perineal health

1.2.15 At each postnatal contact, as part of assessing perineal wound healing, ask the woman if she has any concerns and ask about:

  • pain not resolving or worsening

  • increasing need for pain relief

  • discharge that has a strong or unpleasant smell

  • swelling

  • wound breakdown.

1.2.16 Advise the woman about the importance of good perineal hygiene, including daily showering of the perineum, frequent changing of sanitary pads, and hand washing before and after doing this.

1.2.17 Consider using a validated pain scale to monitor perineal pain.

1.2.18 If the woman or the healthcare professional has concerns about perineal healing or if the woman asks for reassurance, offer or arrange an examination of the perineum by a midwife or a doctor.

1.2.19 If needed, discuss available pain relief options, taking into account if the woman is breastfeeding.

1.2.20 If the perineal wound breaks down or there are ongoing healing concerns, refer the woman urgently to specialist maternity services (to be seen the same day in the case of a perineal wound breakdown).

1.2.21 Be aware that perineal pain that persists or gets worse within the first few weeks after the birth may be associated with symptoms of depression, long-term perineal pain, problems with daily functioning and psychosexual difficulties.

1.2.22 Be aware of the following risk factors for persistent postnatal perineal pain:

  • episiotomy, or labial or perineal tear

  • assisted vaginal birth

  • wound infection or breakdown

  • birth experienced as traumatic.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on perineal health.

Full details of the evidence and the committee's discussion are in evidence review J: perineal pain and evidence review H: tools for the clinical review of women.

1.3 Postnatal care of the baby

Assessment and care of the baby

1.3.1 At each postnatal contact, ask parents if they have any concerns about their baby's general wellbeing, feeding or development. Review the history and assess the baby's health, including physical inspection and observation. If there are any concerns, take appropriate further action.

1.3.2 Be aware that if the baby has not passed meconium within 24 hours of birth, this may indicate a serious disorder and requires medical advice.

1.3.3 Carry out a complete examination of the baby within 72 hours of the birth and at 6 to 8 weeks after the birth (see the Public Health England newborn and infant physical examination [NIPE] screening programme). This should include checking the baby's:

  • appearance, including colour, breathing, behaviour, activity and posture

  • head (including fontanelles), face, nose, mouth (including palate), ears, neck and general symmetry of head and facial features

  • eyes: opacities, red reflex and colour of sclera

  • neck and clavicles, limbs, hands, feet and digits; assess proportions and symmetry

  • heart: position, heart rate, rhythm and sounds, murmurs and femoral pulse volume

  • lungs: respiratory effort, rate and lung sounds

  • abdomen: assess shape and palpate to identify any organomegaly; check condition of umbilical cord

  • genitalia and anus: completeness and patency and undescended testes in boys

  • spine: inspect and palpate bony structures and check integrity of the skin

  • skin: colour and texture as well as any birthmarks or rashes

  • central nervous system: tone, behaviour, movements and posture; check newborn reflexes only if concerned

  • hips: symmetry of the limbs, Barlow and Ortolani's manoeuvres

  • cry: assess sound.

1.3.4 At 6 to 8 weeks, assess the baby's social smiling and visual fixing and following.

1.3.5 Measure weight and head circumference of babies in the first week and around 8 weeks, and at other times only if there are concerns. Plot the results on the growth chart.

1.3.6 For advice on identifying and managing jaundice, see the NICE guideline on jaundice in newborn babies under 28 days.

1.3.7 If there are concerns about the baby's growth, see the NICE guideline on faltering growth.

1.3.8 Carry out newborn blood spot screening in line with the NHS newborn blood spot screening programme.

1.3.9 Carry out newborn hearing screening in line with the NHS newborn hearing screening programme.

1.3.10 Give parents information about:

1.3.11 Consider giving parents information about the Baby Check scoring system and how it may help them to decide whether to seek advice from a healthcare professional if they think their baby might be unwell.

1.3.12 Advise parents to seek advice from a healthcare professional if they think their baby is unwell, and to contact emergency services (call 999) if they think their baby is seriously ill.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on assessment and care of the baby.

Full details of the evidence and the committee's discussion are in evidence review F: content of postnatal care contacts and evidence review L2: scoring systems for illness in babies.

Bed sharing

1.3.13 Discuss with parents safer practices for bed sharing, including:

  • making sure the baby sleeps on a firm, flat mattress, lying face up (rather than face down or on their side)

  • not sleeping on a sofa or chair with the baby

  • not having pillows or duvets near the baby

  • not having other children or pets in the bed when sharing a bed with a baby.

1.3.14 Strongly advise parents not to share a bed with their baby if their baby was low birth weight or if either parent:

  • has had 2 or more units of alcohol

  • smokes

  • has taken medicine that causes drowsiness

  • has used recreational drugs.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on bed sharing.

Full details of the evidence and the committee's discussion are in evidence review M: benefits and harms of bed sharing and evidence review N: co-sleeping risk factors.

Promoting emotional attachment

1.3.15 Before and after the birth, discuss the importance of bonding and emotional attachment with parents, and the approaches that can help them to bond with their baby.

1.3.16 Encourage parents to value the time they spend with their baby as a way of promoting emotional attachment, including:

  • face-to-face interaction

  • skin-to-skin contact

  • responding appropriately to the baby's cues.

1.3.17 Discuss with parents the potentially challenging aspects of the postnatal period that may affect bonding and emotional attachment, including:

  • the woman's physical and emotional recovery from birth

  • experience of a traumatic birth or birth complications

  • fatigue and sleep deprivation

  • feeding concerns

  • demands of parenthood.

1.3.18 Recognise that additional support in bonding and emotional attachment may be needed by some parents who, for example:

  • have been through the care system

  • have experienced adverse childhood events

  • have experienced a traumatic birth

  • have complex psychosocial needs.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on promoting emotional attachment.

Full details of the evidence and the committee's discussion are in evidence review O: emotional attachment.

1.4 Symptoms and signs of illness in babies

1.4.1 Listen carefully to parents' concerns about their baby's health and treat their concerns as an important indicator of possible serious illness in their baby.

1.4.2 Healthcare professionals should consider using the Baby Check scoring system:

  • to supplement the clinical assessment of babies for possible illness, particularly as part of a remote assessment and

  • as a communication aid in conversations with parents to help them describe the baby's condition.

1.4.3 Follow the recommendations in the NICE guideline on neonatal infection on:

1.4.4 Be aware that fever may not be present in young babies with a serious infection.

1.4.5 If the baby has a fever, follow the recommendations in the NICE guideline on fever in under 5s.

1.4.6 If there are concerns about the baby's growth, follow the recommendations in the NICE guideline on faltering growth.

1.4.7 Be aware of the possible significance of a change in the baby's behaviour or symptoms, such as refusing feeds or a change in the level of responsiveness.

1.4.8 Be aware that the presence or absence of individual symptoms or signs may be of limited value in identifying or ruling out serious illness in a young baby.

1.4.9 Recognise the following as 'red flags' for serious illness in young babies:

1.4.10 If a baby is thought to be seriously unwell based on a 'red flag' (see recommendation 1.4.9) or on an overall assessment of their condition, arrange an immediate assessment with an appropriate emergency service. If the baby's condition is immediately life-threatening, dial 999.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on symptoms and signs of illness in babies.

Full details of the evidence and the committee's discussion are in evidence review L1: signs and symptoms of serious illness in babies and evidence review L2: scoring systems for illness in babies.

1.5 Planning and supporting babies' feeding

General principles about babies' feeding

1.5.1 When discussing babies' feeding, follow the recommendations in the section on principles of care, and:

  • acknowledge the parents' emotional, social, financial and environmental concerns about feeding options

  • be respectful of parents' choices.

For a short explanation of why the committee made the recommendation and how it might affect practice, see the rationale and impact section on general principles about babies' feeding.

Full details of the evidence and the committee's discussion are in evidence review T: formula feeding information and support.

Giving information about breastfeeding

1.5.2 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 (see also recommendation 1.5.12):

  • 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.

1.5.3 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.

1.5.4 Inform women that vitamin D supplements are recommended for all breastfeeding women (see the NICE guideline on vitamin D).

1.5.5 Inform women and their partners that under the Equality Act 2010, women have the right to breastfeed in 'any public space'.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on giving information about breastfeeding.

Full details of the evidence and the committee's discussion are in:

Role of the healthcare professional supporting breastfeeding

1.5.6 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.

1.5.7 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.

1.5.8 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.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on the role of the healthcare professional supporting breastfeeding.

Full details of the evidence and the committee's discussion are in evidence review Q: breastfeeding facilitators and barriers and evidence review S: breastfeeding information and support.

Supporting women to breastfeed

1.5.9 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.

1.5.10 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.

1.5.11 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.

1.5.12 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; see also recommendation 1.5.14)

  • 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.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on supporting women to breastfeed.

Full details of the evidence and the committee's discussion are in:

Assessing breastfeeding

1.5.13 A practitioner with skills and competencies in breastfeeding support should assess breastfeeding to identify and address any concerns.

1.5.14 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 1 other feed within the first week.

1.5.15 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.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on assessing breastfeeding.

Full details of the evidence and the committee's discussion are in evidence review R: tools for predicting breastfeeding difficulties.

Formula feeding

1.5.16 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.

1.5.17 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.

1.5.18 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.

1.5.19 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.

1.5.20 For parents who are thinking about supplementing breastfeeding with formula or changing from breastfeeding to formula feeding, support them to make an informed decision.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on formula feeding.

Full details of the evidence and the committee's discussion are in evidence review T: formula feeding information and support.

Lactation suppression

1.5.21 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 section on principles of 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).

For a short explanation of why the committee made the recommendation and how it might affect practice, see the rationale and impact section on lactation suppression.

Full details of the evidence and the committee's discussion are in evidence review K: information for lactation suppression.

Terms used in this guideline

This section defines terms that have been used in a particular way for this guideline.

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 4 and 8 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.

Effective feed

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 2,500 grams 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.

Parental responsibility

See the government definition of parental responsibility.

Parents

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

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.

Prop feeding

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

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 (BFI) information sheet on responsive feeding.

  • National Institute for Health and Care Excellence (NICE)