Breastfeeding Initiation and Birth Setting Practices: A Review of the Literature

Della A. Forster, RN, RM, PhD; Helen L. McLachlan, RN, RM, PhD


J Midwifery Womens Health. 2007;52(3):273-280. 

In This Article


Perineal discomfort after the birth may interfere with early breastfeeding, so perineal suturing is undertaken with minimal delay and any discomfort caused by the stitches should be minimized in the postpartum period.[31] Other readily identifiable factors that may affect breastfeeding initiation are a long labour,[25] a woman having flat or inverted nipples,[25] and a woman having a high body mass index.[48] Women in these categories may benefit from extra breastfeeding support. Women whose infants are admitted to special care nurseries may be less likely to be exclusively breastfeeding at discharge,[48] another cue for offering extra breastfeeding support.

Use of Infant Formula in the Hospital

Step six of the Ten Steps says that newborn infants should be given no food or drink other than breast milk, unless medically indicated. In many maternity facilities, infants are given formula, water, or glucose water either before the first breastfeed or as a supplement to breast milk.[9] A recent study demonstrated that the time infants are most likely to receive a supplement is between 7 pm and 9 am, regardless of the time of birth.[61] Gagnon et al.[61] found that a breastfeed in the labour ward "protected" infants from the use of a formula supplement for up to 10 hours of age. Although the use of formula in the hospital was not shown to have a statistically significant effect on breastfeeding outcomes in an early meta-analysis,[62] recent studies from Turkey, Italy, and the United States have found that the use of formula during the postnatal hospital stay has a negative association with breastfeeding duration after adjusting for confounding factors.[20,63,64] The use of formula in the early postpartum period should be avoided unless medically indicated.

Receiving Breastfeeding Help In Hospital and Rooming-In

Receiving breastfeeding help in hospital was associated with a higher initiation of breastfeeding in one study from Italy.[63] Consistent advice on breastfeeding at all stages of maternity care is also likely to help.[29]

Most studies on rooming-in have not been methodologically rigorous; however, the practice has been shown to have a positive association with breastfeeding outcomes,[7,65] with even partial rooming-in making a difference.[60] In view of the fact that rooming-in is one of the Ten Steps, and no studies have reported a negative effect of rooming in,[9] this practice should be encouraged from birth.

Demand Feeding

Although it is generally accepted that fixed or set breastfeeding schedules lead to breastfeeding problems and insufficient milk supply, there may still be a gap between policy and practice.[9] A recent study on the volume and fat content of breast milk over a 24-hour period confirmed that there is variation in breastfeeding patterns between different infants, and from day-to-day. The authors highlighted the importance of encouraging demand feeding for all breastfed infants.[66] Maternity hospitals should encourage 24-hour rooming in from birth, to best enable and encourage mothers to respond to a baby-led (demand) feeding schedule and successfully initiate breastfeeding.

Pacifiers (Dummies)

The use of dummies (pacifiers) has been associated with a decreased duration of breastfeeding in some studies,[63,67,68] although a recent randomized, controlled trial found that pacifier use was more a marker of breastfeeding difficulties or decreased breastfeeding motivation than a cause of early weaning in itself,[69] and concluded that those promoting breastfeeding should "re-examine their staunch opposition to pacifiers."p 325 Similarly, a recent trial of pacifier use in preterm infants found no difference in breastfeeding outcomes associated with their use.[70] However, it is suggested that the use of pacifiers in the first week of life is likely to interfere with the infant learning to suck effectively, and should be discouraged.[25]


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.