Chapter 6: Breastfeeding

Table of Contents


Lead Author

Marina Green RN MSN IBCLC

Breastfeeding Committee for Canada
Vancouver, British Columbia

Contributing Authors

Beverley Chalmers, DSc(Med), PhD

International Perinatal Health Consultant
Kingston, Ontario

Louise Hanvey, RN, BScN, MHA

Senior Policy Analyst
Maternal and Child Health
Public Health Agency of Canada
Ottawa, Ontario

Michelle LeDrew, RN, BN, MN, CHE

Board of Directors member
Breastfeeding Committee for Canada
Women's and Newborn Health Program
IWK Health Centre
Halifax, Nova Scotia

Lynn M. Menard, RN, BScN, MA

Team Leader
Maternal and Child Health
Public Health Agency of Canada
Ottawa, Ontario

Nancy E. Watters RN, BScN, MScN

Nursing Faculty
University of Ottawa
Ottawa, Ontario


Dina Ryan Davidson RM IBCLC

Registered Midwife, Lactation Consultant
Inlet Community Birth Program
Port Moody, British Columbia

M. Shirley Gross MD, CCFP

Edmonton Breastfeeding Clinic
Assistant Clinical Professor
Faculty of Obstetrics and Gynaecology and of Family Medicine
University of Alberta
Edmonton, Alberta

Cheyenne Joseph, RN, BScK, BScN, MPH, CCHN(C)

Senior Nursing Instructor
Community Health Nursing
University of New Brunswick
Moncton, New Brunswick

Carley Nicholson, RD, MPH

Policy Analyst
Maternal and Child Health
Public Health Agency of Canada
Ottawa, Ontario

Catherine M Pound, MD

Associate Professor
University of Ottawa
Consulting Pediatrician
Children's Hospital of Eastern Ontario
Ottawa, Ontario

Kate Robson, MEd

NICU Family Support Specialist
Sunnybrook HSC
Executive Director
Canadian Premature Babies Foundation
Canadian Family Advisory Network
Toronto, Ontario


Breastfeeding is recognized as the unequalled way to provide optimal nutritional, immunological and emotional nurturing of infants.Footnote 1Footnote 2Footnote 3 Consistent with the World Health Organization (WHO) global recommendation for public health, Health Canada recommends exclusive breastfeeding for the first 6 months, and sustained for up to 2 years or longer with appropriate complementary feeding to support nutrition needs, for immunological protection and growth and development of infants and toddlers. Breastfeeding is also linked to many of the United Nations Sustainable Development Goals, such as no poverty, zero hunger, good health and well-being, no inequity, and responsible consumption and production.Footnote 4

There is no doubt about the importance of breastfeeding for infants, young children, and mothers. The effects occur both during and beyond the breastfeeding period. Recent studies and position statements reflect findings of the dose–response effect of breastfeeding: the more exclusive breastfeeding is in the first 6 months and the longer the duration beyond 6 months, the greater the impact and protection. Important factors for the infant include:Footnote 5Footnote 6Footnote 7Footnote 8Footnote 9

  • Breastmilk is easily digested and offers the right quantity of nutrients as it adapts to the needs of infants as they mature;
  • Breastfeeding enhances cognitive development and may protect against gastrointestinal infections, acute otitis media, and respiratory tract infection;
  • Breastfeeding may be protective against obesity later in life; and
  • Breastfeeding is linked to a decrease in sudden infant death syndrome (SIDS).

Important factors for the mother/family include:Footnote 10Footnote 11Footnote 12Footnote 13

  • Breastfeeding is a preventive health measure for the lactating mother as it is associated with a decrease in the incidence of both breast and ovarian cancers;
  • Breastfeeding is associated with a delay in the return of ovulation and greater postpartum weight loss and with decreased risk of hypertension, diabetes, hyperlipidemia, and cardiovascular disease; and
  • Breastfeeding is cost saving for families – there is no need to buy bottles or breastmilk substitutes.

Important factors for society include:Footnote 14Footnote 15Footnote 16

  • Breastfeeding is cost saving to society as improved maternal and child health reduces loss of productivity due to illness and other health care costs; and
  • Breastfeeding has little environmental impact as there are no by-products and garbage associated with manufacture and purchase of breastmilk substitutes.

Family-centred care respects parents’ informed choices on how they choose to feed their infant. Choosing a feeding method is influenced by a number of factors, including personal experience, knowledge, culture, marketing practices and attitudes of partners, family and friends. Health care providers (HCPs) play an important role in helping families make informed decisions – and in respecting and supporting their decision.

Additional resources on breastfeeding: See appendix A

Breastfeeding in Canada

Breastfeeding initiation rates in Canada have increased from less than 25% in 1965 to 90% in 2015/16, a significant improvement.Footnote 17Footnote 18 But breastfeeding duration falls short of recommendations and, of the mothers who initiate breastfeeding, close to 25% stop before their infant is 1 month old.Footnote 2 The most common reasons mothers give for stopping breastfeeding before 6 months are “not enough milk” (44%) and “difficulty with breastfeeding technique” (18%).Footnote 19

Although the percentage of Canadian mothers who breastfeed their infant exclusively to 6 months has increased from 17% in 2003, it remains low, at 32%.Footnote 18Footnote 19  In 2011/12, over half (57%) of mothers who breastfed continued some breastfeeding beyond 6 months. This percentage dropped to 19% after the infant’s first year of life.Footnote 3

Breastfeeding rates also vary across the country along a general west-to-east gradient. In 2011/12, breastfeeding initiation ranged from 96% in British Columbia and Yukon to 57% in Newfoundland and Labrador.Footnote 19 The greatest increase in breastfeeding initiation between 2003 and 2011/12 was in Quebec, from 76% to 89%.

There is little information about the extent to which Canadian women continue to breastfeed until their children are 2 years or older, as per WHO/UNICEF and Health Canada recommendations.

Breastfeeding Protection, Promotion, and Support – The Baby-Friendly Initiative

Breastfeeding initiation and duration increase with active protection, promotion, and support. The evidenced-based policies and practices of the WHO/UNICEF Baby-friendly Hospital Initiative (BFHI) have been shown to improve breastfeeding initiation, duration, and exclusivity.Footnote 20Footnote 21Footnote 22Footnote 23Footnote 24Footnote 25Footnote 26Footnote 27Footnote 28Footnote 29Footnote 30Footnote 31Footnote 32 The BFHI is based on the policies and practices described in Ten Steps to Successful Breastfeeding (the Ten Steps) and the International Code of Marketing of Breast-milk Substitutes.Footnote 33Footnote 34  The process of becoming a designated Baby-Friendly facility can often be a catalyst for changing a facility’s environment around infant feeding and it motivates facilities to transform their practices. As a result of becoming designated Baby-Friendly, care is more patient centred, quality of care improves, staff attitudes regarding infant feeding improve, and use of infant formula and nurseries decrease.Footnote 33

The 2017 WHO Guideline: Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services provides evidence-based recommendations to support the protection, promotion and support for breastfeeding in facilities that provide maternity and newborn services.Footnote 35 It examined the evidence of the original Ten Steps and developed 15 recommendations relating to immediate support to initiate and establish breastfeeding, feeding practices and additional needs of infants, and creating an enabling environment.

The 2018 WHO/UNICEF update of the Implementation Guidance: Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services: the revised Baby-Friendly Hospital Initiative provides the first update of the Ten Steps since 1989 and complements the 2017 WHO guideline.Footnote 36 The topic of each of the Ten Steps remains the same; however the updated wording is based on the latest evidence and global policies.Footnote 36 Additionally, the WHO Code of the Marketing of Breast-Milk Substitutes is incorporated into Step 1. The first 2 steps address critical management procedures while Steps 3 to 10 describe clinical practice standards.

In Canada, the Baby-Friendly Initiative (BFI) has been adapted from the BFHI to incorporate the continuum of care between hospital and community health services, and to include recommendations for breastfeeding the older infant and young child.Footnote 37 A hospital providing maternity services or a community health facility is designated as Baby-Friendly if it meets the criteria for achieving the Ten Steps and adheres to the International Code of Marketing of Breast-milk Substitutes. The Breastfeeding Committee for Canada (BCC) is the BFI authority for the majority of Canada, and oversees the initiative’s implementation and assessment. Provincial and Territorial Committees collaborate with the BCC and hospital and community facilities to implement the BFI at the local level. In the province of Quebec, the Ministère de la Santé et des Services sociaux (MSSS) is the authority for breastfeeding and the BFI, and applies its own standards and assessment process within the province.

The joint statement, Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months (NHTI recommendations), co-authored by Health Canada, the Public Health Agency of Canada (PHAC), the Canadian Paediatric Society (CPS), Dietitians of Canada, and the BCC, recommends that hospitals and community health services implement BFI policies and practices.Footnote 2 Accreditation Canada has incorporated the BFI and the content of the Ten Steps and WHO Code into the Obstetrics Services Standards for hospitals.Footnote 38 In The BFI 10 Steps and WHO Code Outcome Indicators for Hospital and Community Health Services, the BCC describes the breastfeeding data collection required for Baby-Friendly designation.Footnote 37 Consult the MSSS for data requirements in the province of Quebec.

Despite the recommendations and the endorsement of many professional health organizations, hospitals and community health facilities have a poor record, so far, of implementing the BFI.Footnote 39Footnote 40 Currently, 21 hospitals, 8 birthing centres and 117 community centres have been designated as Baby-Friendly facilities in Canada.Footnote 41 Globally only 10% of infants are born in a hospital designated Baby-Friendly. WHO emphasizes that countries should scale up BFI implementation to universal coverage and ensure sustainability.

A growing body of literature also focuses on optimizing breastfeeding outcomes for newborns within neonatal intensive care units (NICUs). Work is underway internationally to adapt the BFHI to these settings, referred to as Neo-BFHI.Footnote 42Footnote 43

The underlying philosophy of the BFI is based on the basic principles of family-centred care. Mothers and babies are mutually interdependent units, and breastfeeding is the unequalled method of infant feeding. Each mother–infant dyad and their family is supported in finding the best possible approach within their unique context. The role of HCPs includes supporting this normal process, removing barriers to success, and providing additional support when challenges arise.

The content of this chapter is organized according to the sequence in the Ten Steps to Successful Breastfeeding (2018).Footnote 33 The heading of each of the Ten steps includes the WHO description from the BFHI, followed by the Canadian wording from the BCC.Footnote 37

This chapter does not outline the specific criteria for achieving Baby-Friendly designation. Refer to The BFI 10 Steps and WHO Code Outcome Indicators for Hospital and Community Health Services for Baby-Friendly designation requirements and assessments, and consult the MSSS for criteria in the province of Quebec.Footnote 37

1. Written Breastfeeding Policy

Step 1:


  1. Comply fully with the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions.
  2. Have a written infant feeding policy that is routinely communicated to staff and parents.
  3. Establish ongoing monitoring and data-management systems.


  • Have a written infant feeding policy that is routinely communicated to all staff, health care providers and volunteers.

The Code

The International Code of Marketing of Breast-milk Substitutes, published in 1981 and reaffirmed by the World Health Assembly in 2018, to which Canada is a signatory, was developed in response to inappropriate marketing practices that contributed to the decline of breastfeeding, particularly in developing countries.Footnote 44 The WHO Code was developed to ensure that health priorities – not profit interests – influence women’s decisions to breastfeed. The Code prohibits the promotion and marketing of infant formula, bottles, nipples, and complementary foods for infants less than 6 months of age. The WHO Code strives to “...provide safe and adequate nutrition for infants, by the protection and promotion of breast-feeding, and by ensuring the proper use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing.”

This Code seeks to protect and promote breastfeeding by ensuring the ethical marketing of breastmilk substitutes by industry and states. There should be:Footnote 37

  • No advertising of these products (i.e., infant formula, bottles, nipples or teats, pacifiers or soothers) to the public;
  • No free samples of these products to be given to mothers or their families;
  • No promotion of artificial feeding products in health care facilities or distribution of free or low-cost supplies;
  • No company representatives advising mothers;
  • No gifts or personal samples given to health care workers; and
  • No words or pictures idealizing artificial feeding, including pictures of infants on the labels of products.

In addition:

  • Information given to health workers should be evidence-based and factual;
  • All information on artificial infant feeding, including the labels, should explain the importance of breastfeeding and the costs and hazards associated with artificial feeding;
  • Unsuitable products, such as sweetened condensed milk, should not be promoted; and
  • All breastmilk substitutes must be of a high quality and take into account the climatic and storage conditions of the country where they are used.

Governments are responsible for implementing the marketing restrictions through social and legislative means. The infant formula industry must ensure that their marketing and labelling practices are compliant with the legislation. HCPs should promote and protect breastfeeding and avoid any influence by or cooperation with industry marketing of infant formula. The health care system should promote and protect breastfeeding by not promoting infant formula products.Footnote 45

The marketing of infant formula has a negative effect on breastfeeding, playing a role in normalizing a mixed feeding culture of breastfeeding and formula feeding.Footnote 46 Aggressive marketing practices are direct violations of the International Code of Marketing Breast-milk Substitutes. When a relationship is created between formula companies and HCPs, the result is brand loyalty and dependency.Footnote 47

The Canadian Hospital Maternity Policies and Practices Survey found that 68% of hospitals still had exclusive contracts with formula companies in 2007, although that this was down from 82% in 1993.Footnote 39 Still, 90% of hospitals reported that they did not give out sample formula packages – up from 58% in 1993.Footnote 48 The MES found that 64% of women reported that they were not offered or given free sample packages. Women who were younger, having their first babies, with lower education level or living in low income were more likely to be offered free samples.Footnote 49Footnote 50

The relationship between physicians and the pharmaceutical industry influences professional practice. This is also the case with infant formula companies.Footnote 51 International studies have demonstrated that between 80% and 95% of physicians regularly see sales representatives from pharmaceutical companies, despite evidence that their information is biased and affects prescribing habits.Footnote 52 A number of medical associations and other groups are calling for specific measures to disentangle the relationship between HCPs and industry.

There have been known cases of violations of the WHO Code by the formula industry in Canada.Footnote 45 In the Labelling Requirements for Infant Foods, Infant Formula and Human Milk, the Canadian Food Inspection Agency (CFIA) and Health Canada strongly urge the infant formula industry to respect and implement the principles of the Code.Footnote 53  In addition, certain principles set out in the Code also align with section 5(1) of the Food and Drug Act.Footnote 53 Two provincial governments (British Columbia and Nova Scotia) have formula purchase agreements supporting facilities to purchase formula and feeding products rather than accepting free gifts or marketing materials.  

Refer to The BFI 10 Steps and WHO Code Outcome Indicators for Hospital and Community Health Services for the WHO International Code of Marketing of Breast-Milk Substitutes code compliance checklist.Footnote 37Footnote 44

Infant Feeding Policy

Breastfeeding is the unequalled method of infant feeding for their healthy growth and development – and policies to do with infant feeding need to reflect that. Nevertheless, support for mothers who choose to feed their infants breastmilk substitutes (i.e., formula) or who are unable to breastfeed should be included in these policies.

Templates and examples of infant feeding policies are available from Baby-Friendly facilities or online to help in the policy development process. The implementation of policies requires “carefully planned, multipronged and multilevel approaches,” ideally involving multiple stakeholders including families, to be effective and sustainable.Footnote 46 Change management strategies are available from the growing field of implementation science to target organizational culture and clinical practice.

The infant feeding policy development process should include a scan of all existing policies through a Baby-Friendly lens. For example:

  • Policies should encourage and support families to stay together when either mother or infant are readmitted for care;
  • Policies on newborn care at birth should refer to skin-to-skin contact;
  • Policies on painful procedures should include encouraging mothers to soothe their infant by breastfeeding or providing skin-to-skin contact.

Resources that can help develop breastfeeding policies and practice guidelines include:Footnote 2Footnote 3Footnote 35Footnote 36Footnote 37Footnote 44Footnote 54Footnote 55Footnote 56

  • Implementation guidance: Protecting, Promoting, and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services: The Revised Baby-friendly Hospital Initiative;
  • International Code of Marketing of Breast-milk Substitutes;
  • Guideline: Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services;
  • The BFI 10 Steps and WHO Code Outcome Indicators for Hospital and Community Health Services;
  • Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months and Nutrition for Healthy Term Infants: Recommendations from Six to 24 Months;
  • Breastfeeding Healthy Term Infants;
  • Clinical protocols by the Academy of Breastfeeding Medicine; and
  • The Baby-Friendly Hospital Initiative for Neonatal Wards (Neo-BFHI).

Because families interact with staff other than their HCPs in hospitals and community health facilities, it is important that everyone – managers, administrators, auxiliary staff, students, clerks, allied health professionals, volunteers, and all HCPs – know about the importance of breastfeeding, the BFI, and the International Code of Marketing of Breast-milk Substitutes.

Families also need to be aware of the standard of care that they can expect, and can learn about these from their HCPs and via social media, print materials, and prenatal classes.

Monitoring and data collection

Collecting breastfeeding data is an essential component of health surveillance, and monitoring of trends is important in program development, implementation, and evaluation. Lack of consistent data collection and standardized definitions across facilities and provinces/territories can be problematic and create challenges at all levels.Footnote 40 Data collection should include:

  • Rates of breastfeeding initiation and exclusivity at hospital discharge;
  • Rates of exclusive breastfeeding to age 6 months; and
  • Rates of breastfeeding to age 2 years or older.

2. Knowledge and Skills to Implement Breastfeeding Policies

Step 2:


  • Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding.


  • Ensure all staff, health care providers and volunteers have the knowledge and skills necessary to implement the infant feeding policy.

Undergraduate and Postgraduate Education

As awareness of the importance of protecting, promoting, and supporting breastfeeding increases, undergraduate and continuing professional education of HCPs needs to address the biological, social, and emotional components of breastfeeding – and the multiplicity of factors that affect this dynamic relationship. However, numerous studies describe the lack of formal breastfeeding information in HCPs' educational programs.Footnote 57Footnote 58Footnote 59Footnote 60

HCPs are known to affect the breastfeeding relationship. Women who perceive their HCPs as supportive of breastfeeding are more likely to breastfeed than those who perceive them as neutral or favouring formula feeding.Footnote 61Footnote 62 In fact, the more often breastfeeding is mentioned during pregnancy, the more likely women will breastfeed.Footnote 63

Continuing Education

Everyone who works at a health facility – administrators, managers, volunteers, allied health professionals, auxiliary staff, students, clerks, and all HCPs – needs to be aware of the facility's policies, including the BFI. Specific training in keeping with everyone's role should be provided. For example, phlebotomists should actively support mothers in breastfeeding or holding the baby in skin-to-skin contact to comfort their child through blood tests.

Continuing professional education needs to be developed to address the breastfeeding needs of families and enhance the care of mothers and babies. A holistic and interprofessional approach to professional continuing education should be a responsibility shared by HCPs and health facilities.

Education Strategies

WHO and UNICEF recommend 18–20 hours of breastfeeding education (including 3 hours of clinical experience) for HCPs who provide direct breastfeeding care, for example, lactation consultants, perinatal nurses, midwives, obstetricians, and family physicians. Providers responsible for clinical support of breastfeeding mothers and infants require specific knowledge, skills, and attitudes.Footnote 59 Research suggests that clinical mentorships, didactic learning modules, and Internet learning options are also useful training opportunities.Footnote 64 The specific knowledge and skills required are outlined in The BFI 10 Steps and WHO Code Outcome Indicators for Hospital and Community Health Services.Footnote 37

At a minimum, all HCPs require orientation in the policies and practice guidelines of the facility, including the BFI (i.e., the Ten Steps and International Code of Marketing of Breast-milk Substitutes).

Ongoing Competency Validation

Practice change requires more than education.Footnote 65 Numerous professional organizations have breastfeeding guidelines – yet professional practice often does not reflect the guidelines.Footnote 59 To be effective, implementation of evidence-based policies in hospitals and community facilities requires a combination of various education strategies and clinical support.

3. Informing Pregnant Women and their Families about Breastfeeding

Step 3:


  • Discuss the importance and management of breastfeeding with pregnant women and their families.


  • Inform pregnant women and their families about the importance and process of breastfeeding.

Informed decision-making is central to family-centred care. Families need to get the information necessary to make decisions about feeding their infant before birth, through their HCP or prenatal classes. Informed decision-making includes having opportunities to discuss goals and concerns with HCPs so that families can expand their knowledge about:

  • The process of breastfeeding, including supply and demand;
  • The importance of breastfeeding for baby and mother;
  • The health outcomes for baby and mother related to a decision not to breastfeed;
  • The difficulty of reversing the decision once breastfeeding is stopped;
  • Expected newborn behaviour, frequency of feeding (especially at night), and changes in the number of feedings with growth and age;
  • The importance of skin-to-skin contact;
  • Cue-based feeding, position, and latch;
  • Hand expression;
  • Sources of support and information;
  • Common breastfeeding issues; and
  • Sustained breastfeeding – exclusive breastfeeding for the first 6 months, and sustained for up to 2 years or longer with appropriate complementary feedings.

Infants in Specialized Care

Some situations require specialized expertise and care. Mothers at high risk of preterm or medically complicated births require information tailored to their specific needs. If a baby is anticipated to require specialized care, families need additional information about:

  • The importance of skin-to-skin care in the NICU;
  • Establishing milk production, pumping or hand expressing, if babies cannot breastfeed effectively;
  • The vital role of families as part of the infant’s care team.

If a mother is unsure or is choosing not to breastfeed her infant in specialized care, sensitively providing information about the value of breastmilk for their sick or preterm infant can be beneficial. For example, breastmilk is effective in preventing necrotizing enterocolitis, leading to fewer severe infections, reducing colonization by pathogenic organisms, improving neural development, and leading to a shorter hospital stay.Footnote 66 Given this information, some mothers will choose to express milk for their preterm infant even if they do not plan to breastfeed.

Addressing the Needs and Concerns of Women and Their Families

In Canada, most women choose to breastfeed their infants. The women who are least likely to breastfeed are younger, at lower-income and education levels, and living in Eastern Canada. Also, few women continue to breastfeed for 2 years or longer, falling short of the NHTI recommendations. Effective strategies for improving breastfeeding rates require focusing on the full continuum of the mother–child experience, from before pregnancy and through the early parenting years.Footnote 67Footnote 68

Most women decide how to feed their baby early in pregnancy, if not before.Footnote 69 However, decisions about breastfeeding initiation and duration are complex and deeply embedded in the cultural context. Lack of positive peer and effective clinical support, lack of confidence in their ability to breastfeed, perceptions of their family’s and friends’ views about breastfeeding, and exposure to pervasive formula marketing are just a few of the psychosocial factors that affect women’s ability to make truly informed, autonomous decisions about initiating breastfeeding and following through with the decision.

HCPs have a strong influence on women’s decisions to breastfeed. Studies have shown that women who perceive their physician as supportive of breastfeeding are more likely to breastfeed than those who perceive their physician as neutral or favouring formula feeding.Footnote 61Footnote 62 When HCPs take a neutral stance on breastfeeding, women are more likely to consider them not to be in favour of breastfeeding.Footnote 61Footnote 62 On the other hand, the more often breastfeeding is mentioned during the prenatal period, the more likely women will breastfeed.Footnote 63 It is important that all HCPs and all health care facility staff know about the importance of breastfeeding and provide positive messages about it.

Current feeding practices are affected by a long tradition of bottle-feeding in North America.Footnote 49Footnote 70Footnote 71Footnote 72 Beliefs that feedings need to be scheduled or timed and that breastfeeding babies have to learn to bottle-feed must be addressed. Cultural beliefs that breastfeeding is only appropriate for young babies – that extended breastfeeding is abnormal – can limit the duration of breastfeeding.

Families may come from a culture with a long tradition of breastfeeding. Recent immigrants, noticing the lack of visible breastfeeding, may assume that the norm in Canada is to bottle-feed. Others may have come from countries where breastfeeding is not the norm. Special care must be taken to avoid making assumptions about new immigrants’ feeding beliefs based on their country of origin.Footnote 73

Women need the opportunity to discuss their concerns and have them addressed to facilitate their decision to breastfeed. Self-efficacy strategies benefit all women even while such strategies need to be tailored to meet their personal needs.Footnote 68Footnote 74Footnote 75Footnote 76 The attitudes and beliefs of partners, parents, and extended family affect women’s decisions to breastfeed and how long they choose to breastfeed.Footnote 77Footnote 78Footnote 79

Strategies for Providing Information

HCPs need to adopt the principle that women will breastfeed – especially as over 90% of Canadian women intend to. For example, asking open-ended questions before asking a woman to make a decision about breastfeeding helps HCPs provide information; this method has been shown to increase the likelihood of breastfeeding initiation.Footnote 80

A variety of types of education strategies over a period of time are most likely to influence a woman’s decision about breastfeeding initiation and duration.Footnote 32Footnote 81Footnote 82Footnote 83 Reports stress the value of face-to-face interaction rather than just providing print materials. Similarly, needs-based and repeated informal sessions are more effective than generic, formal prenatal sessions. Because partners and family members affect women’s decisions, it is important to find strategies to include the family in breastfeeding education.Footnote 77

Evidence suggests that it is best to avoid routine, forced choice questions about feeding on hospital admission forms. After placing her newborn in skin-to-skin contact with the mother, ask her how she plans to feed her baby.Footnote 84 Women who choose not to breastfeed will let staff know. Regardless, babies who will not be breastfed require the same supportive skin-to-skin contact in the early hours following birth.

Dispelling Common Myths

Mothers and families are often influenced in their decisions about breastfeeding by the many common myths on the subject.

Common Myths About Breastfeeding
Myth Truth
Women with flat or inverted nipples cannot breastfeed Most women can breastfeed. Support the mother by placing the infant in skin-to-skin contact with her at birth. Assess how well the infant feeds. If the infant has difficulty latching, provide skilled assistance and encourage hand expressing and, if necessary, pumping until the infant is able to feed effectively.
Mothers with flat and inverted nipples need to use nipple shields A nipple shield may be useful if, despite expert assistance and a baby eager to feed, the baby is unable to latch and feed effectively. As nipple shields can be associated with inadequate milk transfer, families must know how to ensure adequate weight gain in the infant and have a plan for close follow-up. Mothers may require additional emotional support as they become comfortable with the technique as they may feel added stress because of having to use aids to breastfeed.Footnote 85
Nipple shields may be helpful for breastfeeding the preterm infant.Footnote 85
Breastfeeding is complicated and painful As with any skill, mothers and infants may need time to learn how to breastfeed. Realistic expectations, commitment, and support from family and HCPs help mothers as they learn.
Most mothers have some nipple soreness in the first week. Strategies to help the infant latch and feed better usually alleviate more severe pain.
The father cannot be involved with the baby if mother breastfeeds There is plenty to do with babies besides feeding. Mothers are most likely to be successful when partners provide encouragement and practical and emotional support.Footnote 86Footnote 87Footnote 88
Breastfeeding “ties the mother down” A breastfed baby is very portable. As mothers get comfortable with breastfeeding, babies can go anywhere. Welcome breastfeeding mothers everywhere – not only is it their right to breastfeed, but mothers and babies will be healthier.
Breastfeeding ruins the mother’s figure Pregnancy and aging cause the most significant changes to women’s breasts. Breastfeeding is the normal transition from pregnancy.
Families cannot tell if their infant is getting enough to eat Almost all families worry about how well their infant is feeding. Teach families about infant cues and signs of satiation, so that they can determine how well their infant is feeding. Encourage mothers to watch their babies rather than the clock. If there are concerns, help them find breastfeeding solutions.
Women need to have a perfect diet to breastfeed A healthy diet helps mothers meet the demands of mothering. Breastmilk is the best food for the infant even if the mother’s diet is not perfect. Breastfeeding helps mothers to lose weight and benefits the health of these mothers later life.

Supporting Families who are not Breastfeeding

WHO uses the acronym AFASS (for Acceptable, Feasible, Affordable, Sustainable, Safe in their situation) to describe the process of assisting families who are not breastfeeding to choose breastmilk substitutes. The Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months joint statement provides guidance on the use of breastmilk substitutes including safe preparation and storage.Footnote 2

It is important to provide families with information on responsive, cue-based feeding; signs of satiation; and the importance of skin-to-skin contact as well as information on professional and peer support regardless of feeding method.

Provide non-judgmental and supportive care for families who choose not to breastfeed, whether for medical, personal, or social reasons. Families may feel guilt or shame for not breastfeeding and may require individualized support to deal with these emotions as well as information to optimize their infant’s nutritional well-being.

Lactation Suppression

If women do not breastfeed, lactogenesis still occurs. Research on lactation suppression has primarily focused on pharmacological measures. It is important that HCPs provide women with information on comfort measures for sore breasts, including analgesics, cold compresses, supportive bras, and limited hand expression.Footnote 89 Breast binding and restricting fluids are not recommended.

If lactation suppression is required because the child dies or is placed for adoption, comfort measures and gradually increasing the time between expressing/pumping milk will allow breasts to gradually involute. Mothers who are bereaved or who place their baby for adoption may also want to express their milk and donate it as part of their grieving or separation process.Footnote 90 Consider providing the mothers with information about the process of becoming a milk donor.

4. Skin-to-Skin Contact Immediately Following Birth

Step 4:


  • Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth.


  • Place babies in uninterrupted skin-to-skin contact with their mothers immediately following birth for at least an hour or until completion of the first feeding or as long as the mother wishes. Encourage mothers to recognize when their babies are ready to feed, offering help as needed.

Research over the last 40 years has clearly identified the importance of caring for mothers and babies as an inseparable biological unit, especially in the hours immediately following birth, and on promoting uninterrupted skin-to-skin care during those hours. Incorporating this research into practice requires a shift from the northern European and North American routine of separating mothers and babies at birth.Footnote 91Footnote 92Footnote 93 Skin-to-skin care means placing the naked infant (who may be in diaper) with their chest and abdomen against the mother's naked chest in a position that enables the baby to fully expand the lungs. The infant's arms should be on either side of their body, and not trapped underneath, and the mouth and nose should be uncovered and easily visible.Footnote 94 Warm blankets should cover the mother and baby together until temperature stability is achieved or if the newborn's temperature becomes unstable.

Skin-to-skin care benefits the infant by:Footnote 25Footnote 95Footnote 96Footnote 97Footnote 98Footnote 99Footnote 100Footnote 101Footnote 102

  • Enhancing thermoregulation;
  • Increasing cardiorespiratory stability;
  • Increasing postnatal metabolic adjustment;
  • Decreasing infant stress;
  • Decreasing crying; and
  • Decreasing nosocomial infections.

In North America, the media, especially television, still show images of non-evidence-based hospital practices.Footnote 103 For example, babies are often shown being dried off, cleaned up, and weighed before being given to the mother for bonding. Consequently, families are sometimes not aware that optimal care of the newborn includes immediate skin-to-skin care and uninterrupted contact with the mother until the first feeding is completed. Public health and prenatal class messaging can help change the knowledge and expectations of the family.

Current evidence demonstrates that Canadian practices, although changing, still need to be improved. The Canadian Maternity Experiences Survey (MES) found that although 71.9% of mothers reported holding their infant immediately or within 5 minutes of birth, only 31.1% had skin-to-skin contact. Younger women (15–19 years) were even less likely (18.1%) to report skin-to-skin contact with their babies immediately following birth. Only 29.0% of women who had a caesarean birth reported holding their baby immediately following birth (compared with 85.7% of those giving birth vaginally), and only 7.5% reported holding their infant skin-to-skin.Footnote 49

The Importance of the First Hour Following Birth

Generally, infants show signs of readiness to latch on to the breast and feed within the first hour of birth.Footnote 104 Families should be supported in keeping their baby in uninterrupted skin-to-skin contact immediately following birth until at least after the first feeding is completed. The partner can also provide skin-to-skin contact if the mother cannot.Footnote 105 If the mother and newborn are separated for medical reasons, babies should be reunited as soon as possible.

Newborn infants should be dried and assessed while in skin-to-skin contact with the mother.Footnote 94Footnote 106 Unobtrusively check to see that families know how to position their infant safely while skin-to-skin, breastfeeding, or otherwise holding the baby, and encourage partner participation. Ensure the safety of the infant if the mother has received opioid medications for pain or is very fatigued.

Babies who went through a stressful birth or infants of mothers given medication during labour may take longer to complete the first feeding.Footnote 107 They may be at risk for lower rates of breastfeeding initiation and earlier cessation.Footnote 108 Special attention needs to be given to these mothers and infants.

Mothers who have a caesarean birth are more likely to experience breastfeeding difficulties, and their babies are more likely to receive supplements in the hospital.Footnote 49Footnote 109Footnote 110 The delay in skin-to-skin contact and early suckling because of separation after caesarean birth may be responsible for these difficulties.Footnote 25 Early skin-to-skin contact as well as breastfeeding when babies cue to feed while in the operating room and the recovery room can decrease the need for early supplemental feeding.Footnote 111 Skin-to-skin care with appropriate supervision should be the norm for all births, including caesarean births.

Effects of Skin-To-Skin Care on Breastfeeding

When placed in uninterrupted skin-to-skin contact with their mother, newborns exhibit a pattern of behaviours—breast seeking, rooting, licking, sucking, and feeding —that may be triggered by maternal odour.Footnote 112Footnote 113 Skin-to-skin contact also increases the likelihood of a successful first feeding and improves breastfeeding in the early postpartum period as well as rates of exclusive breastfeeding.Footnote 114Footnote 115Footnote 116Footnote 117 Bramson et al (2010) found a dose–response relationship between early skin-to skin contact and exclusive breastfeeding in the hospital.Footnote 118

See the CPS practice point Kangaroo Care for the Preterm Infant and Family and Neo-BFHI: The Baby-friendly Hospital Initiative for Neonatal Wards for more information on the benefits of skin-to-skin care of the preterm infant.Footnote 56Footnote 119

Maternal Hormonal Response

Delivery of the placenta triggers the maternal hormonal responses necessary for lactation. Skin-to-skin contact and newborn suckling enhance this hormonal response by releasing surges of oxytocin. Oxytocin facilitates uterine contractibility. When the infant stops suckling, he or she may start massage-like movements of their hands on the mother's breast. These hand movements also cause surges of oxytocin release.Footnote 120 Early skin-to-skin contact and suckling may increase maternal sensitivity towards and reciprocity with their infants even up to the age of 1 year.Footnote 25Footnote 121

Providing Information

HCPs need to remove institutional barriers (customary practices, attitudes, values, and environmental limitations) and inform mothers and families about how essential skin-to skin care is to the stability of their infant, regardless of how families choose to feed their infants. Babies who will not be breastfed require the same supportive skin-to-skin care in the early hours following birth.

Painful Procedures

Breastfeeding comforts infants when they experience painful procedures such as heel pokes, blood tests, and immunizations. Numerous studies support the use of skin-to-skin contact and breastfeeding to help infants endure painful procedures.Footnote 97Footnote 122Footnote 123Footnote 124Footnote 125Footnote 126 Skin-to-skin contact and breastfeeding before a painful procedure helps infants cope with pain. Ideally, this skin-to-skin contact should be maintained for at least 15 minutes before the procedure. Reassure parents that even if their child reacts, cries, or fusses their perception of pain is lessened.

5. Assist Mothers with Breastfeeding Challenges

Step 5:


  • Support mothers to initiate and maintain breastfeeding and manage common difficulties.


  • Assist mothers to breastfeed and maintain lactation should they face challenges including separation from their infants.

Step 5 encompasses 2 components: providing breastfeeding support and assistance when mothers and infants are together, and providing this support when they are separated because of newborn instability or illness of mother or child.

Creating the Context for Successful Breastfeeding

Mothers and babies find a wide range of successful approaches to breastfeeding. Many babies placed skin-to-skin with their mothers find the breast and feed well, while others may need assistance. Timely intervention by knowledgeable staff is helpful. Learning about breastfeeding and newborn care and feeding ideally occurs in a family-centred context with many of the other BFI steps:

  • Mother–baby togetherness;
  • Ongoing skin-to-skin contact;
  • Early, frequent, unrestricted feedings;
  • Response to early feeding cues; and
  • Family involvement and presence to help mothers.

Key Skills for Mothers

In addition to the emotional and physical changes mothers experience after birth, mothers need to learn skills that their HCPs can help them develop:

1. Supporting their infant’s feeding abilities: Understanding and responding to infant cues

Infants feed best when they are in a quiet, alert state. If babies are in skin-to-skin contact, they may begin to demonstrate feeding cues. If not in skin-to-skin contact, babies should be close to their mother so that she can become aware of early cues rather than waiting for crying, which is a very late feeding cue. Crying infants usually require calming before they will attempt to feed.Footnote 54 Similarly, infants wakened from a deep sleep often will not feed.

2. Positioning for mothers and infants

Mothers and babies find a wide range of positions that are comfortable and effective, and mothers should be encouraged to experiment and find their preferred positions. It is important to support mothers in using the principles of body mechanics to be comfortable while feeding. Using pillows for support can be helpful.

3. How babies latch

At birth, many babies latch unassisted on to the breast while the mother is in a recumbent position, as a result of the infant’s rooting reflex, which may influence breastfeeding.Footnote 127 Some mothers also find this position effective postpartum if their baby is having difficulty attaching to the breast. Other mothers prefer to sit up using a conventional cradle, modified cradle, or football (clutch) position. With practice, mothers often find lying on their side enables them to rest while they feed. Initially, mothers may appreciate help in assisting their baby to latch in this position.

A variety of latching techniques are described in the literature, and mothers should be encouraged to find what works for them.Footnote 128 General principles include:

  • If the mother is using 1 hand to support her breast from underneath, her fingers should be away from the areola so they do not get in the way of the infant attaching to the breast.
  • Dress the infant in a diaper only or light clothing, i.e. not wrapped in a blanket.
  • The infant should be as close as possible to the mother, with their ventral surface against the mother (“chest to chest and tummy to tummy”) and the head and shoulders supported with the baby’s nose level with the mother’s nipple.Footnote 54
  • The infant’s head should be slightly extended with the chin touching the breast.Footnote 129
  • Encourage the mother to wait until the infant opens their mouth as wide as a yawn.
  • Avoid putting pressure on the infant’s head or forcing the infant on to the breast.
  • The mother should aim the nipple slightly toward the roof (soft palate) of the baby’s mouth.Footnote 128
  • The infant’s nose may be close to the breast as this does not usually impede breathing. Some mothers with large soft breasts may find it helpful to tuck the infants bottom closer to her body, which will bring the infant’s head back and ensure the airway is free.

4. Effective feeding

HCPs can support mothers to learn to recognize how well their infants are feeding. When babies are well-positioned on the breast, their cheeks appear full and their mouth is wide open. The infant will suck with brief pauses between bursts of sucking and does not easily slide off the breast. At the end of the feeding, the nipple is not distorted when released. While most mothers experience some nipple soreness in the first week, breastfeeding should not be painful.Footnote 130 When feeding well, infants exhibit signs of milk transfer: sounds of swallowing, satiety following feedings, appropriate output (stool and urine), and appropriate weight loss in the first 72 hours with subsequent weight gain.

5. Hand expression

There is limited evidence that any 1 type (hand, manual or electric pump) to express breast milk is better than another, yet women should be taught to hand express as it is always readily available and there is reduced potential for microbial contamination if a pump cannot be easily cleaned.Footnote 36 It is important that all mothers learn to hand express their colostrum or milk.Footnote 34Footnote 131Footnote 132 Hand expression helps to:

  • Entice a sleepy baby to feed;
  • Collect colostrum for infants who require extra milk (late preterm infants or infants unable to feed effectively);
  • Stimulate the breasts;
  • Express colostrum onto tender or sore nipples;
  • Relieve fullness of breasts or engorgement; and
  • Collect milk for later use.

Encouraging mothers to hand express early and often enables them to practice this skill and become more comfortable with their breasts.

Teaching mothers that they can express milk by hand may diminish the growing perception that all breastfeeding women need breastmilk pumps. One study found that mothers with initial breastfeeding difficulties who hand expressed were more likely to be breastfeeding at 3 months than those who used pumps.Footnote 133

Tips for teaching hand expressionFootnote 134

Teach women to:

  • Expect that it will take practice and they may not express much milk the first few times.
  • Wash their hands and get comfortable.
  • Have a clean cup, bowl or jar ready to catch the milk.
  • Gently massage their breast. The let-down reflex may be stimulated by gently touching/massaging the nipple.
  • Put their fingers on the bottom and thumb on the top at the outer edge of the areola, in the shape of the letter C.
  • Push their thumb and fingers back towards their chest and squeeze their fingers and thumb together.
  • Press and release, repeat the movement on their breast.
  • Adjust their technique to find what works for them.
  • Catch the milk in a clean cup, bowl or jar.
  • Move their fingers around the areola in a circle to express from different parts of their breast.
  • Switch between breasts every few minutes. 

There has been little research on the best techniques for hand expression, and mothers are encouraged to experiment with techniques to learn what works for them.Footnote 135 See the Perinatal Services BC Breastfeeding Healthy Term Infant guideline for guidance on hand expression.Footnote 54

Key Skills for Health Care Providers

Fundamental skills for HCPs include breastfeeding assessment and knowing the key skills for mothers described above and how to teach those skills. Effective teaching/counselling helps mothers become increasingly confident in their ability to understand their infant’s cues, feed their baby, and recognize the signs that their infant is feeding well.

1. Feeding assessment

Feeding assessments require knowing the normal changes that mothers and infants go through and the feeding relationship – and how each of these parameters changes with time. Perinatal Services BC Breastfeeding Healthy Term Infants guideline has recommendations on breastfeeding assessment and discharge criteria.Footnote 54

As the length of hospital stay for mothers and infants varies from just a few hours to 72 hours or more, appropriate follow-up after discharge, including breastfeeding assessment by a skilled HCP, is essential. The Society of Obstetricians and Gynaecologists of Canada (SOGC) recommends that all mothers and infants be assessed by an HCP within 48 hours of discharge from a hospital or birthing centre.Footnote 136 The CPS gives recommendations on newborn surveillance related to breastfeeding and jaundice in their Guidelines for Detection, Management and Prevention of Hyperbilirubinemia in Term and Late Preterm Newborn Infants.Footnote 137

Several tools exist for breastfeeding assessment; however, clinically relevant, reliable and valid tools have yet to be developed.Footnote 138 If breastfeeding assessment tools are used, additional assessment parameters must also be applied by HCPs to ensure effective feeding and milk transfer: elimination pattern, infant weight, and growth.Footnote 138 Test weighing may be helpful in some clinical settings but should not be part of a routine assessment. A complete feeding assessment should include all 3 components of the breastfeeding relationship: mother, baby, and feeding.

  • Mother: Breast changes that begin during pregnancy continue as milk production (lactogenesis II) increases. Breast fullness usually occurs within 72 hours of giving birth, but may be delayed in primiparous women or women with caesarean births. Lactogenesis that occurs later than 96 hours after birth is considered delayed.Footnote 139 Assessment of the mother includes reviewing history relevant to breastfeeding, for example, hormonal issues; breast changes during pregnancy and appearance of breasts and nipples (including breast filling, nipple variations or anomalies that make latch difficult, nipple damage); previous breastfeeding experience(s); breast surgery; postpartum hemorrhage; and separation of mother and baby.

    Health conditions that may impact breastfeeding are outlined in Appendix B.

Increasing Milk Production

Medications to increase milk production

The usefulness of medications to increase breastmilk production (galactagogues) is unclear. The Academy of Breastfeeding Medicine recommends that medicinal galactagogues be considered only after other modifiable barriers have been addressed and mothers have been provided with ample support and strategies to enhance milk production.Footnote 140

Traditional foods as galactagogues

Most cultures use a variety of foods or herbal products for breastfeeding mothers – many to help increase milk. Families that use traditional foods to increase milk productions need to be respected in their decision, as they may help to relax the mother and give her confidence.

However, in spite of a long history of the use of herbs, there is a lack of evidence of the safety and effectiveness of herbal galactagogues.Footnote 128 Herbal preparations lack standardization, regulation, and evidence as to their efficacy and should be used with caution.

  • Baby: History relevant to breastfeeding (birth trauma, separation from mother); overall health; gestational age; physical appearance (tone, colour); hydration and elimination patterns; oral anatomy; behaviour (alertness for feeding, cueing to feed at least 8 times in 24 hours); and  pattern of weight loss and gain.
Infant urine and stool output on days 1–28 post birthFootnote 54
Infant age in days Voids Stools
1 1 or more wet, clear, pale, yellow 1 or more meconium
2–3 2–3 wet, clear, pale, yellow 1 or more meconium or greenish brown transition stools
3–5 3–5 wet, clear, pale, yellow 3–4 transition stools changing to loose, yellow
5–7 4–6 wet, clear, pale, yellow 3–6 yellow or golden, generally loose
7–28 Frequent and clear pale yellow 5–10+ yellow
  • Research on elimination patterns in the first few days is inconsistent.Footnote 138 Stooling rather than voiding may indicate sufficient milk intake more reliably.Footnote 141 In the first few days, the amount of urine may be small and it may be concentrated, with uric acid crystals that appear as brick-red staining in the diaper. By day 3, when the milk supply increases, more urine is produced (diapers are heavier) and it becomes paler, with no uric acid crystals.
  • Three or fewer stools on day 4 post birth in combination with delayed lactogenesis requires further assessment and monitoring.Footnote 142
  • Feeding: Frequency (newborns typically feed at least 8 times in 24 hours after the first 24 hours); effectiveness (active sucking: rapid sucking that slows and becomes deeper, infant is firmly attached and cannot easily be removed from the breast, mother’s nipple everts but is not distorted or damaged when the infant releases the nipple); signs of milk transfer (sounds of swallowing, satiety following feedings, appropriate output, and weight loss and gain); and mother is comfortable and experiences only transient if any nipple pain.

2. Infant weight loss and expected gain

In the first two weeks, newborns experience normal weight decline and recover, provided they are feeding well.Footnote 2 Milk intake in the first 24 hours varies by newborn from 15cc +/- 11 cc.Footnote 143 A newborn’s stomach capacity gradually increases over the first 3 days of life.Footnote 144 The exact parameters of weight loss and gain remain unclear, but a typical weight loss of an exclusively breastfed infant can be 6–8% of their birth weight by 3 days after birth.Footnote 137 Loss of greater than 7-10% in the first 4 postpartum days indicates a need for close assessment and possible intervention.Footnote 54 From day 4 onward, weight gain of approximately 20-35g per day during the first 2 months of life should continue.Footnote 13Footnote 145 CPS recommends that an infant who loses more than 10% of their birth weight be carefully assessed by an HCP experienced in supporting breastfeeding mothers.Footnote 137

The CPS, College of Family Physicians, Community Health Nurses of Canada and Dietitians of Canada recommend using the WHO growth charts to monitor infant and child growth.Footnote 146

3. Interventions to support breastfeeding and overcoming challenges

Time, support, and patience resolve most breastfeeding concerns. Common problems in the early postpartum days include an infant who is unable to latch or feed effectively, sore nipples, engorgement, and insufficient milk or, more likely, mistaken perceptions of insufficient milk.

When families are struggling with feeding issues, plans for overcoming challenges should be simple, easily understood, and manageable by the family. There are 3 guiding principles:

  • the breasts need stimulation and milk removal (milk production);
  • the infant needs food (milk transfer);
  • time and support enables most infants to feed well at the breast.

These principles apply regardless of the age of the infant. Specific interventions may be required (such as antibiotics for mastitis, frenotomy for tongue-tie, or a brief interruption of breastfeeding for severely damaged nipples), but the basic tenets underlying interventions should include these 3 principles.

Appendix C lists common concerns with breastfeeding.

When Baby is Preterm, Late Preterm, or Ill

Preterm Infants

International work on Neo-BFHI recommends that all NICU babies room-in with their mothers; experience unrestricted skin-to-skin care and other care provided by the parent; and become fully breastfed. Breastfeeding initiation and progression should be based on the infant’s stability rather than the length of gestation or weight.Footnote 43Footnote 56Footnote 147

For preterm infants, the best outcome – sufficient milk for infants and eventual breastfeeding – is supported by skin-to-skin care, early hand expression, and breast expression. HCPs should be supporting and assisting mothers throughout. Starting expression as soon as possible, ideally within the first hour of birth, is associated with increased milk supply.Footnote 132Footnote 148Footnote 149Footnote 150 Promotion of early colostrum can increase the success and duration of feeding with breastmilk among infants in the NICU.Footnote 151 Mothers need to establish an ample volume of milk even before their preterm infant requires full feeding volumes. As a general guideline, mothers who are able to establish milk production sufficient for a full-term baby by 2 weeks are more likely to have enough milk when their preterm baby needs it. Mothers who can pump at least 500ml per 24 hours at 2 weeks postpartum are more likely to have sufficient milk for their infants.Footnote 152 Mothers may be producing enough milk for their premature infant and not recognize that their total 24-hour volume is below 500ml.

It is important to provide ongoing support for mothers as they continue to express milk for their preterm infants. See the CPS practice point Kangaroo Care for the Preterm Infant and Family for more information on the benefits of skin-to-skin care between the preterm infant and parent.Footnote 119

The Late Preterm or Near-Term Infant

The late preterm infant (34+0 through 37+6 weeks) is increasingly considered mature enough to room-in with the mother and is cared for in standard postpartum units. However, late preterm infants can exhibit characteristics of both term and preterm infants.Footnote 131Footnote 153 They are at higher risk for readmission for jaundice, excessive weight loss, and poor feeding. Careful monitoring, skin-to-skin contact, early hand expression and spoon feeding of colostrum are essential elements of care.Footnote 131Footnote 133Footnote 148 The Perinatal Services BC guideline Breastfeeding Healthy Term Infants and the CPS position statement Safe discharge of the late preterm infant offer guidance on breastfeeding the late preterm infant.Footnote 54Footnote 154

Infants in Pediatric Facilities

Establishing and maintaining breastfeeding when infants and children are ill can be challenging. Illness often affects feeding behaviours. It is important to support breastfeeding whenever the infant or child is able to, and effective milk removal if the child is unable to breastfeed. HCPs need to continually assess the mother–infant dyad to ensure that mothers have the support and assistance needed to effectively breastfeed or provide sufficient milk for their infants.

Breastfeeding When the Mother is Hospitalized

Being hospitalized postpartum – for a short or long time – for reasons other than the birth can be potentially difficult for the mother, infant, and family. If the mother’s goal is to breastfeed, hospitals need to support her in her efforts and help her maintain her milk supply through hand expressing/ pumping if feeding at the breast is interrupted. Hospital policies need to support breastfeeding by minimizing separation as much as possible; by encouraging skin-to-skin contact; by supporting and assisting with expressing/pumping; and by helping families in their time of crisis.Footnote 155 Expert lactation support may be required to assist in the selection of breastfeeding-compatible medications, if at all possible, as well as to advise on appropriate collection and storage of breastmilk being fed to the baby.

6. Supplements Only When Medically Indicated

Step 6:


  • Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated.


  • Support mothers to exclusively breastfeed for the first six months, unless supplements are medically indicated.

The Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months advocate exclusive breastfeeding for the first 6 months, and sustained for up to 2 years or longer with appropriate complementary feeding.Footnote 2Footnote 3 Exclusive breastfeeding means an infant is only fed breastmilk. No other food or liquid (not even water) is given to the infant, although exclusively breastfed infants may still receive vitamin and mineral supplements, medicines and oral rehydration solution if needed.Footnote 156 It is essential to support families in exclusive breastfeeding for the first 6 months of the infant’s life unless there is a medical need to give additional or alternative foods.

Supplemental Feeding

Supplemental feeding of newborns occurs frequently in Canadian hospitals. In 2009/10, 32% of breastfed babies were given fluids other than breastmilk (water, glucose solution, or infant formula) before being discharged from hospital.Footnote 39 Similarly, only about two-thirds of newborns in Ontario and British Columbia had been exclusively breastfeeding at discharge.Footnote 157Footnote 158

Supplemental feedings can interfere with establishing and maintaining the maternal milk supply and contribute to engorgement.Footnote 22Footnote 138 Because supplemental feedings may interfere with successful breastfeeding, it is important that HCPs support families in making informed decisions before providing or recommending supplements.

Occasionally, the infant’s medical condition may mean they require supplementation. Infants may also require supplemental feeding when, in spite of effective breastfeeding support, the mother’s milk supply is insufficient to sustain infant growth. Once supplements are started, even for short-term medical indications such as hypoglycemia, the practice tends to continue, and babies often continue to receive supplements after the medical indication has resolved.Footnote 159 If supplemental feedings are indicated, give small, physiologically appropriate amounts of breastmilk substitutes and advise families about how to withdraw the supplement once it is no longer needed.Footnote 160 It is important to assist families who provide supplemental feedings with strategies to preserve and improve the breastfeeding relationship.

Choice of Supplements

In situations when infants are not exclusively breastfed for personal, social, or medical reasons, the family requires information on breastmilk substitutes and support in choosing, safely storing, and handling these.Footnote 3 The Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months states “infants who cannot or should not be fed their mother’s breastmilk, pasteurized human milk from appropriately screened donors and commercial infant formula are suitable alternatives.”Footnote 2 Access to pasteurized breastmilk from milk banks in Canada is limited and is primarily for sick and preterm infants. Milk banks currently exist in 4 provinces: British Columbia (BC Women’s Provincial Milk Bank), Alberta (NorthernStar Mothers Milk Bank), Ontario (Rogers Hixon Ontario Human Milk Bank), and Quebec (Public Mothers’ Milk Bank). See the CPS Position statement Human Milk Banking and the Human Milk Banking Association of North America (HMBANA).Footnote 66

Increasingly, families are looking for donor milk from other mothers, a process referred to as “milk sharing.”Footnote 161 Although women have shared milk (wet nursed) throughout history, milk sharing usually occurred between relatives and close friends.Footnote 162 The use of the Internet as a vehicle for milk sharing between strangers is a relatively new practice. Concerns about sharing milk between strangers are because:Footnote 163Footnote 164

  • Infections can be transmitted through milk;
  • Home heat treatment methods do not guarantee safe milk;
  • Non-human milk has been sold as breastmilk;
  • Quality and safety of milk collection and storage;
  • Mothers are not screened to the same level as done in milk banks that follow HMBANA guidelines.

The Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months does not endorse the sharing or use of unprocessed and unscreened human milk.Footnote 2

Contraindications to Breastfeeding

Some rare conditions require replacement of human milk with an appropriate artificial substitute, for example:Footnote 15Footnote 34Footnote 165Footnote 166

In infants

  • Metabolic disorders such as classic galactosemia;

In mothers

  • Human immunodeficiency virus (HIV) infection or human T-cell lymphotrophic virus type I or II (HTLV) infection;
  • Active untreated tuberculosis;
  • Maternal medications or medical procedures that are incompatible with breastfeeding (e.g., radioisotopes, chemotherapy, etc.).

Temporary Interruptions

Most cases of maternal illnesses are compatible with breastfeeding. See the CPS practice point Maternal Infectious Diseases, Antimicrobial Therapy or Immunizations: Very Few Contraindications to Breastfeeding for recommendations to do with breastfeeding and maternal infectious diseases.Footnote 167 Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months also offers guidance on maternal infection, medication use, and natural health products while breastfeeding.Footnote 2 If a mother’s severe illness or injury prevents her from caring for her infant, families who wish to express breastmilk may require assistance from HCPs.

Substance Use

It is important that families know about the effects on breastfeeding before using alcohol, tobacco, or drugs.

  • Alcohol – Breastfeeding mothers should be advised to limit their alcohol intake because of their infant’s rapidly developing central nervous system and underdeveloped ability to metabolize alcohol. Frequent or heavy drinking can also impair the mother’s judgment and functioning.
  • Smoking –Even women who smoke should be encouraged to breastfeed. Support breastfeeding mothers to stop or reduce smoking.Footnote 2 Smoking may decrease milk production and affect infant sleep patterns.Footnote 168Footnote 169 Breastmilk itself loses many of its health benefits because of changes in its composition.Footnote 170 Second-hand smoke also increases the risk of SIDS. Encourage not smoking in the home and hand washing before touching the infant.
  • Drug Use – Women who use illicit drugs should be helped to abstain during breastfeeding. Advise women of the importance of breastfeeding and the risks drug use poses. Inform women of passage of drugs into breastmilk and the long-term potential cognitive effects on their infant.

See the Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months for guidance on alcohol, smoking, and drug use.Footnote 2

Barriers to Exclusive Breastfeeding

Among the most common reasons breastfeeding infants receive supplements is the concern that the infant is not getting enough milk and mothers’ lack of breastfeeding self-efficacy.Footnote 171Footnote 172Footnote 173 In the first few days following birth, families may perceive frequent cueing to feed, especially during the night, as an indication of insufficient breastmilk rather than the typical behaviour of the newborn who depends on frequent feeding for calories and comfort.Footnote 159 It is important to reassure families and explain about normal feeding patterns and the effect of this typical newborn behaviour on establishing maternal milk production.

It is common for infants to feed frequently, or cluster feed, during the evening, when many mothers feel their breasts are softer and that they have less milk. In addition, infants increase their frequency of feeding every few weeks as they go through growth spurts. The increased feeding frequency usually lasts 24 to 48 hours, during which time milk production increases. After the growth spurt, the infant may feed less frequently. Parents may interpret increased cueing to feed as a shortage of breastmilk. Informing families ahead of time can help families recognize this increased feeding frequency as normal infant behaviour.

Some hospitals contribute to the short duration of exclusive breastfeeding by not adhering to the Ten Steps: they do not promote skin-to-skin contact or rooming-in; and they supplement without medical indications, do not follow a cue-based feeding strategy, use pacifiers, and provide mothers with free samples of infant formula.Footnote 174

Strategies to Support Exclusive Breastfeeding

During pregnancy

  • Explore parental attitudes, values, and beliefs about breastfeeding;
  • Provide clear information about the recommendations for exclusive breastfeeding for the first 6 months, and sustained for up to 2 years or longer with appropriate complementary feeding; and
  • Discuss concerns and correct misinformation to support fully informed decisions about infant feeding.


  • Make sure the family understand the reasons for skin-to-skin contact;
  • Provide an unhurried atmosphere, leaving babies undisturbed on their mother’s chest until they finish their first feeding or for at least the first hour following birth.

Early postpartum days

  • Inform parents about normal newborn behaviour;
  • Reassure mothers and their families by providing accurate information specific to their situation;
  • Help mothers breastfeed effectively;
  • Show mothers how to hand express their milk;
  • Encourage a family member to stay overnight to help with infant care and provide support, including skin-to-skin contact;
  • Suggest soothing techniques other than pacifier use; and
  • Encourage mothers to participate in mother-to-mother (peer) support groups.

Early postpartum weeks

  • Support mothers and their families as they face breastfeeding challenges;
  • Provide anticipatory guidance about normal behaviours such as frequent cueing to feed during growth spurts and night waking;Footnote 175Footnote 176
  • Encourage families to focus on what behaviours indicate hunger, effective feeding, and satiation rather than on the number and timing of feedings;Footnote 177 and
  • Discuss strategies that involve the partner and family in caring for the infant in ways other than feeding.

If supplements are used

  • When supplements are required for a medical reason, support families to give physiologically normal amounts and help them discontinue supplementing when the medical indication has resolved;
  • Document the use of supplements – the type and volume and how it is given – and include the family in discussions about the supplements to help them make informed decisions;
  • Make sure the parents understand how to feed their infant and that they receive written information.Footnote 2

Creating a Breastfeeding Culture

Families need to feel comfortable breastfeeding their children anytime, anywhere. However, many families do not, or feel they need to cover up – a practice often rejected by the older baby. Feeling pressured to breastfeed discretely or in private contributes to early weaning.Footnote 178 If mothers request privacy, it is important that HCPs and agencies provide a comfortable environment.

7. Mother and Infant Rooming-In

Step 7:


  • Enable mothers and their infants to remain together and to practise rooming-in 24 hours a day


  • Facilitate 24-hour rooming-in for all mother–infant dyads: mothers and infants remain together.

Continuous contact between mothers and their infants enhances the stability of the newborn, breastfeeding, and their emotional bonding and attachment. In Canada, 24% of women reported that their infants spent between 1 and 5 hours outside of their rooms in the first 24 hours following birth. Another 11.2% said their infants were not in their rooms for 6 hours or longer.Footnote 49 Mothers who have had a caesarean birth are less likely to room-in with their infants (46.5%) than those who had a vaginal birth (70.9%).Footnote 49 Facilities need to develop policies and an environment that supports rooming-in, such as having a cot for a family member so they can stay overnight and help care for the mother and infant.Footnote 79

As typical hospital stays range from several hours to a few days, maximize opportunities to educate families by caring for mother and babies together and including the family. Keeping mothers and infants together for all routines (vital signs, blood tests, and assessments) optimizes the opportunity to provide information about care and feeding of the infant.

Safe Sleep

Night feedings make an important contribution to total milk intake and infants continue to feed through the night for many months.Footnote 175Footnote 179 In addition, breastfeeding is associated with lowering the risk of SIDS, and exclusive breastfeeding raises the protective effect. However, any amount of breastfeeding provides some protection compared with no breastfeeding.Footnote 180

The need to breastfeed during the night may be perceived as a conflict with recommendations against bed-sharing as a measure to reduce the incidence of SIDS.Footnote 175 It is important to reassure mothers that they can successfully breastfeed during the night without bed-sharing. HCPs need to support families in finding strategies that enable them to meet their infants' nighttime needs and get enough rest. Close proximity to the infant facilitates breastfeeding during the night, and sleeping in the same room as the parents is recommended for the first 6 months.Footnote 181

While PHAC's Joint Statement on Safe Sleep: Preventing Sudden Infant Deaths in Canada does not discuss swaddling, the Registered Nurses' Association of Ontario guidelines Working with Families to Promote Safe Sleep for Infants 0–12 Months of Age highlights concerns with swaddling.Footnote 181Footnote 182

8. Cue-Based Feeding

Step 8:


  • Support mothers to recognize and respond to their infants’ cues for feeding.


  • Encourage responsive, cue-based feeding.
  • Encourage sustained breastfeeding beyond six months with appropriate introduction of complementary foods.

Cue-based, Responsive Feeding

In Canada, half (49.8%) of all mothers reported feeding their infants on cue in the first week following birth.Footnote 49 Frequent, unrestricted breastfeeding is associated with successful breastfeeding.Footnote 183 Feeding on cue supports the demand-and-supply basis of establishing breastmilk production and flow. Timed, restricted, or delayed feedings should be avoided.Footnote 179 With cue-based or infant-led feeding, the mother learns to recognize and respond to her infant’s signals about their appetite, hunger, and fullness.Footnote 2

HCPs need to support new parents in identifying and responding to infant feeding cues – restlessness, rooting, or sucking on a hand – and in identifying signs that their infant is receiving sufficient breastmilk.Footnote 2 Feeding cues can be subtle, and babies who are tightly wrapped or swaddled are less likely to show these cues.Footnote 121 Responsive feeding recognizes that successful breastfeeding is a sensitive, reciprocal relationship between a mother and her child. Breastfeeds can be long or short, and breastfed babies cannot be overfed or spoiled by too much feeding.Footnote 37

Infants who are fed when they are hungry, and who suckle effectively, will obtain what they need for satisfactory growth. Infant-led breastfeeding encourages self-regulation.Footnote 184

To encourage mothers to breastfeed on cue, it is important to avoid setting limits on the number of feedings infants should have in a 24-hour period. In the early postpartum period when families are looking for guidance, language such as “offer the breast at least 8 times in 24 hours” is more appropriate than limits such as “feed every 3 hours” or “8–12 times a day,” as infants exhibit a wide range of frequency of feedings.Footnote 179

Addition of Solid Foods

Exclusive breastfeeding provides the nutrients most healthy infants need until they are 6 months old. The infant may be ready for complementary foods a few weeks before the 6-month mark or just after. The Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months recommends that HCPs and families consider the infant’s signs of readiness before introducing complementary foods.Footnote 2 The signs of physiological and developmental readiness for complementary foods include:Footnote 2Footnote 185

  • Better head control;
  • Ability to sit up and lean forward;
  • Ability to let the caregiver know when they are full (e.g., turns head away); and
  • Ability to pick up food and try to put it in their mouth.

The first complementary foods to introduce include iron-rich foods, such as meat, meat alternatives (e.g., eggs, tofu, and legumes), and iron-fortified infant cereals.Footnote 3 For further guidance on the introduction of complementary foods, see Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months and Nutrition for Healthy Term Infants: Recommendations from Six to 24 Months.Footnote 3

The principles of cue-based feeding apply when other foods are added to the diet, and are not confined to one stage of infant or child development. Responsive feeding means that a parent or caregiver responds in a prompt, emotionally supportive, and developmentally appropriate manner to the child’s hunger and satiety cues.Footnote 186

Supporting Sustained Breastfeeding of the Older Infant and Young Child

Breastfeeding is also an important source of nutrition for the older infant and young child. Breastfeeding can provide 50% or more of the energy needs of the infant aged 6 months to 1 year, with other foods supplying the remainder.Footnote 187Footnote 188 One-third of the 12- to 24-month-old toddler’s energy needs can come from breastmilk.Footnote 188Footnote 189 In addition, the act of breastfeeding is comforting to the child.

Many mothers continue to breastfeed because they believe it enhances their relationship with their child.Footnote 190 Breastfeeding beyond infancy and well into toddlerhood is common in many cultures.

In 2011/12, the rate of breastfeeding beyond the baby’s first year of life was 19%.Footnote 3 Although the reasons for earlier weaning are multifactorial, lack of knowledge about the value of prolonged breastfeeding and the lack of support for mothers breastfeeding older infants and toddlers are contributing factors. Mothers who continue to breastfeed into toddlerhood may face negative attitudes and criticism, and be reluctant to say they are still breastfeeding, a practice called closet nursing.Footnote 2Footnote 128Footnote 191Footnote 192

Increased public awareness of the importance of breastfeeding beyond infancy, including by visually representing breastfeeding toddlers, facilitates sustained breastfeeding. Sustained or long-term breastfeeding must be destigmatized and normalized, with education targeted at the public and HCPs rather than focusing on the mothers themselves.Footnote 191

If a breastfeeding mother becomes pregnant, encourage her to continue and reassure her that breastfeeding is not contraindicated during pregnancy unless the mother is not gaining enough weight, there is unexplained vaginal bleeding, or there is a risk of premature labour. The Nutrition for Healthy Term Infants: Recommendations from Six to 24 Months has strategies for encouraging sustained breastfeeding.Footnote 3


Weaning practices are largely culturally determined. In many countries, breastfeeding continues for 2 years or longer.Footnote 128Footnote 193 One anthropological analysis of when humans would wean based on physiology alone rather than culture suggested that the physiological age of weaning is between 2.5 and 7 years.Footnote 193

For some families, weaning is the natural progression from exclusive breastfeeding, to the addition of other foods and liquids to the infant’s diet while they continue to breastfeed, until the child no longer breastfeeds. For other families, weaning is the intentional replacement of breastfeeding with other fluids (often human milk substitutes) and solid foods. This weaning strategy can be done very quickly (e.g., the mother requires long-term use of medication or treatment where breastfeeding is contraindicated) or over a longer period of time. Ideally, the process is done as slowly as possible to allow the mother’s body and for the infant to adjust. Mothers may be surprised by the feelings of sadness and loss they experience at the end of the breastfeeding relationship and the hormonal shift that occurs.Footnote 194 Weaning may also be unintentional such as because the infant refuses to breastfeed. Refusing to breastfeed can occur for many reasons and is usually temporary and can be resolved.Footnote 195 Informing families ahead of time that infants can have nursing strikes and how to resolve these, can support families in continuing sustained breastfeeding.

It is important that HCPs provide families with information to make informed decisions about weaning. See the CPS position statement Weaning from the Breast.Footnote 195

Working and Breastfeeding

Women have always skilfully combined parenting, breastfeeding, and working. Breastfeeding and working only became problematic when the places of employment separated mothers and young children. Families with children benefit from community support wherever mothers work, be it at home or away.

Canadian women have the right to breastfeed their children. “For children breastfeeding provides the highest attainable standard of health; a basic human right. For women, the right to breastfeed in public and the right to be accommodated by the employer or educational institution to continue to breastfeed on returning to work or school is a human right.”Footnote 196 Accommodations in the work environment must consider the needs of breastfeeding mothers.Footnote 197 Unsupportive workplaces could be in violation of the Canadian Charter of Rights and Freedoms and of provincial human rights legislation/policies.

Evidence shows that women can successfully work or go to school and breastfeed, although support from the work or school environment is essential.Footnote 198Footnote 199Footnote 200 HCPs also need to provide guidance and support breastfeeding mothers returning to work or school to facilitate this transition.

Breastfeeding and Human RightsFootnote 197Footnote 201Footnote 202Footnote 203Footnote 204

Canadian women have the right to breastfeed their children wherever women have the right to be, including in the work environment. International and national statements affirm this right:

  • United Nations Convention on the Rights of the Child: Article 24, relating to health and health services, “Children have the right to good quality health care – the best health care possible – to safe drinking water, nutritious food, a clean and safe environment, and information to help them stay healthy.”
  • Global Strategy for Infant and Young Child Feeding (GSIYCF): Governments should enact imaginative legislation protecting the breastfeeding rights of working women and establishing means for its enforcement in accordance with international labour standards. The Operational Targets for GSIYCF were reaffirmed by the Innocenti Declaration 2005.
  • Canadian Charter of Rights and Freedoms: The Charter includes the equality rights of women.  Furthermore, the Canadian Human Rights Act prohibits discrimination related to pregnancy. Pregnancy-related discrimination is considered a form of sex discrimination, because only women can become pregnant (by extension, only women can breastfeed).
  • The Canadian Human Rights Commission Policy on Pregnancy and Human Rights in the Workplace states that: “Women in the workplace are valued employees entitled to equality, dignity, respect and accommodation of their needs when they are attempting to become pregnant, while they are pregnant and as they return to work following a pregnancy-related absence.”
  • The Policy on Pregnancy & Human Rights in the Workplace identifies best practices such as flexible start times to deal with breastfeeding schedules; allowing women to breastfeed their babies during a work visit; longer or extra breaks; and a private place to breastfeed or express milk. Upon return to work, in order to support breastfeeding, women “who breastfeed or express/pump breastmilk should be provided with accommodation for this purpose, including providing a suitable clean place to breastfeed or express milk and to store milk; providing longer or extra breaks for the purpose of breastfeeding or expressing milk; allowing for the extension of maternity leave and allowing for alternative work arrangements.”

9. Artificial Teats or Soothers

Step 9:


  • Counsel mothers on the use and risks of feeding bottles, teats and pacifiers.


  • Support mothers to feed and care for their breastfeeding babies without the use of artificial teats or pacifiers (dummies or soothers).

Artificial Teats

The onset of lactogenesis II, or copious milk production, depends on frequent, effective milk removal from the breasts.Footnote 192 Feeding in ways apart from breastfeeding (with donor milk or infant formula) may interfere with the supply-and-demand process of establishing milk production. Supplemental feedings, unless medically indicated, are not recommended for breastfed infants. For small amounts of supplement given for documented medical indications during the early postpartum period, spoons or small cups may be used.Footnote 54Footnote 205Footnote 206  Using these alternatives to bottles when providing supplements in the hospital is associated with increased breastfeeding duration.Footnote 160Footnote 207Footnote 208 Though research into other feeding devices is scarce, supplemental feedings can be given via a syringe, dropper, or a feeding tube at the breast.Footnote 206 Cup feeding has also been used for preterm infants during the transition from gavage (tube) feeding to full breastfeeding.Footnote 147

Studies on the effects of artificial teats on breastfeeding duration are inconclusive. The possibility of an infant imprinting on a particular type of nipple, preferring a fast flow of milk requires further research as does the possibility of nipple confusion.Footnote 192Footnote 209 Although occasional bottle use after breastfeeding has been established may not be problematic, routine use, especially when milk is not frequently removed from the breasts, may jeopardize milk production. Some families may be concerned that they need to teach their breastfeeding infant to take a bottle just in case a situation rises where the mother cannot breastfeed. Reassure the family that this is not necessary.

The Nutrition for Healthy Term Infants: Recommendations from Six to 24 Months encourages the use of an open cup when introducing liquids other than breastmilk at 6 months, and when transitioning from a bottle. HCPs are referred to the joint statement for further advice.Footnote 3


The use of pacifiers, also called soothers or dummies, varies depending on the culture, and remains controversial in Canada. Many authorities suggest using these with caution, especially in the early postpartum period before breastfeeding is established.Footnote 15Footnote 78Footnote 128Footnote 205 Routine use of pacifiers can delay breastfeeding or decrease the frequency, and interfere with breastmilk production. Some studies also link pacifier use with decreased breastfeeding duration or with breastfeeding difficulty in the first 3 months.Footnote 20Footnote 208 Other concerns include:

  • Dental and orthodontic problems;
  • Infections; and
  • Accidents and injuries.

The Joint Statement on Safe Sleep: Preventing Sudden Infant Deaths in Canada identifies a protective effect of pacifiers against SIDS.Footnote 181 The joint statement recommends delaying the introduction of a pacifier until breastfeeding is well established. The statement also recommends that infants who use a pacifier have one consistently, for every sleep.

Pacifiers may also be helpful for preterm infants during gavage feedings or painful procedures if breastfeeding is not possible.Footnote 210Footnote 211 However, minimizing the use of a pacifier is positively associated with earlier attainment of exclusive breastfeeding by preterm infants and with exclusive breastfeeding at discharge.Footnote 149Footnote 150

See the CPS guideline Recommendations for the Use of Pacifiers guideline for further recommendations on pacifiers.Footnote 212

10. Breastfeeding Support in the Community

Step 10:


  • Coordinate discharge so that parents and their infants have timely access to ongoing support and care.


  • Provide a seamless transition between the services provided by the hospital, community health services, and peer-support programs.
  • Apply principles of primary health care and population health to support the continuum of care and implement strategies that affect the broad determinants that will improve breastfeeding outcomes.

Partnerships between hospitals and community services to seamlessly transition care during pregnancy, labour, birth, and the postpartum period is essential given the short length of hospital stays and the importance of establishing breastfeeding and lactation in the first 1 to 2 weeks following birth. Collaboration between public health agencies and between HCPs (e.g., midwives, general practitioners, and pediatricians) ensures that families receive support from the most appropriate service in a timely manner, which is vital for the well-being of the baby and mother.

The BFI provides a model of community-wide care. The specifics of how continuity and seamless transition are accomplished vary, but certain essential components increase its effectiveness:Footnote 37Footnote 67Footnote 68Footnote 82

  • Support and interventions spanning pregnancy through the postpartum period;
  • Direct, skilled breastfeeding support via face-to-face home or clinic visits, and 24-hour telephone support;
  • Assessment of breastfeeding before discharge, with the provision of appropriate feeding plans;
  • Assessment of effectiveness of breastfeeding in the community, with the feeding plans in place or being adapted;
  • Strong liaison and communication between hospitals and community health facilities;
  • Presence of a community-based, interprofessional, and interagency breastfeeding committee that includes representation from hospitals, community services, public health, and peer-support groups to promote breastfeeding and provide consistent information and coordinated professional and peer-support services;
  • Multifaceted approaches that include face-to-face professional and peer support;
  • Referral to mother-to-mother (peer) support groups;
  • Written information for parents describing the signs of successful breastfeeding and where to get help;
  • Outreach to women and families who do not routinely use hospital and community services; and
  • Scheduled support so families know what is available.

Sources of Information and Support


Federal and provincial government departments, regional/local health agencies, and professional groups, are important sources of information for breastfeeding women, and these can be accessed via the Internet and social media. But because  there are plenty of sources of inaccurate information, it is helpful if agencies and HCPs direct families to credible sources and even show them how to recognize such sources when they are searching for breastfeeding information.

Telephone Helpline

Some provinces or communities have implemented specialized lactation support phone lines. For example, the Breastfeeding Hotline in Ontario provides 24/7 access to advice on breastfeeding. In some jurisdictions, public health or community agencies offer telephone support lines for breastfeeding women.

Peer Support

Breastfeeding mother-to-mother (peer) support groups emerged in the 1950s with groups such as La Leche League and Nursing Mothers of Australia (now called Australian Breastfeeding Association). These community-based organizations developed as a grass roots network of support for breastfeeding mothers. The model of mother-to-mother support also now exists in a variety of health-related organizations. Research demonstrates that peer support positively impacts the duration and exclusivity of breastfeeding, likely because it normalizes the breastfeeding experience as women learn they are not alone in their successes and challenges. Participants were satisfied with this form of support, benefitting from the sense of community and belonging.Footnote 69Footnote 82 Peer-support programs can also help connect women with important community resources, which can be particularly important for those who cannot easily access mainstream services.Footnote 213

Hospitals and community health agencies should actively support existing peer-support groups and facilitate the development of new ones. The Best Start Resource Centre has developed a useful resource to help communities develop and sustain breastfeeding peer-support programs.Footnote 214

Vulnerable Populations

Some groups of women have lower rates of breastfeeding. These include women who are younger; have lower levels of education; are living in low income situations; have little or no support from their partners, family, or friends; face cultural or societal barriers; and find accessing health care and other types of support challenging. Geographical location also makes a difference: women in the Atlantic provinces were less likely to breastfeed than those living elsewhere in Canada.Footnote 49 It is critical that vulnerable populations have support that is tailored to their needs.Footnote 215Footnote 216

A focus on support, education, intervention, and care is the best strategy for reaching women at risk of not breastfeeding or stopping breastfeeding early.Footnote 215 An example is the Canada Prenatal Nutrition Program (CPNP), a population health intervention jointly managed by the federal and provincial/territorial governments that aims to improve health outcomes for pregnant women and their newborn children facing conditions of risk. CPNP has resulted in an increased likelihood of women breastfeeding and breastfeeding for longer. The overall rate of breastfeeding initiation among CPNP participants (89%) was the same as the rate for the general Canadian population (88%) – a significant finding given the risks faced by the women in the program. Participants with high exposure to CPNP programming were 4 times more likely to breastfeed longer than those with lower program exposure.Footnote 217Footnote 218


Family-centred care creates the context for successful breastfeeding. This includes supporting early and ongoing skin-to-skin contact; mother–baby togetherness and rooming-in; family involvement; and informed decision-making about infant feeding. Regardless of the chosen feeding method families require support and education, and to be treated with respect and dignity.

Breastfeeding is recognized as the unequalled method of feeding infants, and being unparalleled with respect to supporting normal growth and development and protecting from acute and chronic illness. Health Canada, PHAC, CPS, Dietitians of Canada, and the BCC recommends that babies be breastfed exclusively for the first 6 months, and sustained for up to 2 years or longer with appropriate complementary feeding to support the nutrition, immunological protection, growth and development of infants and toddlers. This is consistent with the WHO global public health recommendation.

In Canada, breastfeeding initiation rates have significantly improved, although breastfeeding exclusivity and duration do not achieve the WHO recommendations. Breastfeeding rates also vary across the country, decreasing along a general west-to-east gradient. Breastfeeding initiation and duration increase with active protection, promotion, and support. The WHO/UNICEF BFHI evidenced-based policies and practices have been shown to improve breastfeeding outcomes – duration and exclusivity. Canada continues to work on improving breastfeeding rates across the country through ongoing research, policy development, education, and collaborations and partnerships.

Appendix A - Additional Resources

Clinical Practice Guidelines Relating to Breastfeeding

Community-based and support programs

Guides for health care providers

Hand expression

Human milk banks

Appendix B - Maternal Conditions that may Impact Breastfeeding

Postpartum Anxiety and Depression

Breastfeeding can reduce the risk of postpartum depression.Footnote 128 The release of oxytocin and prolactin during breastfeeding can bring about a sense of calm and encourage a positive mood. Breastfeeding can also reduce the mother's stress levels.Footnote 219Footnote 220Footnote 221Footnote 222

Little is known about the efficacy and safety of antipsychotic and antidepressant medications during breastfeeding.Footnote 175Footnote 223 HCPs need to consider individual medications and their effects on breastfeeding and infant health to balance the risk of exposure against the benefits of the treatment and the importance of breastfeeding.

Chronic Illness

As the average age of childbearing is increasing, a higher number of pregnant and breastfeeding women have chronic illnesses. Many chronic illnesses are exacerbated by a lack of sleep. Therefore, women require not only assistance with breastfeeding, but also practical assistance with infant and family care so that they can get adequate rest.


Approximately 9% of Canadian girls/women over the age of 12 years have asthma.Footnote 224 It may improve, worsen, or remain unchanged during pregnancy. If women have asthma or a family history of asthma, they should be encouraged to breastfeed since it has long-term protective effects on asthma for the breastfed child.Footnote 225


Since studies show that women with diabetes are less likely to initiate breastfeeding, they should be given information about the importance of breastfeeding and the necessary encouragement sooner.Footnote 226Footnote 227 Evidence indicates that lactation improves glucose metabolism in the early postpartum period.Footnote 228 Because women with gestational diabetes may have a delayed onset of lactogenesis II, they often require support from a lactation specialist.Footnote 229Footnote 230 Women who have type 1 diabetes typically have a delay in lactogenesis II of about 1 day.Footnote 231Footnote 232Footnote 233Footnote 234Footnote 235 Therefore, early frequent feedings and support are important.

As with all women and babies, breastfeeding should begin as soon as possible after birth as colostrum helps to stabilize the infant's blood sugar. Sometimes babies of mothers with type 1 diabetes require care in a NICU. Families should be encouraged to stay with the infant and mothers to hand express or pump breastmilk.Footnote 128 Increasingly, women with diabetes are expressing colostrum in the last weeks of their pregnancy to use if their infants blood sugar is low immediately after birth.Footnote 236

The physical and emotional issues for women with type 2 diabetes are similar to those with type 1 diabetes, except that their glucose control may not be as unstable during the early postpartum period.Footnote 128

Women with diabetes may be more susceptible to mastitis. They should be knowledgeable about the signs – particularly if their blood glucose is not well controlled or if any infection raises their blood glucose levels.Footnote 237Footnote 238

Thyroid Disease

Pospartum thyroid dysfunction is fairly common and includes hypothyroidism, hyperthyroidism, and postpartum thyroiditis (PPT). Most women who have thyroid disorders can continue to breastfeed with treatment.Footnote 128

If women with hypothyroidism are on replacement therapy, they need to be re-evaluated postpartum to see if any changes need to be made to their treatment. Usually, the thyroid replacement dose is reduced to the level it was before pregnancy.Footnote 239 If a woman has undiagnosed hypothyroidism postpartum, her milk supply may be reduced, but if she receives acceptable replacement therapy, her milk supply is likely to increase dramatically and her symptoms will be relieved.Footnote 128

Hyperthyroidism does not affect the ability to breastfeed. The usual treatment for hyperthyroidism is antithyroid medication.Footnote 240

Postpartum thyroiditis is the most common form of postpartum thyroid dysfunction, affecting about 7% of women in the first year postpartum. The symptoms, which may go undiagnosed, are fatigue, depression, and anxiety.

Epilepsy (Seizure Disorders)

As most seizure disorders are so well controlled with medication that seizures rarely occur, all women with epilepsy should be encouraged to breastfeed their babies.Footnote 128 If the mother does have seizures, breastfeeding is not contraindicated: the risk of harm to the infant during breastfeeding is no more likely than during bottle-feeding.


Maternal obesity is associated with lower rates of breastfeeding initiation, duration, and exclusivity. Research suggests that these lower rates of breastfeeding among obese women are due to delayed lactogenesis II, thyroid dysfunction, and psychological factors.Footnote 241 As a result, obese mothers may benefit from additional support and guidance on how to know if their infant is getting enough milk; demonstrations of different feeding positions; assistance in supporting large breasts and seeing the baby's latch; and demonstrations of reverse pressure softening around the areola to enable deeper latch. Support from a lactation consultant has been demonstrated to positively affect breastfeeding outcomes for obese women.Footnote 241

Autoimmune Disorders

Inflammatory Bowel Disease

Rates of inflammatory bowel disease (IBD) have increased with time and the highest incidence and prevalence rates are in western countries – northern Europe, Canada, and Australia.Footnote 242

While older studies on other autoimmune disorders found that breastfeeding may be associated with an increased risk for developing postpartum relapse, more recent studies found that the risk of relapse of Crohn's disease was either reduced or unchanged in mothers who were breastfeeding versus those who were not.Footnote 243Footnote 244Footnote 245

Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disease that primarily affects women of childbearing age, which means that lactation experts need to be familiar with the disease. Most women with SLE are able to breastfeed.Footnote 246 As with all conditions, treatment is based on the individual woman's needs. The safety of her medications during breastfeeding needs to be considered and balanced with the importance of breastfeeding.

Multiple Sclerosis

In most cases, the disease-modifying therapies used to treat multiple sclerosis (MS) are discontinued prior to conception or when pregnancy is diagnosed.Footnote 128 Women need to make informed decisions regarding what medications to take postpartum and infant feeding choices. The evidence on the impact of breastfeeding on postpartum exacerbations of MS is mixed, but a recent study found that mothers with MS who exclusively breastfed their babies for the first 2 months postpartum increased their well-being and had a reprieve from their illness for 6 months.Footnote 247

While more research is needed on the impact of breastfeeding on the risk of relapse, a woman with MS must be given evidence-based information so that she can choose what is right for her and so that support is tailored to her needs.Footnote 128

Rheumatoid Arthritis

It is common for women with rheumatoid arthritis (RA) to have their symptoms go into remission during pregnancy and then to relapse postpartum.Footnote 128 This occurs more often with breastfeeding mothers, most likely due to their hyperprolactinemic condition (prolactin has been shown to act as an immunostimulator).Footnote 248Footnote 249 Limited and largely older studies exist about the experiences of women with RA and breastfeeding. Breastfeeding women with RA can feel very fatigued and while they need rest, they also need continued range-of-motion exercises.Footnote 250 Lactation experts can help support women with RA to meet their individual needs and consult with her care team to ensure she has individualized care.

Women with Physical Disabilities

Support for breastfeeding by women with disabilities should be based on their individual goals and abilities. A normalized approach to the care of mothers and babies and appropriate assessment are essential for families. Women's experiences enhance their ability to problem-solve creatively.Footnote 128 Breastfeeding is an important confidence and self-esteem booster for all women, confirming their body's ability to nourish her infant.

Many women with spinal cord injuries breastfeed without difficulties. However, the higher and more complete the injury, the more likely difficulties will occur. The physical ability of the breasts to function normally will become apparent over time during early postpartum.  Family and other support are essential to assist mothers with their own physical needs as well as the needs of their infants. HCPs can help mothers define their own breastfeeding success given their sensory completeness and mobility.

Women with disabilities often find breastfeeding more convenient than bottle-feeding. However, there may be stigma associated women with disabilities breastfeeding. HCPs may need education and families and mothers support in overcoming any challenges and breastfeed effectively. Peer support from other women with disabilities can often be helpful for the breastfeeding mother.

Appendix C - Common Breastfeeding Concerns

Nipple Pain

There is widespread clinical consensus on the importance of effective position and latch technique in preventing and resolving sore nipples.Footnote 251Footnote 252 Despite the plethora of pharmacological and non-pharmacological treatments and devices for sore or damaged nipples, there is little evidence of their effectiveness. Applying no treatment or expressing breastmilk may be equally or more beneficial than applying an ointment.Footnote 251 In fact, there is evidence that several nipple treatments, such as occlusive dressings and hydrogel dressings, are potentially harmful and should be avoided.

Applying expressed breastmilk to the sore nipple before and after every feeding may help to prevent or hasten healing of sore nipples.Footnote 252 Given the availability of breastmilk in breastfeeding women, the lack of cost, the biological components, and the widespread endorsement of breastfeeding by international bodies such as WHO and UNICEF, this may be the optimum treatment.

It is important to examine the infant’s mouth. If the lingual frenulum is attached to the anterior portion of the tongue, the mobility of the tongue may be restricted, causing nipple damage. There is no standard definition or assessment technique to diagnose tongue-tie (ankyloglossia).Footnote 253 The CPS statement, Ankyloglossia and Breastfeeding, recommends a frenotomy only if significant tongue-tie is associated with major breastfeeding difficulties.Footnote 253

Mammary candidiasis, a yeast infection of the nipple, can also lead to nipple pain. Caused by Candida albicans, a normal constituent of the gut microbiota in 80% of the population, this symbiotic organism can become invasive given the right conditions. The risk factors for mammary candidiasis include antibiotic use, a history of vaginal yeast infections, and thrush or a monilial diaper rash in the child.Footnote 254Footnote 255

The most common symptom of candidiasis is burning, deep, or sharp pain in the affected breast that is out of proportion to any physical finding. The pain can radiate along the T4 dermatome around the body to the base of the scapula. Physical findings are erythema with lichenification, or flaking, of the central areola. The erythema has a sharp active edge and does not typically extend beyond the area of the baby’s latch. Secondary bacterial infection can develop. Diagnosis is clinical as C. albicans is difficult to culture in breastmilk; the lactoferrin in breastmilk inhibits the growth of C. albicans.Footnote 256 Careful consideration of other causes of nipple pain, including vasospasm or Raynaud’s phenomenon, and local nipple trauma should be ruled out before treatment with antifungal agents.Footnote 257

Depending on the severity, mammary candidiasis may clear up on its own. Treatment options can include antifungal ointment, cream, or gel on the nipples or in the infant’s mouth, or maternal oral antifungal medications in resistant cases. Pain medication may be used with severe symptoms.Footnote 258 As C. albicans is common on skin and in the gut, there is no need to discard milk that was pumped prior to treatment.Footnote 259


Breast fullness at around the third day postpartum is a reassuring sign of normal lactation. About two-thirds of women experience at least moderate signs of engorgement or swelling and distension of the breasts, usually between the third and fifth day postpartum.Footnote 192 Frequent, effective feeding (or milk removal) and breast massage may minimize severe symptoms.

With engorgement, “the breast is enlarged, painful, shiny and edematous with diffuse red areas. The nipple may be effaced, milk often does not flow easily, and the infant can have difficulties latching. Contributing factors include delayed breastfeeding initiation, infrequent or time-restricted feedings, supplementation, inefficient infant latch, breast surgery, or any situation where milk stasis occurs.”Footnote 54

Prevention and treatment of engorgement is important as unrelieved engorgement can decrease milk production and cause involution of the breast tissue. The most effective prevention and treatment of engorgement is effective breastfeeding.

Plugged Ducts

Plugged or blocked ducts are usually seen as a tender area of local engorgement or palpable lump. They are often associated with missed feedings, pressure from restricting clothing, and an overabundant milk supply.Footnote 54

Care for plugged ducts can include warm compresses prior to breastfeeding, breast massage before and during feeding, breastfeeding often and starting with the affected breast, avoid missing feedings, and not wearing tight clothes/bras.Footnote 54


Mastitis is characterized by localized tenderness, redness, heat, and systemic symptoms of fever, malaise, and occasionally nausea and vomiting.Footnote 192 Onset is usually within the first 6 weeks postpartum, but can occur at any point during lactation. “Technically, mastitis is an inflammation of the breast, which may or may not involve an infection. It is not uncommon for the problem to start with engorgement, then become noninfective mastitis, followed by infective mastitis.”Footnote 192

Mastitis can also be a precursor to abscess formation. In this case, the clinical symptoms of mastitis improve but a tender mass develops. Once the mass is fluctuant, generally within 1 week, treatment is with needle aspiration, ideally under ultrasound guidance. Patients who do not respond to aspiration may require surgery.Footnote 260

Comparison of engorgement, plugged ducts, and mastitisFootnote 54Footnote 128Footnote 192Footnote 257
Symptom Engorgement Plugged duct Mastitis
Onset Gradual, usually 3–5 days postpartum or with sudden cessation of breastfeeding or pumping. Gradual – usually over a few hours. Sudden after 8–10 days.
Site Bilateral Unilateral Usually unilateral, can be bilateral with group strep
Swelling and heat Generalized warmth and fullness; painful, shiny, and edematous with diffuse red areas. The nipple may be effaced, milk often does not flow easily, and the infant can have difficulties latching.   Localized, red, hot, swollen. Can involve part of or all of the breast. Erythema and pain are present. Can be accompanied by induration or an inflammatory mass.
Pain Generalized Mild, localized Intense but localized
Body temperature <38.4 ᵒC <38.4 ᵒC Associated with a fever >38.4 ᵒC
Systemic symptoms Feels well Feels well Flu-like symptoms
Cause Infrequent or ineffective feedings, unnecessary supplements, or any conditions causing milk stasis. Specific cause is unknown but may be due to inadequate draining of the breasts (possibly because of missed feedings, restricting clothing, or an overabundant milk supply). Sore damaged nipples or inadequate draining of breasts.
Treatment Continue breastfeeding. A warm shower or compresses or breast soaks before breastfeeding may facilitate the milk ejection reflex.
Massaging the breast gently and hand express breastmilk or colostrum to soften the areola and facilitate latch before breastfeeding.
Cold compresses between feedings reduces edema and can provide comfort.
Frequent breastfeeding, starting with the engorged breast, may provide relief.
Anti-inflammatory medications compatible with breastfeeding may be required.Footnote 54
Continue breastfeeding. Different feeding positions, such as having the infant's chin or nose towards the blocked area plus frequent effective feeding and hand expressing if necessary.
Massaging the area of the plugged duct after feedings.
Rule out the presence of a milk blister or pimple on the surface of the nipple. In extreme cases, the blister can be drained.
Continue breastfeeding. If breastfeeding is too painful, hand express or use a breast pump
Start breastfeeding on the affected side. If this side is too painful, start on the unaffected side until milk let-down and then switch.
Recurrence in the same location warrants further evaluation to rule out an underlying mass or other abnormality.


It is important to understand the interaction between jaundice and breastfeeding. Infants who become jaundiced may feed poorly and, conversely, infants who feed poorly are at risk of becoming jaundiced (“starvation jaundice” of the newborn or breast non-feeding jaundice).128 All jaundiced infants should be carefully assessed by experienced HCPs to determine the cause and if therapy is required.

When phototherapy is required, most babies can be treated at the mother’s bedside – mothers and babies should remain together as much as possible to ensure breastfeeding is not compromised as the CPS recommends that breastfeeding continue during phototherapy.3,137 If the infant is not breastfeeding effectively, it is important to support the mother in expressing/pumping her milk for the baby. Similarly, if babies are readmitted, mothers should be accommodated to stay with their baby to encourage continued breastfeeding.

The CPS Guidelines for Detection, Management and Prevention of Hyperbilirubinemia in Term and Late Preterm Newborn Infants and Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months offer recommendation on assessing and monitoring infants.2,137


Footnote 1

World Health Organization. Global strategy for infant and young child feeding [Internet]. Geneva (CH): WHO; 2003 [cited 2018 May 1]. Available from:;jsessionid=CE1022E8F58B7C57F1A85F340B05ED8C?sequence=1

Return to footnote 1 referrer

Footnote 2

Health Canada, Canadian Paediatric Society, Dietitians of Canada, Breastfeeding Committee for Canada. Nutrition for healthy term infants: recommendations from birth to six months [Internet]. Ottawa (ON): HC; 2012 [cited 2018 May 2]. Available from:

Return to footnote 2 referrer

Footnote 3

Health Canada, Canadian Paediatric Society, Dietitians of Canada, Breastfeeding Committee for Canada. Nutrition for healthy term infants: recommendations from six to 24 months [Internet]. Ottawa (ON): HC; 2014 [cited 2018 May 2]. Available from:

Return to footnote 3 referrer

Footnote 4

Victora C, Bahl R, Barros A, França G, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475-90.

Return to footnote 4 referrer

Footnote 5

Kramer M, Aboud F, Mironova E, Vanilovich I, Platt R, Matush L, et al. Breastfeeding and child cognitive development: new evidence from a large randomized trial. Arch Gen Psychiatry. 2008;65(5):578-84.

Return to footnote 5 referrer

Footnote 6

Quigley M, Hockley C, Carson C, Kelly Y, Renfrew M, Sacker A. Breastfeeding is associated with improved child cognitive development: a population-based cohort study. J Pediatr. 2012;160(1):25-32.

Return to footnote 6 referrer

Footnote 7

Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evid Rep Technol Assess (Full Rep). 2007(153):1-186.

Return to footnote 7 referrer

Footnote 8

Arenz S, Rückerl R, Koletzko B, Von Kries R. Breast-feeding and childhood obesity-a systematic review. Int J Obes. 2004;28(10):1247-56.

Return to footnote 8 referrer

Footnote 9

Hauck F, Thompson J, Tanabe K, Moon R, Vennemann M. Breastfeeding and reduced risk of sudden infant death syndrome: A meta-analysis. Pediatrics. 2011;128(1):103-110.

Return to footnote 9 referrer

Footnote 10

Newcomb P, Storer B, Longnecker M, Mittendorf R, Greenberg E, Clapp R, et al. Lactation and a reduced risk of premenopausal breast cancer. N Engl J Med. 1994;330(2):81-7.

Return to footnote 10 referrer

Footnote 11

Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50 302 women with breast cancer and 96 973 women without the disease. Lancet. 2002;360(9328):187-95.

Return to footnote 11 referrer

Footnote 12

Rosenblatt K, Thomas D, The WHO Collaborative Study of Neoplasia and Steroid Contraceptives. Lactation and the risk of epithelial ovarian cancer. Int J Epidemiol. 1993;22(2):192-7.

Return to footnote 12 referrer

Footnote 13

Dewey KG, Heinig MJ, Nommsen LA. Maternal weight-loss patterns during prolonged lactation. Am J Clin Nutr. 1993;58(2):162-6.

Return to footnote 13 referrer

Footnote 14

Ball TM, Wright AL. Health care costs of formula-feeding in the first year of life. Pediatrics. 1999;103(4):870-6.

Return to footnote 14 referrer

Footnote 15

American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-41.

Return to footnote 15 referrer

Footnote 16

U.S. Department of Health and Human Services. The importance of breastfeeding. In: The Surgeon General's call to action to support breastfeeding [Internet]. Rockville (MD): Office of the Surgeon General; 2011 [cited 2018 May 14]. p. 1-5. Available from:

Return to footnote 16 referrer

Footnote 17

Maclean H, Millar WJ. Breastfeeding practices [Internet]. Ottawa (ON): Statistics Canada; 2005 [cited 2018 May 14]. 54p. Cat. No.: 82-003. Available from:

Return to footnote 17 referrer

Footnote 18

Statistics Canada. CANSIM (database) [Internet]. Ottawa (ON): SC; 2018 [cited 2018 May 18]. Table 105-0509 Canadian health characteristics, two year period estimates, by age group and sex, Canada, provinces, territories and health regions. Available from:

Return to footnote 18 referrer

Footnote 19

Gionet, L. Health at a glance: Breastfeeding trends in Canada (82-624-X) [Internet]. Ottawa (ON): Statistics Canada; 2015 [cited 2018 May 15]. Available from:

Return to footnote 19 referrer

Footnote 20

Kramer MS, Chalmers B, Hodnett ED, Sevkovskaya Z, Dzikovich I, Shapiro S, et al. Promotion of breastfeeding intervention trial (PROBIT): a randomized trial in the Republic of Belarus. JAMA. 2001;285(4):413-20.

Return to footnote 20 referrer

Footnote 21

Merten S, Dratva J, Ackermann-Liebrich U. Do baby-friendly hospitals influence breastfeeding duration on a national level? Pediatrics. 2005;116(5):e702-8.

Return to footnote 21 referrer

Footnote 22

DiGirolamo AM, Grummer-Strawn LM, Fein SB. Effect of maternity-care practices on breastfeeding. Pediatrics. 2008;122(Suppl 2):S43-9.

Return to footnote 22 referrer

Footnote 23

Chung M, Raman G, Trikalinos T, Lau J, Ip S. Interventions in primary care to promote breastfeeding: an evidence review for the U.S. preventive services task force. Ann Intern Med. 2008;149(8):565-82.

Return to footnote 23 referrer

Footnote 24

Declercq E, Labbok MH, Sakala C, O'Hara M. Hospital practices and women's likelihood of fulfilling their intention to exclusively breastfeed. Am J Public Health. 2009;99(5):929-35.

Return to footnote 24 referrer

Footnote 25

Moore ER, Bergman N, Anderson GC, Medley N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2016;2016(11):CD003519.

Return to footnote 25 referrer

Footnote 26

Cattaneo A, Buzzetti R. Quality improvement report: effect on rates of breast feeding of training for the Baby Friendly Hospital Initiative. Br Med J. 2001;323(7325):1358-62.

Return to footnote 26 referrer

Footnote 27

Dall'Oglio I, Salvatori G, Bonci E, Nantini B, D'Agostino G, Dotta A. Breastfeeding promotion in neonatal intensive care unit: impact of a new program toward a BFHI for high-risk infants. Acta Paediatr. 2007;96(11):1626-31.

Return to footnote 27 referrer

Footnote 28

Hofvander Y. Breastfeeding and the Baby Friendly Hospitals Initiative (BFHI): organization, response and outcome in Sweden and other countries. Acta Paediatr. 2005;94(8):1012-6.

Return to footnote 28 referrer

Footnote 29

Bartington S, Griffiths LJ, Tate AR, Dezateux C, Millennium Cohort Study Health Group. Are breastfeeding rates higher among mothers delivering in Baby Friendly accredited maternity units in the UK? Int J Epidemiol. 2006;35(5):1178-86.

Return to footnote 29 referrer

Footnote 30

Beake S, Pellowe C, Dykes F, Schmied V, Bick D. A systematic review of structured compared with non‐structured breastfeeding programmes to support the initiation and duration of exclusive and any breastfeeding in acute and primary health care settings. Matern Child Nutr. 2012;8(2):141-61.

Return to footnote 30 referrer

Footnote 31

Broadfoot M, Britten J, Tappin D, MacKenzie JM. The Baby Friendly Hospital Initiative and breast feeding rates in Scotland. Arch Dis Child Fetal Neonatal Ed. 2005;90(2):114-6.

Return to footnote 31 referrer

Footnote 32

Balogun OO, O'Sullivan EJ, McFadden A, Ota E, Gavine A, Garner CD, et al. Interventions for promoting the initiation of breastfeeding. Cochrane Database Syst Rev. 2016(11):CD001688.

Return to footnote 32 referrer

Footnote 33

World Health Organization (2018). Ten steps to successful breastfeeding (revised 2018) [Internet]. Geneva (CH): WHO; 2018 [cited Jul 6 2018].  Available from:

Return to footnote 33 referrer

Footnote 34

World Health Organization, UNICEF. Baby-Friendly Hospital Initiative: revised, updated and expanded for integrated care [Internet]. Geneva (CH): WHO; 2009 [cited May 16 2018].  Available from:

Return to footnote 34 referrer

Footnote 35

World Health Organization. Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services [Internet]. Geneva (CH): WHO; 2017 [cited Jul 9 2018].  Available from:

Return to footnote 35 referrer

Footnote 36

World Health Organization, UNICEF (2018). Implementation guidance: protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services: the revised Baby-friendly Hospital Initiative 2018 [Internet]. Geneva (CH): WHO; 2018 [cited Jul 9 2018].  Available from:

Return to footnote 36 referrer

Footnote 37

Breastfeeding Committee of Canada. The BFI 10 steps and WHO code outcome indicators for hospital and community health services [Internet]. Drayton Valley (AB): BCC; 2017 [cited 2018 May 16]. Available from:

Return to footnote 37 referrer

Footnote 38

Accreditation Canada. Standards for hospitals: obstetrics services standards. Ottawa (ON): AC; 2014.

Return to footnote 38 referrer

Footnote 39

Public Health Agency of Canada. Canadian hospitals maternity policies and practices survey. Ottawa (ON): PHAC; 2012.

Return to footnote 39 referrer

Footnote 40

Breastfeeding Committee of Canada. Baby-Friendly Initiative (BFI) in Canada status report [Internet]. Drayton Valley (AB): BCC; 2014 [cited 2018 May 15]. Available from:

Return to footnote 40 referrer

Footnote 41

Breastfeeding Committee of Canada. Baby-friendly facilities in Canada [Internet]. Drayton Valley (AB): BCC; 2018 [cited 2018 July 11]. Available from:

Return to footnote 41 referrer

Footnote 42

Nyqvist KH, Häggkvist A, Hansen MN, Kylberg E, Frandsen AL, Maastrup R, et al. Expansion of the ten steps to successful breastfeeding into neonatal intensive Care: expert group recommendations for three guiding principles. J Hum Lact. 2012;28(3):289-96.

Return to footnote 42 referrer

Footnote 43

Chalmers B. Family-centred perinatal care: improving pregnancy, birth and postpartum care. Cambridge (UK): Cambridge University Press; 2017.

Return to footnote 43 referrer

Footnote 44

World Health Organization. International code of marketing of breast-milk substitutes [Internet]. Geneva (CH): WHO; 1981 [cited 2018 May 18]. Available from:

Return to footnote 44 referrer

Footnote 45

INFACT Canada. Breastfeeding protection and the International Code [Internet]. Toronto (ON): INFACT Canada; no date [cited 2018 June 4]. Available from:

Return to footnote 45 referrer

Footnote 46

Semenic S, Childerhose JE, Lauzière J, Groleau D. Barriers, facilitators, and recommendations related to implementing the Baby-Friendly Initiative (BFI): an integrative review. J Hum Lact. 2012;28(3):317-34.

Return to footnote 46 referrer

Footnote 47

Best Start Resource Centre, Baby-Friendly Initiative Ontario. The Baby-Friendly Initiative: evidence-informed key messages and resources [Internet]. Toronto (ON): Best Start; 2013 [cited 2018 June 4]. Available from:

Return to footnote 47 referrer

Footnote 48

Levitt C, Hanvey L, Kaczorowski J, Chalmers B, Heaman M, Bartholomew S. Breastfeeding policies and practices in Canadian hospitals: comparing 1993 with 2007. Birth. 2011;38(3):228-37.

Return to footnote 48 referrer

Footnote 49

Public Health Agency of Canada. What mothers say: the Canadian Maternity Experiences Survey. Ottawa (ON): PHAC; 2009.

Return to footnote 49 referrer

Footnote 50

Chalmers B, Levitt C, Heaman M, O'Brien B, Sauve R, Kaczorowski J. Breastfeeding rates and hospital breastfeeding practices in Canada: a national survey of women. Birth. 2009;36(2):122-32.

Return to footnote 50 referrer

Footnote 51

Wright CM, Waterston AJR. Relationships between paediatricians and infant formula milk companies. Arch Dis Child. 2006;91(5):383-5.

Return to footnote 51 referrer

Footnote 52

Moynihan R. Who pays for the pizza? Redefining the relationships between doctors and drug companies. 1: entanglement. BMJ. 2003;326(7400):1189-92.

Return to footnote 52 referrer

Footnote 53

Canadian Food Inspection Agency. Labelling requirements for infant foods, infant formula and human milk [Internet]. Ottawa (ON): CFIA; 2018 [cited 2018 June 4]. Available from:

Return to footnote 53 referrer

Footnote 54

Perinatal Services BC. Health promotion guideline: breastfeeding the healthy term infant [Internet]. Vancouver (BC): Perinatal Services BC; 2012 [cited 2018 May 22]. Available from:

Return to footnote 54 referrer

Footnote 55

Academy of Breastfeeding Medicine. Clinical protocols [Internet]. New Rochelle (NY): Academy of Breastfeeding Medicine; 2017 [cited 2017 May 22]. Available from:

Return to footnote 55 referrer

Footnote 56

Nyqvist KH, Maastrup R, Hansen MN, Haggkvist AP, Hannula L, Ezeonodo A, Kylberg E, Frandsen AL, et al. Neo-BFHI: the Baby-Friendly Hospital Initiative for neonatal wards. Core document with recommended standards and criteria [Internet]. Raleigh (NC): International Lactation Consultants Association; 2015 [cited 20118 May 22]. Available from:

Return to footnote 56 referrer

Footnote 57

McFadden A, Renfrew M, Wallace L, Dykes F, Abbott S, Burt S, et al. Does breastfeeding really matter? A national multidisciplinary breastfeeding knowledge and skills assessment. MIDIRS Midwifery Digest. 2007;17(1):85-7.

Return to footnote 57 referrer

Footnote 58

Pound CM, Williams K, Grenon R, Aglipay M, Plint AC. Breastfeeding knowledge, confidence, beliefs, and attitudes of canadian physicians. J Hum Lact. 2014;30(3):298-309.

Return to footnote 58 referrer

Footnote 59

Chalmers B. Breastfeeding unfriendly in Canada? CMAJ. 2013;185(5):375-6.

Return to footnote 59 referrer

Footnote 60

Payne J, Radcliffe B, Blank E, Churchill E, Hassan N, Cox E, et al. Breastfeeding: The neglected guideline for future dietitian‐nutritionists? Nutr Diet. 2007;64(2):93-8.

Return to footnote 60 referrer

Footnote 61

DiGirolamo AM, Grummer-Strawn LM, Fein SB. Do perceived attitudes of physicians and hospital staff affect breastfeeding decisions? Birth. 2003;30(2):94-100.

Return to footnote 61 referrer

Footnote 62

Brodribb W, Jackson C, Fallon A, Hegney D. Breastfeeding and the responsibilities of GPs: a qualitative study of general practice registrars. Aust Fam Physician. 2007;36(4):283-5.

Return to footnote 62 referrer

Footnote 63

Bryant CA, Coreil J, D'Angelo SL, Bailey DF, Lazarov M. A strategy for promoting breastfeeding among economically disadvantaged women and adolescents. NAACOGS Clin Issu Perinat Womens Health Nurs. 1992;3(4):723-30.

Return to footnote 63 referrer

Footnote 64

Feldman-Winter L, Barone L, Milcarek B, Hunter K, Meek J, Morton J, et al. Residency curriculum improves breastfeeding care. Pediatrics. 2010;126(2):289-97.

Return to footnote 64 referrer

Footnote 65

Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients' care. Lancet. 2003;362(9391):1225-30.

Return to footnote 65 referrer

Footnote 66

Kim J, Unger S. Human milk banking (reaffirmed 2018). Paediatr Child Health. 2010;15(9):595-8.

Return to footnote 66 referrer

Footnote 67

EU Project on Promotion of Breastfeeding in Europe. Protection, promotion and support of breastfeeding in Europe: a blueprint for action (revised 2008) [Internet]. Luxembourg (LU): European Commission, Directorate Public Health and Risk Assessment; 2008 [cited 2018 May 24]. Available from:

Return to footnote 67 referrer

Footnote 68

Hannula L, Kaunonen M, Tarkka M. A systematic review of professional support interventions for breastfeeding. J Clin Nurs. 2008;17(9):1132-43.

Return to footnote 68 referrer

Footnote 69

Dennis C. Breastfeeding initiation and duration: A 1990‐2000 literature review. J Obstet Gynecol Neonatal Nurs. 2002;31(1):12-32.

Return to footnote 69 referrer

Footnote 70

Apple RD. "To be used only under the direction of a physician": commercial infant feeding and medical practice, 1870-1940. Bull Hist Med. 1980;54(3):402-17.

Return to footnote 70 referrer

Footnote 71

Apple RD. The medicalization of infant feeding in the United States and New Zealand: two countries, one experience. J Hum Lact. 1994;10(1):31-7.

Return to footnote 71 referrer

Footnote 72

Apple RD. Constructing mothers: scientific motherhood in the nineteenth and twentieth centuries. Soc Hist Med. 1995;8(2):161-78.

Return to footnote 72 referrer

Footnote 73

Schmied V, Olley H, Burns E, Duff M, Dennis C, Dahlen HG. Contradictions and conflict: a meta-ethnographic study of migrant women's experiences of breastfeeding in a new country. BMC Pregnancy Childbirth. 2012;12(1):163.

Return to footnote 73 referrer

Footnote 74

Blyth R, Creedy DK, Dennis C, Moyle W, Pratt J, De Vries SM. Effect of maternal confidence on breastfeeding duration: an application of breastfeeding self-efficacy theory. Birth. 2002;29(4):278-84.

Return to footnote 74 referrer

Footnote 75

Dennis CL. Theoretical underpinnings of breastfeeding confidence: a self-efficacy framework. J Hum Lact. 1999;15(3):195-201.

Return to footnote 75 referrer

Footnote 76

Entwistl F, Kendall S, Mead M. The promotion of breastfeeding among low-income women: midwives' knowledge and attitudes following a WHO/UNICEF breastfeeding management course. Evidence Based Midwifery. 2007;5(1):29-34.

Return to footnote 76 referrer

Footnote 77

Ekstrom A, Widstrom A, Nissen E. Breastfeeding support from partners and grandmothers: perceptions of Swedish women. Birth. 2003;30(4):261-6.

Return to footnote 77 referrer

Footnote 78

Scott JA, Binns CW, Oddy WH, Graham KI. Predictors of breastfeeding duration: evidence from a cohort study. Pediatrics. 2006;117(4):e646-55.

Return to footnote 78 referrer

Footnote 79

Thulier D, Mercer J. Variables associated with breastfeeding duration. J Obstet Gynecol Neonatal Nurs. 2009;38(3):259-68.

Return to footnote 79 referrer

Footnote 80

Hartley BM, O'Connor ME. Evaluation of the 'Best Start' breast-feeding education program. Arch Pediatr Adolesc Med. 1996;150(8):868-71.

Return to footnote 80 referrer

Footnote 81

Fairbank L, O'Meara S, Renfrew MJ, Woolridge M, Sowden AJ, Lister-Sharp D. A systematic review to evaluate the effectiveness of interventions to promote the initiation of breastfeeding. Health Technol Assess. 2000;4(25):1-171.

Return to footnote 81 referrer

Footnote 82

McFadden A, Gavine A, Renfrew M, Wade A, Buchanan P, Taylor J, et al. Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database Syst Rev. 2017(2):CD001141.

Return to footnote 82 referrer

Footnote 83

Chung M, Raman G, Trikalinos T, Lau J, Ip S. Interventions in primary care to promote breastfeeding: an evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008;149(8):565-82.

Return to footnote 83 referrer

Footnote 84

National Institute for Health and Care Excellence. Postnatal care [Internet]. London (UK): NICE; 2015 [cited 2018 May 25]. Available from:

Return to footnote 84 referrer

Footnote 85

Chow S, Chow R, Popovic M, Lam H, Merrick J, Ventegodt S, et al. The use of nipple shields: a review. Front Public Health. 2015;3:236.

Return to footnote 85 referrer

Footnote 86

Gamble D, Morse JM. Fathers of breastfed infants: postponing and types of involvement. J Obstet Gynecol Neonatal Nurs. 1993;22(4):358-65.

Return to footnote 86 referrer

Footnote 87

Mannion CA, Hobbs AJ, McDonald SW, Tough SC. Maternal perceptions of partner support during breastfeeding. Int Breastfeed J. 2013;8:4.

Return to footnote 87 referrer

Footnote 88

Brown A, Davies R. Fathers' experiences of supporting breastfeeding: challenges for breastfeeding promotion and education. Matern Child Nutr. 2014;10(4):510-26.

Return to footnote 88 referrer

Footnote 89

Moore DB, Catlin A. Lactation suppression: forgotten aspect of care for the mother of a dying child. Pediatr Nurs. 2003;29(5):383-4.

Return to footnote 89 referrer

Footnote 90

European Milk Bank Association, Human Milk Banking Association of North America. Milk sharing [Internet]. Milano(IT): EMBA; 2015 [cited 2018 May 25]. Available from:

Return to footnote 90 referrer

Footnote 91

Klaus M, Kennell J. Maternal-infant bonding: The impact of early separation or loss on family development. J Nurse Midwifery. 1977;22(2):16-7.

Return to footnote 91 referrer

Footnote 92

de Chateau P, Wiberg B. Long-term effect on mother-infant behaviour of extra contact during the first hour post partum. I: First observations at 36 hours. Acta Paediatr Scand. 1977;66(2):137-43.

Return to footnote 92 referrer

Footnote 93

de Château P, Wiberg B. Long-term effect on mother–infant behaviour of extra contact during the first hour post partum III: Follow-up at one year. Scand J Soc Med. 1984;12(2):91-103.

Return to footnote 93 referrer

Footnote 94

Davanzo R, De Cunto A, Paviotti G, Travan L, Inglese S, Brovedani P, et al. Making the first days of life safer: preventing sudden unexpected postnatal collapse while promoting breastfeeding. J Hum Lact. 2015;31(1):47-52.

Return to footnote 94 referrer

Footnote 95

Bystrova K, Widstrom A, Matthiesen A, Ransjo-Arvidson A, Welles-Nystrom B, Wassberg C, et al. Skin-to-skin contact may reduce negative consequences of "the stress of being born": a study on temperature in newborn infants, subjected to different ward routines in St. Petersburg. Acta Paediatr. 2003;92(3):320-6.

Return to footnote 95 referrer

Footnote 96

Bystrova K, Matthiesen A, Vorontsov I, Widstrom A, Ransjo-Arvidson A, Uvnas-Moberg K, et al. Maternal axillar and breast temperature after giving birth: effects of delivery ward practices and relation to infant temperature. Birth. 2007;34(4):291-300.

Return to footnote 96 referrer

Footnote 97

Marin Gabriel M, Martín IL, Escobar AL, Villalba EF, Blanco IR, Pol PT. Randomized controlled trial of early skin-to-skin contact: effects on the mother and the newborn. Acta Paediatr. 2010;99(11):1630-4.

Return to footnote 97 referrer

Footnote 98

Takahashi Y, Tamakoshi K, Matsushima M, Kawabe T. Comparison of salivary cortisol, heart rate, and oxygen saturation between early skin-to-skin contact with different initiation and duration times in healthy, full-term infants. Early Hum Dev. 2011;87(3):151-7.

Return to footnote 98 referrer

Footnote 99

Christensson K, Siles C, Moreno L, Belaustequi A, De La Fuente P, Lagercrantz H, et al. Temperature, metabolic adaptation and crying in healthy full‐term newborns cared for skin‐to‐skin or in a cot. Acta Paediatr. 1992;81(6-7):488-93.

Return to footnote 99 referrer

Footnote 100

Christensson K, Cabrera T, Christensson E, Uvnas-Moberg K, Uvnäs–Moberg K, Winberg J. Separation distress call in the human neonate in the absence of maternal body contact. Acta Paediatr. 1995;84(5):468-73.

Return to footnote 100 referrer

Footnote 101

Michelsson K, Christensson K, Rothgänger H, Winberg J. Crying in separated and non-separated newborns: sound spectrographic analysis. Acta Paediatr. 1996;85(4):471-5.

Return to footnote 101 referrer

Footnote 102

Hanson, LA. Immunobiology of human milk: how breastfeeding protects babies. 1st ed. Amarillo (TX): Pharmasoft Publishing; 2004.

Return to footnote 102 referrer

Footnote 103

Morris T, McInerney K. Media representations of pregnancy and childbirth: an analysis of reality television programs in the United States. Birth. 2010;37(2):134-40.

Return to footnote 103 referrer

Footnote 104

Widstrom A-, Ransjo-Arvidson AB, Christensson K, Matthiesen AS, Winberg J, Uvnäs-Moberg K. Gastric suction in healthy newborn infants: effects on circulation and developing feeding behavior. Acta Paediatr Scand. 1987;76(4):566-72.

Return to footnote 104 referrer

Footnote 105

Erlandsson K, Dsilna A, Fagerberg I, Christensson K. Skin-to-skin care with the father after cesarean birth and its effect on newborn crying and prefeeding behavior. Birth. 2007;34(2):105-14.

Return to footnote 105 referrer

Footnote 106

Ludington-Hoe SM, Morgan K. Infant assessment and reduction of sudden unexpected postnatal collapse risk during skin-to-skin contact. Newborn Infant Nurs Rev. 2014;14(1):28-33.

Return to footnote 106 referrer

Footnote 107

Righard L, Alade MO. Effect of delivery room routines on success of first breast-feed. Lancet. 1990;336(8723):1105-7.

Return to footnote 107 referrer

Footnote 108

Holmes AV, McLeod AY, Bunik M, Marinelli KA, Noble L, Brent N, et al. ABM clinical protocol #5: peripartum breastfeeding management for the healthy mother and infant at term, revision 2013. Breastfeed Med. 2013;8(6):469-73.

Return to footnote 108 referrer

Footnote 109

Zanardo V, Svegliado G, Cavallin F, Giustardi A, Cosmi E, Litta P, et al. Elective cesarean delivery: does it have a negative effect on breastfeeding? Birth. 2010;37(4):275-9.

Return to footnote 109 referrer

Footnote 110

Chalmers B, Kaczorowski J, Darling E, Heaman M, Fell DB, OBrien B, et al. Cesarean and vaginal birth in Canadian women: a comparison of experiences. Birth. 2010;37(1):44-9.

Return to footnote 110 referrer

Footnote 111

Hung KJ, Berg O. Early skin-to-skin: after cesarean to improve breastfeeding. MCN Am J Matern Child Nurs. 2011;36(5):318-24.

Return to footnote 111 referrer

Footnote 112

Widström A, Lilja G, Aaltomaa‐Michalias P, Dahllöf A, Lintula M, Nissen E, et al. Newborn behaviour to locate the breast when skin‐to‐skin: a possible method for enabling early self‐regulation. Acta Paediatr. 2011;100(1):79-85.

Return to footnote 112 referrer

Footnote 113

Porter R. The biological significance of skin-to-skin contact and maternal odours. Acta Paediatr. 2004;93(12):1560-2.

Return to footnote 113 referrer

Footnote 114

Mahmood I, Jamal M, Khan N. Effect of mother-infant early skin-to-skin contact on breastfeeding status: A randomized controlled trial. J Coll Physicians Surg Pak. 2011;21(10):601-5.

Return to footnote 114 referrer

Footnote 115

Moore ER, Anderson GC. Randomized controlled trial of very early mother–infant skin-to-skin contact and breastfeeding status. J Midwifery Womens Health. 2007;52(2):116-25.

Return to footnote 115 referrer

Footnote 116

Thukral A, Sankar MJ, Agarwal R, Gupta N, Deorari AK, Paul VK. Early skin-to-skin contact and breast-feeding behavior in term neonates: a randomized controlled trial. Neonatology. 2012;102(2):114-9.

Return to footnote 116 referrer

Footnote 117

Mikiel-Kostyra K, Mazur J, Bołtruszko I. Effect of early skin-to-skin contact after delivery on duration of breastfeeding: a prospective cohort study. Acta Paediatr. 2002;91(12):1301-6.

Return to footnote 117 referrer

Footnote 118

Bramson L, Lee JW, Moore E, Montgomery S, Neish C, Bahjri K, et al. Effect of early skin-to-skin mother-infant contact during the first 3 hours following birth on exclusive breastfeeding during the maternity hospital stay. J Hum Lact. 2010;26(2):130-7.

Return to footnote 118 referrer

Footnote 119

Jefferies AL. Kangaroo care for the preterm infant and family. Paediatr Child Health. 2012;17(3):141-3.

Return to footnote 119 referrer

Footnote 120

Matthiesen A, Ransjo-Arvidson A, Nissen E, Uvnas-Moberg K. Postpartum maternal oxytocin release by newborns: effects of infant hand massage and sucking. Birth. 2001;28(1):13-9.

Return to footnote 120 referrer

Footnote 121

Bystrova K, Ivanova V, Edhborg M, Matthiesen A, Ransjö-Arvidson A, Mukhamedrakhimov R, et al. Early contact versus separation: effects on mother-infant interaction one year later. Birth. 2009;36(2):97-109.

Return to footnote 121 referrer

Footnote 122

Osinaike BB, Oyedeji AO, Adeoye OT, Dairo MD, Aderinto DA. Effect of breastfeeding during venepuncture in neonates. Ann Trop Paediatr. 2007;27(3):201-5.

Return to footnote 122 referrer

Footnote 123

Carbajal R, Veerapen S, Couderc S, Jugie M, Ville Y. Analgesic effect of breast feeding in term neonates: randomised controlled trial. BMJ. 2003;326(7379):13-5.

Return to footnote 123 referrer

Footnote 124

Abdel Razek A, AZ El-Dein N. Effect of breast-feeding on pain relief during infant immunization injections. Int J Nurs Pract. 2009;15(2):99-104.

Return to footnote 124 referrer

Footnote 125

Codipietro L, Ceccarelli M, Ponzone A. Breastfeeding or oral sucrose solution in term neonates receiving heel lance: a randomized, controlled trial. Pediatrics. 2008;122(3):e716-21.

Return to footnote 125 referrer

Footnote 126

Gray L, Miller LW, Philipp BL, Blass EM. Breastfeeding is analgesic in healthy newborns. Pediatrics. 2002;109(4):590-3.

Return to footnote 126 referrer

Footnote 127

Colson SD, Meek JH, Hawdon JM. Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding. Early Hum Dev. 2007;84(7):441-9.

Return to footnote 127 referrer

Footnote 128

Wambach K, Riordan J. Breastfeeding and human lactation. 5th ed. Burlington (MA): Jones & Bartlett Learning; 2016.

Return to footnote 128 referrer

Footnote 129

Cantrill RM, Creedy DK, Cooke M, Dykes F. Effective suckling in relation to naked maternal-infant body contact in the first hour of life: an observation study. BMC Pregnancy Childbirth. 2014;14:20.

Return to footnote 129 referrer

Footnote 130

Ziemer M, Pigeon J. Skin changes and pain in the nipple during the 1st week of lactation. J Obstet Gynecol Neonatal Nurs. 1993;22(3):247-56.

Return to footnote 130 referrer

Footnote 131

Morton J, Hall JY, Pessl M. Five steps to improve bedside breastfeeding care. Nurs Womens Health. 2013;17(6):478-88.

Return to footnote 131 referrer

Footnote 132

Becker GE, Smith HA, Cooney F. Methods of milk expression for lactating women. Cochrane Database Syst Rev. 2016(9):CD006170.

Return to footnote 132 referrer

Footnote 133

Flaherman VJ, Gay B, Scott C, Avins A, Lee KA, Newman TB. Randomised trial comparing hand expression with breast pumping for mothers of term newborns feeding poorly. Arch Dis Child Fetal Neonatal Ed. 2012;97(1):F18-23.

Return to footnote 133 referrer

Footnote 134

HealthyFamilies BC. Getting started on expressing breastmilk [Internet]. Vancouver (BC): HealthyFamilies BC; 2013 [cited July 11 2018]. Available from:

Return to footnote 134 referrer

Footnote 135

World Health Organization, UNICEF. Breastfeeding counselling: a training course. Participants' manual [Internet]. Geneva (CH): WHO; 1993 [cited May 29 2018].  Available from:

Return to footnote 135 referrer

Footnote 136

Cargill Y, Martel M, MacKinnon CJ, Arsenault M, Bartellas E, Daniels S, et al. Postpartum maternal and newborn discharge. SOGC policy statement no. 190. J Obstet Gynaecol Can. 2007;29(4):357-9.

Return to footnote 136 referrer

Footnote 137

Barrington K, Sankaran K. Guidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants. Paediatr Child Health. 2007;12(Suppl B):1B-12B.

Return to footnote 137 referrer

Footnote 138

Hill PD, Johnson TS. Assessment of breastfeeding and infant growth. J Midwifery Womens Health. 2007;52(6):571-8.Neville MC, Morton J, Umemura S. Lactogenesis: the transition from pregnancy to lactation. Pediatr Clin North Am. 2001;48(1):35-52.

Return to footnote 138 referrer

Footnote 139

Neville MC, Morton J, Umemura S. Lactogenesis: the transition from pregnancy to lactation. Pediatr Clin North Am. 2001;48(1):35-52.

Return to footnote 139 referrer

Footnote 140

The Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #9: use of galactogogues in initiating or augmenting the rate of maternal milk secretion (first revision January 2011). Breastfeed Med. 2011;6(1):41-9.

Return to footnote 140 referrer

Footnote 141

Shrago LC, Reifsnider E, Insel K. The neonatal bowel output study: indicators of adequate breast milk intake in neonates. Pediatr Nurs. 2006;32(3):195-201.Neville MC, Morton J, Umemura S. Lactogenesis: the transition from pregnancy to lactation. Pediatr Clin North Am. 2001;48(1):35-52.

Return to footnote 141 referrer

Footnote 142

Nommsen-Rivers LA, Heinig MJ, Cohen RJ, Dewey KG. Newborn wet and soiled diaper counts and timing of onset of lactation as indicators of breastfeeding inadequacy. J Hum Lact. 2008;24(1):27-33.

Return to footnote 142 referrer

Footnote 143

Santoro W, Martinez FE, Ricco RG, Jorge SM. Colostrum ingested during the first day of life by exclusively breastfed healthy newborn infants. J Pediatr. 2010;156(1):29-32.

Return to footnote 143 referrer

Footnote 144

Zangen S, Di Lorenzo C, Zangen T, Mertz H, Schwankovsky L, Hyman PE. Rapid maturation of gastric relaxation in newborn infants. Pediatr Res. 2001;50(5):629-32.

Return to footnote 144 referrer

Footnote 145

Best Start Resource Centre. Breastfeeding your baby: guidelines for nursing mothers [Internet].  Toronto (ON): Best Start; 2009 [cited 2018 July 26]. Available from:

Return to footnote 145 referrer

Footnote 146

Marchand V. Promoting optimal monitoring of child growth in Canada: using the new World Health Organization growth charts. A collaborative statement from Dietitians of Canada, Canadian Paediatric Society, The College of Family Physicians of Canada, and Community Health Nurses of Canada. Paediatr Child Health. 2010;15(2):77-9.

Return to footnote 146 referrer

Footnote 147

Nyqvist K, Anderson G, Bergman N, Cattaneo A, Charpak N, Davanzo R, et al. Towards universal kangaroo mother care: recommendations and report from the first European conference and seventh international workshop on kangaroo mother care. Acta Paediatr. 2010;99(6):820-6.

Return to footnote 147 referrer

Footnote 148

Parker LA, Sullivan S, Krueger C, Kelechi T, Mueller M. Effect of early breast milk expression on milk volume and timing of lactogenesis stage II among mothers of very low birth weight infants: a pilot study. J Perinatol. 2012;32(3):205-9.

Return to footnote 148 referrer

Footnote 149

Maastrup R, Hansen BM, Kronborg H, Bojesen SN, Hallum K, Frandsen A, et al. Breastfeeding progression in preterm infants is influenced by factors in infants, mothers and clinical practice: the results of a national cohort study with high breastfeeding initiation rates. PLoS One. 2014;9(9):e108208.

Return to footnote 149 referrer

Footnote 150

Maastrup R, Hansen BM, Kronborg H, Bojesen SN, Hallum K, Frandsen A, et al. Factors associated with exclusive breastfeeding of preterm infants. Results from a prospective national cohort study. PLoS One. 2014;9(2):e89077.

Return to footnote 150 referrer

Footnote 151

Gephart SM, Weller M. Colostrum as oral immune therapy to promote neonatal health. Adv Neonatal Care. 2014;14(1):44-51.

Return to footnote 151 referrer

Footnote 152

Hill PD, Aldag JC, Chatterton RT, Zinaman M. Comparison of milk output between mothers of preterm and term infants: the first 6 weeks after birth. J Hum Lact. 2005;21(1):22-30.

Return to footnote 152 referrer

Footnote 153

Wang ML, Dorer DJ, Fleming MP, Catlin EA. Clinical outcomes of near-term infants. Pediatrics. 2004;114(2):372-6.

Return to footnote 153 referrer

Footnote 154

Whyte RK. Safe discharge of the late preterm infant. Paediatr Child Health. 2010;15(10):655-60.

Return to footnote 154 referrer

Footnote 155

Watson J, Hermann S, Johnson B. Developing a policy to support breastfeeding in women who are hospitalized and acutely ill. Nurs Womens Health. 2013;17(3):188-96.

Return to footnote 155 referrer

Footnote 156

World Health Organization. Indicators for assessing infant and young child feeding practices [Internet]. Geneva (CH): WHO; 2008 [cited 2018 May 30]. Available from:

Return to footnote 156 referrer

Footnote 157

Toronto Public Health. Breastfeeding in Toronto: promoting supportive environments [Internet]. Toronto (ON): TPH; 2010 [cited 2018 May 30]. Available from:

Return to footnote 157 referrer

Footnote 158

Perinatal Services BC. Perinatal data registry. Vancouver (BC): Perinatal Services BC; 2015.

Return to footnote 158 referrer

Footnote 159

Cloherty M, Alexander J, Holloway I. Supplementing breast-fed babies in the UK to protect their mothers from tiredness or distress. Midwifery. 2004;20(2):194-204.

Return to footnote 159 referrer

Footnote 160

Flaherman VJ, Aby J, Burgos AE, Lee KA, Cabana MD, Newman TB. Effect of early limited formula on duration and exclusivity of breastfeeding in at-risk infants: an RCT. Pediatrics. 2013;131(6):1059-65.

Return to footnote 160 referrer

Footnote 161

Perinatal Services BC. Informal (peer-to-peer) milk sharing: the use of unpasteurized donor human milk [Internet]. Vancouver (BC): Perinatal Services BC; 2016 [cited 2018 May 30]. Available from:

Return to footnote 161 referrer

Footnote 162

Stuart-Macadam P. The culture and biology of breastfeeding: an historical review of Western Europe. In: Breastfeeding: bicultural perspectives. 1st ed. New York (NY): Routledge; 1995. p. 100-26.

Return to footnote 162 referrer

Footnote 163

Keim SA, Kulkarni MM, McNamara K, Geraghty SR, Billock RM, Ronau R, et al. Cow's milk contamination of human milk purchased via the internet. Pediatrics. 2015;135(5):e1157-62.

Return to footnote 163 referrer

Footnote 164

Keim SA, Hogan JS, Mcnamara KA, Gudimetla V, Dillon CE, Kwiek JJ, et al. Microbial contamination of human milk purchased via the internet. Pediatrics. 2013;132(5):e1227-35.

Return to footnote 164 referrer

Footnote 165

World Health Organization, UNICEF. Acceptable medical reasons for use of breast-milk substitutes [Internet]. Geneva (CH): WHO; 2009 [cited 2018 July 26]. Available from:

Return to footnote 165 referrer

Footnote 166

World Health Organization. Guidelines on HIV and infant feeding: principles and recommendations for infant feeding in the context of HIV and a summary of evidence [Internet]. Geneva (CH): WHO; 2010 [cited 2018 May 30].  Available from:

Return to footnote 166 referrer

Footnote 167

MacDonald NE. Maternal infectious diseases, antimicrobial therapy or immunizations: very few contraindications to breastfeeding. Paediatr Child Health. 2016;11(8):489-91.

Return to footnote 167 referrer

Footnote 168

Fríguls B, Joya X, García-Algar O, Pallás CR, Vall O, Pichini S. A comprehensive review of assay methods to determine drugs in breast milk and the safety of breastfeeding when taking drugs. Anal Bioanal Chem. 2010;397(3):1157-79.

Return to footnote 168 referrer

Footnote 169

Mennella JA, Yourshaw LM, Morgan LK. Breastfeeding and smoking: short-term effects on infant feeding and sleep. Pediatrics. 2007;120(3):497-502.

Return to footnote 169 referrer

Footnote 170

Napierala M, Mazela J, Merritt TA, Florek E. Tobacco smoking and breastfeeding: Effect on the lactation process, breast milk composition and infant development. A critical review. Environ Res. 2016;151:321-38.

Return to footnote 170 referrer

Footnote 171

Damota K, Bañuelos J, Goldbronn J, Vera-Beccera LE, Heinig MJ. Maternal request for in-hospital supplementation of healthy breastfed infants among low-income women. J Hum Lact. 2012;28(4):476-82.

Return to footnote 171 referrer

Footnote 172

Chan S, Nelson E, Leung S, Li C. Breastfeeding failure in a longitudinal post‐partum maternal nutrition study in Hong Kong. J Paediatr Child Health. 2000;36(5):466-71.

Return to footnote 172 referrer

Footnote 173

Semenic S, Loiselle C, Gottlieb L. Predictors of the duration of exclusive breastfeeding among first‐time mothers. Res Nurs Health. 2008;31(5):428-41.

Return to footnote 173 referrer

Footnote 174

Chalmers B, Levitt C, Heaman M, O'Brien B, Sauve R, Kaczorowski J. Breastfeeding rates and hospital breastfeeding practices in Canada: a national survey of women. Birth. 2009;36(2):122-32.

Return to footnote 174 referrer

Footnote 175

Galbally M, Lewis AJ, McEgan K, Scalzo K, Islam FA. Breastfeeding and infant sleep patterns: an Australian population study. J Paediatr Child Health. 2013;49(2):E147-52.

Return to footnote 175 referrer

Footnote 176

Sadeh A, Sivan Y. Clinical practice: sleep problems during infancy. Eur J Pediatr. 2009;168(10):1159-64.

Return to footnote 176 referrer

Footnote 177

Dykes F. Breastfeeding in hospital: mothers, midwives and the production line. New York (NY): Routledge; 2008.

Return to footnote 177 referrer

Footnote 178

Mahon-Daly P, Andrews GJ. Liminality and breastfeeding: women negotiating space and two bodies. Health Place. 2002;8(2):61-76.

Return to footnote 178 referrer

Footnote 179

Kent JC, Mitoulas LR, Cregan MD, Ramsay DT, Doherty DA, Hartmann PE. Volume and frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics. 2006;117(3):e387-95.

Return to footnote 179 referrer

Footnote 180

Moon RY, AAP Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: evidence base for 2016 updated recommendations for a safe infant sleeping environment. Pediatrics. 2016;138(5):e20162940.

Return to footnote 180 referrer

Footnote 181

Public Health Agency of Canada. Joint statement on safe sleep: preventing sudden infant deaths in Canada [Internet]. Ottawa (ON): PHAC; 2011 [cited 2018 May 31]. Available from:

Return to footnote 181 referrer

Footnote 182

Registered Nurses' Association of Ontario. Working with families to promote safe sleep for infants 0–12 months of age [Internet]. Toronto (ON): RNAO; 2014 [cited 2018 May 31]. Available from:

Return to footnote 182 referrer

Footnote 183

Enkin M, Keirse M, Neilson J, Crowther C, Duley L, Hodnett E, et al. Guide to effective care in pregnancy and childbirth. 3rd ed. Oxford (UK): Oxford University Press; 2000.

Return to footnote 183 referrer

Footnote 184

Li R, Fein SB, Grummer-Strawn LM. Do infants fed from bottles lack self-regulation of milk intake compared with directly breastfed infants? Pediatrics. 2010;125(6):e1386-93.

Return to footnote 184 referrer

Footnote 185

Grenier D, Leduc D. Well-beings: a guide to health in child care. 3rd ed. Ottawa (ON): Canadian Paediatric Society; 2008.

Return to footnote 185 referrer

Footnote 186

Disantis KI, Hodges EA, Johnson SL, Fisher JO. The role of responsive feeding in overweight during infancy and toddlerhood: a systematic review. Int J Obes. 2011;35(4):480-92.

Return to footnote 186 referrer

Footnote 187

Michaelsen K, Weaver L, Branca F, Robertson A. Feeding and nutrition of infants and young children: guidelines for the WHO European Region, with emphasis on the former Soviet countries [Internet]. Copenhagen (DK): WHO; 2000 [cited 2018 May 31]. Available from:

Return to footnote 187 referrer

Footnote 188

World Health Organization. Infant and young child feeding: model chapter for textbooks for medical students and allied health professionals [Internet]. Geneva (CH): WHO; 2009 [cited 2018 May 31].  Available from:;jsessionid=D9C83BD65A66A89DE454BC8B248EF616?sequence=1.

Return to footnote 188 referrer

Footnote 189

Pan American Health Organization. Guiding principles for complementary feeding of the breastfed child [Internet]. Washington (DC): PAHO/WHO; 2003 [cited 2018 May 31]. Available from:

Return to footnote 189 referrer

Footnote 190

Wrigley EA, Hutchinson SA. Long-term breastfeeding: the secret bond. J Nurse Midwifery. 1990;35(1):35-41.

Return to footnote 190 referrer

Footnote 191

Dowling S, Brown A. An exploration of the experiences of mothers who breastfeed long-term: What are the issues and why does it matter? Breastfeed Med. 2013;8(1):45-52.

Return to footnote 191 referrer

Footnote 192

Lawrence RA, Lawrence RM. Breastfeeding: a guide for the medical professional. 8thed. New York (NY): Elsevier; 2015.

Return to footnote 192 referrer

Footnote 193

Dettwyler, KA. A time to wean: the hominid blueprint for the natural age of weaning in modern human populations. In: Stuart-Macadam P, Dettwyler K, editors.  Breastfeeding: biocultural perspectives. New York (NY): Aldine de Gruyter; 1995. p. 39-73.

Return to footnote 193 referrer

Footnote 194

Uvnäs Moberg, K. The oxytocin factor: tapping the hormone of calm, love and healing. London (UK): Pinter & Martin; 2011.

Return to footnote 194 referrer

Footnote 195

Grueger B. Weaning from the breast. Paediatr Child Health. 2013;18(4):210.

Return to footnote 195 referrer

Footnote 196

Breastfeeding Committee for Canada. Breastfeeding statement of the Breastfeeding Committee for Canada [Internet]. Ottawa (ON): BCC; 2002 [cited 2018 May 31]. Available from:

Return to footnote 196 referrer

Footnote 197

Canadian Human Rights Commission. Pregnancy & human rights in the workplace - policy and best practices [Internet]. Ottawa (ON): CHRC; no date [cited 2018 June 1]. Available from:

Return to footnote 197 referrer

Footnote 198

Johnston ML, Esposito N. Barriers and facilitators for breastfeeding among working women in the United States. J Obstet Gynecol Neonatal Nurs. 2007;36(1):9-20.

Return to footnote 198 referrer

Footnote 199

Hawkins SS, Griffiths LJ, Dezateux C, Catherine Law and the Millennium Cohort Study Child Health Group. The impact of maternal employment on breast-feeding duration in the UK Millennium Cohort Study. Public Health Nutr. 2007;10(9):891-6.

Return to footnote 199 referrer

Footnote 200

Heymann J, Kramer MS. Public policy and breast-feeding: a straightforward and significant solution. Can J Public Health. 2009;100(5):381-3.

Return to footnote 200 referrer

Footnote 201

UNICEF. Factsheet: a summary of the rights under the Convention on the Rights of the Child [Internet]. New York (NY): UNICEF; 2014 [cited July 11 2018]. Available from:

Return to footnote 201 referrer

Footnote 202

UNICEF Innocenti Research Centre. Innocenti Declaration 2005 on infant and young child feeding [Internet]. Florence (IT): UNICEF; 2007 [cited 2018 June 1]. Available from:

Return to footnote 202 referrer

Footnote 203

Government of Canada. Canadian Charter of Rights and Freedoms [Internet]. Ottawa (ON): Government of Canada; 1982 [cited 2018 June 1]. Available from:

Return to footnote 203 referrer

Footnote 204

Government of Canada. Canadian Human Rights Act [Internet]. Ottawa (ON): Government of Canada; 1985 [cited 2018 June 1]. Available from:

Return to footnote 204 referrer

Footnote 205

Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #7: model breastfeeding policy (revision 2010). Breastfeed Med. 2010;5(4):173-7.

Return to footnote 205 referrer

Footnote 206

Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #3: hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate (revised 2009). Breastfeed Med. 2009;4(3):175-82.

Return to footnote 206 referrer

Footnote 207

Chantry CJ, Dewey KG, Peerson JM, Wagner EA, Nommsen-Rivers LA. In-hospital formula use increases early breastfeeding cessation among first-time mothers intending to exclusively breastfeed. J Pediatr. 2014;164(6):1339-45.

Return to footnote 207 referrer

Footnote 208

Howard CR, Howard FM, Lanphear B, Eberly S, deBlieck EA, Oakes D, et al. Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding. Pediatrics. 2003;111(3):511-8.

Return to footnote 208 referrer

Footnote 209

Neifert M, Lawrence R, Seacat J. Nipple confusion: toward a formal definition. J Pediatr. 1995;126(6):S125-9.

Return to footnote 209 referrer

Footnote 210

Nelson AM. A comprehensive review of evidence and current recommendations related to pacifier usage. J Pediatr Nurs. 2012;27(6):690-9.

Return to footnote 210 referrer

Footnote 211

Foster J, Psaila K, Patterson T. Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants. Cochrane Database Syst Rev. 2016(4):CD001071.

Return to footnote 211 referrer

Footnote 212

Ponti M. Recommendations for the use of pacifiers. Paediatr Child Health. 2003;8(8):515-9.

Return to footnote 212 referrer

Footnote 213

Best Start Resource Centre. Giving birth in a new land: strategies for service providers working with newcomers [Internet]. Toronto (ON): Best Start Resource Centre; 2014 [cited 2018 June 1]. Available from:

Return to footnote 213 referrer

Footnote 214

Best Start Resource Centre. Breastfeeding peer support programs: an effective strategy to reach and support populations with lower rates of breastfeeding [Internet]. Toronto (ON): Best Start; 2015 [cited 2018 June 1]. Available from:

Return to footnote 214 referrer

Footnote 215

Best Start Resource Centre. Populations with lower rates of breastfeeding: a summary of findings [Internet]. Toronto (ON): Best Start; 2015 [cited 2018 June 1]. Available from:

Return to footnote 215 referrer

Footnote 216

Andrew N, Harvey K. Infant feeding choices: experience, self-identity and lifestyle. Matern Child Nutr. 2011;7(1):48-60.

Return to footnote 216 referrer

Footnote 217

Public Health Agency of Canada. Celebrating and building on success: the Canada Prenatal Nutrition Program (CPNP). Popular report featuring highlights of the Summative Evaluation of CPNP 2004–2009 [Internet]. Ottawa (ON): PHAC; 2011 [cited 2018 June 4]. Available from:

Return to footnote 217 referrer

Footnote 218

Public Health Agency of Canada. Evaluation of the Community Action Program for Children, Canada Prenatal Nutrition Program and associated activities 2010-2011 to 2014-2015 [Internet]. Ottawa (ON): PHAC; 2016 [cited 2018 July 25]. Available from:

Return to footnote 218 referrer

Footnote 219

Donaldson-Myles F. Can hormones in breastfeeding protect against postnatal depression? Br J Midwifery. 2012;20(2):88-93.

Return to footnote 219 referrer

Footnote 220

Groer MW, Davis MW, Hemphill J. Postpartum stress: current concepts and the possible protective role of breastfeeding. J Obstet Gynecol Neonatal Nurs. 2002;31(4):411-7.

Return to footnote 220 referrer

Footnote 221

Uvnäs-Moberg K. Oxytocin may mediate the benefits of positive social interaction and emotions. Psychoneuroendocrinology. 1998;23(8):819-35.

Return to footnote 221 referrer

Footnote 222

Kendall-Tackett K. A new paradigm for depression in new mothers: the central role of inflammation and how breastfeeding and anti-inflammatory treatments protect maternal mental health. Int Breastfeed J. 2007;2(1):6.

Return to footnote 222 referrer

Footnote 223

McDonagh MS, Matthews A, Phillipi C, Romm J, Peterson K, Thakurta S, et al. Depression drug treatment outcomes in pregnancy and the postpartum period: a systematic review and meta-analysis. Obstet Gynecol. 2014;124(3):526-34.

Return to footnote 223 referrer

Footnote 224

Statistics Canada. Asthma, by age group [Internet]. Ottawa (ON): SC; 2018 [cited 2018 July 17]. Available from:

Return to footnote 224 referrer

Footnote 225

Dogaru CM, Nyffenegger D, Pescatore AM, Spycher BD, Kuehni CE. Breastfeeding and childhood asthma: systematic review and meta-analysis. Am J Epidemiol. 2014;179(10):1153-67.

Return to footnote 225 referrer

Footnote 226

Finkelstein SA, Keely E, Feig DS, Tu X, Yasseen AS, Walker M. Breastfeeding in women with diabetes: lower rates despite greater rewards. A population‐based study. Diabetic Med. 2013;30(9):1094-104.

Return to footnote 226 referrer

Footnote 227

Taylor JS, Kacmar JE, Nothnagle M, Lawrence RA. A systematic review of the literature associating breastfeeding with type 2 diabetes and gestational diabetes. J Am Coll Nutr. 2005;24(5):320-6.

Return to footnote 227 referrer

Footnote 228

Gunderson EP. Impact of breastfeeding on maternal metabolism: implications for women with gestational diabetes. Curr Diab Rep. 2014;14(2):1-9.

Return to footnote 228 referrer

Footnote 229

Matias SL, Dewey KG, Quesenberry Jr CP, Gunderson EP. Maternal prepregnancy obesity and insulin treatment during pregnancy are independently associated with delayed lactogenesis in women with recent gestational diabetes mellitus. Am J Clin Nutr. 2014;99(1):115-21.

Return to footnote 229 referrer

Footnote 230

Nommsen-Rivers LA, Chantry CJ, Peerson JM, Cohen RJ, Dewey KG. Delayed onset of lactogenesis among first-time mothers is related to maternal obesity and factors associated with ineffective breastfeeding. Am J Clin Nutr. 2010;92(3):574-84.

Return to footnote 230 referrer

Footnote 231

Arthur PG, Kent JC, Hartmann PE. Metabolites of lactose synthesis in milk from diabetic and nondiabetic women during lactogenesis II. J Pediatr Gastroenterol Nutr. 1994;19(1):100-8.

Return to footnote 231 referrer

Footnote 232

Bitman J, Hamosh M, Hamosh P, Lutes V, Neville MC, Seacat J, et al. Milk composition and volume during the onset of lactation in a diabetic mother. Am J Clin Nutr. 1989;50(6):1364-9.

Return to footnote 232 referrer

Footnote 233

Hartmann P, Cregan M. Lactogenesis and the effects of insulin-dependent diabetes mellitus and prematurity. J Nutr. 2001;131(11):3016S-20S.

Return to footnote 233 referrer

Footnote 234

Miyake A, Tahara M, Koike K, Tanizawa O. Decrease in neonatal suckled milk volume in diabetic women. Eur J Obstet Gynecol Reprod Biol. 1989;33(1):49-53.

Return to footnote 234 referrer

Footnote 235

Murtaugh M, Ferris A, Capacchione C, Reece E. Energy intake and glycemia in lactating women with type 1 diabetes. J Am Diet Assoc. 1998;98(6):642-8.

Return to footnote 235 referrer

Footnote 236

Forster DA, Moorhead AM, Jacobs SE, Davis PG, Walker SP, Prof, McEgan KM, MMid, et al. Advising women with diabetes in pregnancy to express breastmilk in late pregnancy (Diabetes and Antenatal Milk Expressing [DAME]): a multicentre, unblinded, randomised controlled trial. Lancet. 2017;389(10085):2204-13.

Return to footnote 236 referrer

Footnote 237

Ferris AM, Dalidowitz CK, Ingardia CM, Reece EA, Fumia FD, Jensen RG, et al. Lactation outcome in insulin-dependent diabetic women. J Am Diet Assoc. 1988;88(3):317-22.

Return to footnote 237 referrer

Footnote 238

Gagne MP, Leff EW, Jefferis SC. The breast-feeding experience of women with type I diabetes. Health Care Women Int. 1992;13(3):249-60.

Return to footnote 238 referrer

Footnote 239

De Groot L, Abalovich M, Alexander EK, Amino N, Barbour L, Cobin RH, et al. Management of thyroid dysfunction during pregnancy and postpartum: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(8):2543-65.

Return to footnote 239 referrer

Footnote 240

Carney LA, Quinlan JD, West JM. Thyroid disease in pregnancy. Am Fam Physician. 2014;89(4):273-8.

Return to footnote 240 referrer

Footnote 241

Bever Babendure J, Reifsnider E, Mendias E, Moramarco MW, Davila YR. Reduced breastfeeding rates among obese mothers: A review of contributing factors, clinical considerations and future directions. Int Breastfeed J. 2015;10(1):21.

Return to footnote 241 referrer

Footnote 242

Molodecky NA, Soon IS, Rabi DM, Ghali WA, Ferris M, Chernoff G, et al. Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review. Gastroenterology. 2012;142(1):46-54.e42.

Return to footnote 242 referrer

Footnote 243

Julsgaard M, Norgaard M, Hvas CL, Grosen A, Hasseriis S, Christensen LA. Self-reported adherence to medical treatment, breastfeeding behaviour, and disease activity during the postpartum period in women with Crohn's disease. Scand J Gastroenterol. 2014;49(8):958-66.

Return to footnote 243 referrer

Footnote 244

Mañosa M, Navarro-Llavat M, Marín L, Zabana Y, Cabré E, Domènech E. Fecundity, pregnancy outcomes, and breastfeeding in patients with inflammatory bowel disease: A large cohort survey. Scand J Gastroenterol. 2013;48(4):427-32.

Return to footnote 244 referrer

Footnote 245

Moffatt DC, Ilnyckyj A, Bernstein CN. A population-based study of breastfeeding in inflammatory bowel disease: initiation, duration, and effect on disease in the postpartum period. Am J Gastroenterol. 2009;104(10):2517-23.

Return to footnote 245 referrer

Footnote 246

Tsokos GC. Mechanisms of disease: systemic lupus erythematosus. N Engl J Med. 2011;365(22):2110-21.

Return to footnote 246 referrer

Footnote 247

Hellwig K, Rockhoff M, Herbstritt S, Borisow N, Haghikia A, Elias-Hamp B, et al. Exclusive breastfeeding and the effect on postpartum multiple sclerosis relapses. JAMA Neurol. 2015;72(10):1132-8.

Return to footnote 247 referrer

Footnote 248

Brennan P, Silman A. Breast-feeding and the onset of rheumatoid arthritis. Arthritis Rheum. 1994;37(6):808-13.

Return to footnote 248 referrer

Footnote 249

Hampl JS, Papa DJ. Breastfeeding‐related onset, flare, and relapse of rheumatoid arthritis. Nutr Rev. 2001;59(8):264-8.

Return to footnote 249 referrer

Footnote 250

Carty EA, Conine TA, Wood-Johnson F. Rheumatoid arthritis & pregnancy: helping women to meet their needs. Midwives Chron. 1986;99(1186):254-7.

Return to footnote 250 referrer

Footnote 251

Dennis C, Jackson K, Watson J. Interventions for treating painful nipples among breastfeeding women. Cochrane Database Syst Rev. 2014(12):CD007366.

Return to footnote 251 referrer

Footnote 252

Vieira F, Bachion MM, Mota DDCF, Munari DB. A systematic review of the interventions for nipple trauma in breastfeeding mothers. J Nurs Scholarsh. 2013;45(2):116-25.

Return to footnote 252 referrer

Footnote 253

Rowan-Legg A, Cummings C, Gander S, Grimes RB, Grueger B, Pancer LB, et al. Ankyloglossia and breastfeeding. Paediatr Child Health. 2015;20(4):209-13.

Return to footnote 253 referrer

Footnote 254

Moorhead AM, Amir LH, O'Brien PW, Wong S. A prospective study of fluconazole treatment for breast and nipple thrush. Breastfeed Rev. 2011;19(3):25-9.

Return to footnote 254 referrer

Footnote 255

Francis-Morill J, Heinig MJ, Pappagianis D, Dewey KG. Diagnostic value of signs and symptoms of mammary candidosis among lactating women. J Hum Lact. 2004;20(3):288-95.

Return to footnote 255 referrer

Footnote 256

Wiener S. Diagnosis and management of candida of the nipple and breast. J Midwifery Womens Health. 2006;51(2):125-8.

Return to footnote 256 referrer

Footnote 257

Amir LH. ABM clinical protocol #4: mastitis, revised March 2014. Breastfeed Med. 2014;9(5):239-43.

Return to footnote 257 referrer

Footnote 258

Berens P, Eglash A, Malloy M, Steube AM, Brodribb W, Noble L, et al. ABM clinical protocol #26: persistent pain with breastfeeding. Breastfeed Med. 2016;11(2):46-53.

Return to footnote 258 referrer

Footnote 259

Hoppe J. Treatment of oropharyngeal candidiasis in immunocompetent infants: a randomized multicenter study of miconazole gel vs. nystatin suspension. Pediatr Infect Dis. J 1997;16(3):288-93.

Return to footnote 259 referrer

Footnote 260

Kataria K, Srivastava A, Dhar A. Management of lactational mastitis and breast abscesses: review of current knowledge and practice. Indian J Surg. 2013;75(6):430-5.

Return to footnote 260 referrer

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