Baby-Friendly e-Newsletter : Baby Friendly Watch (Dec 2020)

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Initiating and Maintaining Breastfeeding and Managing Common Difficulties: Implementation and Monitoring


Ms Christine C.O. Lam
Nurse Consultant (Breastfeeding)
Queen Elizabeth Hospital


The World Health organization (WHO) has reviewed the evidence for the Ten Steps to Successful Breastfeeding and the implementation of Baby-friendly Hospital Initiative (BFHI), and a number of recommendations emerged. This has led to the launch of the 2018 revised guidelines “Implementation Guidance on Protecting, Promoting and Supporting Breastfeeding in Facilities providing Maternity and Newborn Services: The Revised Baby-friendly Hospital Initiative”1.

One of the key modifications in clinical practice is Step 5: Support mothers to initiate and maintain breastfeeding and manage common difficulties.

Though breastfeeding is a natural human behaviour, mothers need to learn and practice how to breastfeed. In Hong Kong the breastfeeding initiation rate has gradually increased over the past decades and in 2018 more than 87% of women initiated breastfeeding.  According to a survey conducted by the Department of Health in 2019, for babies born in 2018, the breastfeeding rates (BF rates) at 1, 2, 4, 6 months were 76.6%, 66.4%, 55.7% and 46.5% respectively, whereas the exclusive breastfeeding rates (EBF rates) at the same ages were 32.6%, 31.5%, 29.1% and 26.3 % respectively2. It is remarkable that the exclusive breastfeeding rates were kept relatively stable from 1 month onwards. That means, if mothers could be supported to exclusively breastfeed for the first month, exclusive breastfeeding could largely be maintained throughout the first 6 months (Figure 1).

For Figure 1 : Breastfeeding Survey (Department of Health, 2019), please click PDF version.

Studies done locally3, in China4, as well as overseas5 inform that “insufficient breastmilk”, “suckling and latching problems”, “sore and cracked nipples”, “baby is always hungry” and “maternal illness” are the most significant reasons of weaning in the first month postpartum.  Anxiety over the insufficiency of breastmilk often results in the early unnecessary supplementation and weaning of breastfeeding. The suckling and latching problems further lead to sore nipples, prolonged and frequent feeding, maternal fatigue and perceived insufficient milk supply.

Besides healthy mothers and babies, there are about 10-15% of mother-baby dyads (including preterm infants and newborns or mothers having illnesses) with the risk of being separated from each other after birth. This brings more demands on healthcare support for them to establish successful breastfeeding.

Health care workers both in the maternity and neonatal units take a leading role, not only in supporting mothers to initiate, but also maintain (or ensure successful) breastfeeding and manage common difficulties. The importance of breastfeeding training for healthcare professionals cannot be overemphasised.

The WHO has prepared a new and detailed training curriculum as the recommended programme for hospitals with maternity and neonatal unit6.  The training content includes the physiology of milk production, practices to ensure good milk supply, skills in the initiation of breastfeeding, assessment to differentiate between effective and ineffective suckling, principles in handling common problems and counselling skills to empower mothers to make their own decisions. The training enables healthcare workers to provide emotional and motivational support, impart knowledge, teach concrete skills and empower mothers to go through the hurdles of nurturing their babies.

As the Queen Elizabeth Hospital is working to equip its staff with the knowledge and skills in supporting the early initiation and maintenance of breastfeeding, and the management of common problems, we have incorporated the above elements into the staff training curriculum according to their post, level of care and roles. To monitor the effectiveness of training, the steps of “Plan-Do-Check-Act” were adopted. Since both the obstetric and neonatal teams provide care for the mother-baby dyads, their training on breastfeeding and early neonatal problems, such as the management of sore nipple and neonatal jaundice, is the same. Regular sharing sessions are conducted for staff to provide updates in lactation management. For example, it is recommended to start breastmilk expression within 1-2 hours after delivery if babies are separated from their mothers; and mothers who are bottle-feeding are supported to feed their babies responsively.   

In order to monitor the effectiveness of training, the updated practices have been added to the hospital’s regular audit. These items feature both in the staff breastfeeding knowledge audit and mothers’ experience audit. Thus, the audit team can check from both sides whether the knowledge, skills or practice has been adequately implemented by the staff and received by mothers, and follow up on the audit result accordingly. This Continuous Quality Improvement (CQI) system ensures that practices are unified, being up-dated and maintained.



1.  The WHO has revised the guidelines "Implementation Guidance on Protecting, Promoting and Supporting Breastfeeding in Facilities providing Maternity and Newborn Services" in 2018. Step 5 has been changed to "Support mothers to initiate and maintain breastfeeding and manage common difficulties".

世界衞生組織於2018年修訂了「在提供產婦和新生兒服務的設施中,實施保護,促進和支持母乳餵養的指引」。步驟5已更改為 「支持母親開展和維持母乳餵養並處理常見困難」。


2.  Health workers should pay equal attention to concerns of mothers of healthy term babies or those of premature or sick babies.  The management of common breastfeeding difficulties should be included in the training curriculum for both obstetric and neonatal team members.


3.  Through regular audits on staff knowledge and mothers' experience, hospitals can monitor and follow up the effectiveness of teaching and practice of the updated items.



For the note of References, please click PDF version.


Views expressed in this article are the author's and do not necessarily reflect the opinion or position of the BFHIHKA.



Editor-in-Chief: Dr Shirley Leung


All rights reserved by Baby Friendly Hospital Initiative Hong Kong Association.



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