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March 2018
 Supporting Mothers to Establish and Sustain Breastfeeding:
the Role of an Expert Infant Feeding Team in Kwong Wah Hospital

Wong Wing Yan Crystie
Lactation Consultant
Kwong Wah Hospital


The Global Strategy for Infant and Young Child Feeding (WHO, 2003) states that breastfeeding mothers should be provided with accurate information, support within their families and communities and from the health care system. Mothers should have access to skilled practical help such as trained health workers and certified lactation consultants who can help to build mothers’ confidence, improve feeding techniques and prevent or resolve breastfeeding problems.1 As such, an Infant Feeding Team, aiming at providing expert support to the breastfeeding mother-baby dyads and their families as well as the staff looking after them, has been established in Kwong Wah Hospital since September 2013. The team comprises 3 members (2 Advanced Practice Nurse & 1 Registered Nurse Midwife) who are experienced midwives with the qualification of International Board Certified Lactation Consultant (IBCLC). The team is under the guidance of a Midwife Consultant in the Department of Obstetrics & Gynaecology. Expert lactation services are provided for both in- and out-patients, mothers with healthy terms babies as well as mothers and their babies with special needs. The mission of the Team is to achieve effective breastfeeding for all within a mother-baby friendly atmosphere.

The Team works daily from 9am to 5pm with at least 2 staff members. In the morning, one of them focuses on supporting mothers in the maternity wards and the other provides support and consultation in the neonatal unit. In the afternoon, the Team conducts Breastfeeding Clinic (BFC) sessions, small group breastfeeding classes in the maternity wards and telephone follow-up. The Team also participates in staff training related to infant feeding.
A daily service round is conducted in the maternity wards, providing general lactation support to mothers and babies, thus enabling them to get breastfeeding off to a good start. It also aims at early identification of breastfeeding problems so that timely and skilled support can be given, to reduce the need for unnecessary medical intervention. Mothers at high risk of delayed lactogenesis or having unresolved breastfeeding problem referred by midwives are seen by the Team as a priority. The referral criteria include (1) babies with excessive weight loss (>5% on Day1, >7% on Day 2, >10% on Day 3), (2) sore nipple/ nipple problems, (3) poor attachment, (4) breast engorgement, (5) sleepy/fussy/restless babies, (6) Prematurity <34 weeks gestation, birth weight <1.5 kg and mothers whose babies are in the NICU.
Full lactation support is given to mothers with preterm / sick babies, especially those with babies staying in the neonatal intensive care unit (NICU). During its daily service round, the team provides these mothers with direct breastfeeding coaching which is essential for the mother-baby dyads who are separated immediately after birth and beginning to practice direct breastfeeding. These mothers are vulnerable and require intensive and on-going support in order to establish good milk supply and sustain breastfeeding.
Besides, one-on-one counselling and coaching are provided to mothers referred by the nursing or medical staff of the Paediatric unit. Common reasons for referral include (1) excessive weight loss or poor weight gain, (2) neonatal jaundice related to breastfeeding problems, (3) nipple problems / breast engorgement, (4) transitioning from tube-feeding to breastfeeding, (5) babies with special needs, e.g. cleft lips, Down Syndrome, and (6) mothers with insufficient milk supply.

Sustaining breastfeeding after discharge from the hospital setting where comprehensive support is readily available could be a challenge. The Breastfeeding Clinic (BFC) aims to provide support to mothers who encounter difficulties in their journey of sustaining breastfeeding. It operates on every Monday, Wednesday, Friday afternoon with 3 quotas by appointment and 1 for urgent consultation. Due to limited resources, the clinic only accepts mothers and their babies born in Kwong Wah Hospital and until 6 months postnatal. All referrals are screened and appointments arranged by the Team members. Referrals may come from the antenatal clinic, postnatal clinic or hotline (self-referral). Since mid-2015, the BFC also accepts back referrals from 7 designated Maternal and Child Health Centres in Kowloon. These are mainly cases with unresolved breastfeeding problems which may require further management by other disciplines, such as assessment by the breast surgery team, ultrasound therapy to relieve blockage of milk ducts, etc.
The Team also looks after breastfeeding mothers admitted to the Medical and Surgical units. Referrals can be made through the hospital Clinical Management System or directly to the Team through telephone, between 9am and 5pm. For mothers with breast complications admitted to the Surgical unit, the breast care nurse would notify the Team as soon as possible, so that an agreed plan can be made between the mother, the breast care team and the lactation consultant, with an aim to maintaining the lactation.
As more mothers choose to breastfeed, direct or through pumping, the incidence of blocked milk ducts increases. There is emerging evidence2,3 suggesting that therapeutic ultrasound may be an effective treatment option when compresses and frequent milk removal fail to resolve the blocked ducts. Since 2015, the Team has collaborated with the physiotherapists to establish a fast track mechanism so that ultrasound treatment can be given as early as possible.
To resolve breastfeeding problems related to tongue-tie in the baby, a multidisciplinary team approach is warranted. This involves close collaboration between the Infant Feeding Team, paediatrician, plastic surgeon, occupational therapist and physiotherapist. For babies who have undergone release of their tongue-tie, post-operative tongues exercise supervised by the occupational / physio-therapists and monitoring by the Team is mandatory.
Providing comprehensive and expert breastfeeding support service is part and parcel of a high quality maternity service. To support mothers to successfully establish and sustain breastfeeding, services need to be continuous (which may span from antenatal through postnatal to post-hospital discharge) and comprehensive (often requiring input from a multidisciplinary team). Other than technical assistance, mothers with breastfeeding problems also need encouragement from dedicated and caring health professionals to help them build confidence. It is the duty of the Infant Feeding Team to make all these happen.
Key Message:

1 Global strategy for infant and young child feeding. World Health Organization, UNICEF. 2003. 
Available at: http://www.who.int/nutrition/publications/infantfeeding/9241562218/en/ 
(accessed 16 March 2018)
2 Lavigne V and Gleberzon BJ. Ultrasound as a treatment of mammary blocked duct among 25 postpartum lactating women: a retrospective case series. J Chiropr Med. 2012 Sep; 11(3): 170–178.
3 Cooper B & Kowalsky B. Physical Therapy Intervention for Treatment of Blocked Milk Ducts in Lactating Women. Journal of Womenʼs Health Physical Therapy, 2015, Vol.39(3), p.115-126

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
Editorial Team: Ms Georgiana Cheung, Ms Candice Chin, Ms Sing Chu, Ms Christine Lam, Ms Iris Lam, Ms Grace Ma

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