Importance of rooming-in

• Rooming-in has many benefits:

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  Babies sleep better and cry less.

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  Before birth the mothers and infant have developed a sleep/awake rhythm that would be disrupted if separated.

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  Breastfeeding is well established and continues longer and the baby gains weight quickly.

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  Feeding in response to a baby’s cues is easier when the baby is near, thus helping to develop a good milk supply.

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  Mothers become confident in caring for their baby.

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  Mothers can see that their baby is well and they are not worried that a baby crying in a nursery is their baby.

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  Baby is exposed to fewer infections when next to his or her mother rather than in a nursery.

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  It promotes bonding between mother and baby even if mother is not breastfeeding.

Ask: What barriers are sometimes seen to rooming-in as the routine practice?

Wait for a few responses. Also ask what might be solutions to these barriers.

Barriers to rooming-in and possible solutions

• Barriers to rooming-in may be raised that include:

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  Concerns that mothers are tired.

  Ward routines need to facilitate the mother’s rest with quiet times during which there is no cleaning, and there are no visitors or no medical rounds or procedures. In addition, review birth practices to determine if long labours, inappropriate use of anaesthesia and episiotomies, lack of nourishment and stressful conditions are resulting in mothers being extra tired and uncomfortable.

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  Taking the baby to the nursery for procedures.

  Baby care should generally take place at the mother’s bedside or with the mother present. This can provide reassurance and teaching opportunities for the mother as well as providing comfort for the baby if distressed.

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  Belief that newborn babies need to be observed.

  A baby can be observed next to the mother as easily as in a nursery. A mother is very good at observing her own baby and often notices change before a busy nurse notices them. Close observation is not possible in a nursery with many babies.

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  There is no space on the ward for the baby cots.

  Babies can share their mothers’ bed. Bed sharing or co-sleeping can help a mother and baby to get more rest and to breastfeed frequently. The bed may need a side rail, chair against the bed or the bed against the wall, to reduce the risk of the baby falling out of bed.

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  Staff do not know how to assist mothers in learning to care for their babies.

  Soothing and caring for a baby is an important part of mothering. Helping a mother to learn to care for her baby at night is more useful to the mother than taking her baby away to a nursery. Taking the baby away may reduce the mother’s confidence that she can cope with being a mother.

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  Mothers ask for their babies to be taken to the nursery.

  Explain to the mother why the hospital encourages rooming-in as a time to get to know her baby and as beneficial to her baby and herself. Discuss the reason why the mother wants the baby taken to the nursery and see if the difficulty could be solved without taking the baby away. Address the benefits of rooming-in during antenatal contacts.

• If separation of a mother and her infant is required because of a medical situation, document the reason for this separation in the mother/baby record. The need for separation should be reviewed frequently so that it is for as short a time as possible.
• During separation, encourage the mother to see and hold her baby if possible, and to express her milk³².

Ask: How is rooming-in presented to mothers? Is it routine to have all babies with their mothers unless there is a medical reason for separation, or does a mother have to ask for her baby to be beside her – implying that the normal place for the baby is in the nursery or in a cot?

Wait for a few replies and then continue.

Importance of baby-led feeding

• Baby-led feeding results in:

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  Baby gets more immune rich colostrum and therefore more protection from illness.

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  Faster development of milk supply.

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  Faster weight gain.

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  Less neonatal jaundice.

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  Less breast engorgement.

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  Mother learns to respond to her baby.

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  Easy establishment of breastfeeding.

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  Less crying so less temptation to supplement.

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  Longer breastfeeding duration.

• Infants who are allowed to control the frequency and duration of a feed learn to recognise their own signs of hunger and satiety. This ability to self-regulate may be related to the lower rates of obesity in children who were breastfed.

Miriam says she understands the idea of baby-led feeding, but how will she know when to feed her baby and how long to feed her baby for each time if she doesn’t go by the clock?

Ask: What are the signs to watch for in a newborn baby to indicate when to feed the baby?

Wait for a few responses.

Signs of hunger

• The time to feed a baby is when the baby shows early hunger signs. The baby:

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  Increases eye movements under closed eye lids or opens eyes.

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  Opens his or her mouth, stretches out the tongue and turns the head to look for the breast.

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  Makes soft whimper sounds.

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  Sucks or chews on hands, fingers, blanket or sheet, or other object that comes in mouth contact.

• If the baby is crying loudly, arches his or her back, and has difficult attaching to the breast, these are late hunger signs. The baby then needs to be held and calmed before the baby is able to feed.
• Some babies are very calm and wait to be fed or go back to sleep if not noticed. This can result in underfeeding. Other babies wake quickly and become very annoyed if not fed immediately. Help the mother to recognise her baby’s temperament and learn how to best meet her baby’s needs.

Ask: What indicates that the baby has finished feeding?

Wait for a few responses.

Signs of satiety

• At the start of a feed, most babies have a tense body. As they get full, their body relaxes.
• Most babies let go of the breast when they have had enough, though some continue to take small gentle sucks until they are asleep.
• Explain to the mother that she should let her baby finish one breast before she offers the other breast in order to feed the rich hind milk and to increase milk supply.

Feeding patterns

• Some babies feed for a short time at frequent intervals. Other babies feed for a long time and then wait a few hours until the next feed. Babies may change their feeding pattern from day to day or during one day.
• Teach mothers the typical feeding pattern for a full term healthy newborn:

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  Newborns want to breastfeed about every one to three hours in the first two to seven days, but it may be more frequent.

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  Night feeds are important to ensure adequate stimulation for milk production and milk transfer, and for fertility suppression.

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  Once lactation is established (the milk supply ‘comes in’), eight to twelve breastfeeds in 24 hours is common. There are usually some longer intervals between some feeds.

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  During periods of rapid growth, a baby may be hungrier than usual and feed more often for a few days to increase milk production.

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  Let babies feed whenever they want. This satisfies the baby’s needs if hungry or thirsty and the mother’s needs if her breasts are full.

• Very long feeds (more than 40 minutes for most feeds), very short feeds (less than 10 minutes for most feeds) or very frequent feeds (more than 12 feeds in 24 hours on most days) may indicate that the baby is not well attached at the breast.
• Sore nipples are the result of poor attachment, not the result of feeding too often or too long. If a baby is well attached, it does not matter if she or he feeds often or for a long time at some feeds³³.

Special situations

• The mother may need to lead the feeding for a day or two and wake the baby for feeds if a baby is very sleepy due to prematurity, jaundice, or the effects of labour medication, or if the mother’s breasts are overfull and uncomfortable.
• Babies who are replacement fed also need to be fed in response to their needs. Sometimes there is a tendency to push the baby to finish a feed because the milk is prepared. This can lead to overfeeding. A mother can watch her baby for signs of fullness – turning away, reluctance to feed. A replacement feed should be used within one hour of the baby starting the feed and not kept for later as bacteria will grow in the milk. If baby does not finish the milk in one feed, this can be mixed into older sibling’s meal.

Wake a sleepy baby

• If the baby seems too sleepy to feed, suggest that the mother:

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  Remove blankets and heavy clothing and let her baby’s arms and legs move.

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  Breastfeed with her baby in a more upright position.

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  Gently massage her baby’s body and talk to her baby.

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  Wait half an hour and try again.

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  Avoid hurting the baby by flicking or tapping on the cheek or feet.

Settle a crying baby

• A mother and her family may think that a crying baby means that the mother does not have enough milk or that her milk is not good milk. A crying baby can be difficult for a mother and reduce her confidence in herself, and her family’s confidence in her.
• A baby who is ‘crying too much’ may really be crying more than other babies, or the family may be less tolerant of crying or less skilled at comforting the baby. It is not possible to say how much crying is ‘normal’.
• If a baby is crying frequently, look for a cause. Listen to the mother and learn what her situation may be, observe a breastfeed, examine the baby and refer for further medical attention if needed. Babies may cry from hunger, pain, loneliness, tiredness or other reasons.
• Build the mother’s confidence in her ability to care for her baby and give her support:

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  Listen and accept what the mother is feeling.

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  Reinforce what the mother and baby are doing right/what is normal.

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  Give relevant information.

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  Make one or two suggestions.

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  Give practical help.

• Suggestions and practical help can include:

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  Make the baby comfortable – dry, clean nappy, warm, dry bedding, not too warm.

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  Put the baby to the breast. The baby may be hungry or thirsty or sometimes just wants to suck because this makes the baby feel secure.

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  Put baby on the mother’s chest, skin to skin. The warmth, smell, and heartbeat will help to soothe the baby.

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  Talk, sing and rock the baby while holding close.

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  Gently stroke or massage the baby’s arms, legs and back.

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  Give one breast at each feed; give the other breast at the next feed. If the breast not used at that feed becomes overfull, express a small amount of milk.

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  Reduce the mother’s coffee and other caffeine drinks.

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  Do not smoke around the baby and smoke after a feed, not before or during, if a smoker.

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  Have someone else carry and care for the baby for a while.

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  Involve other family members in the discussion so the mother does not feel pressure to give unnecessary supplemental feedings.

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  Hold the baby in a manner that wraps around and supports head, body, legs and arms so the baby feels secure.

Dangers of supplements

• Exclusive breastfeeding is recommended for the first six months. Supplements can:

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  Overfill a baby’s stomach so the baby does not suckle at the breast.

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  Reduce milk supply because the baby is not suckling, resulting in over fullness of the breasts.

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  Cause the baby to gain insufficient weight if feeds of water, teas, or glucose water, are given instead of milk feeds.

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  Reduce the protective effect of breastfeeding thus increasing the risk of diarrhoea, and other illnesses.

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  Expose the baby to possible allergens and intolerances that could lead to eczema and asthma.

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  Reduce the mother’s confidence if a supplement is used as a means of settling a crying baby.

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  Be an unnecessary and potentially damaging expense.

• In addition to the points listed above that could be explained to a mother, there are more reasons why supplement use is not recommended:

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  A mother who is looking for a supplement may be indicating that she is having difficulties feeding and caring for her baby. It is better to help the mother to overcome the difficulties than to give a supplement and ignore the difficulties.

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  A health worker who offers a supplement as the solution to difficulties may be indicating a lack of knowledge and skill in supporting breastfeeding. Frequent use of supplements may indicate an overall stressful atmosphere where a quick temporary solution is chosen in preference to solving the problem.

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  Prelacteal feeding or offering formula to an infant of an HIV-positive woman who will breastfeed may alter the GI mucosa and allow the transmission of the virus. When we cannot test the HIV status of mother, it is important to emphasise that exclusive breastfeeding reduces the risk of HIV transmission during breastfeeding.

• If a mother has been counselled, tested and found to be HIV-positive and has decided not to breastfeed, this is an acceptable medical reason for giving her infant formula (replacement food).
• Even if many mothers are giving replacement feeds, this does not prevent a hospital from being designated as baby-friendly if those mothers have all been counselled, tested, and made genuine informed choices.

Case study

Carolina³⁶ has a long labour for her first baby and no-one from her family was allowed to be with her. When her baby is born, he is wrapped in a blanket and shown to her briefly. She sees that he has a birthmark between her baby’s eyes. Then he is taken away to the nursery because it is night-time. The staff gives him a bottle of infant formula for the next two feeds.

Carolina’s baby is brought to her early the next morning - 10 hours after birth. The nurse tells her to breastfeed. She is told to limit breastfeeding on each side to three minutes. The nurse says, “You don’t want the pain of sore nipples, dear, do you?”.

Carolina starts to take her baby while lying down, but the nurse tells her she must always sit up to feed. Carolina sits up with difficulty; the mattress sags and her back must be bent. She is sore from the birth and it hurts to sit. The nurse leaves Carolina to feed her baby.

She holds her baby to her breast, and pushes the breast towards her baby’s mouth with her hand. But the baby is sleepy and suckles very weakly. Carolina thinks that she has no milk yet because her breasts are soft.

Carolina wonders if the birthmark on the baby’s face was caused by something that she did wrong during the pregnancy. She is worried what her husband and his mother will say about it. The nurses look very busy and Carolina does not want to ask questions of them. Her family will not be allowed to visit until the afternoon.

The nurse returns and takes the baby back to the nursery. She comes back in a few minutes and tells Carolina that she has weighed the baby and finds that he took only 25 g of milk, and that this was not an adequate feed. The nurse says, “How can you go home tomorrow if you can’t feed your baby properly?”.

Possible answers:

• No support during labour may result in a longer labour and Carolina may be more tired and stressed.
• No skin-to-skin contact means Carolina does not get time to be with her baby and all that she notices is his birthmark, which worries her.
• Carolina and her baby are separated for many hours. The baby is given bottles of formula. The baby is not getting the valuable colostrum and Carolina’s breasts are not receiving stimulation to make milk.
• Carolina is not given any help to breastfeed. The baby is full from formula and sleepy, so does not want to suckle. The nurse worries her by talking about sore nipples.
• It is sore for Carolina to sit to feed the baby. This would inhibit the oxytocin release. Carolina could be helped to feed lying down.
• Carolina feels that she is alone in the hospital with no one to help her or talk to her, which caused her stress.
• The nurse frightens Carolina by saying she is not able to feed her baby and will not be able to go home.
• The result is that Carolina is worried, sore, frightened and lonely as well as not knowing how to feed her baby. She is likely to go home thinking that she is not able to make milk and to feed her baby a breast-milk substitute.

Ask if there are any questions. Then summarise the session.

Rooming in and baby-led feeding help breastfeeding and bonding

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Mothers can notice and respond to their babies with ease when they understand their baby’s feeding cues.

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Babies cry less so there is less temptation to give artificial feeds.

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Mothers are more confident about caring for their babies and breastfeeding.

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Breastfeeding is established early, a baby gains weight well, and breastfeeding is more likely to continue for longer.

Help mothers to learn skills of mothering

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Help to learn how to wake a sleepy baby.

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Help to learn how to settle a crying baby.

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Help to learn how to look for hunger cues.

Prelacteal and supplemental feeds are dangerous

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They increase the risk of infection, intolerance and allergy.

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They interfere with suckling and make breastfeeding more difficult to establish.

Artificial teats can cause problems

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Use of teats, pacifier, or nipple shield may effect milk production.

Additional information for Session 8