Bibliographic Info
GuidelineWHO recommendations on maternal health: guidelines approved by the WHO Guidelines Review Committee, second edition. Geneva: World Health Organization; 2025
Year of Publication2023
Issuing InstitutionWorld Health Organization
Recommendation
Status
Updated
Recommended
Certainty of evidence
Low
For preterm infants who are unable to breastfeed directly, non-nutritive sucking and oral stimulation may be beneficial until breastfeeding is established.
Notes and Remarks
- 1.Focused and optimal immediate support to initiate and establish breastfeeding in the first hours and days of life have positive effects far beyond the stay at the facilities providing maternity and newborn services.
- 2.Although there is evidence of benefit for immediate and uninterrupted skin-to-skin contact starting at less than 10 minutes after delivery, this practice can often be started much sooner, by the second or third minute after delivery, while continued assessment, drying and suctioning (if needed) are done while the infant is experiencing skin-to-skin contact. Uninterrupted skin-to-skin contact ideally lasts for more than an hour, and longer periods, when well tolerated by both mother and infant, should be encouraged.
- 3.During early skin-to-skin contact and for at least the first 2 hours after delivery, sensible vigilance and safety precautions should be taken, so that health-care personnel can observe for, assess and manage any signs of distress.
- 4.Early initiation of breastfeeding has been shown to have positive effects when done within the first hour after delivery. Among healthy term infants, feeding cues from the infant may be apparent within the first 15–20 minutes after birth, or may not be apparent until later.
- 5.Because there is a dose-response effect, in that earlier initiation of breastfeeding results in greater benefits, mothers who are not able to initiate breastfeeding during the first hour after delivery should still be supported to breastfeed as soon as they are able. This may be relevant to mothers that deliver by caesarean section, after an anaesthetic, or those who have medical instability that precludes initiation of breastfeeding within the first hour after birth.
- 6.Mothers should be enabled to achieve effective breastfeeding, including being able to position and attach their infants to the breast, respond to their infants’ hunger and feeding cues, and express breast milk when required.
- 7.Expression of breast milk is often a technique used to stimulate attachment and effective suckling during the establishment of breastfeeding, not only when mothers and infants are separated.
- 8.Mothers of infants admitted to the neonatal intensive care unit should be sensitively supported to enable them to have skin-to-skin contact with their infants, recognize their infants’ behaviour cues, and effectively express breast milk soon after birth.
- 9.Additional foods and fluids apart from breast milk should only be given when medically acceptable reasons exist. Lack of resources, staff time or knowledge are not justifications for the use of early additional foods or fluids.
- 10.Proper guidance and counselling of mothers and other family members enables them to make informed decisions on the use or avoidance of pacifiers and/or feeding bottles and teats until the successful establishment of breastfeeding.
- 11.Supporting mothers to respond in a variety of ways to behavioural cues for feeding, comfort or closeness enables them to build caring, nurturing relationships with their infants and increase their confidence in themselves, in breastfeeding and in their infants’ growth and development. Ways to respond to infant cues include breastfeeding, skin-to-skin contact, cuddling, carrying, talking, singing and so forth.
- 12.There should be no promotion of breast-milk substitutes, feeding bottles and teats, pacifiers or dummies in any part of facilities providing maternity and newborn services, or by any of the staff.
- 13.Health facilities and their staff should not give feeding bottles and teats or other products within the scope of the International Code of Marketing of Breast-milk Substitutes (2) and its subsequent related WHA resolutions (3), to breastfeeding infants.
- 14.Creating an enabling environment for breastfeeding includes having policies and guidelines that underpin the quality standards for promoting, protecting and supporting breastfeeding in facilities providing maternity and newborn services. These policies and guidelines include provisions of the International Code of Marketing of Breast-milk Substitutes (2) and its subsequent related WHA resolutions (3).
- 15.Relevant training for health workers is essential to enable quality standards to be implemented effectively according to their roles.
- 16.Parents should be offered antenatal breastfeeding education that is tailored to their individual needs and sensitively given and considers their social and cultural context. This will prepare them to address challenges they may face.
- 17.Mothers should be prepared for discharge by ensuring that they can feed and care for their infants and have access to continuing breastfeeding support. The breastfeeding support in the succeeding days and weeks after discharge will be crucial in identifying and addressing early breastfeeding challenges that occur.
- 18.Minimizing disruption to breastfeeding during the stay in the facilities providing maternity and newborn services will require health-care practices that enable a mother to breastfeed for as much, as frequently and for as long as she wishes.
- 19.Coordination of clinical systems in facilities providing maternity and newborn services, so that standards of care for breastfeeding support are coordinated across the obstetric, midwifery and paediatric services, helps develop services that improve the outcomes for those using them.