Skip to main content

The AHRQ National Guideline Clearinghouse (NGC, guideline.gov) Web site will not be available after July 16, 2018 because federal funding
through AHRQ will no longer be available to support the NGC as of that date. For additional information, read our full announcement.

Guideline: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services.

World Health Organization (WHO). Guideline: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. Geneva (Switzerland): World Health Organization (WHO); 2017. 120 p. [258 references]

View the original guideline documentation External Web Site Policy

This is the current release of the guideline.

This guideline meets NGC's 2013 (revised) inclusion criteria.

National Guideline Clearinghouse (NGC) has assessed this guideline's adherence to standards of trustworthiness, derived from the Institute of Medicine's report Clinical Practice Guidelines We Can Trust External Web Site Policy.

NEATS Assessment More about NGC's appraisal Standard of Trustworthiness
Yes Disclosure of Guideline Funding Source
Excellent Disclosure and Management of Financial Conflict of Interests
Guideline Development Group Composition
Yes Multidisciplinary Group
Yes Methodologist Involvement
Excellent Patient and Public Perspectives
Use of a Systematic Review of Evidence
Very Good Search Strategy
Excellent Study Selection
Excellent Synthesis of Evidence
Evidence Foundations for and Rating Strength of Recommendations
Excellent Grading the Quality or Strength of Evidence
Excellent Benefits and Harms of Recommendations
Excellent Evidence Summary Supporting Recommendations
Very Good Rating the Strength of Recommendations
Excellent Specific and Unambiguous Articulation of Recommendations
Excellent External Review
Excellent Updating

Major Recommendations

Definitions for the strength of the recommendations (recommended, recommended only in specific contexts, not recommended) and the quality of evidence (high, moderate, low, very low) are provided at the end of the "Major Recommendations" field.

Immediate Support to Initiate and Establish Breastfeeding

  1. Early and uninterrupted skin-to-skin contact between mothers and infants should be facilitated and encouraged as soon as possible after birth (recommended, moderate-quality evidence).
  2. All mothers should be supported to initiate breastfeeding as soon as possible after birth, within the first hour after delivery (recommended, high-quality evidence).
  3. Mothers should receive practical support to enable them to initiate and establish breastfeeding and manage common breastfeeding difficulties (recommended, moderate-quality evidence).
  4. Mothers should be coached on how to express breast milk as a means of maintaining lactation in the event of their being separated temporarily from their infants (recommended, very low-quality evidence).
  5. Facilities providing maternity and newborn services should enable mothers and their infants to remain together and to practise rooming-in throughout the day and night. This may not apply in circumstances when infants need to be moved for specialized medical care (recommended, moderate-quality evidence).
  6. Mothers should be supported to practise responsive feeding as part of nurturing care (recommended, very low-quality evidence).

Feeding Practices and Additional Needs of Infants

  1. Mothers should be discouraged from giving any food or fluids other than breast milk, unless medically indicated (recommended, moderate-quality evidence).
  2. Mothers should be supported to recognize their infants' cues for feeding, closeness and comfort, and enabled to respond accordingly to these cues with a variety of options, during their stay at the facility providing maternity and newborn services (recommended, high-quality evidence).
  3. For preterm infants who are unable to breastfeed directly, non-nutritive sucking and oral stimulation may be beneficial until breastfeeding is established (recommended, low-quality evidence).
  4. If expressed breast milk or other feeds are medically indicated for term infants, feeding methods such as cups, spoons or feeding bottles and teats may be used during their stay at the facility (recommended, moderate-quality evidence).
  5. If expressed breast milk or other feeds are medically indicated for preterm infants, feeding methods such as cups or spoons are preferable to feeding bottles and teats (recommended, moderate-quality evidence).

Creating an Enabling Environment

  1. Facilities providing maternity and newborn services should have a clearly written breastfeeding policy that is routinely communicated to staff and parents (recommended, very low-quality evidence).
  2. Health-facility staff who provide infant feeding services, including breastfeeding support, should have sufficient knowledge, competence and skills to support women to breastfeed (recommended, very low-quality evidence).
  3. Where facilities provide antenatal care, pregnant women and their families should be counselled about the benefits and management of breastfeeding (recommended, moderate-quality evidence).
  4. As part of protecting, promoting and supporting breastfeeding, discharge from facilities providing maternity and newborn services should be planned for and coordinated, so that parents and their infants have access to ongoing support and receive appropriate care (recommended, low-quality evidence).

Definitions

Types of Recommendations

Three options for types of recommendations were agreed, namely:

  • Recommended
  • Recommended only in specific contexts
  • Not recommended.

A recommendations that is "recommended" is one for which the guideline development group is confident that the desirable consequences clearly outweigh the undesirable consequences. Most mothers, patients or end-beneficiaries would want the recommended course of action; only a small proportion would not. The implication for health-care workers is that most individuals should receive the intervention. The implication for policy-makers is that the recommendation can be adopted as a policy, quality standard or performance indicator in most situations.

A recommendations that is "recommended only in specific contexts" is one in which the balance between the benefits and harms of implementing the recommendation may be different for certain situations. Recommendations in this category will specify the contexts in which these recommendations may be applied.

Table of Standardized Statements about Effect

  Important Benefit or Harm Less Important Benefit or Harm No Important Benefit or Harm
High quality of evidence [Intervention] improves/reduces [outcome] (high quality of evidence) [Intervention] slightly improves/reduces [outcome] (high quality of evidence) [Intervention] makes little or no difference to [outcome] (high quality of evidence)
Moderate quality of evidence [Intervention] probably improves/reduces [outcome] (moderate quality of evidence) [Intervention] probably slightly improves/reduces [outcome] (moderate quality of evidence) [Intervention] probably makes little or no difference to [outcome] (moderate quality of evidence)
Low quality of evidence [Intervention] may improve/reduce [outcome] (low quality of evidence) [Intervention] may slightly improve/reduce [outcome] (low quality of evidence) [Intervention] may make little or no difference to [outcome] (low quality of evidence)
Very low quality of evidence It is uncertain whether [intervention] improves/reduces [outcome], as the quality of the evidence has been assessed as very low
No studies None of the studies looked at [outcome]

Clinical Algorithm(s)

None provided

Disease/Condition(s)

Infant health/nutrition

Guideline Category

Counseling

Management

Prevention

Clinical Specialty

Nutrition

Obstetrics and Gynecology

Pediatrics

Intended Users

Advanced Practice Nurses

Allied Health Personnel

Health Care Providers

Hospitals

Nurses

Physician Assistants

Physicians

Public Health Departments

Guideline Objective(s)

  • To help World Health Organization (WHO) Member States and their partners to make evidence-informed decisions on the appropriate actions in their efforts to achieve the Sustainable Development Goals, and implement the Comprehensive implementation plan on maternal, infant and young child nutrition, the Global strategy for women's, children's and adolescents' health (2016–2030) and the Global strategy for infant and young child feeding (see the "Availability of Companion Documents" field)
  • To provide global, evidence-informed recommendations on protection, promotion and support of optimal breastfeeding in facilities providing maternity and newborn services, as a public health intervention, to protect, promote and support optimal breastfeeding practices and improve nutrition, health and development outcomes

Note: This guideline does not aim to be a comprehensive guide on all potential interventions that can protect, promote and support breastfeeding. For instance, it will not discuss breastfeeding support beyond the stay at the facility providing maternity and newborn services, such as community-based practices, peer support or support for breastfeeding in the workplace. Neither will it review the articles and provisions of the International Code of Marketing of Breast-milk Substitutes and its subsequent related World Health Assembly (WHA) resolutions.

Target Population

Women delivering in hospitals, maternity facilities or other facilities providing maternity and newborn services, and their infants

Note:

  • These include mother–infant pairs with term infants, as well as those with preterm, low-birth-weight or sick infants and those admitted to neonatal intensive care units. There is further guidance for low-birth-weight infants from the WHO Guidelines on optimal feeding of low birth-weight infants in low- and middle-income countries. Infants who are, or who have mothers who are, living with human immunodeficiency virus (HIV) can, in addition, be referred to current guidelines on HIV and infant feeding.
  • Infants born at home or in the community setting and those with medical reasons not to breastfeed, temporarily or permanently, will not be considered in this guideline.

Interventions and Practices Considered

  1. Immediate support to initiate and establish breastfeeding
    • Skin-to-skin contact
    • Practical support for breastfeeding
    • Coaching on how to express milk
    • Rooming-in
  2. Feeding practices and additional needs of infants
    • Discouraging other foods and fluids
    • Responsive feeding and recognition of infant cues
    • Non-nutritive sucking and oral stimulation
    • Feeding of expressed milk
  3. Creating an enabling environment
    • Creation and communication of breastfeeding policy
    • Competent and knowledgeable staff
    • Counselling about benefits and management of breastfeeding
    • Discharge planning

Major Outcomes Considered

  • Infant outcomes
    • Early skin-to-skin contact
    • Early initiation of breastfeeding within 1 hour after birth
    • Early initiation of breastfeeding within 1 day after birth
    • Exclusive breastfeeding during the stay at the facility, at 1 month, at 3 months, and at 6 months
    • Duration of exclusive breastfeeding (in months)
    • Duration of any breastfeeding (in months)
    • Morbidity (respiratory infections, diarrhoea, others)
    • Neonatal, infant or child mortality (all-cause)
  • Maternal outcomes
    • Onset of lactation
    • Breast conditions (sore or cracked nipples, engorgement, mastitis, etc.)
    • Effectiveness of breast-milk expression (volume of breast milk expressed)
  • Facilities providing maternity and newborn services and staff outcomes
    • Awareness of staff of the infant feeding policy of the hospital
    • Knowledge of health-care workers on infant feeding
    • Quality of skills of health-facility staff in improving practices of mothers in optimal infant feeding
    • Attitudes of staff on infant feeding
    • Adherence to the provisions of the International Code of Marketing of Breast-milk Substitutes

Methods Used to Collect/Select the Evidence

Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Evidence Identification and Retrieval

A search for previous reviews that address each of the key questions was done in the Campbell Collaboration, Cochrane Library, EMBASE, Epistemonikos, Health Systems Evidence, MEDLINE and the WHO Global Index Medicus up to December 2015. Fifty-two (n = 52) systematic reviews were found and assessed for relevance, quality and timeliness. Of these reviews, nine were previous reviews from the Cochrane Pregnancy and Childbirth Group, seven were from the Cochrane Neonatal Review Group and two were from independent (non-Cochrane) publications. Updates of these systematic reviews were contracted to the original authors. There were four Population, Intervention, Comparator, Outcome (PICO) questions that the steering group decided to commission to the St Luke's International University (as part of the Cochrane Pregnancy and Childbirth Group in Tokyo, Japan). In all, 22 systematic reviews were updated or developed to inform the recommendations. The details of the systematic reviews can be found in Annex 2 of the original guideline document. The full systematic reviews are available through the World Health Organization (WHO) Web site External Web Site Policy.

The WHO Secretariat further performed a qualitative evidence synthesis of published literature, to identify and summarize qualitative research for the values and preferences of mothers and factors that influence acceptability among health workers and stakeholders. A search of the published literature was also performed, to inform on resource use, feasibility and equity and human rights issues for each of the interventions.

Number of Source Documents

In all, 22 systematic reviews were updated or developed to inform the recommendations.

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Table of Standardized Statements about Effect

  Important Benefit or Harm Less Important Benefit or Harm No Important Benefit or Harm
High quality of evidence [Intervention] improves/reduces [outcome] (high quality of evidence) [Intervention] slightly improves/reduces [outcome] (high quality of evidence) [Intervention] makes little or no difference to [outcome] (high quality of evidence)
Moderate quality of evidence [Intervention] probably improves/reduces [outcome] (moderate quality of evidence) [Intervention] probably slightly improves/reduces [outcome] (moderate quality of evidence) [Intervention] probably makes little or no difference to [outcome] (moderate quality of evidence)
Low quality of evidence [Intervention] may improve/reduce [outcome] (low quality of evidence) [Intervention] may slightly improve/reduce [outcome] (low quality of evidence) [Intervention] may make little or no difference to [outcome] (low quality of evidence)
Very low quality of evidence It is uncertain whether [intervention] improves/reduces [outcome], as the quality of the evidence has been assessed as very low
No studies None of the studies looked at [outcome]

Methods Used to Analyze the Evidence

Meta-Analysis

Review of Published Meta-Analyses

Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

Quality Assessment and Grading of Evidence

Systematic reviews based on the Population, Intervention, Comparator, Outcome (PICO) questions were used to summarize and appraise the evidence. These reviews followed the procedures of the Cochrane handbook for systematic reviews of interventions. Each study included in the systematic reviews was assessed for risk of bias. This was recorded and contributed towards the assessment of the overall quality of the evidence. During the discussion and deliberations, the steering group and the guideline development group carefully reviewed the quality, scope and study inclusion criteria for the systematic reviews. The relative weight given to the trials and non-randomized studies was taken into account when evaluating the quality assessment for each study. When possible, the findings were synthesized with a pooled estimate of effect. The results of the systematic reviews were presented to the guideline development group, along with an assessment of the confidence in the estimates of effect for the critical outcomes.

Evidence profiles were prepared according to the Grading of Recommendations Assessment, Development and Evaluation(GRADE) approach, to assess the overall quality of the evidence. The quality of evidence for each outcome was rated as "high", "moderate", "low" or "very low", based on a set of criteria including risk of bias, inconsistency, imprecision, indirectness and publication bias. The summary of findings tables can be found in Annex 3 of the original guideline document.

The findings of the qualitative reviews on maternal values and preferences and acceptability to health workers of interventions that promote, protect and support breastfeeding were appraised using the GRADE Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) approach. Overall confidence in the evidence from reviews of qualitative research was based on methodological limitations of the individual studies; adequacy of the data; coherence of the evidence; and relevance of the individual studies to the review findings. The summary of qualitative findings tables on maternal values and preferences can be found in Annex 4 of the original guideline document and the summary of qualitative findings tables on the factors that influence acceptability among health workers and stakeholders can be found in Annex 5.

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Identification of Priority Questions and Outcomes

An initial set of questions to be addressed in the guidelines was the starting point for formulating the recommendation. The questions were drafted by technical staff at the Evidence and Programme Guidance Unit of the Department of Nutrition for Health and Development, based on the policy and programme guidance needs of Member States and their partners. The questions were discussed and reviewed by the steering group.

A meeting of the guideline development group on 11–13 April 2016 in Geneva, Switzerland, was held to finalize the scope of the questions and to rank the outcomes and populations of interest for the recommendations on protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. The guideline development group discussed the relevance of the questions and modified them as needed. The group scored the relative importance of each outcome from 1 to 9 (where 7–9 indicated that the outcome was critical for a decision, 4–6 indicated that it was important and 1–3 indicated that it was not important). The final key questions on this intervention, along with the outcomes that were identified as critical for decision-making, are listed in Population, Intervention, Comparator, Outcome (PICO) format in Annex 1 of the original guideline document.

Formulation of Recommendations

The draft recommendations were discussed by the steering group, in consultation with the guideline development group, in a meeting held on 7–11 November 2016 in Florence, Italy.

The systematic review and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence profiles for each of the critical outcomes were used for drafting recommendations. An evidence-to-decision framework (based on the Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence [DECIDE] framework) was used to lead discussion and decision-making.

The domains listed in the original guideline document were prepared by the steering group and discussed during the guideline development group meeting for each of the key PICO questions.

Consensus Decision-making Rules and Procedures

The chairpersons were nominated by the World Health Organization (WHO) Secretariat at the opening of the consultation. The nominations were approved by the guideline development group.

The procedures for consensus decision-making were established at the beginning of the meetings, including a minimal set of rules for agreement and documentation of decision-making. At least two thirds of the guideline development group was required to be present for an initial discussion of the evidence and proposed recommendation and remarks. By secret ballot, each member of the guideline development group noted the direction of each of the recommendations, using an online form specifically designed for this purpose. Abstentions were not allowed.

Once voting was complete, subsequent deliberations among the members of the guideline development group could take place. If there was no unanimous consensus (primary decision rule), more time was given for deliberations and a second round of online voting took place. If no unanimous agreement was reached, a two-thirds vote of the guideline development group was required for approval of the proposed recommendation (secondary decision rule). The results from voting forms will be kept on file by WHO for up to 5 years.

Document Preparation

The responsible technical officer wrote the first draft of the guideline, with comments from the steering group. Technical editing and proofreading was done by a contracted party.

Rating Scheme for the Strength of the Recommendations

Types of Recommendations

Three options for types of recommendations were agreed, namely:

  • Recommended
  • Recommended only in specific contexts
  • Not recommended.

A recommendations that is "recommended" is one for which the guideline development group is confident that the desirable consequences clearly outweigh the undesirable consequences. Most mothers, patients or end-beneficiaries would want the recommended course of action; only a small proportion would not. The implication for health-care workers is that most individuals should receive the intervention. The implication for policy-makers is that the recommendation can be adopted as a policy, quality standard or performance indicator in most situations.

A recommendations that is "recommended only in specific contexts" is one in which the balance between the benefits and harms of implementing the recommendation may be different for certain situations. Recommendations in this category will specify the contexts in which these recommendations may be applied.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

External Peer Review

Internal Peer Review

Description of Method of Guideline Validation

Peer Review

The final draft guideline was peer-reviewed by content experts, to provide technical feedback; identify errors of fact; ensure that there were no important omissions, contradictions or inconsistencies with scientific evidence or programmatic feasibility; and assist with clarifying the language, especially in relation to implementation, adaptation and contextual issues. The independent peer-reviewers were selected by the steering group. Twenty-one potential peer-reviewers were approached after assessment of the declarations of interests, and 16 agreed. The list of peer-reviewers appears in Annex 10 of the original guideline document.

The steering group reviewed all comments and revised the document, in order to ensure clarity of the recommendation while maintaining consistency with the original meaning.

Type of Evidence Supporting the Recommendations

The type of supporting evidence is specifically stated for each recommendation (see the "Major Recommendations" field).

The available evidence included 22 systematic reviews that followed the procedures of the Cochrane handbook for systematic reviews of interventions and assessed the effects of interventions to protect, promote and support breastfeeding in facilities providing maternity and newborn services.

Potential Benefits

  • 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.
  • 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.
  • 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.
  • Mothers and infants who room-in together are almost twice as likely to be exclusively breastfeeding during the stay at the facilities providing maternity and newborn services. Fostering sensitive, reciprocal and nurturing relationships between mothers and infants results in considerable benefit to both.

Refer to the "Balance of benefits and harms" section for each recommendation for additional information.

Potential Harms

  • One study emphasizes that breast-milk expression and pumping may be a complex and individual activity outside of the norm. There was no evidence that a particular type of pump was associated with a higher level of milk contamination, infant sepsis or transfer to feeding at the breast. Adverse effects related to the mother, such as nipple or breast pain, were reported in three of the 41 studies included in the review and showed no difference between methods of breastmilk expression, though the actual numbers reporting these adverse outcomes were small.
  • 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.

Refer to the "Balance of benefits and harms" section for each recommendation for additional information.

Qualifying Statements

  • The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization (WHO) concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement.
  • The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
  • All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use.
  • This document is not intended as a comprehensive operational manual or implementation tool for the Baby-friendly Hospital Initiative, the International Code of Marketing of Breast-milk Substitutes or other breastfeeding protection, promotion and support programmes.

Description of Implementation Strategy

Implementation of the Guideline

An implementation guide that will encompass the recommendations included in this guideline, the International Code of Marketing of Breast-milk Substitutes and the Baby-friendly Hospital Initiative has been developed by the World Health Organization (WHO) and United Nations Children's Fund (UNICEF) and will be published separately in Protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services: the revised Baby-friendly Hospital Initiative 2017.

The implementation of this guideline complements the interventions and guidance presented in the Essential newborn care course, Kangaroo mother care: a practical guide, Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice and the Standards for improving quality of maternal and newborn care in health facilities.

Implementation Considerations

As this is a global guideline, Member States are expected to adapt the recommendation according to their settings and contexts. Public health nutrition and child health programmes that include breastfeeding protection, promotion and support require supportive policies, and health-care services that enable the proper availability of and access to quality services, which should also be culturally acceptable. WHO regional and country offices assist Member States with these processes.

Scaling up breastfeeding programmes entails several components working synchronously. Evidence-based advocacy generates political will to enact legislation and policies to protect, promote and support breastfeeding. Policies and strategies help channel the resources towards development of human resources and programme delivery. Evaluation and monitoring, in turn, are needed to provide feedback and drive adaptation or improvement. Implementing the interventions to protect, promote and support breastfeeding in facilities providing maternity and newborn services will require endorsements of both local administrators and governmental policy-makers; effective leadership to transform processes; training of health-care workers; and alignment of hospital-wide health services related to breastfeeding, so that they are people centred, i.e., with the infants, mothers and their families at the centre of care.

Guiding principles to expand implementation of the interventions that protect, promote and support breastfeeding to neonatal intensive care units and the care of vulnerable infants have also been described.

Engaging with multiple stakeholders and partners is critical for strengthening implementation and sustaining gains in breastfeeding. Working in collaboration with programmes involved in child and adolescent well-being (e.g., sexual and reproductive health; water, sanitation and hygiene; early childhood development and education; social marketing; and others) can help ensure a comprehensive, cross-sectoral and more sustainable approach to protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services.

Implementation of this guideline should be a planned and monitored process, including collection of data on how the recommendations are accepted, contested or easily implemented. Adequate collection and recording of data, difficulties, decisions and results can inform implementation research questions that may arise during monitoring and evaluation, and hence provide robust evidence for scaling up and sustainability.

Regulatory Considerations

Implementing interventions that protect, promote and support breastfeeding in facilities providing maternity and newborn services entails improving the quality and standards of care for mothers and their infants during and immediately after the time of childbirth. WHO has produced a technical reference document with eight standards of care and 31 quality statements for improving maternal and newborn care in health facilities. Implementation of interventions to protect, promote and support breastfeeding in facilities providing maternity and newborn services should be aligned to the overall quality standards for the care of mothers and newborns.

Ethical and Equity Considerations

Ethical principles lead to consideration of whether an intervention is producing benefits to individuals and communities; preventing harms at the individual and societal levels; and distributing health benefits across social groups, that is, how much an intervention is contributing to health equity; and respecting and promoting the exercise of human rights.

Breastfeeding is a complex social act that encompasses behaviours, values, beliefs and social roles and interplays with the implementation of policies, strategies and actions to protect, promote and support breastfeeding. Achieving equity in breastfeeding entails political leadership to create an enabling environment that supports the availability of and access to quality breastfeeding support. Policymakers need to have a holistic view of what is needed for breastfeeding and how to address the needs of diverse, vulnerable populations.

Monitoring and Evaluation of Guideline Implementation

Monitoring and evaluation should be built into the implementation process, in order to provide important lessons for uptake and further implementation. World Health Assembly (WHA) Resolution 65.6 endorsed a Comprehensive implementation plan on maternal, infant and young child nutrition, which specified six global nutrition targets for 2025. One of the targets is to increase the rate of exclusive breastfeeding in the first 6 months up to at least 50%.

For evaluation at the global level, the WHO Department of Nutrition for Health and Development has developed a centralized platform for sharing information on nutrition actions in public health practice implemented around the world. By sharing programmatic details, specific country adaptations and lessons learnt, this platform provides examples of how guidelines are being translated into actions. The Global database on the Implementation of Nutrition Action (GINA) provides valuable information on the implementation of numerous nutrition policies and interventions.

IOM Care Need

Staying Healthy

IOM Domain

Effectiveness

Patient-centeredness

Bibliographic Source(s)

World Health Organization (WHO). Guideline: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. Geneva (Switzerland): World Health Organization (WHO); 2017. 120 p. [258 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2017

Guideline Developer(s)

World Health Organization - International Agency

Source(s) of Funding

The World Health Organization (WHO) thanks the Bill & Melinda Gates Foundation for providing financial support for this work. Nutrition International (formerly Micronutrient Initiative) and the International Micronutrient Malnutrition Prevention and Control Programme of the United States Centers for Disease Control and Prevention (CDC) provided financial support to the Evidence and Programme Guidance Unit, Department of Nutrition for Health and Development, for the commissioning of systematic reviews of nutrition interventions. Donors do not fund specific guidelines and do not participate in any decision related to the guideline development process, including the composition of research questions, membership of the guideline groups, conduct and interpretation of systematic reviews, or formulation of recommendations.

Guideline Committee

WHO Guideline Development Group

Composition of Group That Authored the Guideline

Guideline Development Group Members: Dr Paluku Bahwere, Research Manager, Valid International, Belgium; Dr Mary Christine Castro, Executive Director, Nutrition Center of the Philippines, Philippines; Dr Hoosen Coovadia, Director, Maternal, Adolescent and Child Health, Health Systems, South Africa; Dr Maria Elena del Socorro Jefferds (Chairperson in the first meeting), Behavioural Scientist, Division of Nutrition, Physical Activity and Obesity, Centers for Disease Control and Prevention, United States of America; Dr Luz Maria De-Regil, Chief Technical Advisor and Director, Research and Evaluation, Micronutrient Initiative, Canada; Ms Solange Durão (Chairperson in the second meeting), Senior Scientist South Africa Cochrane Collaboration Centre, South Africa; Dr Shams El Arifeen, Senior Director and Senior Scientist, Division of Maternal and Child Health, International Centre for Diarrhoeal Disease Research, Bangladesh; Dr Rukhsana Haider (Chairperson in the first meeting), Founder, Training and Assistance for Health and Nutrition, Bangladesh; Dr Jalila Hassan Ep El Ati, Head, Study and Planning Department, National Institute of Nutrition and Food, Tunisia; Ms Anne-Dominique Israel-de Monval, Senior Nutrition and Health Adviser, Action Contre La Faim, France; Dr Susan Jack (Chairperson in the second meeting), Senior Research Fellow, University of Otago, New Zealand; Dr Alexis Nzila, Assistant Professor, Department of Life Sciences, King Fahd University of Petroleum and Minerals, Saudi Arabia; Dr Indi Trehan, Associate Professor, Department of Pediatrics, Washington University in St Louis, United States of America; Dr Tran Khanh Van, Vice Head of Micronutrients and Coordinator, National Institute of Nutrition, Viet Nam

Financial Disclosures/Conflicts of Interest

Management of Conflicts of Interests

The steering group, in compliance with the World Health Organization (WHO) Guidelines for declaration of interests for WHO experts and in collaboration with the Office of Compliance and Risk Management and Ethics, managed the potential conflicts of interests. All potential guideline development group members were asked to fill in and sign the standard WHO declaration-of-interests and confidentiality undertaking forms. Updated curriculum vitae were also required from the prospective members of the guideline development group, as they engage in their individual capacity and not as institutional representatives.

The steering group reviewed the declaration-of-interests statements in conjunction with the curriculum vitae for all guideline development group members. Information from the internet or media were gathered, in order to identify any public statements made or positions held by the prospective guideline development group members and experts on the issue of protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. These were assessed for intellectual bias that may be perceived to, or actually, affect impartiality. All concerns or potential issues were discussed with the WHO Office of Compliance, Risk Management and Ethics. All potential conflicts of interest were managed on a case-by-case basis.

Refer to the original guideline document for individual disclosures.

Guideline Status

This is the current release of the guideline.

This guideline meets NGC's 2013 (revised) inclusion criteria.

Guideline Availability

Availability of Companion Documents

The following is available:

The systematic reviews as well as a list of related documents on maternal and infant nutrition are available from the WHO Web site External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on March 15, 2018. The guideline developer agreed to not review the content.

This NEATS assessment was completed by ECRI Institute on March 15, 2018. The guideline developer agreed to not review the content.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria.

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.