Breastfeeding or nursing is the practice of feeding your baby with breast milk directly from the breast. Experts recommend that new mothers exclusively breastfeed their child within the first 6 months after birth and continue through the infant’s first year of life if possible. The frequency of breastfeeding will depend on the baby’s size and feeding preferences. Newborns typically feed every 2 to 3 hours. As the baby grows, the frequency changes.
Breast milk contains vitamins, fats, and proteins and offers complete nutrition for babies. Colostrum is the rich gold or yellow liquid first produced from the breast and contains antibodies and nutrients that provide immunity to the baby.
Breastfeeding is beneficial for the mother, too. Breastfeeding can help mothers burn extra calories, return to pre-pregnancy weight, reduce uterine bleeding after birth, and enable the uterus to return to its pre-pregnancy state and size.
Breastfeeding offers an opportunity for mother and baby to bond but can be a source of stress and frustration if difficulties arise. Dry, cracked, and sore nipples, breast engorgement, breast infection, and worries about producing, pumping, and storing breastmilk are some common breastfeeding challenges.
In this article:
Nursing Process
Protection, promotion, and support of breastfeeding is a priority public health need. Nurses play an essential role in providing accurate information about breastfeeding and support to the mother and their partner.
The nurse often assists with breastfeeding initially after birth and ensures latching. The postpartum nurse helps encourage and support frequent maternal-infant contact to promote effective breastfeeding.
The nurse’s role in supporting breastfeeding varies in the time and place of care. However, the same goals are present: to help the mother initiate breastfeeding, enjoy it, and ensure the baby gets the optimum nutrition needed for growth and development.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to breastfeeding.
Review of Health History
1. Identify the patient’s readiness and willingness to breastfeed her baby.
The motivation and willingness of the patient enhance the breastfeeding experience. Attempts at supporting and educating the patient will only be successful if the mother is interested in breastfeeding.
2. Interview the patient about their breastfeeding experience.
Allow the patient to describe her breastfeeding experience. This includes any past challenges, how she performs breastfeeding, and if there is any pain, discomfort, or anxiety.
3. Determine if the patient has support from the family.
Effective breastfeeding requires teamwork, patience, practice, and time. The patient will need the support of the family, especially her partner, to achieve their breastfeeding goals.
4. Ask about the patient’s breastfeeding goals.
Ask the patient about their short- and long-term goals for breastfeeding. Patients may plan to breastfeed the baby for the first six months or longer, but initially, this may seem like a very long period. Set attainable short-term goals rather than concentrating on the long term.
5. Obtain the patient’s nutritional status and food preferences.
Nutrition for nursing mothers can be complex. Determine their appetite, eating habits, and how this affects their milk supply.
6. Assess the mother’s work status.
Discuss the mother’s current work status and if/when they plan to return to work. Returning to work does not mean breastfeeding ends. Discuss taking time to pump while at work.
7. Note the use of pumps and suckling replacements.
Note whether the patient prefers direct latch breastfeeding or pumping to collect breast milk. Ask if the patient uses suckling replacements such as pacifiers, artificial teats, or bottles.
8. Interview the patient about the baby’s experience during and after feeding.
Ask the patient to describe the baby’s experience during and after feeding. Note for any signs of:
- Difficulty during feeding, such as the baby gagging and inadequate latch
- Ineffective breastfeeding, such as being fussy after feeding
9. Assess for signs of milk let-down.
Oxytocin is the hormone responsible for the let-down reflex. Mothers may experience breast tingling or tightening or report feeling relaxed or sleepy when the let-down reflex occurs.
10. Review the medical history.
The nurse should educate the mother not to breastfeed in instances of:
- HIV without viral suppression
- Use of opioids or illegal substances
- Certain medications
Physical Assessment
1. Observe the condition of the patient’s breasts.
Examine the nipples and breasts for form and shape. Check for any redness, skin injury, or swelling. Look for signs of the following:
- Previous surgery
- Mastitis
- Swelling
- Infection
- Engorgement
- Breast and nipple skin and shape changes
2. Assess the nipples and breast skin.
Candida is frequently associated with red, shiny, itchy, and flaky skin. The nipple and breast can develop eczema, dermatitis, and other skin disorders like other body regions.
3. Assess the nipples.
Inverted nipples may not necessarily cause issues. Instead of the nipple, babies latch onto the breast. Large or protruding nipples might also make it harder for the baby to take the breast back into their mouth. Note for swelling, cracking, and soreness.
4. Observe breastfeeding.
Check how the patient positions herself and the baby. Ensure that the baby’s mouth latches on properly to the breast, covering the nipple with the baby’s mouth. Breastfeeding should not be painful.
5. If the patient uses a breast pump, ask them to demonstrate it.
Show the patient how to attach and remove the breast pump. Ensure the proper use of the breast pump to maximize breastmilk collection and emptying of the breasts.
6. Check how the patient manually expresses milk.
Manual milk expression allows the patient to express milk without a breast pump. It can help prevent engorgement.
7. Assess the infant’s rooting, suckling, and hand movements.
The infant’s hand movements, suckling, and rooting on the mother’s breast can cause the release of oxytocin, which starts the letdown and initiates milk flow.
8. Monitor the baby’s weight.
Weight gain is the main factor when evaluating an infant’s development and breastfeeding success. With efficient breastfeeding, the initial weight loss of a healthy term child will settle in 3–4 days, followed by a gradual weight gain.
9. Ask the patient to verbalize the signs of hunger in babies.
Babies give signs that they are hungry. Initially, the baby may display the following to signal that they are ready to be fed:
- Rooting
- Sticking out their tongue
- Licking their lips
- Placing hands in their mouth
- Sucking on things
- Fussiness
- Crying (late sign)
10. Identify signs of infant hydration.
Signs of infant hydration include:
- A pink and moist mouth
- Alert and active before feeding
- Normal skin turgor
- Soft and flat fontanelles
- Vigorous cries
- The infant’s weight gain and output are appropriate for the age
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions related to breastfeeding.
Assist With Breastfeeding
1. Encourage breastfeeding immediately after birth.
Most babies will breastfeed successfully right away, although others may merely lick and sniff the breast initially and may not necessarily actively suck. Delay procedures, monitoring, and measurements until the initial breastfeeding is completed.
2. Place the baby in skin-to-skin contact with the mother.
Lay the infant skin-to-skin on the mother’s chest for at least an hour until the first feeding is over, or for however long the mother chooses. The patient and the baby should be together for the first 24 hours as applicable.
3. Recognize early feeding cues.
Determine the baby’s readiness for breastfeeding. Breastfeed when the baby displays early hunger signs like rooting or smacking the lips. Breastfeeding should be done on demand, not on a schedule.
4. Breastfeed when the patient is relaxed.
The mother should breastfeed when at ease and relaxed. Breastfeeding sessions should be frequent, unscheduled, and unrestrained by time. A comfortable breastfeeding experience helps increase breast milk production and promotes commitment to breastfeeding.
5. Teach the patient different breastfeeding positions.
Different breastfeeding positions can help the mother and baby feel more comfortable and relaxed while feeding. These positions include:
- Cradle position
- Football position
- Side-lying position
- Cross-cradle hold
- Laid-back position
6. Assist the patient in breastfeeding.
Advise the patient to let the infant breastfeed on the first breast until the infant can no longer efficiently suck and swallow (i.e., sucking deeply and slowly). If the infant shows interest, the second breast should be offered. When a baby is learning to breastfeed, this may occur numerous times throughout a breastfeeding session. The baby should be permitted to fully breastfeed from the first breast once nursing and breast milk production have been established before switching breasts.
7. Explain the need for short and frequent breastfeeding.
Babies should effectively suck and swallow until they are satisfied. Breastfeeding may occur 8-12 times initially, with sessions lasting 5-20 minutes.
8. Discourage the use of suckling replacements.
Avoid using a bottle or a pacifier to prevent nipple confusion. Assist the mother in making an informed decision regarding using pacifiers or artificial nipples. If the mother chooses to use them, urge her to hold off until the infant is at least four to six weeks old and has developed reliable breastfeeding and sucking patterns.
9. Ensure the suck, swallow, and breathe cycle.
The infant’s ability to successfully nurse requires coordination of the suck-swallow-breathe reflex. Infant sucking requires intricate interaction and coordination of the jaw, hyoid bone, palate, throat, and tongue.
10. Emphasize the need to monitor the urine output of the infant.
Urine can initially be concentrated, noticeably yellow, and occasionally have an odor. As breast milk production rises, an infant’s urine will become pale or clearer and odorless. Wet diapers become notably heavier.
11. Monitor for stool changes.
Early weight gain and less baby weight loss are linked to the change to yellow stools. Lack of newborn stools or a delayed transition to light-colored feces could indicate insufficient milk consumption.
12. Assess for signs of effective breastfeeding.
The baby is getting enough milk if the following is observed:
- They are feeding 8 times within 24 hours
- They are satisfied and relaxed after feeding
- They have 6-8 wet diapers per day
- Breastfeeding is comfortable for mom and baby
Manage Possible Complications
1. Treat breast inflammation and infections.
Mastitis symptoms can be lessened with anti-inflammatory medication. Antibiotic treatment is advised if:
- The patient has had a fever for at least 24 hours.
- There are indications of a potential infection (such as a cracked nipple).
- The patient’s symptoms did not improve after expressing milk or feeding.
2. Assist with latching the baby to the breast.
Offer extra help with attachment and positioning during the first couple days before the breasts are full. The baby latches on to the areola, not the nipple, for patients with an inverted nipple. Ensure the following with latching:
- The nipple is high and deep in their mouth
- Their top and bottom lips are wide open
- Their upper lip is very close to the nipple, and the lower lip is near the border of the nipple and areola
- Their chin is touching the breast, and the nose is close to the breast
- Their cheeks are full
- Their tongue comes out over the lower lip during latch-on and stays below the areola during nursing
3. Suggest a gentle milk expression before feeding the infant.
Before a feed, advise the patient to gently self-extract milk from her breasts to soften the areola and facilitate the baby’s attachment.
4. Encourage breast milk expression in between feedings.
Instruct the mother to express milk several times in between feedings until she feels at ease if breastfeeding does not lessen the engorgement.
5. Promote relaxation.
A warm bath or shower promotes the flow of milk. Massaging the breasts or other forms of relaxation may also increase the milk flow.
6. Offer comfort measures for the affected breast.
Always start each feeding with the breast that is least sore. After breastfeeding, dab some breast milk on the nipples to lubricate the nipple tissue. Warm compresses may alleviate discomfort and engorgement.
7. Promote good hygiene.
Nipples should be washed once daily, as part of general body hygiene, not after each feed. Do not use soap on the nipples because it may cause drying, cracking, and irritation.
8. Provide support and assistance.
Create a supportive environment and give the mother confidence in breastfeeding. Assist the patient with any concerns and answer questions about breastfeeding.
Offer Education
1. Discuss the use of breast pumps.
Pumping helps prevent engorgement when the mother is away from the baby, such as when returning to work. The mother should start using the pump 2 weeks before the planned separation. Pumps may be manual or electric. Pumping should occur at the usual times when the infant feeds, such as every 3-4 hours for 15 minutes.
2. Assist the patient in performing manual milk expression.
Using the breast model, demonstrate manual milk expression techniques, ensuring that hands are placed in a C-shape around the breast.
3. Inform the patient about common conditions affecting the breast.
Early recognition of conditions affecting the breast, such as mastitis, infection, and engorgement, will allow immediate action to prevent it from worsening.
4. Emphasize the need to make healthy food choices.
Encourage the patient to choose healthy options to support milk production. Choose protein-rich foods, including lean meat, eggs, dairy, beans, lentils, and mercury-free seafood, along with plenty of fruits, vegetables, and whole grains.
5. Promote hydration.
Encourage one glass of water for every breastfeeding session. Avoid consuming more than 2 to 3 cups of caffeinated beverages daily. The infant may become restless or agitated if caffeine is in the breast milk.
6. Encourage adherence to prescribed supplements.
Advise continuing to take a daily multivitamin or mineral supplement as prescribed until weaning the baby to ensure they get all the required vitamins.
7. Refer to breastfeeding support groups.
Encourage breastfeeding support groups to help the patient relate to other mothers about breastfeeding and their experiences. It may also promote commitment to achieving their breastfeeding goals.
8. Refer to a lactation consultant.
A lactation consultant is a health professional who specializes in helping mothers navigate breastfeeding.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for breastfeeding, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for breastfeeding.
Imbalanced Nutrition: Less Than Body Requirements
Imbalanced nutrition less than body requirements occurs in infants due to ineffective breastfeeding patterns, inadequate breast milk intake and production, and the inability of the infant to breastfeed.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related to:
- Inaccurate breastfeeding information
- Inadequate knowledge of infant nutrient requirements
- Insufficient breast milk production
- Interrupted breastfeeding
As evidenced by:
- Hypoglycemia
- Inadequate height increase for age and gender
- Inadequate head circumference growth for age and gender
- Neonatal weight gain < 30 g (1 ounce) per day
- Lethargy
- Pale mucous membranes
- Poor stool or urine output
Expected outcomes:
- The infant will progressively gain weight toward the desired goal with an average weight gain of 1 ounce per day.
- The infant will be free from any signs of malnutrition, such as poor weight gain, lethargy, and < 6 wet diapers per day.
Assessment:
1. Assess the infant’s nutritional status.
An infant’s nutritional status must be assessed frequently to determine the extent of malnutrition and help plan appropriate interventions to resolve imbalances. Babies receiving adequate breast milk are bright, alert, and responsive. They exhibit moist lips, good skin tone, and steady weight gain.
2. Assess the baby’s weight gain.
The average weight gain for breastfed babies is about 150-200 grams (5-7 ounces) per week from birth to 3 months, 100-150 grams (3.5-5 ounces) per week from 3 months to 6 months old, and 70-90 grams (2-3 ounces) per week from 6 months to 12 months old.
3. Assess the baby’s intake and output.
The baby’s intake and output can indicate adequate breast milk intake. Babies getting enough breast milk will have at least 6-8 heavy wet diapers each day. Their urine is pale, odorless, and not concentrated, and they will have soft, yellow, or mustard-colored stools.
Interventions:
1. Encourage the mother to breastfeed more frequently.
Newborn babies should breastfeed 8-12 times per day in the first month. With frequent breastfeeding, breast milk production is stimulated, which ensures adequate nutrition and breast milk intake.
2. Encourage the mother to eat healthy and well-balanced meals.
Nutrients in the food and drinks that the mother consumes will pass to the infant via breast milk. When breastfeeding, mothers are encouraged to eat healthy foods like lean meats, whole grains, fruits, and vegetables and avoid sweets, caffeine, and salty foods. Remind the mother that she will need to consume 400-500 extra calories per day while breastfeeding.
3. Encourage the mother to limit caffeine intake while breastfeeding.
Caffeine is found in drinks like tea, coffee, soda, and energy drinks. Too much caffeine in breast milk can make the breastfeeding infant fussier and have trouble sleeping. It is recommended that breastfeeding mothers drink no more than two cups of caffeine a day.
4. Encourage vitamins and supplements.
Postnatal vitamins may be recommended while breastfeeding. DHA, vitamin D, iron, iodine, and vitamin B12 are necessary for both mom and baby.
5. Monitor the baby for any signs of malnutrition.
Inadequate weight gain is the main indicator of poor infant nutrition. Refusal to feed, trouble sucking the breast, gagging/spitting up breast milk, irritability, fever, and lethargy are warning signs that can indicate a medical condition or make breastfeeding difficult.
Ineffective Breastfeeding
Breastfeeding experiences vary, and ineffective breastfeeding can occur due to many reasons.
Nursing Diagnosis: Ineffective Breastfeeding
Related to:
- Inadequate family support
- Inadequate knowledge of breastfeeding techniques
- Inadequate knowledge regarding the importance of breastfeeding
- Ineffective infant suck-swallow response
- Insufficient breast milk production
- Interrupted breastfeeding
- Maternal breast pain
- Maternal ambivalence
As evidenced by:
- Infant:
- Crying at breast
- Crying within one hour after breastfeeding
- Fussing within one hour after breastfeeding
- Inability to latch on to breast correctly
- Inadequate weight gain
- Resisting latching on to the breast
- Sustained weight loss
- Unsustained suckling at the breast
- Mother:
- Insufficient emptying of each breast during breastfeeding
- Sore nipples persisting beyond the first week
- Perceived inadequate milk supply
Expected outcomes:
- The mother will achieve effective breastfeeding with adequate breast milk intake for the infant.
- The mother will efficiently demonstrate breastfeeding techniques and proper breastfeeding positioning and latching.
Assessment:
1. Assess the patient’s thoughts and knowledge about breastfeeding.
Assessing the patient’s current knowledge and beliefs can help determine the appropriate breastfeeding information needed and correct any breastfeeding myths.
2. Assess risk factors that can contribute to ineffective breastfeeding.
Addressing modifiable risk factors can enable nurses to provide accurate information and support the development of breastfeeding skills.
3. Perform a breast assessment.
The nurse should assess for barriers by evaluating for sore nipples, engorgement, poor breast enlargement during pregnancy, and a history of breast surgery.
4. Assess the infant’s sucking reflex.
Early intervention of infant sucking problems can help correct the problem. Poor sucking is associated with poor feeding and can lead to complications like poor weight gain for the infant and breast engorgement for the mother.
Interventions:
1. Provide emotional support as needed and allow the patient to express her expectations.
Nurses play a vital role in the establishment and continuation of breastfeeding. Expressing support and allowing the patient to voice concerns promotes understanding and will determine the most appropriate plan of care.
2. Encourage skin-to-skin contact immediately after delivery.
Skin-to-skin holding promotes early breastfeeding initiation, improved milk supply, and breastfeeding duration.
3. Promote comfort and relaxation during breastfeeding.
Discomfort can lead to poor let-down reflexes and premature discontinuation of breastfeeding.
4. Assist in proper breastfeeding positioning.
Proper positioning can promote effective breastfeeding and reduce discomfort. Instruct the mother on multiple positions.
5. Refer the patient to lactation consultants.
Lactation consultants are available inpatient as well as in the community to address ongoing breastfeeding issues after discharge.
Insufficient Breast Milk Production
Several factors can cause low breast milk supply, including delaying the initiation of breastfeeding, and can cause poor infant feeding, low birth weight, and irritable and fussy infants even after feeding.
Nursing Diagnosis: Insufficient Breast Milk Production
Related to:
- Maternal alcohol consumption
- Maternal smoking
- Maternal malnutrition
- Ineffective latching on to the breast
- Infant’s refusal to breastfeed
- Ineffective sucking reflex
- Insufficient maternal fluid volume
- Insufficient suckling time at the breast
- Insufficient opportunity for suckling at the breast
As evidenced by:
- Breast milk expressed is less than the prescribed volume for an infant
- Absence of milk production with nipple stimulation
- Delayed milk production
- Infant frequently crying
- Infant constipation
- Infant frequently seeks to suckle at the breast
- Infant rejects breast
- Inadequate infant weight gain
- Infant voids small amounts of concentrated urine
- Unsustained suckling at the breast
- Prolonged breastfeeding time
Expected outcomes:
- The mother will increase their daily caloric and fluid intake.
- The mother will increase breastfeeding frequency and duration while maintaining the correct breastfeeding position.
- The infant feeds for 5-10 minutes on each breast.
Assessment:
1. Assess how the patient breastfeeds.
Assessing how the patient breastfeeds can guide interventions and promote the best approaches in correcting and improving the breastfeeding experience and breast milk supply.
2. Assess causes of slow milk let-down.
Stress, caffeine or alcohol intake, pain, certain medications, smoking, and cold temperatures can all interfere with milk let-down.
Interventions:
1. Massage the breast.
Massaging the breast prior to feeding can stimulate the nerves to increase oxytocin and milk production.
2. Breastfeed when the baby is hungry.
This may be as often as 8-12 times a day in the beginning. Follow the baby’s cues and feed when they are hungry instead of trying to follow a schedule.
3. Pump in between feedings.
Pumping in between nursing sessions or when away from the baby can help build the milk supply.
4. Provide strategies on how to increase milk supply.
Offering and emptying both breasts during breastfeeding, drinking adequate fluids, and ensuring latch-on can help increase breast milk supply.
Interrupted Breastfeeding
Interrupted breastfeeding results in compromised success in breastfeeding and/or nutritional status of the infant.
Nursing Diagnosis: Interrupted Breastfeeding
Related to:
- Abrupt weaning of infant
- Infant illness
- Maternal illness
- Prematurity
- Maternal-infant separation
- Maternal employment
- Intake of medications contraindicated in breastfeeding
As evidenced by:
- Nonexclusive breastfeeding
- Infant weight loss
- Inadequate knowledge of the importance and benefits of breastfeeding
Expected outcomes:
- The infant will be able to successfully breastfeed without delays or interruptions.
- The mother will be able to demonstrate the use of a breast pump and milk storage if breastfeeding is not possible.
Assessment:
1. Assess the causative factors of interrupted breastfeeding.
It is important to assess the causative factor of breastfeeding interruption and ensure that it is necessary and appropriate. In some cases, mothers are inappropriately advised to stop breastfeeding due to inaccurate breastfeeding beliefs.
2. Assess the mother’s beliefs and knowledge of the benefits and importance of breastfeeding.
The mother’s beliefs and understanding of the importance of breastfeeding can affect breastfeeding continuation and success. Inappropriate breastfeeding beliefs can further affect exclusive breastfeeding.
3. Assess the infant for any illness or medical condition affecting breastfeeding.
Feeding problems and medical conditions like prematurity can affect and interrupt exclusive breastfeeding.
Interventions:
1. Demonstrate proper use of breast pumps.
Breastfeeding pumps can encourage continued breast milk feeding to infants. If maternal employment is the cause of interrupted breastfeeding, some workplaces provide breastfeeding support by allocating breast pumping stations to encourage continuous breastfeeding. Educate on the proper storage of breast milk.
2. Collaborate with the mother on creating a breastfeeding schedule.
Planning breastfeeding sessions can reduce interruptions and help the mother prioritize breastfeeding at expected times throughout the day.
3. Teach the mother techniques about skin-to-skin contact.
Skin-to-skin contact with the baby promotes infant attachment, facilitates breast milk production, and improves the rate and duration of breastfeeding.
4. Educate the mother that any amount of breast milk is beneficial.
Some mothers may believe their baby is not getting adequate milk if they can’t breastfeed, so they stop completely. Educate the mother that any amount of breast milk is better than none.
Readiness for Enhanced Breastfeeding
The patient’s motivation to learn and initiate breastfeeding can help ensure breastfeeding success. Mothers must be willing to learn and motivated to achieve effective breastfeeding.
Nursing Diagnosis: Readiness for Enhanced Breastfeeding
Related to:
- Confidence to initiate breastfeeding
- Adequate knowledge of basic breastfeeding concepts
- Normal anatomy and function of maternal breast
- Adequate family and peer support
- Interest and willingness to learn
As evidenced by:
- Infant is satiated after feeding
- Infant latches effectively
- Infant displays appropriate weight gain
- Mother expresses satisfaction with breastfeeding
- Mother responds to infant’s feeding cues
Expected outcomes:
- The mother will maintain effective breastfeeding without the need for supplemental formula.
- The mother verbalizes understanding and satisfaction with the breastfeeding process.
Assessment:
1. Assess for barriers.
A prior history of ineffective breastfeeding, a lack of resources or outside support, and misinformation can all be overcome to enhance breastfeeding.
2. Assess the patient’s feelings about the breastfeeding process.
This can help determine the patient’s motivation and improve the breastfeeding experience. If the mother is unwilling or uninterested in breastfeeding, attempts will be futile.
Interventions:
1. Involve the support of a partner or family.
If the mother has encouragement and help in other areas from a partner or family members, this can enhance her time and ability to breastfeed.
2. Encourage rooming in and breastfeeding on demand.
Patients who room in with the baby have greater chances of initiating exclusive breastfeeding and continuing this after discharge.
3. Ensure a balanced diet and fluid intake.
The mother requires increased caloric intake when breastfeeding and should be encouraged to drink plenty of water to support milk production.
4. Refer to WIC and community groups.
Referrals to professionals (such as Women, Infants, and Children) with special skills in breastfeeding and peer support programs help promote continued breastfeeding.
References
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- Toronto Public Health Division. (2019, April). BREASTFEEDING PROTOCOL: Signs of Effective Breastfeeding. Retrieved May 2023, from https://breastfeedingresourcesontario.ca/sites/default/files/pdf/BFI_Signs_of_Effective_BF_web_final.pdf
- Toronto Public Health Division. (n.d.). Protocol #1 The Initiation of Breastfeeding. Toronto Public Health Division. Retrieved May 2023, from https://breastfeedingresourcesontario.ca/sites/default/files/pdf/Res_Strategy_Positioning_Latching.pdf
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