2. Breastfeeding should begin as soon as possible after birth, usually within the first hour. Except under special circumstances, the newborn infant should remain with the mother throughout the recovery period. Procedures that may interfere with breastfeeding or traumatize the infant should be avoided or minimized.
3. Newborns should be nursed whenever they show signs of hunger, such as increased alertness or activity, mouthing, or rooting. Crying is a late indicator of hunger. Newborns should be nursed approximately 8 to 12 times every 24 hours until satiety, usually 10 to 15 minutes on each breast. In the early weeks after birth, nondemanding babies should be aroused to feed if 4 hours have elapsed since the last nursing. Appropriate initiation of breastfeeding is facilitated by continuous rooming-in. Formal evaluation of breastfeeding performance should be undertaken by trained observers and fully documented in the record during the first 24 to 48 hours after delivery and again at the early follow-up visit, which should occur 48 to 72 hours after discharge. Maternal recording of the time of each breastfeeding and its duration, as well as voidings and stoolings during the early days of breastfeeding in the hospital and at home, greatly facilitates the evaluation process.
4. No supplements (water, glucose water, formula, and so forth) should be given to breastfeeding newborns unless a medical indication exists. With sound breastfeeding knowledge and practices, supplements rarely are needed. Supplements and pacifiers should be avoided whenever possible and, if used at all, only after breastfeeding is well established.
5. When discharged less than 48 hours after delivery, all breastfeeding mothers and their newborns should be seen by a pediatrician or other knowledgeable health care practitioner when the newborn is 2 to 4 days of age. In addition to determination of infant weight and general health assessment, breastfeeding should be observed and evaluated for evidence of successful breastfeeding behavior. The infant should be assessed for jaundice, adequate hydration, and age-appropriate elimination patterns (at least six urinations per day and three to four stools per day) by 5 to 7 days of age. All newborns should be seen by 1 month of age.
6. Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first 6 months after birth. Infants weaned before 12 months of age should not receive cow's milk feedings but should receive iron-fortified infant formula. Gradual introduction of iron-enriched solid foods in the second half of the first year should complement the breast milk diet. It is recommended that breastfeeding continue for at least 12 months, and thereafter for as long as mutually desired.
7. In the first 6 months, water, juice, and other foods are generally unnecessary for breastfed infants. Vitamin D and iron may need to be given before 6 months of age in selected groups of infants (vitamin D for infants whose mothers are vitamin D-deficient or those infants not exposed to adequate sunlight; iron for those who have low iron stores or anemia. Fluoride should not be administered to infants during the first 6 months after birth, whether they are breast- or formula-fed. During the period from 6 months to 3 years of age, breastfed infants (and formula-fed infants) require fluoride supplementation only if the water supply is severely deficient in fluoride (<0.3 ppm).
8. Should hospitalization of the breastfeeding mother or infant be necessary, every effort should be made to maintain breastfeeding, preferably directly, or by pumping the breasts and feeding expressed breast milk, if necessary.