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Anatomy of a Hospital Breastfeeding Policy That Will Work Every Time

Think of your hospital breastfeeding policy like a skeleton.

At Breastfeeding Outlook, we get many calls from hospital staff members asking for help with their hospital breastfeeding policy.

How many hospital breastfeeding policies have I written single-handedly, helped others to write, reviewed and critiqued since the early 1980s? I have no idea. It’s a lot. But if you haven’t seen as many as I have, I know it can seem a daunting task.

But, here’s a tip: Think of your hospital breastfeeding policy as a skeleton. 

The skeleton is the policy’s main body. The skeleton reaches out with arms and legs of who-what-when-where-how, along with the why and what-if.

Details and Dates

Your breastfeeding policy should follow the format of your “house” model. All hospital policies should begin with the why, and follow with the who-what-when-where-how- and what-if.

When is the policy effective? How often should it be reviewed and/or revised? Is the date of the latest revision shown on the policy consistent with the stated frequency for review and/or revision?

How will the hospital breastfeeding policy be communicated to current staff, and how must it be communicated to new orientees. How soon must this happen, and who is responsible for reviewing, revising and signing off on the policy?

Where is this policy applicable? For a small hospital, it’s probably the entire hospital, but for a larger facility it may be only one unit, or several. If you have a prenatal clinic, or a postpartum clinic, does the “inpatient” policy extend to those “outpatient” departments? (Note: If you do not have any outpatient departments, you should specify that the hospital serves only inpatient childbearing families.)

What are the hospital “rules” for promoting formula and artificial nipples?

Goal or Purpose

I usually see a lot of gobbledygook in this part of the draft policy: long sentences with pie-in-the-sky philosophical junk that swirls around the importance of education, mentions the goodness of breastfeeding, conveys a grandiose message of advocacy, and gives some nod to patient satisfaction. But, that’s not the purpose of a hospital breastfeeding policy.

It’s your hospital, so you can write whatever you wish as your “purpose” or “goal”! But it needs to be a purpose or a goal, not just a bunch of philosophizing and idealizing. What’s the clinical “so-what” here?

Why do you have a hospital breastfeeding policy? I believe the ONLY reason for a policy is to ensure safe, evidence-based care and deliver a clear, measurable outcome. (In this case, that would be exclusive breastfeeding.) Here’s how I would write it: “To have 80% of all healthy term newborns exclusively breastfeeding at discharge.” Anything more is just fluff.

Core Content

In my experience, most people write policies with way more content than is required to meet the Baby-Friendly requirements. For a number of practical and legal reasons, policies should be kept lean and mean. Think “skeleton,” not “fat man”!

The breastfeeding policy is the hospital’s “stance” or “position” on the Ten Steps to successful breastfeeding. It dictates “how we do things here” to achieve the goal. The Ten Steps make up the axial skeleton; you will need to put flesh onto these bare bones.

Each “step” has arms and legs that reach out to address the who-what-when-where-how and what-if for each Step. For example, let’s look at Step 2, on staff education. To address this, the policy should include:

  • Who will be responsible for providing the education?
  • Who will be required to complete the education?
  • How much education will be provided?
  • What content must the education address?
  • When will it be provided?
  • Where will attendance be documented? (Note: You should be prepared to retrieve that documentation for Baby-Friendly assessors, if you are pursuing designation.)
  • What will you do if a new employee says they had Baby-Friendly training at a hospital where they worked before this?
  • When will you need to repeat or review or this training, and for whom?

Keep going here, and continue in like manner with each of the Ten Steps.

“Exceptions” or “Variations”

Hospital breastfeeding policies shouldn’t have too many “exceptions.” For breastfeeding, you should address issues related to babies in circumstances of separation from their mothers, situations in which the risks of breastfeeding outweigh the benefits (often inaccurately called “contraindications”), and situations in which the ideals cannot realistically be met. (For example, the mother wants to formula-feed.)


The “house model” for policies sometimes include a separate section on documentation. I prefer integrating the directive for documentation, but you should follow your house model.


Finally, your hospital breastfeeding policy needs to include references to back up the content. If you’ve heard that references should be “no more than 5 years old,” don’t worry! Such an arbitrary idea is itself outdated! You’ll want to be sure to choose relevant references that represent the highest level of evidence. Focus on listing references for issues that you believe to be contentious.

Are you having trouble drafting your hospital breastfeeding policy? Where are you getting hung up? Drop me a note about what your issues are in the comments below, or contact our office.

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