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Table 1 Comparison of the original Ten Steps to Successful Breastfeeding, the proposed expanded steps to successful breastfeeding and Spatz’s Ten Steps for Promoting and Protecting Breastfeeding for Vulnerable Infants

From: When is the use of pacifiers justifiable in the baby-friendly hospital initiative context? A clinician’s guide

Original Ten Steps to Successful Breastfeeding [40]
Every facility providing maternity services and care for newborns should implement the following Ten Steps
Expanded BFHI for Neonatal Units [8] Promoting and Protecting Breastfeeding for Vulnerable Infants in the Spatz Ten Steps Model [9]
1. Have a written breastfeeding policy that is routinely communicated to all health care staff. No change.  
2. Train all health care staff in skills necessary to implement this policy. Educate and train all staff in the specific knowledge and skills necessary to implement this policy. Correct breast milk management (storage and handling)
3. Inform all pregnant women about the benefits and management of breastfeeding. Inform all hospitalized pregnant women at risk for preterm delivery or birth of a sick infant about the management of lactation and breastfeeding and benefits of breastfeeding. Providing parents with information to make an informed decision to breastfeed
4. Help mothers initiate breastfeeding within a half-hour of birth. Encourage early, continuous, and prolonged mother–infant skin-to-skin contact (kangaroo mother care) without unjustified restrictions. Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour. Encourage mothers to recognize when their babies are ready to breastfeed and offer help if needed. Assisting mother with the establishment and maintenance of milk supply.
Skin-to-skin care
Create opportunities for NNS at the breast
5. Show mothers how to maintain lactation even if they are separated from their infants. Show mothers how to initiate and maintain lactation and establish early breastfeeding with infant stability as the only criterion. Managing the transition to breast
6. Give newborns no food or drink other than breastmilk unless medically indicated. No change. Develop procedures to feed the infant the breast milk
7. Practise rooming-in – that is, allow mothers and infants to remain together 24 h a day. Enable mothers and infants to remain together 24 h a day.  
8. Encourage breastfeeding on demand. Encourage demand feeding or, when needed, semi-demand feeding as a transitional strategy for preterm and sick infants. Measuring milk transfer
9. Give no artificial teats (also called dummies or soothers) to breastfeeding infants. Use alternatives to bottle-feeding at least until breastfeeding is well established and use pacifiers and nipple shields only for justifiable reasons.  
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. Prepare parents for continued breastfeeding and ensure access to support services/groups after hospital discharge. Preparation of infant and family for discharge; and appropriate follow-up care