Baby Friendly UK recently announced that it is intending to expand its Baby Friendly Initiative into children’s hospitals. It opened a consultation for views on its new standards for paediatrics services. These are some of the comments we submitted:
Our comment about staff training:
We want our NHS staff to put our children and our families at the centre of their care, not ‘the promotion and protection of breastfeeding’. When some of our babies were readmitted to paediatrics services in the early days of life for the complications of insufficient breastfeeding, including excessive weight loss, dehydration and jaundice, we were grateful for pragmatic and compassionate care from paediatrics staff. These clinicians prioritised our babies’ adequate nutrition, while ensuring that the needs of the whole family were met through realistic and sustainable feeding plans. We hope that children’s hospital staff will reject Baby Friendly standards. We hope they will continue to offer balanced, family-centred care that does not prioritise a public health agenda or a feeding method over individual patient health and autonomy.
Our comment on ‘Standard One’ of the Baby Friendly Initiative for children’s hospitals:
As parents who experienced readmissions to paediatrics services with our babies for feeding complications, we find Standard One highly concerning.
Firstly, the idea of parents feeling ‘unambiguously supported to continue breastfeeding’ presents a coercive model of care. The language throughout does not highlight parents’ autonomy but undermines it, insisting ‘mother’s milk is the first choice for babies’ and mothers are always supported to keep breastfeeding. This chimes with our experience of Baby Friendly care on postnatal wards, where the commitment to ‘promote and protect breastfeeding’ undermined our autonomy to make infant feeding decisions according to our needs and values. We believe this is not compatible with NHS and NICE commitments to personalised care and shared decision-making.
Secondly, we question the safety of these guidelines when applied to young babies admitted to paediatrics services with complications from insufficient breastfeeding. The priority here should be adequate infant nutrition and a sustainable plan for achieving this, not ‘mothers’ milk’ or the continuation of breastfeeding. The language is vague (‘where possible’) – as it is in Baby Friendly general standards as regards the threshold for ‘medically indicated’ supplementation. Supplementation is not mentioned although it will be the solution for many parents and may not contribute to the cessation of breastfeeding.
Finally, we fear this may contribute to a lack of compassion for parents whose babies are readmitted for feeding complications. Mothers may be excessively sleep deprived from attempting to exclusively breastfeed a hungry baby and may be at risk of mental health complications. The focus of care must be to help families plan a sustainable method of feeding adequate nutrition to the baby that best allows the whole family to thrive. Continuing breastfeeding or introducing expressing into the routine may not allow a woman adequate rest and may not be viable. For many of us, after distressing experiences of Baby Friendly postnatal care, infant underfeeding and excessive sleep deprivation, the solution was sharing care with a partner by combination feeding or formula feeding. Mothers’ sleep and physical and mental health must always be a top priority.
Our comment on ‘Standard Two’ of the Baby Friendly Initiative for children’s hospitals:
Statements such as the following show Baby Friendly standards to be coercive and undermining of parental autonomy: ‘When mothers are unable or choose not to exclusively breastfeed, it is important that they are still encouraged and that any breastfeeding or breastmilk is valued so that the baby is able to benefit from receiving as much breastmilk as possible.’ Encouraging parents who choose not to exclusively breastfeed to ‘value breastmilk’ is not in line with NICE principles of shared decision-making and personalised care. This statement is also lacking in basic compassion, since, as described above, mothers of babies readmitted for complications of underfeeding are likely to be exhausted, and feeding plans need to take into account their need for sleep and to safeguard their mental health. Finally, this statement is dangerous, since the focus of care for a baby who has been readmitted with complications of underfeeding – jaundice, dehydration, hypoglycaemia and excessive weight loss – should be immediate and sustainable nutrition, not breastmilk.
We question how Baby Friendly’s standards for supplementation can be described as evidence-based when they ignore evidence from randomised controlled trials that early limited supplementation with formula does not increase breastfeeding cessation but does reduce babies’ risk of readmission to hospital with feeding-related complications (Flaherman et al., 2013, 2018, 2019; Straňák et al., 2016).
We find the demand that first stage infant formula not be sold on hospital premises to be shaming and cruel. It potentially creates an obstacle for families visiting or staying in hospital with an older child while caring for a formula fed baby. This standard is not in the interests of families and babies and is purely an ideological position to shame and penalise families who use formula. We find it shameful that an organisation who claims to promote infant health can make this demand.
Our comment on ‘Standard Three’ of the Baby Friendly Initiative for children’s hospitals:
Standard Three includes some ideas that are desirable, such as ‘the facility makes being with their baby as comfortable as possible for parents (for example, creating a welcoming atmosphere, putting comfortable chairs/bed by the side of each cot, giving privacy when needed and providing adequate facilities for parents to stay for long periods or overnight, e.g. food and drink, bathroom facilities, etc.)’ However, we do not believe that to implement such practices, paediatrics services need to shackle themselves to an ideological programme that has been shown to negatively impact mothers’ wellbeing (Fallon et al., 2019). Children’s hospitals should work directly with families to find out how to make facilities more welcoming for them.
The idea that parents need to be ‘actively encouraged to provide comfort and emotional support for their baby, including prolonged skin contact, comforting touch and responsiveness to their baby’s behavioural cues’ is based on no evidence and is undermining of parents. Loving relationships cannot be prescribed or micromanaged, and this sort of injunction is likely to cause more harm to relationships, undermining parents’ own instincts and confidence.
Regarding skin-to-skin, we point to recent reports suggesting rare but potentially catastrophic risks of skin-to-skin, including sudden unexpected postnatal collapse (supc) and newborn falls (Bass et al., 2017; Goldsmith, 2013). We also point towards the recent HSIB report into supc occurring when babies are in skin-to-skin contact (HSIB, 2020). This highlighted the need to ensure optimal positioning of the baby to protect their airway, as well as monitoring babies’ skin colour, tone and temperature while in skin-to-skin.
The most recent Cochrane review into the effects of skin-to-skin highlights methodological weakness in the trials, but recommends skin-to-skin on the basis of relatively weak evidence of benefit and lack of evidence of harm (Moore et al., 2016). While some families enjoy skin-to-skin, we should not be under pressure to practice it with information from our trusted healthcare providers that vastly exaggerates the health effects.
Our overall comment:
We can find no evidence that Baby Friendly standards have improved any maternal or infant outcomes, so we see no reason why they would do so in children’s hospital settings. Our experience of Baby Friendly postnatal care and the recent review of the Baby Friendly Initiative in the UK (Fallon et al., 2019) suggest that these standards extended to children’s hospital settings will lead to lower standards of care and potential harms.
As parents, we found Baby Friendly postnatal care to be coercive and that it undermined our autonomy to make infant feeding decisions based on our needs and values. We found it promoted a lack of compassion, leading staff to view us as a ‘breastfeeding dyad’ rather than as two patients with their own needs, including our need for sleep, rest and recovery. Worst of all, the promotion of exclusive breastfeeding and the withholding of formula on postnatal wards deprived some of our infants of adequate nutrition and led to some of our babies being readmitted for jaundice, dehydration, excessive weight loss and other complications of underfeeding.
Infant readmissions for jaundice and feeding complications in the UK more than doubled between 2006 and 2016 (Keeble and Kossorova, 2017). A recent review of the literature by researchers in the US, which sought to quantify the health effects of different infant feeding methods, calculated that for every 71 exclusively breastfed babies, one is readmitted to hospital in the first month of life, primarily due to dehydration, failure to thrive, excessive weight loss or hyperbilirubinemia (Wilson and Wilson, 2018). The researchers also calculated that for every 13 exclusively breastfed babies, one loses greater than 10% of their birthweight. While it is unclear how these numbers needed to harm calculations apply in the UK context, it is clear that exclusive breastfeeding is a risk factor for some adverse infant outcomes, which Baby Friendly UK refuses to acknowledge.
We would also highlight research from the US suggesting Baby Friendly standards may be connected to an increase in newborn falls and cases of supc (Bass et al., 2017; Goldsmith, 2013). Finally, we would stress that the 2019 review of the impact on maternal and infant health outcomes showed that Baby Friendly did not lead to anything but a very short-term increase in breastfeeding rates (Fallon et al., 2019).
We do not believe that any organisation should support the extension of Baby Friendly into children’s hospitals until Baby Friendly UK:
- Provides safety data on the protocol as currently practiced
- Acknowledges that exclusive breastfeeding is a risk factor for readmission
- Acknowledges that there is not sufficient evidence for interventions to resolve some common breastfeeding problems, such as low milk supply
- Acknowledges evidence from randomised controlled trials that shows that early limited supplementation with formula does not lead to more breastfeeding cessation but does reduce infant readmissions and so withholding supplementation is unacceptable (Flaherman et al., 2013, 2018, 2019; Straňák et al., 2016)
- Acknowledges the findings of the 2019 review that showed that many UK women do not like the Baby Friendly Initiative and that it impacts their mental health, and acts on recommendations to carry out further research into this area
- Seeks the views of the full range of families who have experienced Baby Friendly care, including those who report bad experiences and those who don’t breastfeed. The NICE committee for the recent draft guidelines on postnatal care scored Baby Friendly low on involvement of patients in their guidelines (National Institute for Healthcare Excellence, 2020). Baby Friendly should be committing to work with families to co-produce care.
We think children’s hospitals are no place for an ideological agenda that puts breastfeeding above the needs of families. We think paediatrics services should instead work with families to find out what support they require to feed and be with their babies in hospital. Families should be taking the lead on this, not Baby Friendly UK.
We would be happy to share our experiences of Baby Friendly care with the organisation further if they will hear our voices.
Infant Feeding Alliance
Bass, J., Gartley, T., Kleinman, R., 2016. Unintended Consequences of Current Breastfeeding Initiatives. JAMA Pediatr.170 (10):923–924. https://doi.org/10.1001/jamapediatrics.2016.1529.
Dennis, C.L., Jackson, K., Watson, J., 2014. Interventions for treating painful nipples among breastfeeding women. Cochrane Database Syst. Rev. 12, CD007366. https://doi.org/10.1002/14651858.CD007366.pub2.
Fallon, V., Harrold, J., Chisholm, A., 2019. The impact of the UK Baby Friendly Initiative on maternal and infant health outcomes: a mixed-methods systematic review. Matern. Child Nutr. 15 (3), e12778. https://doi.org/10.1111/mcn.12778.
Flaherman, V.J., Aby, J., Burgos, et al., 2013. Effect of early limited formula on duration and exclusivity of breastfeeding in at-risk infants: an RCT. Pediatrics 131 (6), 1059–1065. https://doi.org/10.1542/peds.2012-2809.
Flaherman, V.J., Narayan, N.R., Hartigan-O’Connor, D., et al., 2018. The effect of early limited formula on breastfeeding, readmission, and intestinal microbiota: a randomized clinical trial. J. Pediatr. 196, 84–90. https://doi.org/10.1016/j.jpeds.2017.12.073.
Flaherman, V.J., Cabana, M.D., McCulloch, C.E., et al., 2019. Effect of early limited formula on breastfeeding duration in the first year of life: a randomized clinical trial. JAMA Pediatr 173 (8), 729–735. https://doi.org/10.1001/jamapediatrics.2019.1424.
Goldsmith, J., 2013. Hospitals should balance skin-to-skin contact with safe sleep policies. AAP News. 34 (11) 22. Available from: https://www.aappublications.org/content/34/11/22. Accessed date: 27 November 2020.
HSIB, 2020. National Learning Report Neonatal collapse alongside skin-to-skin contact. Available from: https://www.hsib.org.uk/documents/238/hsib-national-learning-report-neonatal-collapse-alongside-skin-to-skin-contact.pdf. Accessed date: 27 November 2020.
Keeble, E., Kossarova, L., 2017. Focus on: Emergency hospital care for children and young people. Available from: https://www.nuffieldtrust.org.uk/files/2018-10/1540142848_qualitywatch-emergency-hospital-care-children-and-young-people-full.pdf. Accessed date: 27 November 2020.
Moore, E.R., Bergman, N., Anderson, G.C., Medley, N, 2016. Early skin‐to‐skin contact for mothers and their healthy newborn infants. Cochrane Database Syst. Rev. 11, CD003519. https://doi.org/10.1002/14651858.CD003519.pub4.
National Institute for Healthcare Excellence, 2020. Postnatal care: content of postnatal care contacts – evidence review. Available from: https://www.nice.org.uk/guidance/gid-ng10070/documents/evidence-review-6. Accessed date: 17 January 2021.
Straňák, Z., Feyereislova, S., Čern., M., et al., 2016. Limited amount of formula may facilitate breastfeeding: randomized, controlled trial to compare standard clinical practice versus limited supplemental feeding. PloS One 11 (2), e0150053. https://doi.org/10.1371/journal.pone.0150053.
Wilson, J., Wilson, B.H., 2018. Is the “breast is best” mantra an oversimplification? J.Fam. Pract. 67 (6), E1–E9. Available from: https://www.mdedge.com/clinicianreviews/article/166932/pediatrics/breast-best-mantra-oversimplification. Accessed date: 27 November 2020.