We have written to UKHSA and NHS England, as well as to the new Health Secretary, to raise our concerns about exclusive breastfeeding promotion and the Baby Friendly Initiative. We highlighted a paper commissioned by UKHSA (when it was known as Public Health England) to review the evidence for Baby Friendly. Published last year, this paper showed there was no evidence Baby Friendly improves any health outcomes.
This is what we wrote to UKHSA:
Dear Professor Dame Harries,
Harms of the Promotion of Exclusive Breastfeeding and the Baby Friendly Initiative
We are writing to raise serious concerns about the promotion of exclusive breastfeeding and the UNICEF Baby Friendly Initiative. We are parents who experienced harm as a result of these policies. We had babies readmitted to hospital for the complications of insufficient breastmilk intake, sometimes hours after initial discharge. We experienced inhumane treatment when our need for rest, recovery and sleep after birth was disregarded by staff in pursuit of exclusive breastfeeding targets. For some of us, these experiences contributed to postnatal mental illness. We have looked at the evidence for current policy and practice and have concluded that change is urgently needed.
We can find no evidence that attempts to increase breastfeeding rates have led to any improvements in health in the UK. However, there is evidence that exclusive breastfeeding is a risk factor for infant hospital admission for excessive weight loss and jaundice (Flaherman et al., 2018b).
Between 2006 and 2016, emergency hospital admissions for neonatal jaundice more than doubled. Newborn admissions for other feeding-related problems also increased (Keeble and Kossarova, 2017). Last month, an increase in newborn admissions between 2014/15 and 2020/21 was reported (QualityWatch, 2022). Nuffield Trust have not responded to our enquiries about the reasons for these admissions, but it seems likely that the trend of rising readmissions for jaundice and feeding problems is a contributor to this overall increase.
Recent attempts to address the problem of newborn readmissions, such as the Atain programme, have clearly failed. The only intervention demonstrated by RCTs to prevent readmission is early limited supplementation with formula (Flaherman et al., 2013, 2018a, 2019; Straňák et al., 2016). How is the so-called Baby Friendly practice of withholding formula supplementation from newborns contributing to the rise in admissions (UNICEF, 2014)?
Tragically, in rare cases, insufficient intake of breastmilk can lead to brain injury in newborns. Between 1995 and 2010, the NHS paid £162 million in compensation claims for 25 cases of brain injury from hypoglycaemia (Hawdon et al., 2016). We spoke with a midwife who now acts as an expert witness in hypoglycaemia claims. She told us that she did not see cases of hypoglycaemia before the implementation of the Baby Friendly Initiative.
Hypoglycaemia is not the only complication of insufficient breastfeeding that can have devastating consequences. There may be additional compensation costs relating to injuries from other complications, such as feeding-related jaundice. In addition, the government should consider the cost of the increase in hospital admissions for neonatal jaundice and feeding complications.
The NHS Long Term Plan calls for an ‘evidence-based infant feeding programme’ to be in every hospital, ‘such as the UNICEF Baby Friendly Initiative’. Other than a study conducted in 1990s Belarus (a very different context), there is no evidence that the so-called ‘Baby Friendly Initiative’ improves any health outcomes. These are not our conclusions. This is what researchers found when they were commissioned by your own agency (when Public Health England) to review the evidence for Baby Friendly (Fair, F. J., Morrison, A. and Soltani, H., 2021).
Not only is there no evidence of any improved outcomes, other reviews have suggested that Baby Friendly may have an adverse effect on women’s mental health, fuelling stigma and shame around infant feeding decisions (Fallon et al., 2019).
Given the lack of evidence of benefit and given the evidence of harm, there is no justification for the continued support for and roll-out of the Baby Friendly Initiative. We urge the government to remove exclusive breastfeeding as a ‘public health priority’ and to refocus infant feeding policy on actually feeding babies. It is time to put families at the centre of their care and to end the harmful obsession with breastfeeding rates. As parents, we want:
- Infant feeding policies that ensure sufficient nutritional intake for all babies and acknowledge that it is not uncommon for breastfeeding to be insufficient to achieve this
- Healthcare that considers women’s needs for sleep, recovery and sometimes medical care after birth, acknowledging that this may not be compatible with assuming 24/7 care of a baby or with exclusive breastfeeding
- Respect for our autonomy to make decisions about infant feeding as we see fit, according to our own needs and priorities.
We have also passed on these concerns to the Secretary of State for Health and Social Care and to the Chief Executive of NHS England.
Dr Ruth Ann Harpur
On behalf of Infant Feeding Alliance
Fair, F. J., Morrison, A., Soltani, H., 2021. The impact of Baby Friendly Initiative accreditation: An overview of systematic reviews. Maternal & Child Nutrition, 17(4), e13216. https://doi.org/10.1111/mcn.13216.
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., 2018a. 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., Schaefer, E.W., Kuzniewicz, M.W., et al., 2018b. Health care utilization in the first month after birth and its relationship to newborn weight loss and method of feeding. Acad Pediatr 18 (6), 677–684. https://doi.org/10.1016/j.acap.2017.11.005.
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.
Hawdon, J.M., Beer, J., Sharp, D., et al., 2016. Neonatal hypoglycaemia: learning from claims. Arch Dis Child Fetal Neonatal Ed 2017 (102), 110–115. https://doi.org/10.1136/archdischild-2016-310936.
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: 14 July 2022.
QualityWatch, 2022. Maternity care. Available from: https://www.nuffieldtrust.org.uk/resource/maternity-care. Accessed date 13 September 2022.
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.
UNICEF, 2014. The Baby Friendly Initiative – the 10 steps to successful breastfeeding. Available from: https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2014/02/10_steps_maternity.pdf. Accessed date: 14 July 2022.