The government recently announced an inquiry into prevention in health. The Health and Social Care Committee asked for submissions from organisations and individuals to highlight issues the government should be looking at. We submitted a proposal for how to reverse the alarming rise in newborn admissions to hospital for jaundice and other feeding complications in the early days of life. This is what we wrote:
We are a parent-led organisation campaigning for compassion, autonomy and safety in infant feeding policy and practice. Many of our members had newborn babies readmitted to hospital in the early days of life for the complications of insufficient breastmilk intake, such as jaundice, dehydration and excessive weight loss.
Between 2006 and 2016, emergency hospital admissions for neonatal jaundice more than doubled. Admissions for newborns with other feeding-related complications also increased (Keeble and Kossarova, 2017). Last year, an increase in newborn admissions between 2014/15 and 2020/21 was reported (QualityWatch, 2022), although the reasons for these admissions have not been published.
We are aware that the increase in hospital admissions for neonatal jaundice has been identified as a problem by government. The ATAIN programme was set up to address this but has clearly failed. And we are aware that the government has committed £50 million to breastfeeding support. But since we know of no good evidence for interventions to resolve the most common breastfeeding problems, we fail to see how this will help.
We have looked at the evidence for the policies in place in hospitals and have serious concerns that these policies are a leading cause of the increase in infant readmissions for jaundice and feeding complications.
The UNICEF Baby Friendly Initiative, which the NHS Long Term Plan requires in all hospitals, mandates hospitals to increase rates of exclusive breastfeeding. But there is evidence that exclusive breastfeeding is a risk factor for infant hospital admission for excessive weight loss and jaundice (Flaherman et al., 2018b; Wilde, V., 2021). In its guidance on how to ‘promote, protect and support breastfeeding,’ the Baby Friendly Initiative advises services to withhold formula supplementation from babies ‘unless medically indicated’ (UNICEF, 2014).
In our experience, hospital staff closely followed these so-called ‘Baby Friendly’ guidelines: they encouraged us to exclusively breastfeed from birth; they provided breastfeeding support and 1ml syringes to collect drops of colostrum to give our babies when they were deemed ‘reluctant to feed’; they did not offer or mention formula supplementation.
However, hours or days after initial discharge, some of our babies were readmitted to hospital for jaundice, hypernatremic dehydration or weight loss in excess of 10% of their birth weight. Only formula supplementation resolved the problems. Indeed formula supplementation is the only intervention demonstrated by randomised controlled trials to prevent readmission (Flaherman et al., 2013, 2018a, 2019; Straňák et al., 2016).
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). Hypoglycaemia is not the only complication of insufficient breastfeeding that can have devastating consequences. Feeding-related jaundice and hypernatremic dehydration can also cause brain injury and even death. There may be additional compensation costs relating to injuries from these other complications.
It is often claimed that breastfeeding is a preventative health measure in itself, linked to better health outcomes. But we can find no evidence that attempts to increase rates of breastfeeding in the UK have led to any improvements in health. As regards the UNICEF Baby Friendly Initiative, other than a study conducted in 1990s Belarus (a very different context), there is no evidence that it improves any health outcomes. These are not our conclusions. This is what researchers found recently when they were commissioned by Public Health England to review the evidence for Baby Friendly (Fair, F. J., Morrison, A. and Soltani, H., 2021).
We recommend that the government
- Remove the requirement for hospitals to become Baby Friendly accredited or to follow Baby Friendly guidelines.
- Carry out an independent review of the safety of Baby Friendly guidelines with patient safety experts who are external to maternity services and have no vested interest in breastfeeding promotion.
- Monitor rates of infant readmissions and insist hospitals take action to reduce readmissions that are a result of underfeeding.
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.
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.
Wilde, V.K., 2021. Breastfeeding insufficiencies: common and preventable harms to neonates. Cureus, Oct 13 (10), e18478. https://doi.org/10.7759/cureus.18478.