We recently contributed to a ‘topic engagement’ on the NICE guidelines for postnatal care. We previously submitted detailed comments on the full set of guidelines for postnatal care, which you can read here.
This time, NICE wanted comments on its ‘quality standards’ and areas for quality improvement in postnatal care. We said the following:
Infant feeding guidance
Current UK infant feeding policy and practice need urgent reform. They fail to:
– promote adequate nutrition for all babies as standard and protect them from the complications of insufficient feeding, including jaundice, excessive weight loss, hypernatraemia and hypoglycaemia
– consider the physical and mental health needs of the mother or birthing person and their family
– follow principles of personalised care, shared decision-making and informed choice.
The NICE postnatal care quality standards are in line with current policy and include outcome measures such as ‘rates of breastfeeding initiation’ and ‘rates of exclusive or partial breastfeeding’. In our view as parents, these are the wrong outcome measures. We think NICE’s priority should be to promote and protect the health of babies and mothers, not to promote and protect exclusive breastfeeding. The focus should be on feeding babies, not on feeding methods.
The artificial separation of the quality standards into ‘Breastfeeding’ and ‘Formula Feeding’ (statements 5 and 6) does not ensure the focus is on infant nutrition. Neither does it represent the experience of most UK families. Mixed feeding, perhaps the most common method of feeding a baby in the UK, is absent. The common reasons families begin formula supplementation, choose to mixed feed or decide to switch from breastfeeding to bottle feeding are also absent, e.g. low milk supply, latching problems, baby always being hungry, mastitis, maternal exhaustion and the desire to share the responsibility of feeding, to name a few.
The ‘Breastfeeding’ quality standard requires that breastfeeding support is evidence-based, referring to the Unicef Baby Friendly Initiative as the minimum standard. A recent review funded by Public Health England is the latest to find there is no evidence that the Baby Friendly Initiative increases breastfeeding or improves health outcomes (Fair et al., 2021). Your own evidence review, as part of the postnatal care guidelines update, did not score the Baby Friendly Initiative guidelines highly, stating, ‘Recommendations are quite vague and different options are not discussed’ (Evidence Review F).
But what would an evidence-based approach to breastfeeding support look like? This is unclear, since your own evidence reviews found no evidence for interventions to increase breastfeeding rates and were vague on what practical interventions actually help to solve breastfeeding problems (Evidence Reviews P, Q, R, S). The latest Cochrane review for managing breastfeeding-related nipple pain, one of the most common reasons women give for stopping breastfeeding, found insufficient evidence to make recommendations (Dennis et al., 2014). We have been unable to identify any similar review of interventions to manage problems with latching or low milk supply.
The ‘Breastfeeding’ quality standard lists women’s satisfaction with breastfeeding support as an outcome measure. We would point NICE to a recent review of the impact of the Baby Friendly Initiative on maternal and infant health outcomes, which found adverse effects on women’s mental health and emotional wellbeing (Fallon et al., 2019). We would also point to a number of studies showing women experiencing breastfeeding support as ‘pressure’ and describing being desperate to stop breastfeeding but feeling they had to continue (Ayers et al., 2019; Lee, E., 2007).
The ‘Formula Feeding’ quality standard requires that ‘mothers and main carers who totally or partially formula feed their baby, and breastfeeding mothers who plan to formula feed their baby’ are given ‘advice about how to sterilise feeding equipment and safely prepare formula milk’. We fail to see how limiting this advice to certain parents is sensible or safe, since parents who will need this information most urgently are those introducing formula under pressure in the early days of a baby’s life. The recommendation that parents should not receive information on formula if they are considering exclusively breastfeeding is based on the ‘Baby Friendly’ idea that bottle feeding shouldn’t be ‘reinforced as the cultural norm’ and women’s confidence in breastfeeding shouldn’t be ‘undermined’ (UNICEF UK, 2014). These ideas are based on ideology and cultural theory, not on evidence, and they should not guide clinical practice.
Your own evidence reviews for the postnatal care guidelines showed that parents felt unprepared for the realities of breastfeeding and for formula feeding if it was not planned, and that they did not feel informed about supplementation (Evidence Reviews P, Q, R, S). Meanwhile, Evidence Review T showed that women want information on formula feeding antenatally, but the committee disregarded this, concluding that it was ‘not feasible’ to give all women information on formula. The quality standards maintain the artificial separation between breastfeeding and formula feeding and wording is carefully chosen to make clear who is ‘allowed’ to receive information on formula. By refusing to provide parents with all information, NICE is undermining their autonomy.
The ‘Formula Feeding’ quality standard suggests women should receive information on ‘how to bond with the baby when bottle feeding, through skin-to-skin contact, eye contact and the potential benefit of minimising the number of people regularly feeding the baby’. There is no evidence that bottle feeding is associated with bonding problems. This statement is not evidence-based, is lifted from the Baby Friendly Initiative and is stigmatising and offensive. It has the potential to cause harm if families have found sustainable ways to feed their baby by sharing feeds between them or other family members. It may also be experienced as judgment and foster mistrust in healthcare providers.
Your Evidence Review Q for the postnatal care guidelines showed that parents are finding ways to survive the newborn period by sharing bottle feeding. We find it unconscionable that the quality standard problematises parents making use of their support network by involving family members or close friends to feed their babies. (We would also appeal to common sense here: it is in fact easier and more comfortable to make eye contact with a baby while bottle feeding than while breastfeeding!)
As parents, we have had enough! Evidence is mounting that, in line with our lived experience, the promotion of exclusive breastfeeding and the Baby Friendly Initiative are causing unintended harms. A recent review of the literature, 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). They 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, we know that infant readmissions for feeding complications and jaundice more than doubled between 2006 and 2016 (Keeble and Kossorova, 2017).
Recent reports from the US have also suggested rare but potentially catastrophic risks of the ‘Baby Friendly’ principles of mandatory rooming-in and skin-to-skin contact, including sudden unexpected postnatal collapse (SUPC) and newborn falls in hospital (Bass et al., 2017; Goldsmith, 2013). We also point to a recent HSIB investigation into a number of cases of SUPC in the UK that occurred when babies were in skin-to-skin contact (HSIB, 2020).
We urge NICE to reconfigure the infant feeding quality standards so that they are founded on evidence and on the needs of UK parents. We ask NICE to:
• Prioritise adequate infant nutrition. Prioritise preventing newborn babies suffering unnecessarily from the complications of insufficient feeding, including jaundice, dehydration and excessive weight loss.
• Give a balanced perspective on the health effects of different feeding options, including accurate statistics and clear representations of the absolute benefits and risks. This should use the full range of high-quality scientific evidence and acknowledge uncertainties in breastfeeding research.
• Give parents information about the strength of the evidence for infant feeding support, so they can make informed decisions about how to proceed with feeding.
• Recognise the ways in which infant feeding decisions interplay with other aspects of family life, such as sharing parenting responsibilities, sleep and looking after other children. Recognise that how we feed our babies is our right and we should not be slaves to a public health agenda.
• Consider the impact of sleep deprivation on women’s mental health, therefore acknowledging the key role that shared feeding plays in safeguarding maternal mental health.
• Remove as outcome measures ‘rates of breastfeeding’ and ‘rates of breastfeeding initiation’. Measures of success by which to judge quality standards should be: fully fed babies; protecting infants from the complications of insufficient feeding; families reporting enjoyable feeding experiences; parents reporting respectful and personalised care that considers their individual needs; women no longer reporting ‘pressure’ from healthcare authorities or feelings of ‘shame’ about how they feed their babies.
Bonding and attachment as part of healthcare quality standards
The private and personal matter of bonding and attachment should not be part of NICE quality standards and we are deeply concerned about quality statement 9, ‘Emotional wellbeing and bonding with the baby’. There is no evidence for the recommendation: ‘regular assessment of the woman’s emotional wellbeing, including bonding with her baby, may lead to earlier detection of problems’ (as your own Evidence Review O concluded).
We suggest that such interference in family life could contribute to the very problems it seeks to prevent. As parents, we found that healthcare professional advice and focus on bonding undermined our confidence. We found it anxiety-inducing, intrusive and unhelpful, especially in the stressful postnatal period. We found that bonding happened when pressure was taken off us and we were given space to develop our relationships with our babies. Healthcare providers should not overstep healthcare provision into interference with family life. In our experience, this can cause unnecessary worry and stress and lead to distrust of healthcare providers.
Just as the 2019 review of the Baby Friendly Initiative found, we experienced exclusive breastfeeding promotion and support to have adverse effects on our wellbeing (Fallon et al., 2019). Some of us found it affected our bond with our baby in the short-term. Many of us found that exclusive breastfeeding contributed to difficulties with bonding with our babies, when it was difficult or painful, involved excessive sleep deprivation or frequent feeding and when it led to infant hospital readmission. For us, bottle feeding provided a solution and contributed to bonding with our baby. Current policy and practice that promote exclusive breastfeeding as an outcome measure will only continue to cause harm to women’s wellbeing, as described in the previous comment.
There is no one-size-fits all approach to bonding and attachment and you cannot prescribe how to fall in love! In our view: leave bonding and attachment out of healthcare guidelines.
Ayers, S., Crawley, R., Webb, R., et al., 2019. What are women stressed about after birth? Birth. 46, 678-685. https://doi.org/10.1111/birt.12455.
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.
Fair, F.J., Morrison, A., Soltani, H., 2021.The impact of Baby Friendly Initiative accreditation: An overview of systematic reviews. Matern. Child Nutr. 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.
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.
Lee, E., 2007. Health, morality, and infant feeding: British mothers’ experiences of formula milk use in the early weeks. Sociol. Health Illness 29, 1075-1090. https://doi.org/10.1111/j.1467-9566.2007.01020.x.
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 Health and Care Excellence, 2020, Postnatal care: evidence reviews. Available from: https://www.nice.org.uk/guidance/ng194/evidence/evidence-reviews-april-2021-9076791277?tab=evidence. Accessed date: 4 February 2022
UNICEF UK, 2014. Guidelines on providing information for parents about formula feeding. Available from: https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2018/02/Guidelines-on-providing-information-for-parents-about-formula-feeding.pdf. Accessed date: 27 November 2020.
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.