We have once again commented on guidance from the National Institute for Health and Care Excellence (NICE) for the postnatal care of women and babies. This time we addressed new draft ‘quality standards’ for infant feeding advice. We asked the NICE panel: what is the priority here?! You can read our full response below:
We question the approach to infant feeding in this quality standard and the proposed outcome measures. We have considered the two statements that relate to infant feeding (statements 2 and 4) in one comment. This allows us to address the general ethos around feeding.
An outcome measure set in statement 4 is ‘Rates of exclusive or partial breastfeeding at 6 to 8 weeks after the birth’. Breastfeeding is not a health outcome. It is a process that may have a positive effect on health outcomes or it may have an adverse effect on health outcomes. Therefore, it is possible this outcome measure is at odds with another in statement 2: ‘Rates of newborn hospital attendances and admissions for feeding-related conditions’.
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. These admissions are primarily due to dehydration, failure to thrive, excessive weight loss or hyperbilirubinemia. The researchers also calculated that for every 13 exclusively breastfed babies, one loses greater than 10% of their birthweight (Wilson and Wilson, 2018). 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).
So, we ask the panel to clarify: what is the priority here? Is the priority rates of breastfeeding? Or is it ensuring adequate nutrition for babies and thus preventing feeding-related admissions?
We do not think the present draft quality standard can expect to reduce rates of admissions for feeding complications. Far too much faith is placed in the effectiveness of breastfeeding support and observing feeds to resolve breastfeeding complications. In fact, there is little evidence for what helps to resolve the common problems that women report as reasons for stopping breastfeeding, such as pain, latching difficulties and low milk supply (McAndrew et al, 2012).
The latest Cochrane review for managing breastfeeding-related nipple pain found insufficient evidence to make recommendations (Dennis et al., 2014). We have been unable to identify any similar review of interventions to manage difficulties with latching or low milk supply. This matches what NICE found in its evidence reviews to inform the postnatal care guidelines (NICE, 2020). Yet, despite not having evidence for what helps to resolve breastfeeding problems, quality statement 4 suggests that if a healthcare professional observes ‘ongoing concerns with breastfeeding’, they ‘should consider:
– adjusting positioning and attachment to the breast
– giving expressed milk
– referring to additional support such as a lactation consultation or peer support
– assessing for tongue‑tie.’
Supplementation with formula is the only intervention we know of that is demonstrated to reduce infant hospital readmissions (Flaherman et al., 2013, 2018, 2019; Straňák et al., 2016). The quality standard lacks clarity on when formula supplementation is required and seems to minimise it as ‘sometimes, but not commonly, clinically indicated’. The rates of infant hospital admissions for feeding complications that we discussed above would suggest that insufficient breastmilk intake is not uncommon. Therefore, families need to know clearly when formula supplementation is required and to be prepared for it.
Another omission in the quality standard is the relationship between feeding and maternal mental health and wellbeing. Nowhere is it acknowledged that exclusive breastfeeding is not compatible with comfort and wellbeing for many women and does not allow sufficient sleep to prevent mental health problems for others. Many families in the UK resolve this problem by sharing feeds using bottles, which allows the mother to get a solid block of sleep, as NICE found in its evidence reviews for the postnatal care guidelines (e.g. Breastfeeding Barriers and Facilitators [Q]). We ask the panel for clarity on the point ‘strategies to manage fatigue when breastfeeding’ in statement 2, since we know of no other strategy for getting more sleep other than sharing feeds with another person.
NICE has a duty to present evidence-based, balanced information on the benefits and risks of different feeding methods so that parents can make informed decisions. Unfortunately, according to these quality statements, parents should receive information that reflects a distorted picture of the evidence. There is no evidence for some of the claims, for instance, that breastfeeding ‘soothes and comforts a baby’ any more than bottle feeding does, or that families who bottle feed need special advice about how to bond with their baby. The latter claim is as offensive as it is lacking evidence.
The health claims for breastfeeding largely rely on observational data that cannot prove causation, but this is not made clear to parents. This distorted picture of the importance of breastfeeding may lead mothers to pursue breastfeeding beyond what is comfortable and sustainable for them or safe for their baby, should complications arise.
We note that combination feeding is absent from the quality standard, and that information is split between ‘breastfeeding’ and ‘formula feeding’, although this doesn’t represent the reality of many UK families.
Finally, we note that statement 2 appears to specify who can receive information about formula and under what circumstances: ‘Information and advice about formula feeding for parents who are considering or who need to fully or partially formula feed.’ We believe this is an attempt to steer women’s choices and is not in keeping with principles of informed decision-making. Withholding information about formula specifically from mothers who are breastfeeding risks leaving them unprepared in the case of any complications. This can surely not be deemed to support the aim of reducing ‘newborn hospital attendances and admissions for feeding-related conditions’.
Again, we ask: what is the priority is here and what outcomes matter to the panel? Outcome measures that we would like to see include:
- Infants adequately fed, as measured by weight and by rates of admissions for feeding complications, such as hypoglycaemia, hypernatremia and jaundice
- Good maternal mental health and sufficient sleep
- Maternal comfort during feeds.
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.
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.
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: 8 June 2022.
McAndrew, F., Thompson, J., Fellows, L., et al., 2012. Infant Feeding Survey 2010. Health and Social Care Information Centre. Available from: https://sp.ukdataservice.ac.uk/doc/7281/mrdoc/pdf/7281_ifs-uk-2010_report.pdf, Accessed date: 8 June 2022
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: 8 June 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.
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: 8 June 2022