“Breast is best,” but current efforts to increase the rate of breastfeeding may be misguided. A recent article in JAMA Pediatrics by pediatricians Joel Bass, Tina Gartley, and Ronald Kleinman is titled “Unintended Consequences of Current Breastfeeding Initiatives.” They criticize the Baby-Friendly Hospital Initiative (BFHI), saying “there is now emerging evidence that full compliance…may inadvertently be promoting potentially hazardous practices and/or having counterproductive outcomes.”
The Baby-Friendly Hospital Initiative was launched by WHO and UNICEF in 1991 and has been adopted in 152 countries. In the US it has been promoted as the standard of care by government agencies like the CDC and the Joint Commission, and has been implemented by a growing number of hospitals. The criteria for a hospital’s Baby Friendly accreditation include:
- Have a written breastfeeding policy that is routinely communicated to all health care staff.
- Train all health care staff in skills necessary to implement this policy.
- Inform all pregnant women about the benefits and management of breastfeeding.
- Help mothers initiate breastfeeding within one half-hour of birth.
- Show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants.
- Give newborn infants no food or drink other than breastmilk, not even sips of water, unless medically indicated.
- Practice rooming in – that is, allow mothers and infants to remain together 24 hours a day.
- Encourage breastfeeding on demand.
- Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants
- Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.
In addition, the program restricts hospitals from using free formula donated by formula companies and recommends that when formula is medically needed, it should be given in a small cup or spoon, rather than a bottle and should only be used to supplement breastfeeding.
That all sounds good. What could possibly go wrong?
Apparently a lot of things could go wrong. Bass et al. expressed a number of concerns.
Sudden unexpected postnatal collapse
In order to initiate breastfeeding in the first half hour of life, the guidelines state that “all mothers should have continuous skin-to-skin contact with their baby immediately after birth until completion of the first feeding and that skin-to-skin contact should also be encouraged throughout the hospital stay.” Last February our own Clay Jones wrote about the unfortunate association between prolonged maternal skin-to-skin contact (SSC) as commonly practiced in newborn nurseries in the United States and the potentially devastating outcome of sudden unexpected postnatal collapse (SUPC). These babies suddenly stop breathing; half of them die and many of the rest become disabled.
SUPC is admittedly rare, but its true incidence may have been underestimated; it might even be one of the most common causes of death in healthy newborns. In most places, SUPC is not tracked as a unique entity. Bass et al. reviewed data on all categories of sudden unexplained deaths among newborns in Massachusetts. Sudden infant death syndrome (SIDS) is thought to be uncommon in the first month of life, so they didn’t expect to find many cases, but they found that 14% of SIDS cases occurred during the first 28 days of life. 22.2% of the cases categorized as newborn SIDS and 35.1% of the newborn deaths categorized as “sudden unexplained deaths” occurred in the first 5 days of life. This is consistent with higher estimates of SUPC risk from Europe and suggests that there are cases of SUPC that are not being counted, and that the American Academy of Pediatrics report may have underestimated the risk.
A study in Sweden found that the majority of cases of SUPC were associated with prone positioning during skin-to-skin contact and initial unsupervised attempts at breastfeeding. Hospitals should not leave these patients unattended, but in practice they often do. The mother is often left alone to “rest” and may fall asleep from post-partum exhaustion. Infants should either be monitored or kept under direct observation by medical personnel.
Rooming in and breastfeeding exclusivity
When rigidly enforced, rooming-in policies may result in an exhausted or sedated mother attempting to feed her infant in bed overnight when she is not able to do so safely. Risks include prone positioning, suffocation from co-sleeping on a soft surface, and the possibility of the newborn falling out of bed. There is evidence that formula supplementation for medical indications has no adverse effects on the duration of breastfeeding.
There is strong evidence that pacifiers reduce the risk of sudden infant death syndrome (SIDS). The authors feel that “the recommendation to proscribe the use of pacifiers is difficult to defend based on risk.”
The authors’ recommendations
Bass et al. conclude by pointing out the 2011 Surgeon General call to action to make all hospitals in the United States meet Baby-Friendly Hospital Initiative requirements. They think that call to action needs to be rethought, and they propose a better way to focus our resources in order to support both breastfeeding and newborn safety. Instead of focusing on the monitoring of Baby-Friendly practices and breastfeeding exclusivity, we should emphasize breastfeeding initiation rates and lactation support during and after the newborn hospitalization. We should also focus on compliance with safe sleep recommendations and work on ways to educate families so that breastfeeding and SIDS risk reduction go hand in hand.
Joan Younger Meek and Lawrence Noble have published a rebuttal in JAMA Pediatrics titled “Implementation of the Ten Steps to Successful Breastfeeding Saves Lives.” It essentially reads like an ad for BFHI. They stress the health benefits of breastfeeding and report that the BFHI increases exclusive breastfeeding by 49%. They stress the benefits of skin-to-skin contact and argue that the risk of SUPC can be reduced by measures implemented by hospital staff. They downplay the risk of SUPC as “rare;” but surely even rare cases are tragic, especially if they are preventable. While acknowledging that pacifiers reduce the risk of sudden death, they show evidence that pacifiers are associated with shortened duration of breastfeeding.
In reality, the original article and the rebuttal are not so far apart. They both support most of the measures of the BFHI and both recommend taking precautions to improve safety. I wonder if both sides might be willing to meet in the middle and adopt policies that would reduce the risks without interfering with breastfeeding success, policies like better monitoring during skin-to-skin contact, less emphasis on continuous skin-to-skin, allowing fatigued mothers to send the baby to the nursery part-time if they feel they need to do so to get adequate rest, and allowing judicious use of pacifiers.
Has breastfeeding been oversold?
Breastfeeding is better than bottle-feeding but it’s not that much better. We have addressed this subject repeatedly on Science-Based Medicine. When I reviewed the evidence for breastfeeding six years ago I concluded, “Breastfeeding is clearly better for babies…but I think the facts leave us room to support those women who make an informed choice not to breastfeed.” Studies showing health benefits for infants have recently been criticized for failing to rule out confounders like socioeconomic status. And when obstetrician Amy Tuteur examined five long-term outcomes, she found that the existing scientific evidence shows that breastfeeding has either no benefit or a small benefit for those outcomes.
While breastfeeding is “better” in general, there are different degrees of “better” in different populations, for instance in areas where the water used to mix formula may be contaminated. There may be individual cases where formula is better and where judicious supplementation with formula is better than exclusive breastfeeding. Much of the benefit of breastfeeding in the US appears to come from the environment that surrounds the child rather than from the content of breast milk.
Conclusion: We should think again about the BFHI
The BFHI seemed like a good idea at the time, but evidence-based concerns have been raised and draconian implementation of BFHI policies may be harmful. Hospitals have achieved a greater than 90% breastfeeding initiation rate while allowing pacifiers and allowing mothers to put their babies in the nursery part-time. Most doctors agree that bottle-feeding is also a healthy option and that women who are unable to breastfeed for medical reasons or who decide not to breastfeed for personal or practical reasons should be supported and not made to feel guilty. A growing number of women are speaking out about how badly treated they felt at BFHI-certified facilities.