Q&A: One Nurse’s View on Strict Breastfeeding Policies

Jody Segrave-Daly, our co-founder and the pro-mom advocate known as “The Momivist” regularly interviews nurses about their view and experiences, working with strict breastfeeding-only policies. Here is an excellently informative interview with a nurse we’ll call Sarah, as she’s asked we keep her name and hospital anonymous. 

Jody Segrave-Daly, AKA The Momivist: What are the most common encounters that you see with breastfed babies in the first 48 hours of life,  in your hospital, which has strict breastfeeding policies?

Sarah, RN at Hospital with Strict Breastfeeding Policies: I’ll start with the positive. One thing I really like about hospitals that have these policies, such as the Baby Friendly Hospital Initiative, is the emphasis on skin-to-skin after delivery. Instead of baby immediately being taken to a warmer, baby is placed on mom’s chest. Mothers seem to really enjoy this immediate contact with their babies, babies’ vital signs tend to stabilize better, and breastfeeding is encouraged in the first hour after birth (if baby shows interest).

Another positive is the breastfeeding support. If a mother does want to breastfeed, and most do, they offer a lot of support. For example, at our hospital, we have two lactation consultants, and all nurses and nursing aids are trained in breastfeeding. Our training includes shadowing a lactation consultant and an extensive course that is required through the hospital. I am by no means an expert, but we do offer great breastfeeding resources to mothers who are interested, and many of my colleagues are very knowledgeable in helping with positioning, latching, etc.

As far as negative encounters associated with hospitals with strict breastfeeding policies, one that stands out quite a bit to me is maternal exhaustion. Many mothers endure long labors and are very tired after delivery. We are supposed to encourage babies to remain in the room with their mothers 24/7, and if the baby is breastfed, the responsibility of the baby is largely placed on the mother.

After babies have their long sleep after birth, they are usually very hungry and want to feed frequently. Mothers haven’t had a chance to catch up on rest with nursing checks, visitors, and difficulty relaxing with a newborn in the room (not to mention the added recovery a c-section mother needs). We are not supposed to offer to take the baby out of the room, because it could “interfere with bonding and/or breastfeeding.”  Exhausted mothers then bear the responsibility of feeding a hungry newborn around the clock, and we have found that some accidentally fall asleep with the baby in bed, and instances where babies have fallen out of bed due to maternal exhaustion.

We also are not supposed to offer a pacifier, because that could also interfere with the breastfeeding relationship. So a baby that could be soothed with a pacifier now must be soothed with a finger or mom’s breast, both of which require an adult to be awake and attentive.

Momivist: What percent of new babies need to be supplemented and how much?

Sarah, RN: I do not know for sure, and I think there is a discrepancy between how many “need” supplementation and how many actually get it. I think supplementation is underused in fear that it will hinder breastfeeding, at the expense of the baby. I would say 10% are supplemented with a doctor’s order, but after the first 24 hours some mothers request supplementation due to excessive crying, inability to console the baby, and exhaustion due to cluster feeding.

If supplementation is used, we encourage the mother to have baby breastfeed on both breasts, then give a bottle, although the ordered amount of formula is usually only 10 cc, even though a term baby can take much more than that. We are not required to ask mothers to hand express to ensure there is colostrum, which is dangerous. Every mother produces differently, but we are supposed to give the same explanation regardless of that fact: “You have colostrum, and that is enough for your baby right now.”

I’ve had a couple recent situations that dispel the myth that every mother makes enough colostrum for her baby. One mother was having extreme pain with breastfeeding due to a combination of sensitivity, upper lip tie, and lower tongue tie in baby. She decided to pump until the baby’s ties were clipped.

She pumped religiously every 1-2 hours after her son’s birth and produced nothing, not even drops to give the baby. I was her nurse that night and after the second pumping session with no results, I gently told her that her baby needed to be fed. She readily agreed and we gave him formula- he drank 60 cc at once. This baby was obviously hungry, and we had concrete proof that mom wasn’t making sufficient colostrum for him. If this mother had continued to breastfeed, staff would have continued to tell her that, yes, her baby is getting enough because he’s sucking. This mother’s situation made me wonder how many babies are going hungry while we reassure mothers that their babies are being fed, when in reality they are not.

Breastfed jaundiced babies stand out to me as well. Breastfed babies are at a higher risk for jaundice, and even if they do become jaundiced, supplementation is not routinely encouraged. Instead, more breastfeeding is encouraged (obviously there’s nothing wrong with continuing to breastfeed, but if it is not sufficient, something else needs to be done). I am much less concerned about jaundice when a baby is formula fed, and their transcutaneous bilirubin readings are almost always lower. (Editor’s note: you can read more about jaundice here)

Momivist: How is a baby managed if they are crying excessively from not supplementing?

Sarah, RN: This is very tough. As a BFHI hospital, we are not supposed to offer formula or a pacifier when a baby is crying excessively, even though it will usually help quite a bit. I offer all of my moms the opportunity to send their baby to the nurses’ station so they can rest, regardless of if their baby is upset or not. Most of my colleagues will offer if the baby is upset and the parents seem like they are at the end of their rope. We take baby to the nurses’ station, swaddle the baby, and attempt to console the baby by patting, walking, offering a pacifier (if mom requested one), or a gloved finger to suck on. None of these things replace food, but they console the baby long enough to allow mom to get some rest until we bring baby back to breastfeed again. To be clear, I do not agree with distracting a hungry baby, but I cannot give a baby formula without parental consent.

Momivist: Are there concerns among staff about not supplementing?

Sarah, RN: Sadly, not enough. Speaking out about supplementing is frowned upon in my
experience. I think that there are a few nurses who may share my concerns, but the majority do not. I took care of a baby one night who was having major breastfeeding issues, and the mother was rightly concerned. I checked the baby’s blood sugar to make sure that it was not too low, and the nurse I gave report to in the morning questioned me and clearly disagreed with my judgement call, saying “if the baby is sucking with a good latch he’s fine!”


Supplementing at the Hospital

Nurses often roll their eyes at the desk when mothers request formula after hours of breastfeeding, as though a mother’s intuition that her baby might be hungry is silly. I think there is a huge fear associated with supplementing that nurses play into – that supplementing equals breastfeeding failure. Or if baby is given formula in the hospital, the baby will reject the breast and the breastfeeding relationship is ruined. Neither of these are true, and this exaggerated fear comes at the expense of the babies.

Momivist: If a mom is formula feeding, does she sign a consent form?

All of our mothers sign a feeding contract upon admission. You sign either for exclusive breastfeeding, exclusive formula feeding, or a combination. You also have to sign if you want a pacifier.

The feeding consent form lists all of the positive aspects of breastfeeding (increased bonding, less illness, WHO recommendations, etc), and all of the negative aspects of formula feeding  – and none of the positives. If a mother who signed for exclusive breastfeeding decides at some point to supplement, she has to sign another consent that goes into further detail about, essentially, how “bad” formula is. I do not like the biased nature of these forms, and feel that they misinform parents about the big picture of infant feeding  – and thereby make them feel unnecessary guilt if they do choose to supplement.

Momivist: If there were one of two things you could change with these strict breastfeeding policies, like the BFHI’s, what would they be?

Sarah, RN: The first thing that comes to mind is how negatively formula is portrayed. I wish that BFHI were truly “baby friendly” in that feeding a hungry baby is much more “baby friendly” than starving him in pursuit of the mythical perfect breastfeeding relationship. I also wish it acknowledged that the benefits of breastfeeding are very exaggerated in our developed country, versus that of a less developed country where breastfeeding, even if not sufficient, is often the cleanest, safest form of feeding based on those countries’ sanitation and health infrastructures.

The second thing I would definitely change would be to have a nursery again. We technically still have a nursery, but it is not staffed and not used for much more than a place to chart and storage. If a mother wants her baby by her side during her stay, that is perfectly fine. But I think it is wrong to expect an exhausted mother to be solely responsible for a newborn.

Most moms haven’t had adequate sleep since before labor and some are taking narcotics for pain. This is not a safe situation. Most babies are not hurt, but the risk is definitely there. Our fall risk assessments that we complete every four hours even acknowledge that a tired, breastfeeding mother has a higher risk of dropping her baby. Even though adverse outcomes like falls are infrequent, the fact that we are sending new mothers home in states of exhaustion is not acceptable. Most women do not have help at home, and the hospital is the only place they do have some assistance. Instead, they are looked down upon when they ask for it.

Mothers who routinely ask for their babies to be sent to the nurses’ station are viewed as bad mothers who do not want to bond with their babies (this is not said out loud, but it is so obvious on staff’s faces). Mothers cannot take care of their babies if haven’t taken care of themselves, and these strict breastfeeding protocols, like those in the BFHI, seem to overlook this. I would love to have a staffed nursery and information for moms on admission that encouraged sleeping/resting after delivery and using the nursery, with the option to have baby room-in 24/7 if preferred.


18 thoughts on “Q&A: One Nurse’s View on Strict Breastfeeding Policies

  1. SCNRN says:

    As a fellow maternal-child health nurse, all I can say is AMEN TO ALL OF THE ABOVE! It amazes me that we would never starve a two week old child, a two month old child, or a two year old child, but it’s supposed to be completely OK to let a two day old child remain hungry! Also, I feel so guilty expecting mothers who have possibly labored for days before a c-section to care for their newborn. I love that hospitals offer so much more breastfeeding support than we did 20 years ago when I had my first baby. But we need to keep some common sense!

    • Christie del Castillo-Hegyi, M.D. says:

      Thank you so much for your comment! We have learned dangerous things about newborn feeding and our newborns are paying the price. We hope to re-educate mothers and health professionals about the critical, life-threatening issues of newborn feeding to prevent breastfeeding tragedies from occurring! Thank you for supporting mothers and babies in your daily work! Christie del Castillo-Hegyi, M.D.

  2. Maria says:

    This foundation is wonderful. Your message helped us decide to supplement feed our 4-day-old daughter when she was starving and my milk still hadn’t come in. Thankfully my milk did come in 1 day later but had this information not been out there we may not have done it. I was determined to EBF and I am now, but my newborn did not have to endure hunger because I was afraid to hurt the breastfeeding relationship. Thank you thank you thank you!!!

  3. Emily says:

    NICU RN here and I completely agree with this whole account. I also work at a Baby-Friendly Hospital but being that I’m in the NICU and that we have plenty of donor milk at our disposal, the pressure for moms to get baby to latch and eat isn’t as intense. Being that we’re in the NICU, I also feel like we’re more realists. We usually get babies whose sugars are crap and at that point, they have to eat a sufficient amount or they get an IV. What I don’t understand about a lot of facilities is the pervasive mentality that a happy medium like offering the breast to begin with and supplementing with a bottle afterwards is not enough. I’ve seen this technique work well so many times but the idea that giving a baby a bottle (even when you continue to offer him/her the breast first) is going to screw up breastfeeding is a myth that just won’t die.

  4. MBRN says:

    I am so glad I found this website. As an RN taking care of newborns this information has rocked my core. I feel totally betrayed by my training. I work in a baby friendly hospital and was required to attend lactation training. I did not learn of starvation jaundice or the full consequences of hypoglycemia. I am guilty of judgment towards moms who have asked for bottles or complained that it’s too hard or that they aren’t producing milk – and I feel awful. So I pledge from this day forth with new knowledge in my book to listen to moms and babies and go with the Fed is Best motto. Thank you so much for this information.

  5. Leanne Abbott says:

    Thank you thank you. I am an IBCLC and postpartum doula. In my view the pendulum just needs to come to the middle. We went so far in promotion of breastfeeding that we lost common sense! And, yes, things can escalate into the danger zone and our “go to” during the breakdown is often: colostrum is enough…
    A few situations have happened that made me suggest supplementation early on. These both are fairly common. The first is PCOS. Every mom I have worked with that had this medical history was never told by anyone (OB, midwife, other IBCLC) that this condition could affect how much milk they will have! One mom in particular had her second baby and gave a long and sad history of her first baby crying non-stop, while IBCLC’s and everyone else just encouraged her to keep trying. Keep trying these marathon nursing sessions with a non-stop crying infant? The second situation is what I would term (in my head) “resentment nursing”. These mother and baby pairs have had a very difficult beginning. Mom has “tried everything” but still has pain, little milk, or sheer exhaustion brought on by so much trying. More then once I have seen mew moms avoiding feeds, crying, and borderline angry with the baby. They are so relieved when given “permission” to offer formula. But with that relief they still feel guilt, and like they failed. Their relationship with the baby improves however! This is of major importance!
    I try to offer the idea of supplementation with their own milk but sometimes they are so “over it” that they do not even want to pump. Of course with PCOS they may not get enough anyway.
    It breaks my heart to think of how horribly close some babies must come to death! Scarey!

  6. Alex says:

    Is the form mentioned above (the one that mothers sign about the benefits of breastfeeding and the negatives of formula feeding) in the united states only? Or is this in Canada as well?

    • Christie del Castillo-Hegyi MD says:

      As far as we know, the Baby-Friendly guidelines of informing mothers of the risks of formula feeding apply to all Baby-Friendly institutions.

  7. Sarah Norris says:

    One of the most well balanced, thoughtful, insightful articles I have read on this subject…thank you to this nurse for speaking out, she obviously cares greatly about her work and her patients.
    As someone has already said…the pendulum has swung too far in both directions from formula pushing at the expense of breastfeeding over to exclusive breastfeeding at the expense of mother and babies mental and physical health.
    What we need now is for everything to calm down and for compassion and common sense to reassert itself until we find a happy medium.
    Thank you FIB for this excellent interview ❤️X

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