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!”

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.