On October 14, 2019, theJournal of Pediatrics published astonishing findings regarding the effects of the Baby-Friendly hospital certification on sustained breastfeeding rates as defined by the 2020 Healthy People Goals of:
any breastfeeding at 6 and 12 months
exclusive breastfeeding at 3 and 6 months.
They did so by measuring the relationship between statewide breastfeeding initiation rates data and the above breastfeeding rates. They then measured the contribution of Baby-Friendly hospital designation on these same breastfeeding outcomes.
According to the study authors, the increase in hospital designation in the Baby-Friendly Hospital Initiative (BFHI) began in 2011 when the U.S. Surgeon General issued a call to action for maternity care practices throughout the U.S. to support breastfeeding. The Centers for Disease Control (CDC) became involved in promoting the BFHI policies in hospitals and health facilities, as breastfeeding was thought to be associated with lower rates of childhood obesity. The assumption was that by increasing breastfeeding rates through the BFHI, there would be a concomitant decline in childhood obesity. Upon initiation of this program, the CDC initiated surveillance of state-specific data on breastfeeding outcomes after discharge including BFHI designation rates. This data is made available to the public through the CDC Breastfeeding Report Card, which provides annual reports from 2007 through 2014 and biennial reports from 2014.
As expected, they found that states with higher breastfeeding initiation rates had higher rates of these sustained breastfeeding outcomes. You cannot have high breastfeeding rates unless mothers are given education and successfully initiate breastfeeding. However, when they measured the effects of Baby-Friendly certification, this is what they found.
“Baby-Friendly designation did not demonstrate a significant association with any post-discharge breastfeeding outcome (Figures 1, B and 2, B). There was no association between Baby-Friendly designation and breastfeeding initiation rates.”Continue reading →
A key recommendation of the 1989 World Health Organization Ten Steps to Successful Breastfeeding which guides the Baby-Friendly Hospital Initiative (BFHI) is: “give infants no food or drink other than breast-milk, unless medically indicated.” This has led to serious complications from accidental starvation of babies, including dehydration, hyperbilirubinemia (jaundice) and hypoglycemia (low blood sugar) — known causes of infant brain injury and permanent disability. Last week, the WHO issued draft revised breastfeeding guidelines, failing to revise this recommendation. These guidelines define the standard of care for breastfeeding management in all healthcare facilities worldwide. Nearly 500 U.S. hospitals and birthing centers and thousands more worldwide that meet the criteria of the BFHI are certified as Baby-Friendly, adhering to the application of the WHO’s Ten Steps.
On Sept. 22, 2017, senior members of the Fed is Best Foundation, and guests including a neonatologist from a leading U.S. tertiary care hospital and a pediatric endocrinologist, Dr. Paul Thornton, M.D, from Cook Children’s Hospital Fort Worth, lead author of the Pediatric Endocrine Society’s newborn hypoglycemia guidelines, met via teleconference with top officials of the WHO Breastfeeding Program: Dr. Laurence Grummer-Strawn, Ph.D., Dr. Nigel Rollins, M.D. and Dr. Wilson Were, M.D. to express their concerns about the complications arising from the BFHI Ten Steps and to ask what, if any, monitoring, research, or public outreach the WHO has planned regarding the risks of accidental starvation of exclusively breastfed newborns. The Foundation members who attended were 1) Christie del Castillo-Hegyi, MD, Co-Founder, 2) Jody Segrave-Daly, RN, IBCLC, Co-Founder, 3) Julie Tibbets, JD, Partner at Alston & Bird, LLP, Pro-Bono Attorney for the Foundation, 4) Brian Symon, MD, Senior Advisor, and 5) Hillary Kuzdeba, MPH, former quality improvement program coordinator at a children’s hospital, managing infant feeding projects and Senior Advisor.
Emails confirming meeting between the WHO and the Fed is Best Foundation available here.
by Jillian Johnson with commentary from Dr. Christie del Castillo-Hegyi
Landon would be five today if he were still alive. It’s a very hard birthday–five. It’s a milestone birthday. Most kiddos would be starting kindergarten at this age. But not my little guy. I wanted to share for a long time about what happened to Landon, but I always feared what others would say and how I’d be judged. But I want people to know how much deeper the pain gets.
I share his story in hopes that no other family ever experiences the loss that we have.
Jarrod and I wanted what was best for Landon as every parent does for their child. We took all of the classes. Bought and read all of the books. We were ready! Or so we thought….every class and book was geared toward breastfeeding and how it’s so important if you want a healthy child. Landon was born in a “Baby-Friendly” hospital. (What this means is everything is geared toward breastfeeding. Unless you’d had a breast augmentation or cancer or some serious medical reason as to why you couldn’t breastfeed, your baby would not be given formula unless a prescription was written by the pediatrician.)
In most hospitals and prenatal educational materials, exclusive breastfeeding (EBF) is the recommendation for infant feeding. EBF is promoted as the only healthy way to feed a baby, with partial breastfeeding, temporary supplementation, and formula feeding falsely characterized as “suboptimal.” Other infant feeding options such as exclusive pumping or formula supplementation are discouraged, even when requested by parents. But does this narrow definition of healthy infant feeding support patient rights and ethical infant feeding principles? No, it does not.
Infant feeding support in postpartum units should consider ethical principles of autonomy, beneficence, justice, and non-maleficence when considering the extent to which lactation should be promoted.
What Are The Principles of Ethical Infant Feeding?
Autonomy: The parents choose how they intend to feed their baby at each feeding, and maternal bodily autonomy is affirmed and respected.
Beneficence: The benefits of infant feeding types are provided to the parent to help them make an informed decision. Health care providers must not decide what is best for the parent.
Justice: Do not assume a feeding method. Ask the parent how they want to feed their baby. Affirmative consent must be obtained before touching a patient’s body.
Non-maleficence: Avoids harm to the parent and/or babies, such as insufficient colostrum/milk intake while EBF. Research shows that 1 in 77 EBF babies are hospitalized from complications of insufficient feeding, and EBF is the most common risk factor for hyperbilirubinemia (excessive jaundice that can impair brain development). Sleep deprivation for parents causes newborn falls and accidental suffocation. Infant feeding should always be discussed using nonjudgmental language and unconditional positive regard to avoid instilling or exacerbating psychological distress. Mental health disorders affect 1 in 5 parents during pregnancy, and the first year after birth, making them particularly vulnerable.
What Do Parents Want?
In the United States, parents have limited or no paid time off from work after childbirth, often directly impacting how they feed their babies. They depend on their employers for job security and medical insurance to provide housing, food, clothing, transportation, and daycare expenses. Not every parent can physically lactate or provide 100% human milk to their baby, and not every parent chooses to breastfeed or chestfeed. In some cases, the parent’s mental or physical health takes priority over exclusive breastfeeding or chestfeeding.
Parents have told us theyneed individualized and unbiased infant feeding support that prioritizes their own and their baby’s safety, honors their bodily autonomy, prioritizes optimal parental mental health, and supports how they wish to divide infant feeding responsibilities with their partners. They want to receive support that leaves them confident with their chosen infant feeding method.
We believe that they deserve no less.
The Ten Steps To Ethical, Successful, And Inclusive Infant Feeding
Implement an inclusive infant feeding policy that is routinely communicated to staff and parents, prioritizes infant safety, parental rest, and recovery, and protects parental mental health. Monitor and publicly disclose the hospital or institution’s infant feeding complications and readmissions rates.
Ensure that all medical staff has up-to-date knowledge, competence, and skills to support breastfeeding, formula feeding, pumping, supplementing, and combination feeding.
Discuss all feeding options with expectant parents without judgment or bias at every interaction. Provide education about the differences between all feeding options, so parents can be fully informed tochoose the feeding method that works best for their family.
Facilitate immediate and uninterrupted skin-to-skin contact, if desired. Support parents to initiate feeding within the first hour of life or as soon as parent and baby are medically stable.
Teach parents how to initiate breastfeeding and how to maximize their milk supply and manage common breastfeeding or chestfeeding difficulties. Educate them on how to supplement, pump, and combination feed as needed or desired by parents. Teach them how to prepare infant formula safely and bottle-feed their baby responsively.
Ensure affirmative consent before touching the parent’s breasts, nipples, or body with every encounter.
Enable parents and their infants to remain together 24 hours a day if desired; provide A well-baby nursery for those who want to use it for rest, recovery, or any other reason requested by the parents.
Support parents in recognizing and responding to their infant’s hunger and fullness cues. Educate parents on the importance of feeding a baby until they are satisfied after every feeding.
Provide information to parents about feeding devices such as bottles, nipples, pacifiers, and breast pumps. Educate parents about the types of formula available and how to prepare infant formula safely.
Coordinate discharge by providing parents with community feeding support groups and resources that support their feeding method. A follow-up pediatrician appointment should be made at discharge for ongoing feeding support.
Hospitals must have policies to support ethical infant feeding.
The Fed Is Best Foundation works to identify critical gaps in the current breastfeeding protocols, guidelines, and education programs and provides families and health professionals with the most up-to-date scientific research, education, and resources to practice safe infant feeding with human milk, formula, or a combination of both.
Above all, we strive to eliminate infant feeding shaming and preventable hospitalizations for insufficient feeding complications while prioritizing perinatal mental health.
Sarah Christopherson is a mother and the Policy Advocacy Director at the National Women’s Health Network, a non-profit advocacy organization in Washington, D.C. She talks about her breastfeeding experiences and her recent experience in a Baby-Friendly hospital where her child became severely dehydrated and lost 15% of her birth weight while in the hospital. She discusses how policies can negatively affect patient health and how systemic change is needed to support positive patient health outcomes and prevent patient coercion.
Is that some kind of sick joke? Infant formula is safe nutrition—scientifically created to replace human milk and thus consists of fluids and nutrients necessary to nourish a baby. Brain damage is irreversible. That should be glaringly obvious, but it looks like the AAP Breastfeeding Section responsible for the recently released “Breastfeeding and the Use of Human Milk” (June 2022) has lost sight of this critical fact.
Let’s focus on this appalling statement:
“The need for phototherapy in an otherwise healthy infant without signs of dehydration and/or insufficient intake is not an indication for supplementation with formula unless the levels are approaching exchange transfusion levels.”
Hyperbilirubinemia (excessive jaundice) and Phototherapy
To explain why we are horrified, let’s look carefully at what the statement means. Jaundice is a common and usually benign condition experienced by about 60% of healthy newborns. It is caused by a substance called bilirubin, a breakdown product of fetal red blood cells after birth to transition to mature red blood cells. However, if a baby’s bilirubin levels are greater than a certain level and continue to climb, the risk for brain damage increases.
A baby should never be allowed to experience a dangerous bilirubin level, and all interventions should be utilized to bring the levels down quickly!
There is, however, a cost-effective preventable intervention available—it’s called adequate feeding of donor milk or infant formula with a bottle which is the absolute BEST way to reduce bilirubin levels. It also provides comfort for a baby who is lethargic, hungry, thirsty and has dry, chapped lips and mouth. Multiple blood checks will also be necessary to monitor bilirubin levels, which are painful for newborns.
To be clear, supplementation does NOT interfere with exclusive breastfeeding. Exclusive breastfeeding can be resumed when the full milk supply has come in after the danger has passed. Brain damage can never be undone.
Source: The World Health Organization
This video educates parents about newborn jaundice and the importance of supplementing.
brain-threatening Jaundice is preventable
Jaundice high enough to require phototherapy happens to about 15% of newborns (according to a large 2018 study). Prevention of phototherapy from insufficient breastfeeding can be prevented with temporary supplementation.
Ella (now two years old) was one of these newborns. (Her mother, Becca shared her story with us in 2019, after her baby experienced multiple complications of insufficient milk, while she received loads of professional advice not to supplement.) Ella wouldn’t have been supplemented with formula under these guidelines because her jaundice wouldn’t have been considered severe enough. Her pediatrician would probably disagree, given that he’s watching her closely for suspected developmental delay—a known complication of severe jaundice:
Ella, under phototherapy lights
Becca (Ella’s mother) and other parents of babies who experienced high bilirubin levels have to live with the knowledge that their babies didn’t get enough to eat and that it may have affected their brains. The psychological trauma of this cannot be overstated.
Medical Ethics: “do no harm” and informed consent
Rarely are parents told that increased feeding from supplementation with formula (or banked donor human milk if available) can prevent as well as reduce high bilirubin levels, shorten the need for costly and emotionally grueling hospitalizations, and most importantly, reduce their baby’s exposure to a substance that damage brain cells.
Instead of emphasizing the dangers of excessive jaundice, the guidelines claim that the higher bilirubin levels commonly found in exclusively breastfed newborns may be beneficial because bilirubin is an “antioxidant.” Studies on excessive jaundice are very clear—high bilirubin levels can result in developmental delay, cognitive impairment, and behavioral and psychiatric disorders. There are simply no facts—none—to support their idea that there are benefits.
In every other area of medicine, patients (and parents of patients) receive informed consent and counseling about their options, especially when a serious complication like excessive jaundice can occur. However, providing this information is not currently standard practice. In reality, the failure to fully inform parents of the causes (e.g., insufficient milk intake) and risks of newborn jaundice commonly result in parents going home believing they are doing what is best for their infants by avoiding formula supplementation. If their infant does not receive enough milk because the milk comes in late or it is not enough, then they may find a distressed or lethargic jaundiced, and dehydrated baby that now requires hospital admission for conditions that can cause permanent disability. It is unbelievable—yet true—that parents aren’t being informed that insufficient feeding problems and jaundice are currently the leading causes of newborn rehospitalization.
This lying by omission is an outrageous violation of patient rights.
Parents should be told that temporary supplementation in response to signs of infant hunger and jaundice can prevent and treat these complications. Supplemental milk, whether it be formula or banked donor milk, can reduce bilirubin levels in both insufficiently fed babies and babies who have excessive bilirubin due to other medical conditions (like blood type incompatibility) because elimination through digestion is the way babies remove bilirubin.
While exclusive breastfeeding can be resumed when the full milk supply has come in, and the danger has passed, brain damage can never be undone.
Sydney F.’s baby was supplemented for five days using our feeding plan, then exclusively breastfed. She is still breastfeeding at 11 months.
The authors’ concern seems to be that if parents are made aware that breastfeeding isn’t perfect, they might entirely stop. Or worse, parents may come to believe that there can be benefits to supplementing some breastfed babies with formula (especially jaundiced newborns) and that the narrative that exclusive breastfeeding is best for all babies (with rare exceptions) is false.
Parents can understand the concept of a temporary nutritional intervention to bridge the gap until their supply increases and how this can protect their baby and support continued breastfeeding. In other words, you don’t have to choose between breastfeeding and reducing your baby’s risk of excessive jaundice—you can do both!
Five well-designed studies suggest that they do understand this and that breastfeeding isn’t destroyed with temporary small supplements. How many clinical trials have shown that judicious supplementation impairs sustained breastfeeding? None. Regardless—and this is important—what gives anyone the right to withhold information because it might change how a parent chooses to feed their child?
WHEN PHOTOTHERAPY ISN’T ENOUGH: EXCHANGE TRANSFUSIONS
The American Academy of Pediatrics—the authority that advises all pediatricians—now recommends that pediatricians should not offer formula supplementation for jaundiced babies receiving phototherapy without signs of “dehydration and/or insufficient intake,” which they do not define until they are “approaching exchange transfusion levels.” An exchange transfusion is essentially a blood transfusion done when a jaundiced baby’s blood has become so toxic from high bilirubin levels that they risk severe brain damage, a condition called kernicterus.
Baby Finn was set up for a blood transfusion for jaundice. Photo by Jim Campion (his father) via Flickr
“Signs of dehydration” range from a slightly dry mouth to total lack of urination and a sunken fontanel (soft spot on babies’ heads). “Insufficient intake” can mean anything from insufficient to make the baby full and comfortable to only enough milk to keep the baby out of danger. We assume they mean the latter, as the Academy of Breastfeeding Medicine, which sets the standards for newborn exclusive breastfeeding management under the Baby Friendly Hospital Initiative endorsed by the AAP guideline, says that if supplementation is necessary, only 1–3 teaspoons (5–15 ml) on days 1 and 2 should be given, respectively. This is despite evidence that the newborn stomach is 20 mL at birth and that much higher volumes of supplemental feedings than they recommend actually reduces rates of jaundice readmission.
How can the AAP discourage pediatricians from offering parents the choice to reduce their child’s bilirubin levels with formula when supplementing can rapidly reduce bilirubin levels, shorten the need for phototherapy, and prevent levels that can require a blood transfusion for any baby with high bilirubin levels?
Studies have shown elevated markers of brain injury in the blood occur by bilirubin levels of 19 and 20 mg/dL. Large studies have shown increased risk of developmental problems, cognitive impairment, speech/language impairment and behavioral problems in newborns who develop high bilirubin levels, even in the moderate range of 13.5–19 mg/dL, wellbelow the threshold for exchange transfusion. These impairments are from BIND—bilirubin induced neurological dysfunction—which is less severe than kernicterus, but still seriously disabling.
Have they ever met a parent whose child has to live with the lifelong disabilities caused by kernicterus, as shown in this video?
Anyone familiar with the devastating impact of kernicterus would not be so casual about jaundice; in fact, they would be outraged at the suggestion in this report.
How can the AAP be trusted with making recommendations on infant feeding when they appear to have lost perspective on what constitutes safe versus unsafe conditions for infants?
Chloe’s baby Lucas
Can we all agree that infant formula is far better than the risk of brain damage? Can we at least let parents know these facts and put the decision in their hands? Can we please prioritize protecting babies’ brains over avoiding formula?
Written by Lynnette Hafken, MA, IBCLC, with Christie del Castillo-Hegyi, MD, and Jody Segrave-Daly, RN, IBCLC (Retired)
“The sight and sound of babies crying out for food and fluids are why I decided to speak out. Babies are denied food and fluids to promote exclusive breastfeeding.”
As a mother-baby nurse, I’ve seen many preventable episodes of emotional distress for families in my thirty-year career. Unfortunately, The emotional distress increased significantly when the Baby-Friendly Hospital Initiative was implemented at my hospital. Some episodes of emotional distress are unforgettable, so I felt compelled to speak out about them, hoping to bring about the much-needed change to protect newborns from hunger and maternal mental health.
Mothers are incredibly vulnerable after giving birth, as their bodies transition physically and hormonally. They have a new life to take care of while recovering from birth and require compassionate, respectful, and individualized care. However, the Baby-Friendly breastfeeding protocol is one-size-fits-all and does not allow individualized care. Mothers must follow the BFHI protocol regardless of how they feed their baby or how complicated their birth was. We know as health care professionals that no protocol can be safe and effective without individualized care.
Evidence based medicine cannot replace clinical judgment or account sufficiently for the complexity of individual cases. The limitations of EBM must be acknowledged and addressed so that it can be used effectively and without compromising patient care. -Mark R. Tonelli, MD, MA
The current breastfeeding culture instills the belief that all women can exclusively breastfeed without any acknowledgment of our biological, physical, social, and psychological abilities to exclusively breastfeed.
Auli shared with us how her mindset shifts as a low milk supply mother. She has insufficient glandular tissue, which is thought toaffect up to 1 in 20 mothers.
Paced bottle feeding is a wildly popular bottle feeding technique that is promoted as the best way to feed babies who are breastfed. When I did a google search for paced bottle feeding, there were a whopping 572,000,000 results!What’s more, definitions of paced bottle feeding techniques varied significantly, often contradicting each other, and there were many unproven claims to promoting paced feeding.
As a 30-year NICU nurse and lactation consultant, I’m mystified why paced feeding for healthy term babies has become the norm. Pace feeding is a therapeutic feeding technique primarily used for medically complex and premature babies whose suck, swallow, and breathe (SSB) reflex is not coordinated or matured, which is essential to bottle-feed without aspirating milk into the lungs.
Come tune in and listen to a podcast where Fed is Best Co-Founder, Christie del Castillo-Hegyi talks with Hayley Zimak of “Growing Up: Baby” about her breastfeeding story, the birth of the #FedisBest movement, and what needs to change in parent-infant feeding education to ensure the safety of every child.
Parents from the Fed is Best Infant Feeding Support group have told us that their prenatal education didn’t prepare them for the realities of breastfeeding and didn’t teach them the education they wanted and needed. They want other families to be informed to have a safe and positive breast/chestfeeding experience. This is what they said:
A meme posted by an IBCLC states that breastfeeding 12 or MORE times a day is “normal” with no further education on when it can be a sign of newborn hunger, poor feeding, inadequate milk transfer, or failure to thrive.
Overly simplistic memes like this are irresponsible, confusing and in some cases are the reason why parents miss red flags that require medical attention and lactation assessment to be sure the baby is receiving adequate nutrition and fluids when nursing. (Source of meme to the left, Facebook, Lucy Ruddle, IBCLC)
Here at the Fed Is Best Foundation, we receive messages frequently from families who tell us they were repeatedly assured by trusted health professionals that nursing 12 or more times a day is completely normal.