The Ten Steps to Ethical, Successful, And Inclusive Infant Feeding

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 they need 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

  1. 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.
  2. Ensure that all medical staff has up-to-date knowledge, competence, and skills to support breastfeeding, formula feeding, pumping, supplementing, and combination feeding. 
  3. 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 to choose the feeding method that works best for their family.
  4. 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.
  5. 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.
  6. Ensure affirmative consent before touching the parent’s breasts, nipples, or body with every encounter.
  7. 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.
  8. 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.
  9. 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.
  10. 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.

Resources:

Breastfeeding Support Guided by Swanson’s Theory of Caring – PubMed (nih.gov)

Infant formula feeding practices and the role of advice and support: an exploratory qualitative study – PubMed (nih.gov)

The impact of Baby Friendly Initiative accreditation: An overview of systematic reviews – PubMed (nih.gov)

The supporting role of the midwife during the first 14 days of breastfeeding: A descriptive qualitative study in maternity wards and primary healthcare – PubMed (nih.gov)

My “Baby Friendly” Hospital Harmed My Baby: How Hospitals Can Do Better | National Women’s Health Network (nwhn.org)

The impact of Baby Friendly Initiative accreditation: An overview of systematic reviews – PubMed (nih.gov)

Autonomy for Mothers? Relational Theory and Parenting Apart by Susan B. Boyd :: SSRN

Breast Is Best . . . Except When It’s Not – Lynne M. McIntyre, Adrienne Marks Griffen, Karlynn BrintzenhofeSzoc, 2018 (sagepub.com)

Well-Informed and Willing, but Breastfeeding Does Not Work: A Qualitative Study on Perceived Support from Health Professionals among German Mothers with Breastfeeding Problems – PubMed (nih.gov)

Women’s advice to healthcare professionals regarding breastfeeding: “offer sensitive individualized breastfeeding support”- an interview study – PubMed (nih.gov)

Professional and non‐professional sources of formula feeding advice for parents in the first six months – PMC (nih.gov)

A Qualitative Study of Breastfeeding and Formula-Feeding Mothers’ Perceptions of and Experiences in WIC – PubMed (nih.gov)

Could the Baby-Friendly Hospital Initiative be hurting mothers—and babies too? (advisory.com)

Do ‘Baby-Friendly’ Hospitals Work for All Moms? – The New York Times (nytimes.com)

A Lack of Evidence for Baby-Friendly Hospitals (undark.org)

Nurses Are Speaking Out About The Dangers Of The Baby-Friendly Health Initiative – Fed Is Best

Letter to Doctors and Parents About the Dangers of Insufficient Exclusive Breastfeeding and the Baby-Friendly Hospital Initiative – Fed Is Best

 


Our mission statement is:

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.

 

 

Is Formula More Dangerous than Irreversible Brain Damage?

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 levelsshorten 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 much milk a baby needs: Milk Calculator

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, well below 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)

Resources

 

 

 

Mother Speaks Out About Her Baby’s Death After Exclusive Breastfeeding: What She Wants Human Rights Organizations to Know

Josephine contacted us after reading Dr. Christie del Castilo-Hegyi’s letter to health care professionals about the dangers of insufficient breastfeeding and the Baby-Friendly Hospital Initiative. Josephine is from Lagos, Nigeria, and wants to tell her story, because she believes every mother should know how to supplement her baby safely until her milk is flowing, no matter what country she lives in, to prevent brain damage and death from insufficient breastfeeding. 

Continue reading

How To Prepare For Supplementing When Breastfeeding Your Baby In The Hospital

Mothers who experienced delayed onset of milk production or experienced low milk supply with their first baby often contact us for support to try breastfeeding again. They typically have anticipatory anxiety, because they have lost trust in their lactation professionals and hospital staff and are unwilling to attempt breastfeeding again without supplementation. They want to know how to supplement their baby until their milk supply becomes sufficient to feed their baby safely while providing proper stimulation to their breasts for optimal milk production.

The most common concerns expressed:

 

  • Fear of the pressure to exclusively breastfeed
  • Fear of failing to breastfeed again
  • Fear of advocating for themselves and their babies while in the hospital
  • Fear of being shamed by hospital staff when wanting to supplement until their milk comes in
  • Fear of being denied formula or not receiving it in a timely manner
  • Triggers from the previous negative breastfeeding experience, such as being touched without consent

Monica writes: “I lost confidence in breastfeeding because I didn’t make enough milk for my first son, who required hospitalization for severe jaundice and a 13% weight loss. I was devastated and furious when the neonatologist told me he was starving. In my birth hospital, my son had been forced to cry from hunger, and I was told my body would make enough milk for him by every lactation consultant and nurse in the hospital. I trusted them. They were wrong! I no longer trusted breastfeeding and decided to pump and bottle feed to ensure he got enough milk. I purposely delivered my second baby at a hospital that didn’t force me to breastfeed exclusively. After starving my son,  I was not taking any chances, and I supplemented my daughter after every breastfeeding session. My breastfeeding experience was the opposite of my son’s, and I remember tearing up several times because she was so peaceful and never cried.  Thankfully I supplemented her because it took five days for my milk to come in. Supplementing saved my breastfeeding journey, and we are still breastfeeding 19 months later.”

 

Continue reading

The New Seven Letter “F” Word

As soon as the word “formula” rolls off your tongue and leaves your mouth for everyone to hear, uncomfortable silence occurs. Parents are reluctant to talk about or admit freely they feed their babies infant formula. Most are suffering from the deeply entrenched shame and judgment that is associated with formula feeding; they have experienced it first hand in countless social media parenting groups, from friends, their health care professionals, WIC offices, and even in their hospitals.

How did we get to the place where talking about infant formula is profoundly divisive, shameful, and anxiety provoking for parents? 

 Let’s face it, infant FORMULA is the new seven letter F word. The scarlet letter F.  FAILURE. 

Continue reading

My Breastfed Baby Starved While Under The Care Of Health Professionals For 5 Weeks

My beautiful baby girl Mary-Kate was delivered by emergency c-section, and although there were complications during labor, she was healthy on arrival. Having done a bit of research and listened to the advice of professionals, as well as the threat of the global pandemic posing a risk, I decided I would breastfeed my daughter, to provide her with passive antibodies for COVID-19 from my milk.

I began exclusively breastfeeding in the hospital and the midwife said Mary-Kate had the perfect latch. I loved being a mummy, I could not stop looking at this beautiful little human me and my partner had created, but Mary-Kate was becoming increasingly unsettled. She was almost always attached to my breast and would fall asleep soon after latching on. I spoke to the health visitors, and we were told her crying was colic.  We began giving Mary-Kate lots of colic-type remedies. 

Each time somebody came to weigh her whether it be the GP, HV, or Midwife, Mary-Kate was not gaining and was in fact losing weight. I could not understand, because she was ALWAYS feeding. Nobody seemed alarmed by this. I was told to just keep trying, she might be a ‘slow starter’. Never once did they check to see what my milk supply was or how much she was getting. The professionals would leave, and I would carry on as normal. Baby attached to the breast, me trying to maintain some sort of order in the home, taking care of my personal needs and sleep. Mary-Kate would just cry and cry and cry unless asleep at my breast.  I was exhausted, I was falling asleep whilst holding my baby and I knew this presented its own risks.  Continue reading

Why Fed Is Best: From One Therapist’s Point Of View

Written by Sarah Edge

I am a Counsellor Psychotherapist, specialising in postnatal mental health in the United Kingdom. I am also a Mum of two small children. I recently wrote a guest blog on “The Process of Healing From Infant Feeding Trauma, Guilt, and Shame: When You Wanted To Breastfeed and Couldn’t” for the Fed is Best Foundation, and when I was asked to write again, I jumped at the chance. In this piece, I aim to examine the Fed is Best message through my therapist’s lens and discuss why the Fed is Best message is an essential part of healing and recovery. 

It is well known amongst those in the psychology field, whether it be researchers, psychologists, or therapists, that people are often drawn to study and work in a field where they have personal experience. The well-regarded and highly accomplished trauma academic Bessel Van Der Kolk has described his own research as “self-search.” And most have heard of the phrase “the wounded healer.” I am no different. I became interested in working therapeutically with postnatal mental health and infant feeding guilt due to my own experience of breastfeeding difficulties.

I personally have a complicated and emotional relationship with infant feeding. I experienced formula feeding my firstborn and breastfeeding my second child. I have personally undergone my own therapy and recovery, meaning I am now able to work safely and supportively with other women experiencing psychological distress compounded by, or sometimes caused by, their infant feeding experiences. But that’s not to say my heart doesn’t ache when I hear a mother sharing her raw and moving story of when breastfeeding didn’t work out. Continue reading

The Process of Healing from Infant Feeding Trauma, Guilt, and Shame: When You Wanted to Breastfeed, but Couldn’t

My name is Sarah Edge, and I am a counsellor psychotherapist and mum of two. After my experience with breastfeeding trauma, guilt, and shame, and the associated decline in my mental health after the birth of my son, I was motivated to start my own practice specialising in postnatal mental health. 

I suspect that most of you reading this are doing so because you have your own experience of infant feeding guilt or trauma, where breastfeeding didn’t work out how you had planned. My personal story is a tale as old as time. My son was born late preterm, healthy but sleepy and unable to latch. He developed significant jaundice and low blood sugars, resulting in us returning to the hospital, and him being admitted onto the children’s ward at five days old.

I tried everything to breastfeed: nipple shields, continuous pumping, cup feeding expressed breast milk, triple feeding, lactation consultants, and infant feeding professionals. I had alarms set every 90 minutes to feed my son, and I kept this up for almost two weeks without any results. His feeding consultant then prescribed him formula milk, and he began to thrive. He was happy and healthy, and we returned home to start our lives as a family of three, this time formula feeding him. 

My baby was finally thriving but I was not. I was left with so much sadness, jealousy, disappointment, and animosity towards breastfeeding. World Breastfeeding Week was unbearable, as the social media pages were flooded with beautiful photos of babies at breast, and seeing other women breastfeeding sparked this intense and animalistic jealousy I had never felt before. 

So why was I left with all this sadness?

 

Sadness is an emotional pain that is associated with feelings of loss, sorrow, depression, grief, guilt, disappointment, shame, despair, helplessness, fear, and disadvantage.  It can be difficult to shake and needs to be processed.

 

I was personally experiencing grief. I had suffered a loss. Breastfeeding was important to me, and my feelings were—and are—absolutely valid. 

No matter the reasons you could not breastfeed—and there are countless—you are allowed to mourn the loss of breastfeeding. Just because your baby is thriving without breastmilk doesn’t mean you don’t deserve to grieve or ask for support or comfort, especially if healing has been difficult. 

Continue reading

Dear Chrissy Teigen, You Are Right; We Need To Destigmatize Formula Feeding Our Babies

Dear Chrissy Teigen,

Thank you for your Twitter post raising the very important topic of stress, guilt, and sadness when a breastfeeding mother experiences low milk production.  

I could feel the deep despair you expressed through your words because I have supported thousands of mothers, just like you, who felt tremendous guilt and stress when they tried their best to make enough milk.

Can I emphatically tell you something? You and your body did not “fail” with making enough milk. You were failed by the current breastfeeding education and guidelines, which don’t fully inform mothers about their biological and psychosocial risk factors for low milk supply. Instead, parents are taught that every mother can make enough breast milk if she has the right support; but the research tells us that low milk supply is far more common than people realize.   All of the support in the world cannot increase breastmilk supply if your body cannot biologically produce it!       

Continue reading