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

 

 

 

Is Breastfeeding Twelve or More Times a Day Normal? Not Always

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. 

But is it always normal?

No, it’s not.  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. 

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I Supplemented My Baby Until My Milk Came In And We Are Still Breastfeeding At 3 Months

My son will be three months old tomorrow, and I’m reflecting on our nursing journey with gratitude. I had infertility and recurrent pregnancy loss prior to having him, and (after two rounds of IVF and six embryo transfers), he was born at 35 weeks. So we had a lot working against us for successful breastfeeding, but I wanted to try breastfeeding and I was ready to advocate for myself and the baby if needed in the hospital, since I knew I had significant risk factors for delayed onset of milk. 

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We Were Awarded A Malpractice Financial Settlement Because My Baby Suffered From Starvation In A BFHI Hospital

By A Mother from the Fed is Best Community who wishes to remain anonymous

This is my baby girl in NICU. She developed a high fever, jaundice, and dehydration with a 10.1% weight loss 56 hours after birth while exclusively breastfeeding in a ‘Baby-Friendly’ hospital.

During our stay, the hospital pediatrician saw my baby twice a day but he failed to inform us she had a 7.2% weight loss in the 30th hour of life. Hence, we were not given the information to decide if we should supplement with formula.

According to a review published in the Journal Of Family Practice in June 2018, “exclusive breastfeeding at discharge from the hospital is likely the single greatest risk factor for hospital readmission in newborns. Term infants who are exclusively breastfed are more likely to be hospitalized compared to formula-fed or mixed-fed infants, due to hyperbilirubinemia, dehydration, hypernatremia, and weight loss.” They estimated that for every 71 infants that are exclusively breastfed, one is hospitalized for serious feeding complications.

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Dr. Christie del Castillo-Hegyi and Jillian Johnson Speak at the 2020 USDA Dietary Guidelines Meeting

July 17, 2019

 

Washington, DC — On July 11, 2019, Dr. Christie del Castillo-Hegyi, Co-Founder of the Fed is Best Foundation and Jillian Johnson, Fed is Best Advocate and mother to Landon Johnson, who died from hypernatremic dehydration while exclusively breastfeeding, traveled to Washington, DC to provide testimonies to the 2020 USDA Dietary Guidelines Advisory Committee. This is the first year that the Dietary Guidelines for Americans (DGA) have included pregnancy and birth to 24 months.

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Dying for Milk: The Pam and Chaz Floyd’s Story

By Pam Floyd, Mother and Fed is Best Advocate

Twenty-five years ago, Chaz, the son of Pam Floyd, was born and developed hypernatremic dehydration from insufficient breast milk intake while exclusively breastfeeding. Chaz developed brain injury from dehydration and now lives disabled with cerebral palsy. Their story was published on the front page of the Wall Street Journal. She was subsequently interviewed on 20/20, which prompted a similar feature on ABC’s Prime Time Live. Pam contacted the Fed is Best Foundation to share her story again to warn mothers of the dangers of insufficient feeding.

Chaz develop hypernatremic dehydration from insufficient feeding while exclusively breastfeeding

“25 Year Anniversaries Should Be Celebrated Not Served As A Warning”

Twenty-five years ago my son almost died.  He was only six days old. I had chosen to breastfeed, as everyone around me kept reminding me that ‘breast is best.’  So I followed their advice, and I exclusively breastfed. Even though I felt like something wasn’t quite right those first few days, everyone assured me everything was fine.  The nurses in the maternity ward suggested that since I was a new mother, I wasn’t able to appreciate how much he was getting. The home health nurse that visited me, courtesy of my health insurance, the day after I left the hospital, reassured me that as long as he was getting six to seven wet diapers a day, then he was getting enough. And the nurses in my pediatrician’s office told me not to worry, that he was a big baby that he would eat when he got hungry. And my personal favorite, “the great thing about breast milk is that you never have to worry about how much or how little he’s getting. Because he’ll always get what he needs.” Well, that works great, if your milk comes in.  My colostrum wasn’t enough for my son, Chaz. And my body never produced enough milk to keep a 10 lb. 4 oz. baby boy healthy.

Then when my son’s eyes started rapidly zig-zagging back and forth on that sixth day of life and I called the pediatrician’s office to tell them he was having a seizure, they told me that I didn’t know what I was talking about and that sometimes newborn’s eyes do that as they often wander.  Well, the pediatrician finally agreed to see us. We were immediately sent to the emergency room. Then we were transferred to the children’s hospital. There, my son was put into a drug-induced coma until his seizures were under control. His diagnosis was a stroke due to hypernatremic dehydration.  Children’s Hospital had me use their hospital grade breast pumps those first few days. The most I ever pumped was 3 cc’s. About a teaspoon. Usually, I just came back with mist. Or what looked like spit. There was never milk. I never got engorged. I never leaked. There was never any milk.

I got mad about this.  Especially when I found out that it can and does happen regularly.  It didn’t show up in any of my baby books or videos. So I called our local newspaper, The Virginian Pilot, and asked them to write an article about it, they did, it was called, “Mother Knows Best.” That was later revived by a journalist from The Wall Street Journal in an article entitled, “Dying for Milk: Some Mothers, Trying In Vain to Breast-Feed, Starve Their Infants — `Yuppie Syndrome’ Among Well-Meaning Parents Stems From Bad Advice — A Generation of Perfectionists.”  We made the front page with that one. Of course, that set off a media frenzy.
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I Begged for Food for my Baby and I Begged for Nipple Relief at my BFHI Hospital

It was on December 13th at 2:30 in the morning. My water broke as I was sleeping. I woke my husband up and the panic set in. My son was a scheduled C-Section due to the fact he was breech and he was going to be a big baby according to all the scans. I was scheduled for the 18th, which was my birthday, but he decided to come early. My husband and I rushed to St. Joseph’s Hospital in Tacoma, WA. This hospital was a “Baby-Friendly” hospital, which meant they push things like exclusive breastfeeding, no pacifiers, and no nurseries. I didn’t think much of these things at the time, as I was a first-time mom and hadn’t pondered on them much. On paper, this all sounded great, and I was excited to go there. I had a simple birth plan: no circumcision and I wanted my husband in the operating room. That was it really. I trusted the doctors and nurses there to help me out.

Continue reading

My Baby Went Through Hell And Suffered Needlessly From Starvation

Jenn T.

My son was born on February 18, 2019. He was 6 lbs 10 oz and had a little trouble regulating his temperature at birth. But after 24 hours, he was okay. I was always told breast was the best way to go. I never breastfed my 9 year old so this was my first experience with it.

My son had latching issues at first and it caused major pain and bleeding. But after latch correction and using nipple shields, the pain dissipated. When we left the hospital, my son weighed 6 lbs (9.3 percent weight loss) and at his checkup the next day, he had gained half an ounce.

At home I was feeding straight from my breasts, every time. My son was content and seemed happy.  He smiled and was great the entire time, so I thought. I didn’t pump to see how much milk I had because the hospital where I delivered told me pumping in the first 6 weeks could cause confusion for the baby with latching.

Now fast forward to when he was 21 days old. He had his three week checkup and he was extra sleepy that morning. When we got to the doctor, and not only did he lose weight, (down to 5.5 lbs), but he also had a temperature of 92 degrees. He was hypothermic! So they sent us urgently to the children’s hospital in Nashville. Continue reading