Safety First

Patient safety is, of course, a critically important component of the Baby-Friendly Hospital Initiative (BFHI) and is of utmost concern to Baby-Friendly USA. Nothing is more important to BFUSA than the safety and wellbeing of mothers and babies. Baby-Friendly practices are evidence-based and highly beneficial to both mother and baby when implemented properly.

Baby-Friendly protocols are designed to support individualized care and appropriate clinical decision-making, not inflexibility or rigid adherence at all cost. Healthcare professionals are responsible for making clinical judgments on a case-by-case basis.

As BFUSA’s Guidelines and Evaluation Criteria clearly state, “each participating facility assumes full responsibility for assuring that its implementation of the BFHI is consistent with all of its safety protocols.” Facilities can ensure all patients receive current, evidenced-based care in a safe and culturally-sensitive manner by training staff in breastfeeding management, verifying competencies, providing continuing education, and monitoring practices.

It is the responsibility of all facilities to ensure providers are sufficiently trained on the safe implementation of Baby-Friendly practices before they engage in the practices, as part of Step 2 of the Ten Steps to Successful Breastfeeding. Ideally, this training would be provided during pre-service education, as recommended by the WHO and UNICEF in their 2018 BFHI Implementation Guidance, but it is not currently a component of many academic pre-service health programs in the US.

Three practices in particular have been the subject of much of the discussion on safe practices in the BFHI: supplementation, rooming-in, and skin-to-skin care. We address each below:


BFUSA’s Guidelines and Evaluation Criteria clearly state that all practices associated with the Ten Steps to Successful Breastfeeding should be implemented in a sensitive manner that is responsive to the family’s needs.

The decision to supplement is delicate. Infant formula changes the infant’s gut. It can also negatively impact the establishment of the mother’s milk supply, thus affecting long-term breastfeeding success. It is important to emphasize that practitioners should work with mothers and carefully weigh the risks and benefits of this decision.

Most importantly, individualized care requires health professionals to recognize conditions that merit further assessment of a mother’s infant feeding practices and close follow-up with the mother, infant, or both when indicated. The Guidelines and Evaluation Criteria call for this kind of judgment by stating that “additional individualized assistance should be provided to high risk and special needs mothers and infants and to mothers who have breastfeeding problems.”

It is important to note that this may include situations in which the baby would benefit from – or critically needs – supplementation, which might be temporary and serve as a bridge back to breastfeeding or, in some cases, result in continued supplementation. Practitioners and parents must carefully weigh the risks and benefits of this decision, while always putting the patients’ health and safety first.


Purchase the NRP Text book and Flow Diagram from the American Academy of Pediatrics:

Read “Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns” from the September 2016 issue of Pediatrics:

Watch “Safety First,” a webinar offered by Baby-Friendly USA in August 2016:

For more detailed discussion and information on this issue, please see the Academy of Breastfeeding Medicine’s Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate. The ABM’s guidance aligns with BFUSA’s position on individualized care and provider responsibility, stating that “These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care.”


Rooming-in is an evidence-based practice where the baby is kept in the mother’s room as much as possible during the hospital stay, optimizing the opportunity for the parents to get to know their baby during the precious first days. Keeping mother and baby together as much as possible enhances bonding and allows the mother to learn about her baby’s feeding cues under the expert guidance of trained staff. While the mother is rooming-in with her infant, hospital staff are expected to provide ongoing support, discuss safety issues, and explain how to request help when needed.

BFUSA’s Guidelines and Evaluation Criteria call for rooming-in to be the routine standard of care. We have never called for closing newborn nurseries, although some facilities have chosen to go this route. Ultimately, we recognize that some circumstances necessitate mother-baby separation and leave it to each facility to determine how to best address this need on a case-by-case basis.

Skin-to-Skin Care

Skin-to-Skin care has also been shown to have numerous benefits for both mothers and infants. It is physiologically stabilizing for both, helps soothe an upset infant, and facilitates breastfeeding.

As with all protocols, proper implementation and support is critical. Parents should be taught how to safely practice skin-to-skin care. A component of excellent breastfeeding care is to help the mother understand that sleepiness is a normal, hormonally-driven, physiological response to breastfeeding for both the mother and infant. As a component of safe skin-to-skin care and breastfeeding, she should be encouraged to ask for help from hospital staff and, when at home, from her support person, to place the baby on his/her back in the bassinet/crib whenever sleepiness sets in.

An excellent resource on the safe practice of skin-to-skin care and rooming-in is an article from the September 2016 issue of Pediatrics entitled “Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns.” Authors Lori Feldman-Winter, MD, MPH, and Jay Goldsmith, MD, provide excellent guidance for facilities to assist in the establishment of appropriate skin-to-skin care and safe sleep policies.

Another important resource is the AAP’s Neonatal Resuscitation Program (NRP), which offers a flow diagram for assessing infant stability and care, an excellent protocol for initiating skin-to-skin care immediately following birth.