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BFUSA response to "Unintended Consequences of Current Breastfeeding Initiatives," published in the August 2016 issue of JAMA‐Pediatrics

October 2016

The evidence is clear; breastfeeding confers significant health benefits to both the mother and infant. Skin‐to‐skin care helps the infant transition to extra uterine life and facilitates early breastfeeding [1] [2] [3] [4] [5] [6] [7]. The more of the Ten Steps to Successful Breastfeeding experienced by a mother, the more likely she is to reach her breastfeeding goals [8]. The recent article published in JAMA‐Pediatrics titled "Unintended Consequences of Current Breastfeeding Initiatives" [9] is filled with comments not supported by research. It has triggered a firestorm of on‐line articles with sensational headlines that are geared towards frightening practitioners and families away from the Baby‐Friendly Hospital Initiative.

Safety is an important component of the Baby‐Friendly Hospital Initiative (BFHI). This is addressed in the Guidelines and Evaluation Criteria (GEC), which clearly state, “Each participating facility assumes full responsibility for assuring that its implementation of the BFHI is consistent with all of its safety protocols.” [10] The AAP Neonatal Resuscitation Program (NRP) offers a Flow Diagram for assessing infant stability and care.  The NRP Flow Diagram for routine care starts with assessing if the infant is “Term Gestation?”, “Good Tone?”, “Breathing or Crying?” If the answer is “yes” to all of those questions, the direction is to remain with the mother and provide routine care which includes maintaining normal temperature, positioning the airway, clearing secretions if needed, drying, and conducting ongoing evaluation.’ [11] This is an excellent protocol for initiating skin‐to‐skin care immediately following birth. A recently published article titled "Safe Sleep and Skin‐to‐Skin Care in the Neonatal Period for Healthy Term Newborns" [1] also provides sound advice for safe ways to practice skin‐to‐skin care and rooming‐in.

Due to the cost, Step 2 of the Ten Steps to Successful Breastfeeding (Train all health care staff in the skills necessary to implement this [breastfeeding] policy) is often cited as one of the barriers to Baby‐Friendly designation. However, this step is essential for ensuring that hospital staff have the knowledge and skills necessary to safely implement the new practices.  In addition, the BFHI “expects Clinical competency verification ... [will] be a focus of all staff training”. [10]

Baby‐Friendly practices are designed to be responsive to a mother’s choice, but it is expected to be her informed choice. The GEC explicitly says, “When a mother specifically states that she has no plans to breastfeed or requests that her breastfeeding infant be given a breast milk substitute, the health care staff should first explore the reasons for this request, address the concerns raised, and educate her about the possible consequences to the health of her infant and the success of breastfeeding. If the mother still requests a breast milk substitute, her request should be granted and the process and the informed decision should be documented.” [10] The intent of this Guideline is to patiently elicit specific information about real or perceived barriers to breastfeeding that hospital staff may be able to help the mother overcome. Health care staff are expected to have this conversation with the mother in a manner responsive to her needs and her specific concerns. Baby‐Friendly is not about making a mother feel guilty; it is about preventing her regret for decisions made without the proper information. Further, Baby‐Friendly policies protect the mother from the influences of commercial interests so that she may make decisions on the basis of scientific evidence and not marketing material. [10]

Recently, the American College of Obstetricians and Gynecologists (ACOG) endorsed the Ten Steps to Successful Breastfeeding. [12] In accordance with Step 3 (prenatal education), the role of the OB is vital in providing breastfeeding education and information about maternity care practices to support breastfeeding. This helps the mother prepare for the hospital stay and allows for her to proactively address any concerns so that she may room with her baby in the safest way possible.

Baby‐Friendly practices represent a significant culture change for most institutions. This takes time. Utilizing the Plan Do Study Act (PDSA) quality improvement approach and auditing practices allow for change to occur incrementally, safely and in a manner that builds staff confidence. To aid in this process, Baby‐Friendly USA, Inc. supplies and assortment of planning and audit tools to those facilities enrolled in the 4‐D Pathway. As stated in the Guidelines and Evaluation Criteria, well‐constructed, comprehensive policies effectively guide staff to deliver evidence‐based care. Well‐trained staff provide current, evidence‐based care and monitoring of practice is required to assure adherence to policy. Safe, evidence‐based care leads to healthy outcomes.  

Another article published in the same issue of JAMA-Pediatrics discusses how Baby-Friendly practices save lives. Click here to access the article by Drs. Meek and Noble titled Implementation of the Ten Steps to Successful Breastfeeding Saves Lives.


[1] L. Feldman‐Winter, J. Goldsmith, Committee on Fetus and Newborn and AAP Task Force on Sudden Infant Death Syndrome, "Safe Sleep and Skin‐to‐Skin Care in the Neonatal Period for Healthy Term Newborns," Pediatrics, vol. 138, no. 3, p. e20161889, 2016.  

[2]   E. Moore, G. Anderson, N. Bergman and T. Dowswell, "Early skin‐to‐skin contact for mothers and their healthy newborn infants," Cochrane Database of Systematic Reviews, no. 5, 2012.  

[3]   S. Nimbalkar, V. Patel, D. Patel, A. Nimbalkar, A. Sethi and A. Phatak, "Effect of early skin‐to‐skin contact following normal delivery on incidence of hypothermia in neonates more than 1800 g: randomized control trial," Journal of Perinatology, vol. 34, no. 5, p. 364, 2014.  

[4]   J. Vetulani, "Early maternal separation: a rodent model of depression and a prevailing human condition," Pharmacological Reports, vol. 65, no. 6, pp. 1451‐61, 2013.  

[5]   C. Dani, A. Cecchi, A. Commare, G. Rapisardi, R. Breschi and S. Pratesi, "Behavior of the newborn during skin‐to‐skin," Journal of Human Lactation, vol. 31, no. 3, pp. 452‐7, 2015.  

[6]   S. Beiranvand, F. Valizadeh, R. Hosseinabadi and Y. Pournia, "The effects of skin‐to‐skin contact on temperature and breastfeeding successfulness in full‐term newborns after cesarean delivery," International Journal of Pediatrics, vol. 2014, 2014.  

[7]   A. Saxton, K. Fahy, M. Rolfe, V. Skinner and C. Hastie, "Does skin‐to‐skin contact and breastfeeding at birth affect the rate of primary postpartum haemorrhage: Results of a cohort study," Midwifery, vol. 31, no. 11, pp. 1110‐17, 2015.  

[8]   R. Pérez‐Escamilla, J. Martinez and S. Segura‐Pérez, "Impact of the Baby‐friendly Hospital Initiative on Breastfeeding and Child Health Outcomes: A Systematic Review. doi: /mcn.12294.," Maternal Child Nutrition, 2016.  

[9]   J. Bass, T. Gartley and R. Kleinman, "Unintended Consequences of Current Breastfeeding Initiatives," JAMA Pediatrics, 2016.  

[10] Baby‐Friendly USA, "Guidelines and Evaluation Criteria for Facilities Seeking Baby‐Friendly Designation," 2016. [Online].  

[11] American Academy of Pediatrics and American Heart Association, Textbook of Neonatal Resuscitation (NRP) 7th Edition, Elk Grove Village: American Academy of Pediatrics, 2016.  

[12] Gynocologists, American College of Obstetricians and Gynocologists, "Breastfeeding," [Online]. Available: http://www.acog.org/About‐ACOG/ACOG‐Departments/Breastfeeding. [Accessed 22 August 2016].

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