by Anne Eglash MD, IBCLC, FABM
What are the 2018 revisions to the Baby Friendly Hospital Initiative? The Baby Friendly Hospital Initiative was established by the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO) in 1991, after recognizing that breastfeeding support immediately after birth is crucial to breastfeeding success and to lowering high infant mortality rates in many countries as the result of insufficient breastfeeding. The Baby Friendly Hospital Initiative involves the implementation of a standard of care for mothers and infants in hospitals/birthing centers, to optimize breastfeeding success right after birth. There is good evidence that implementing the Baby Friendly Hospital Initiative leads to increased breastfeeding rates at the time of hospital discharge.
The 10 steps of the Baby Friendly Hospital Initiative have been revised recently, based on challenges faced by countries and institutions in the implementation and sustainment of the changes in birthing centers. Some of these challenges include limited resources for training staff, the pressure to continue accepting free formula, and the lack of outpatient breastfeeding support for dyads leaving the birthing center.
What do you think are changes to the BFHI 10 steps? Choose 1 or more:
- Step 1 is changed from ‘Have a written breastfeeding policy that is routinely communicated to all health care staff’. It adds i) comply fully with the International Code of Marketing of Breastmilk Substitutes, and ii) establish ongoing monitoring and data-management systems
- Step 3 is changed from ‘Inform all pregnant women about the benefits and management of breastfeeding’ to ‘Discuss the importance and management of breastfeeding with pregnant women and their families’
- Step 4 is changed from ‘Help mothers initiate breastfeeding within one hour of birth’ to ‘Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth.’
- Step 9 is changed from ‘Give no pacifiers or artificial nipples to breastfeeding infants’ to ‘Counsel mothers on the use and risks of feeding bottles, teats and pacifiers’
- Step 10 is changed from ‘Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center’ to ‘Coordinate discharge so that parents and their infants have timely access to ongoing support and care.’
See the Answer
All of the Above
The Ten Steps to Successful Breastfeeding Revised 2018
Critical management procedures
- 1 a. Comply fully with the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions.
- b. Have a written infant feeding policy that is routinely communicated to staff and parents.
- c. Establish ongoing monitoring and data-management systems.
- 2 Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding.
Key clinical practices
- 3. Discuss the importance and management of breastfeeding with pregnant women and their families.
- 4. Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth.
- 5. Support mothers to initiate and maintain breastfeeding and manage common difficulties.
- 6. Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated.
- 7. Enable mothers and their infants to remain together and to practice rooming-in 24 hours a day.
- 8. Support mothers to recognize and respond to their infants’ cues for feeding.
- 9. Counsel mothers on the use and risks of feeding bottles, teats and pacifiers.
- 10. Coordinate discharge so that parents and their infants have timely access to ongoing support and care.
Milk Mob Comment by Anne Eglash MD, IBCLC, FABM
Several of the changes to the Ten Steps to Successful Breastfeeding as outlined by BFHI appear to be driven by experience and practicality. For example, it makes sense for Step 4 that we should not be timing the initial breastfeed to occur in the first hour. What is most important is the process by which infants ‘arrive to the dinner table’ so to speak, recognizing that immediate skin-to-skin after birth is just as valuable for the mother and infant as the ‘measurable goal’ of early breastfeeding.
The change in wording invites shared decision-making between mothers, family, and hospital staff. For example, Step 9 is changed from a command of not giving pacifiers or artificial nipples, to counseling mothers on the use and risks, allowing her to make that informed decision.
The changes for Step 10 appear rather substantial and are the most concerning to me. The content changed from ‘fostering the establishment of breastfeeding support groups and refer mothers to them…’ to ‘coordinate discharge so that parents and their families have timely access to ongoing support and care’. While I agree that breastfeeding support groups are awesome for addressing the psychosocial challenges of breastfeeding, they are unable to address individual breastfeeding medicine needs or medical complications that a dyad may have. For this reason, the change to coordinating outpatient support makes sense. However, in the USA, hospitals are increasingly investing in outpatient clinics for financial reasons, so they are prime candidates to foster and develop outpatient breastfeeding support strategies. We need to expect hospitals associated with outpatient medical systems to take responsibility in building strong sustainable systems for outpatient breastfeeding support and management. Until we amp up the knowledge, skills, and commitment for breastfeeding support in outpatient medical institutions, Baby Friendly will remain in its silo, training mothers to prepare for their breastfeeding marathons, yet sending the dyads into an outpatient desert with little sustenance and unacceptable risks of morbidity related to breastfeeding complications for both mother and infant. Just ask Fed Is Best.
Polly Kocher
I would like further discussion on the easing of ‘restrictions on bottles and pacifiers’. Is it true that they have not been shown to be harmful as we once thought?
Deb
I don’t believe the wording change means the use of bottles and pacifiers is now ok. It just has to do with informed consent if mom chooses to use them. She needs to be educated on the effects they have on breastfeeding which hasn’t changed. Still not a good idea.
Uwaga Dozie
That’s true. If you get through the 9th step in the BFHI, it states that the mom can be educated on the use and “risk” of feeding bottles, pacifiers, etc. Because regular cleaning of those items may not be guaranteed at all times. So, it’s safe to avoid them.
Lee S.
As a lactation consultant i read the reply with interest. I believe the changes to step 10 are more broad to include a wider range of medical resources. Everyone is working very hard to make sure mom’s have access to care on discharge, myself included. I have to say the comment about Baby Friendly in a silo and reference to.the fear inducing Fed is Best initiative made this thoughtful post less valid to me.
Yonge Charlotte
I think that if breastfeeding in the first hour is not an official recommendation that an explanation of why breast emptying is the key to preventing milk supply problems should be part of the “early” feeding recommendation. Breast emptying by manual expression should be mandatory teaching to all people involved in starting breastfeeding. Given that most births at least in the western world are going to be under some kind of medical intervention even if its just limiting free movement of the mother in labour and that mother-baby separation is imposed to do testing within the first hour, most babies are going to be start out with a certain amount of tension, especially if frequent bb massage is not part of the picture. Therefore we can be sure that most babies are not going to be as efficient and mobile as they could be. (tongue and jaw etc). Therefore manual breast emptying by breast compression should be done frequently with and without baby at the breast. The frequent and complete emptying of the breasts starting with colostrum is the sure-fire way to prevent milk production problems. Why is this ancient practice not part of breastfeeding initiation? Why are all mothers not taught this in prenatal classes? See Dr Jane Morton studies for details. More and more IBCLCs are learning about the power of breast compression and teaching mothers. Why is it not part of the “early feeding” recommendation. If a baby cannot feed, ok, we compensate by frequent and complete manual expression. Global Health Media illustrates the point very well.
Yonge Charlotte
Step 9 has been transformed in France (A particular surgeon, ex president has created a special “France” version of Baby Friendly) to : pacifyers are ok to give. I think above all, the BB friendly label should be patented and not allowed to be modified to suit any incompetent doctor’s personal approach.
Step 10 changes is self-defeating because no IBCLC who is also a health professional, who’s visits and counceling are refunded by the state filling her schedule to breaking point will have the time to provide essential support to isolated mothers. Mothers need to be mothered and that requires joining some kind of group of like minded mothers. Individual help is good for technical points but expecting state refunded professionals to provide ongoing support is ridiculous and impossible.