Re-evaluating what is really friendly to babies

Many hospitals are very proud of being “baby friendly” or are trying to achieve “baby friendly hospital” certification, under the WHO initiative.

Unfortunately many parts of that program are not evidence-based, such as (as one example) the ban on soothers (or dummies or pacifiers or whatever they are called in your part of the world). But does the baby-friendly initiative even work? Does introducing “baby-friendly” hospital initiatives (BHFI) and/or becoming certified actually improve breastfeeding initiation rates, or duration, or exclusivity?

A new systematic review, punctiliously performed as always by the USPSTF (US public service task force), actually runs to 150 pages in its original version. Fortunately a much more manageable summary of the evidence has been published in JAMA. The review was not just about the BHFI, but a review of all the interventions that have been studied to try and improve the 3 elements of breastfeeding success that I mentioned (initiation, duration, exclusivity).

Overall, the evidence shows that system-wide interventions (such as getting your hospital certified as baby-friendly) have not been proven to improve anything about breastfeeding. The evidence is rather scanty, but what exists is negative (by which I mean not that the evidence is of a negative impact, but that there is no evidence of benefit). Various individual parts of the BHFI, as system-wide approaches, have also not been shown to be  effective, either.

The system-level interventions that were evaluated within these 9 studies included receiving accreditation for the BFHI, a clinic policy to provide breastfeeding support groups for pregnant women and breastfeeding mothers, and establishing maternity care practices for maintaining mother and infant contact following delivery or restricting or delaying pacifier use. Across these 9 studies (7 RCTs and 2 before-after studies), there was no consistent evidence of an association between system-level changes and the rate of any or exclusive breastfeeding at up to 16 weeks’ postpartum.

In contrast, individual-level interventions, which include a whole host of different interventions such as individualized lactation support, educational interventions, peer counseling, and telephone support, were effective, and were maybe more effective if applied at multiple time points, antenatally and postnatally.

One of the individual level interventions which did not work in 2 RCTs was counseling to avoid pacifier use.

An editorial accompanying the USPSTF papers gives a clear interpretation of the review and the recommendations that the USPSTF makes based on them. It also includes this:

A second potentially controversial area involves use of feedings other than breast milk. Counseling mothers to avoid giving infants any food or drink other than breast milk during the newborn period is step 6 of the BFHI and one of the primary care interventions most commonly used to support breastfeeding. Three randomized trials have specifically examined the effectiveness of counseling to avoid giving newborns any food or drink other than breast milk; none showed a beneficial effect of such counseling on breastfeeding duration.

The editorial notes that these 3 studies were not included in the new SR. I checked over the inclusion criteria for the USPSTF review, and I don’t really understand why they weren’t included. It was maybe because it is an intervention that only applies to mothers who are, or were intending to, breastfeed, but that isn’t listed as an exclusion criterion in the methodology part of the 150 page document.

Avoiding any and all supplemental food or drink is potentially hazardous. A mother’s milk may take several days to “come in” and babies can get dehydrated with hyperbilirubinemia, hypernatremia (occasionally severe), and may need to be hospitalized. Those complications are strongly associated with exclusive breastfeeding. Such complications might be acceptable if there were proven adverse consequences of occasional supplementation of breastfeeding babies with formula if there is an indication to do so. But I don’t think that is proven, at all. Nor is there an evidence in this whole systematic review of impacts of the various interventions on health outcomes. Even though the individual level studies do mostly show benefits on initiation of breastfeeding, breastfeeding for at least 3 months, and exclusive breastfeeding for at least 3 months, there is no clear decrease in gastroenteritis, or respiratory infections. Which is not too surprising as few studies have actually measured those outcomes, and the observational studies showing those impacts of breastfeeding often show relatively small effect sizes in the high-resource countries where many of these trials have been done. You would really need a very large trial in a higher risk population to prove, what I think there is little doubt about, that a specific intervention which actually increases breastfeeding rates and durations will have significant health benefits.

It is because of those benefits that we need better data. Not data about the health benefits of breastfeeding, they are already overwhelming. Data about how to improve breastfeeding initiation and duration, better studies to prove what works so that we can focus our resources on effective and beneficial practices.

The avoidance of soothers/pacifiers also came up in another influential review, this time from the AAP, and about reducing sudden unexpected death in infancy, which recommends considering pacifier use at sleep times. In the text they specify that this should only be after establishment of breastfeeding, but what they mean by “well-established” is not clear, nor do they give any data that shows that early pacifier use adversely impacts on establishment of breastfeeding.

Improving breastfeeding duration requires us to be supportive of mothers who are trying their best without the extensive social supports that societies provided in the past, without a network of wet-nurses, mothers who may be surrounded by ill-informed healthcare workers, family, or friends. A mother who feels good about herself and her attempts to give breast milk to her baby, as much as she can for 3 or 4 months if she can, will be much more likely to be successful than if she is made to feel inadequate by policies or by individuals that demand perfectly exclusive breastfeeding for 6 months.

Let her give the baby a soother/pacifier/dummy if she wants, and if the feeding is not going well in the first few days, a few bottles of formula, or pumped breast milk are not only harmless, they are better than harmless, they may help the mother and her baby to get over the hump and carry on breastfeeding, rather than giving up all together. They may even get the Dad more involved, many of us like being involved in feeding babies, and feel a bit jealous when breastfeeding is going well and we are excluded!

That sounds really baby friendly to me.

About keithbarrington

I am a neonatologist and clinical researcher at Sainte Justine University Health Center in Montréal
This entry was posted in Clinical Practice Guidelines, Neonatal Research and tagged , . Bookmark the permalink.

3 Responses to Re-evaluating what is really friendly to babies

  1. Sam Oddie says:

    Hi Keith,

    Always enjoy your challenges to orthodoxy. And that’s why we read you. And adds to your authority. But, although you say there’s no evidence that supplemental formula is harmful, there’s plenty of biological plausibility that it is a threat to exclusivity and duration of breastfeeding. Your piece can be read as supporting more use of supplemental formula in order to support breastfeeding. I can’t help thinking if you were discussing a more medical intervention, you might look for evidence of benefit, as opposed to dismissing the perception of harm from the intervention, before suggesting widespread implementation.

    I have noticed that male paediatricians often support supplemental formula, and reading your blog illustrates one possible bias they may have. Another is that male paediatricians whose babies haven’t been exclusively breastfed (or almost entirely so) sometimes seem to support supplementation disproportionately (to my view of the evidence!).

    Are your experiences as a parent affecting the way you view the (relative lack of) evidence?

    Sam Oddie

    • What a thoughtful comment!
      You are right, I think it depends on where you are starting from, maybe as a male, or maybe as a parent of an extreme preemie, I might have a different evaluation of the evidence than a woman who has “only” had full term babies.

      The question I think should be posed as a risk/benefit equation. What is the risk of supplementation (none proven, but very poor data, I admit; and potential harms substantial) compared to the benefits (possible limitation of weight loss, reduction of hypernatremia and hyperbilirubinemia; none of which are proven either!)

      Right now my evaluation of the situation is that occasional supplementation with formula might help some mothers get over the first few days of low milk output, as long as it was clear that this was not an admission of failure, but a reasonable response to a situation which is more than 2 SD beyond the mean.
      Being too doctrinaire risks more harm than benefit.
      If we can arrive at a conclusion which leads to more mothers providing more breast milk for longer then everyone benefits.
      I am sure that making mothers feel guilty is the worst thing we can do. It helps no-one and risks interrupting breastfeeding.

      Just to be clear for everyone: cows’ milk is meant for cows. Mother’s milk is “designed” for babies.

  2. anniejanvier says:

    Keith, you forgot to answer completely the question asked by Sam Oddie. Our first child got exclusive breast milk for 6 months, and our preemie 24wk baby child had 4 months (in NICU) + 6 months of exclusive breast milk after discharge. And this affected our way to look at how we often make women and families feel guilty about not reaching the “ultimate goal” we set for them. Every mom should feel she is supported in her goals, that she did her best and that she is a great mother. Making her feel like a great mom and congradulating her often on how she takes care of her baby is probably superior to encourage breastfeeding; as opposed to making her feel inadequate because her baby was not entirely breast fed; the baby got a bottle; the baby is getting breast milk but not from the breast; did not get only breast milk but also milk from a bank; did not get breast milk for a whole year; etc etc etc Mothers and NICU mothers have the right to feel like amazons, they are trying hard to be.

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