Fed Is Best Foundation Vs The Baby Friendly Hospital INITIATIVE - A Question Of Ethics. Part 2

Last week Forbes released an article entitled “Fed Is Best Foundation Says Says WHO Breastfeeding Guidelines Fail To Meet Human Rights Standards"

If your first encounter with the Fed Is Best Foundation was reading the Forbes article, you would probably come away agreeing that the WHO is being negligent and denying babies human rights. ​

So, you might be wondering if their claim is valid. 

Is the UNICEF/WHO focus on breastfeeding rates and the Baby Friendly Hospital Initiative putting babies lives at needless risk for the sake of politics?

Part 2 in a multi-part series investigating the ethics infant feeding.

The second issue to deconstruct is: What do Fed Is Best want to achieve in their interactions with the Baby Friendly Hospital Initiative?
Details are pretty thin on the ground, but from press releases, their own blog and news articles it basically seems like the purpose of the meeting was to “ express their concerns about the complications arising from the BFHI Ten Steps and to ask what, if any, monitoring, research, or public outreach the WHO has planned regarding the risks of accidental starvation of exclusively breastfed newborns.”  

In a blog post from March 2017, FIB seem to be calling for the BFHI USA to make a public statement and apology over the death of Landon Johnson.

Del Castillo-Heigi goes on to say

A patient has the right to know all the risks and benefits related to health-care decisions regardless of how rare they are...Patient autonomy can only be fully realized if mothers are given honest and complete information on any and all the risks of their healthcare decisions so that they may voluntarily choose, free of coaxing or coercion, in order to optimize their children’s health outcomes while minimizing the risks

Again I absolutely agree with that statement. 

But this issue goes far beyond BFI hospitals.

It goes far beyond breastfeeding.

Hell in the USA you have entire states where VBAC is banned in hospitals despite the ACOG supporting it because of clear evidence showing that not only is VBAC safe, repeat c-sections have high risks. You have women being forced to sit through religious based “options counselling” before they can receive an abortion. You have abstinence education programs in schools. 

The issue is a lack of informed consent in women’s medical treatment. Not Baby Friendly Hospitals. 

They are not immune to the wider cultural issue. But they are not the cause. 

Still as a major licensing body, if the evidence is there to back the claim that a lack of prelacteal feeding is putting babies at unnecessary risk of dehydration, then they are a good place to start in a campaign for change. 

So how are the Fed Is Best Foundation actually doing that? 

Ginger Day’s bio in the about page says “her goal is to advocate for Fed is Best in the Hospital Setting”  Hillary Kuzdeba’s Bio says “ As a professional trained in both health promotion initiatives and quality improvement, she believes that the current exclusive breastfeeding protocols and advice utilized in many hospitals, and promoted by breastfeeding advocacy groups, are directly contributing to the clinical deterioration of a subset of exclusively breastfed infants. Hillary suspects that the Fed is Best approach to breastfeeding, which emphasizes baby’s safety, mother’s well-being, and an inclusive vision of successful breastfeeding, will soon be at the forefront of the ongoing public health conversation on breastfeeding, neonatal health, and postpartum care.” 

Their ethical stance is as follows: 

Now the website has no further information about what advocating for FIB in hospitals or in public policy might look like beyond a letter writing campaign to hospital CEO’s and a link to report to the joint commission for safety.

Nor could I find any information on what specifically the FIB Foundation want the Baby Friendly Initiative to do. 

The best I could find was this article by Hillary Kuzdeba on the Fearless Formula Feeder. 

Kuzdeba states “The strategy of withholding health information from patients and families, out of a misguided fear that more information might encourage an undesired behavior, has long been debunked by the scientific community as ineffective and potentially harmful. And yet we continue to implement this strategy in regards to formula feeding.... practical guides discussing formula selection, appropriate mixing, safe storage, and feeding have been almost completely eliminated.” The blurb by the Fearless Formula Feeder at the top of the article adds “I’m incredibly thankful that someone in the field of public health is taking a stand on how we ignore the reality of formula use, and I really hope others will follow. We need decision-makers and influencers – physicians, scientists, public health professionals, nurses, politicians, hospital administrators – to start looking more closely at these issues, and to speak up when they see flaws in the current system. It’s the only way true change can happen.” 

Again, these are both statements that I completely agree with. Not only are there major discrepancies in the accuracy of bottle measurement markings causing parents to inadvertently give their child inaccurately prepared formula despite following the guidelines, many families are either unaware of the guidelines, or are given inaccurate information by health care providers. 

A complete lack of information is certainly just as dangerous as pushing inaccurate information, and it would be naive to suggest that there are not hospitals, LC’s and overseeing bodies who actively discourage (or heavily imply to their staff that their are discouraged from) sharing information on safe bottle feeding.

It is however untrue that the Baby Friendly Initiative as an organisation are are purposefully withholding information, or discouraging their staff from giving information about safe formula/bottle feeding. 

This may certainly be an issue with specific Baby Friendly accredited hospitals. It may even be an issue with the US branch. But it is not the BFHI’s overall policy or practice. 

This is the UK branch’s safe formula feeding booklet for parents; co-written by the BFHI, the WHO and the NHS. 

I would also be incorrect to say that the BFHI do nothing to support formula feeding families or that they actively discourage formula feeding.

Again from the UK website  “All maternity and community services which are accredited as Baby Friendly must demonstrate that their staff support families who bottle feed….. In response, commercial companies have often claimed that the Baby Friendly standards deny parents information because they do not allow advertising via the healthcare system. In fact, the Baby Friendly standards require that there is information available on breastfeeding, bottle feeding, formula milks and starting solid food for both professionals and parents. However, this information has to be accurate and evidence based and free from commercial bias. Working with all four departments of health and the charity First Steps Nutrition Trust has ensured that free, comprehensive information is available for health professionals, and the Baby Friendly Initiative has produced a range of resources for both health professionals and parents. These developments are helping to protect babies from commercial interests, ensuring that parents receive clear, factual information from their health professionals rather than biased information from companies.” 

This is from their signature sheet for health professionals:
All mothers are offered support to
• Appreciate the importance of closeness and responsiveness for mother/baby wellbeing
• Hold their baby for feeding
• Understand responsive feeding

Breastfeeding mothers are offered support to
• Hand express
• Value exclusive breastfeeding
• Understand how to know their baby is getting enough milk
• Access help with feeding when at home
​
Mothers who formula feed are offered support to
• Sterilise equipment and make up feeds
• Feed their baby first milks
• Limit the number of people who feed their baby

This is their Guidelines  On  Providing  Information  For  Parents About The Use Of  Infant  Formula  And  Formula  Feeding.

I don’t actually agree with some of the statements in this guideline. I think they are paternalistic, and they do likely allow women to fall through the cracks in relation to knowledge of safe bottle feeding. There is definitely room for improvement, and an acknowledgement that 92% of UK women have used formula at least once by 6 weeks of age. Which means 92% of women need to know how to do so safely.

But overall it is clear that the UK branch of the Baby Friendly Hospital Initiative have guidelines in place to discuss formula use with mothers, put out information on safe formula use and that accreditation is supposed to be dependent upon them advocating for all babies regardless of feeding method. 

So what about outside the UK?

Well the international site contains a booklet for parents that is much the same as the UK one. Along with follow up booklets on safe preparation of formula for cup feeding or in daycare 

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Summary: Yes the BFHI could have better guidelines for informing parents of safe formula usage, but they do have guidelines and information booklets.

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On the previous version of the Fed Is Best website I seem to recall reading that FIB were calling on the BFHI to introduce prelacteal feedings for all babies. The implication was that these feeds were to be either glucose water or formula, as they were the only options mentioned. 

This no longer seems to be on their website. Additionally their feeding guideline now at least mentions Donor Milk from a milk bank as an option for premature babies.

Again should pre-lacteal feeds truly be necessary, then pushing for a change of policy is perfectly sound. But that change of policy should offer all mothers a full selection of alternative feeding methods: glucose water, their own expressed milk, a wet nurse, donor milk, or formula, and the information necessary to make an informed choice about which if any option each mother wishes to choose. 

So are Prelactal feeding NECESSARY? 

The question now becomes one of who to trust? 

The WHO/UNICEF and multiple other organisations who believe that prelacteal feeding are unnecessary, or the Fed Is Best Foundation who believe them to be vitally important to brain development. 

Unless you are skilled in dissecting research, you are going to be floundering. 

But as others have noted that the Fed Is Best Foundation’s references often have very little to do with the claims they are making. Such as this excerpt

Dr. del Castillo-Hegyi, then discusses a paper in which 10% of exclusively breastfed newborns were  diagnosed with hypoglycemia.  I clicked on the word, hypoglycemia, that leads to her reference. The paper referenced is entitled, "Study of Asymptomatic Hypoglycemia in Full Term Exclusively Breastfed Neonates in First 48 Hours of Life,"     
It states:
"Many studies have shown that early initiation of exclusive breastfeeding meets the nutritional and metabolic needs of healthy term neonates.  Establishment of normal breastfeeding may be interfered, when unnecessary supplementation of healthy term neonates with water, glucose water or formula is done." Then they go on to state, "Transient, asymtomatic hypoglycemia in healthy newborns may be a part of the normal transition to extrauterine life."  

This paper does not support her statement on hypoglycemia in the exclusively breastfed infant  causing "long-term cognitive declines by 6 hours of life." The paper concludes with a number of statements.  One of the paper's statements was, "At present, the universal screening of uncomplicated term neonates for hypoglycemia is not recommended."  
​

So what does the research say about their other claims?

In regards to dehydration causing Autism or ADHD, not much, mostly because it doesn't exist.
Del Castillo-Hegyi herself gave the following quote to Forbes in 2016.
“While hypernatremic dehydration, hyperbilirubinemia and hypoglycemia have all been implicated in dozens of studies to increase the risk of these conditions, (Autism and ADHD) “no studies have been done to directly measure the effects of fasting physiology that exclusively breastfed newborns are exposed to in the first days of life in comparison to supplemented or formula-fed newborns.Simply put, the correlation is there, but we don’t know for sure that insufficient feeding can cause specific conditions like autism and ADHD” 

The Autism Speaks website states “In terms of autism risk, a number of research reports have considered breastfeeding versus formula. None directly tested whether breast milk – from the breast or a bottle – reduces or increases risk for autism spectrum disorder (ASD). However, most show that children with ASD are more likely to have been either bottle fed from birth or weaned early than are comparison groups of children not affected by ASD....While we can’t say whether breastfeeding or formula feeding is related to autism risk, we know there are many good reasons to encourage breastfeeding whenever possible.”

In regards to the statement in the Fed Is Best feeding plan that  “Earlier supplementation may be needed for babies who are premature or have medical conditions.” 

Necrotizing Enterocolitis (NEC) affects 7-12% of premature babies weighing less than 1500g, and formula feeding increases the risks of NEC substantially.

In one study it was found that for babies over 30 weeks gestation the risk of NEC increases by a whopping 20% when formula fed. Though the medical consensus is 6 times higher relative risk. (E.g. six babies need to be fed human milk to prevent one case of NEC.)

There is evidence to suggest that the risk reduction effect of human milk is quantity dependant, so the FIB Foundation’s push for mothers to be taught to check for milk production before feeding has some merit here.  

However, in order to truly save these babies lives, they need access to human milk. Via hospital milk banks, hospital wet nursing services or hospitals approving peer-to-peer wet nursing from family/friends of the mother.

And those are suggestions I am yet to see FIB Foundation advocate for
​Which brings us to part 3. What have the Fed Is Best Foundation not done in their campaign to change breastfeeding education and public policy, and what does that suggest?