In part 2 we looked at what it is the Fed Is Best Foundation are asking the Baby Friendly Hospital Initiative to do. This time we will be considering the things Fed Is Best are not asking the BFHI to do and what that suggests about their overall mission.
The Fed Is Best Foundation are most concerned with dehydration issues in the first few weeks of life.
It seems logical that their negotiations with the BFHI would focus on ensuring that mothers have adequate support and accurate information during those first few weeks.
Here are some ways I think they could be doing that, but have not chosen to do so.
1: Longer Hospital stays and in home visits:
The majority of hospitals discharge mothers approximately three days post vaginal birth and 5-7 days post Cesarean. This means that a lot of mothers are being discharged before their milk has come in, and/or before they have really gotten breastfeeding working.
In a world where the general population are all knowledgeable in breastfeeding and normal infant feeding/sleeping/crying, had a support network rallying around them and were able to take a golden month, this wouldn’t be a problem.
But that’s not the world we live in in the west.
As a result most mothers go home to at best two support people, their partner and mother/mother in law. Given the breastfeeding rates in the 70’s-80’s it’s highly likely that their mother/MIL didn’t breastfeed. This means that they go home to a house full of people who don’t know what they are doing, have no idea how to tell accurate information from inaccurate and are completely dependent upon their health professionals and google for help. Help that they usually have to drive to, and possibly pay for.
This is obviously setting mothers up for failure.
Campaigning to change the BFHI’s hospitals policies to include the (advertised) option of longer hospital stays, and guaranteed in home visits from IBCLCs (at least 3/week if not daily) for the first 3 weeks, with the ability for IBCLCs to apply for an extension of those daily visits for anything up to 8 weeks.
This of course should be delivered free in countries with socialized health care, and be a standard part of the maternity package for BFHI hospitals in the USA, or private hospitals in Australia.
Running such a program could easily be made a requirement for BFHI accreditation.
2: Informing mothers of their rights to refuse to be sent home until breastfeeding is established
In Australia at least, mothers do have the right to request an extended stay if they feel they need it for their own health, their baby’s health or because breastfeeding is yet to be established. It’s not something that’s advertised or widely known, but you have the right. I was offered an extension on my hospital stay, but chose to decline since I had a family member who was an LC with that hospital anyway, so I had guaranteed in home support despite not being in the catchment area for their home visits.
FIB could easily run a social media campaign raising awareness of mother’s rights to refuse being discharged if they do not yet feel confident breastfeeding, or their milk has not come in.
3: Creating a “Ryan’s Rule”
In Queensland hospitals if a parent feels that there is just something not quite right with their child despite tests and doctors claiming the child is fine, the parent can call “Ryan’s Rule” and the hospital is not allowed to discharge them until either a problem is identified, or the parent is satisfied that the child is back to normal.
This legislation was introduced after a child (named Ryan) was sent home with doctors claiming they couldn't find anything wrong, despite mum’s objections that he wasn’t right, and subsequently died. The legislation exists in other New South Wales as well, but is known as REACH.
By far the majority of the stories on the Fed Is Best website contain mother's proclaiming that they knew something wasn’t right, despite doctor's assurances. Had they been able to enact legislation like Ryan’s Rule the hospital staff would have been legally bound to continue investigating. The law also entitles parents to an independent second opinion, so you don’t get the same nurse/doctor simply rolling their eyes at you and dismissing you as a troublemaker.
Obviously hospitals in different states and countries have different medical laws. However since the Baby Friendly Hospital Initiative is an accreditation body, it shouldn't be that hard for them to put a policy in place that all their hospitals have a similar ruling.
Yet as far as I can tell there has been no attempt from the Fed Is Best Foundation to campaign for such a ruling. If their goal is saving babies from iatrogenic harm due to the dismissal of parents legitimate concerns, why is this not an option they are exploring?
4: Extensive antenatal breastfeeding information classes and postnatal support groups.
These are the requirements for antenatal breastfeeding education laid out by the BFHI for facilities seeking accreditation:
The antenatal education/discussion covers at least the following key points:
• the facility’s breastfeeding policy including the Ten Steps to Successful Breastfeeding.
• why breastfeeding is important and the risks associated with not breastfeeding.
• the benefits of having a support person of the mother’s choice with her throughout labour and birth.
• ways to help with comfort and non-pharmacological pain relief during labour.
• the importance of early uninterrupted skin-to-skin contact (the importance of the first hour).
• how to recognise when the baby is ready to attach to the breast for the first feed.
• basic breastfeeding and lactation management, including positioning and attachment, feeding cues and frequency of feeding.
• why 24-hour rooming-in (staying close to baby) is important.
• why bottle teats and dummies are discouraged while breastfeeding is being established.
• exclusive (full) breastfeeding for around six months and that breastfeeding continues to be important after other foods are introduced and may be continued for up to two years and beyond as per WHO guidelines.
• breastfeeding support groups and services in the community.
This is a massively inadequate policy.
It is a real failure on behalf of the BFHI.
Those bullet points do not cover anywhere near the kind of information that mothers need to know in order to successfully breastfeed.
On this on the Fed Is Best Foundation are absolutely right that BFHI are failing mothers and babies.
But it is fixable.
If I were Dr del Castillo-Hegyi I would be campaigning with the BFHI to write a fully comprehensive breastfeeding education curriculum to be delivered to all mothers antenatally as part of the hospital's accreditation requirements. It should have back up resources (video and handouts) in multiple languages, should be created by a panel of IBCLCs with feedback from mothers on what information they wish they had had, and should encompass at least ten hours worth of knowledge. All mothers should also receive a lifetime access link to the online training and videos so that they have the information available post birth when they need it. The coursework should also be delivered over multiple sessions so as not to overload expectant mothers, should be started early enough that most mothers will complete the course before giving birth, even if their baby is premature, and should include information on breastfeeding premmies, and complications.
5: Requiring that all staff in Emergency, Paediatrics and Maternity to be re-trained and regularly complete both professional development and assessment on breastfeeding, breastfeeding complications including hormonal issues and tongue ties/oral-motor issues and the accurate management of those in order to obtain BFHI accreditation.
These are the current requirements of BFHI for accreditation.
All facility personnel who have contact with pregnant women, mothers and infants in the facility (must) have received orientation to and education on the ‘policies for BFHI’ outlined in step 1 and have the skills necessary to implement these policies.
Personnel are divided into three groups, based on what they do in their role in the facility rather than on their position title. Allocation to the various groups can be determined by the facility, but needs to meet the following criteria:
Group 1: Those who assist mothers with breastfeeding, or provide education in relation to breastfeeding, in any part of the maternity unit, antenatal clinic and/or neonatal nurseries. For example, lactation consultants, midwives (antenatal, delivery suite, postnatal and domiciliary), registered or enrolled nurses who work permanently or on a casual basis in the maternity unit and/or neonatal nurseries, and paediatric unit personnel who frequently assist mothers with breastfeeding or breast expression.
Group 2: Those who may provide general breastfeeding advice but do not assist mothers with breastfeeding. For example, obstetricians, paediatricians, other medical personnel, most paediatric unit personnel (unless they frequently assist mothers with breastfeeding or breast expression), speech pathologists, physiotherapists and dieticians who advise or provide care related to infant feeding or lactation to mothers and/or their babies.
Group 3: Those who have contact with pregnant women and mothers but do not assist mothers with breastfeeding and do not provide infant feeding advice as part of their role. For example, ward clerks, relevant domestic/hotel personnel, auxiliary volunteers, some physiotherapists, perioperative and recovery room personnel (unless they assist with skin-to-skin contact and the first breastfeed in which case they are considered to be Group 1).
Now that all sounds fine at first glance, but when you read the training requirements a glaring issue shows up.
Group 1 personnel “have a minimum of 20 hours of education which covers the BFHI curriculum. Up to 12 hours of the 20 hours can be by RPL. The education must include: at least 8 hours theoretical education in the previous 3 years; and at least 3 hours relevant supervised clinical experience”
Twenty hours. That’s all. With only 3 hours of that needing to be practical.
That’s the training requirement for the highest level.
Group 2 is a minimum of two hours. Total. None of that needs to be practical.
Group 3. One hour.
In comparison the IBCLC training requires those who already have a health services degree to complete 90 hours of education in human lactation and breastfeeding within the 5 years immediately prior to applying for the IBLCE exam and 1000 hours of clinical practice in lactation and breastfeeding care that was obtained within the 5 years immediately prior to applying for the exam.
Also only 80% of BFH staff from any category have to have received the training for accreditation. Which means there’s a 20% chance that your hospital “LC”/nurse or postnatal midwife hasn’t received even this minimum training.
Again this is a massive failure on behalf of the BFHI.
Twenty hours of training is really not very much. And three hours of supervised practical training, god, no wonder so many midwives and nurses just smash baby’s head into your boob and say “there you go”.
So once again if I were Dr del Castillo-Hegyi I would be focusing on fixing this problem. And again it’s not a hard fix.
It’s simply writing a comprehensive curriculum, and rolling it out with the condition that all staff have to have completed it and be tested in it (with an online exam) in order to gain or keep accreditation.
BFHI could co-ordinate with the IBCLC accreditation board to ensure that their programs are complimentary and will count for RPL. Hell they could simply insist that all Group 1 staff have to have passed the IBCLC exam. That would cause a massive change in the quality of information and help mothers are getting.
Just make it mandatory for accreditation.
Group 2 staff - which includes the vital to breastfeeding success roles of Speech Pathology, Paediatricians, Obstetricians, Physiotherapists and Dietitians should have more like 50 hours minimum training in breastfeeding physiology and management. 2 hours is nowhere near enough to cover what they need to know. At an absolute minimum their training should match the current group 1 training. Additionally group 2 should include ER staff.
This is something that Fed is Best could be focusing on in their negotiations with the Baby Friendly Hospital Initiative.
Which brings me to
6: Requiring that BFI accredited hospitals have clinical guidelines that refer mothers to specialists in breastfeeding
Even if the BFHI deem it “too hard” to upgrade the training requirements for accreditation, FIBF could be pressuring them to update their clinical guidelines.
There is no step that insists that all mother-baby dyads who are having breastfeeding difficulties must be referred to an IBCLC.
There isn’t even mention of doing so in the entire accreditation information document.
When you go to see the GP and explain that you are feeling thirsty all the time and feel faint regularly s/he refers you to endocrinology. Because they are the experts in diabetes. If you tell them you are hearing voices and feeling disconnected from reality s/he refers you to a psychiatrist. But with breastfeeding GP’s and Pediatricians attempt to take on the role of expert in a field they have little training in.
The Fed Is Best Foundation could easily put pressure on the Baby Friendly Hospital Initiative to change their clinical pathways to ensure that all group 1-3 staff are required to refer up the chain. Level 3 staff should refer directly to group 1 staff, group 1 staff should refer complicated case up again to an IBCLC (who may refer back to speech pathology or dieticians if their specific skills are needed)
This would require that all Baby Friendly Hospitals have a number of IBCLCs on staff, but would be less HR intensive than requiring that all group 1 staff re-train to IBCLC standard.
So are the FIBF doing this? No.
Instead the infant feeding plan released by Fed Is Best, contains this particular baffling statement; “Please consult with a lactation consultant, nurse or breastfeeding educator to optimize breastfeeding technique. Medical necessity for supplementation is primarily based on the judgment of a pediatrician,who is the only person qualified to protect your child’s brain from underfeeding” - Feeding plan
Now, ok, *perhaps* the paediatrician is the only person with the qualifications to be able to officially diagnose serious dehydration issues, they are probably the only one qualified to put a treatment plan involving phototherapy, IV transfusions and so on in place. But they are not experts in infant feeding.
Whilst they most likely have a working knowledge of safe formula preparation, they are far from equipped to deal with breastfeeding complications. Especially complications of the sort that are likely to cause hypernatremic dehydration, hyperbilirubinemia or hypoglycemia.
No only have we already established that Baby-Friendly Hospital Pediatricians need only have 2 hours worth of training in breastfeeding in order for the hospital to be accredited, it is also a well established fact that pediatricians and GP’s do not have the skills and knowledge to help with breastfeeding issues.
Multiple survey style studies have been done on family physicians, paediatricians and obstetricians, looking into their breastfeeding knowledge, the amount of training they received in breastfeeding during residency, how long it has been since they last attended training in breastfeeding management, and how confident they felt addressing nursing mother’s concerns.
The following quotes are from the findings.
“Paediatricians report feeling inadequately trained in breastfeeding management and may need guidance in the care of breastfeeding mothers”
"The majority of paediatricians had not attended a presentation on breastfeeding management in the previous 3 years; most said they wanted more education on breastfeeding management" .https://www.ncbi.nlm.nih.gov/pubmed/10049991
"Over half (51%) reported no or limited education in breastfeeding, whereas only 9% reported adequate education. Promotion practices included most (82%) thinking the physician has a primary role in the feeding decision. Problem-solving was the main area physicians reported needing more education." https://www.ncbi.nlm.nih.gov/pubmed/16321602
"Physician support has been shown to increase breastfeeding rates, but anecdotal reports suggest that physicians are ill prepared for their role in breastfeeding promotion. Inadequate breastfeeding education during residency training may be a contributing factor…….Although residents and physicians were strongly convinced that family physicians should be involved in breastfeeding promotion, both groups demonstrated significant deficits in knowledge about breastfeeding benefits and clinical management strategies".
"Although more than 90% of respondents agreed that paediatricians should be involved in breastfeeding promotion, their clinical knowledge and experience did not suggest a high degree of competency…..Residents reported that the breastfeeding instruction provided during training was primarily in lecture format, with limited clinical opportunities to practice skills needed to assist breastfeeding mothers. Reflecting on their own training, more than 70% of practitioners recommended that more time be devoted to direct patient interaction and practice of counselling and problem-solving skills…..These results indicate that residency training does not adequately prepare paediatricians for their role in breastfeeding promotion. Improvements in residency training and innovative continuing education programs should be implemented to help paediatricians meet the needs of their breast-feeding patients"
So it seems that the Fed is Best Foundation are encouraging mothers to view Paediatricians as the experts in an area in which they actually receive very little training. This puts mothers at a hugely increased risk of receiving inadequate help and misinformation.
Pediatricians should always be involved in the care team. But the only person with the qualifications to identify the cause of a mother's late onset of milk (lactogenesis 2) or decreased milk supply is an IBCLC with additional training in oral motor restrictions.
And that’s because you need to have a very strong understanding of the physiology of breastfeeding in order to be able to spot red flags.
Now once again, seeing an IBCLC is no guarantee of quality support. There are bad examples in every profession. But you can not honestly expect a pediatrician whose entire training in breastfeeding was a few hours worth of lectures back in their residency and two hours worth of CPD when the hospital got credited to know why a mother having had a Pitocin induction or suffering PCOS is a red flag for milk production.
7: Milk banks or wet nursing services at all hospitals as an option for supplementing at least servicing preemies and those babies who have complications (birth, physical or feeding)
The Fed is Best Foundation maintain that supplementing babies in the first few days of life would massively reduce the chances of brain damage from dehydration and weight loss.
So the question becomes, why are they not fighting for mothers to have access to human milk?
If colostrum is not sufficient to maintain baby's brain, then mature milk should be offered as an option. This could of course be alongside formula and glucose water, but it should be an option that all mothers have access too. At the very least, all mothers of premature babies and those who have suffered birth or feeding complications or have physical complications that may negatively impact breastfeeding such as cleft lip.
Yet, whilst the FIB Foundation’s feeding plan now lists screened donor milk in it’s list of potential supplementation choices, they do not seem to be negotiating with BFHI to increase the number of hospitals with milk banks or introduce wet-nursing programs.
They do however seem to want the BFHI to relax their policy around providing formula to allow babies to be supplemented with formula regardless of any indication of medical need.
This is a particularly baffling approach for two reasons.
One, it makes them seem like nothing but formula company shills, creating distrust and animosity between them and BFHI/other pro-breastfeeding organisations.
Two, formula is not guaranteed to prevent dehydration anyway.
The safe use of formula relies on both hygiene practices and accurate ratios of formula to water. However as mentioned in part 2, one in five baby bottles for sale (in Australia) have inaccurate markings. This means that formula fed babies are at risk of complications such as dehydration (from not enough water : formula) or water intoxication (from too much water : formula). Surely introducing formula to breastfed babies in order to prevent dehydration is misguided when a large proportion of the bottles used puts the baby at risk of just that.
Now a hospital could overcome this by weighing the measurements instead of relying on the bottle markers, but it still means that formula is not a guaranteed fix. With human error at the mixing stage the baby could still be just as dehydrated as they were before supplementation.
If the Fed Is Best foundation are focusing on formula access because that’s a much faster fix than building milk banks and obtaining donors, then fine. But they need to communicate that.
Which brings me to my final point
8: Work with pro-breastfeeding organisations to reach the common goal of helping babies to thrive.
On the 15th of August 2017, eighty breastfeeding promotion organisations including Baby Friendly USA, sent a letter to Dr del Castillo-Hegyi. In it they ask for her to come to the table with them in order to “engage in some honest and constructive dialogue to find shared messaging focused on providing the accurate and unbiased information families need to make their personal infant feeding decisions, along with the appropriate care and support they need to implement those decisions.”
As of the 1st November, the only response from Dr del Castillo-Hegyi had been to insist on a public apology from the Executive Director at 1000 Days, who had expressed concern over a post FIB had shared (in February) promoting the use of formula in Africa. 1000 days made a public apology adding this paragraph.
“I understand if you do not wish to meet with me or 1,000 Days because of what I wrote in response to the aforementioned post. But please do not let that be the reason you decline the invitation to meet with the 43 other organizations that represent parents, physicians, health professionals and volunteers working tirelessly to help families give kids the strongest start to life and that signed the letter sent to you seeking a constructive dialogue with the Fed Is Best Foundation. In no way does 1,000 Days speak for these organizations. 1,000 Days does however stand together with these groups in genuinely wanting to explore if there is common ground with the Fed Is Best Foundation when it comes to providing families with accurate and unbiased information on infant feeding.”
The Fed Is Best Foundations reply to 1000 Days’ apology and the re submission of the original letter with additional signatories was a form letter. “Thanks for inquiring into our organisation, this is what we do.” No acknowledgement of the apology, or the request to meet (from 84 other organisations).
The obvious question has to be why?
Why not meet with them?
They are offering you the chance to win them over with your science and to work together to find solutions that benefit babies.
So why not meet with them?
And in the end. That really says everything about the Fed Is Best Foundations ethics and integrity.
During the writing of this article, UNICEF / WHO released updated Guidelines for Baby Friendly Hospitals that replace the 10 steps. They are available here.
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