Breastfeeding, Baby-Friendly, and Safety: Getting the Balance Right

Abstract

See related articles, p 11 and p 16Breastfeeding has multiple health and social benefits and is regarded by most experts, including the American Academy of Pediatrics, as the optimal feeding practice for newborns. Even so, in the US, rates of breastfeeding initiation and continued breastfeeding at 6 and 12 months remain well below Healthy People 2020 national goals. In 1991, the World Health Organization and the United Nations Children's Fund launched the Baby-Friendly Hospital Initiative to improve breastfeeding initiation at birth and breastfeeding duration through the first year of life. Hospitals and birthing centers gain Baby-Friendly designation status by demonstrating implementation of the Ten Steps to Successful Breastfeeding, which include maternal support and breastfeeding promotion practices, such as restricting use of pacifiers, not offering formula without a medical indication, and keeping the mother and baby together 24 hours a day. The World Health Organization updated their implementation guidance in 2018, but the Ten Steps have remained unmodified by Baby-Friendly USA since designating the first hospital program in 1996. See related articles, p 11 and p 16 Any medical or systems intervention comes with risk for adverse events. Overall, this has been understudied for the Baby-Friendly Health Initiative, with only 2 studies identified by the US Preventive Services Task Force as reporting any adverse events, and with those studies only describing maternal outcomes.1Flaherman V. Von Kohorn I. Interventions intended to support breastfeeding: updated assessment of benefits and harms.JAMA. 2016; 316: 1685-1687Crossref PubMed Scopus (12) Google Scholar In this volume of The Journal, articles by Bass et al and by Bartick et al extend what is known about the safety and efficacy of Baby-Friendly.2Bass J.L. Gartley T. Kleinman R. Outcomes from the Centers for Disease Control and Prevention 2018 Breastfeeding Report Card: public policy implications.J Pediatr. 2020; 218: 16-21Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar,3Bartick M. Boisvert M.E. Philipp B.L. Feldman-Winter L. Trends in breastfeeding interventions, skin-to-skin care, and sudden infant death in the first 6 days after birth.J Pediatr. 2020; 218: 11-15Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar A central tenet in the Ten Steps of Baby-Friendly is to enable mothers and infants to practice rooming in and remain together 24 hours a day. This step, perhaps more than any other, has led to concerns about safety of Baby-Friendly practices, particularly when mothers accidentally or intentionally practice bed-sharing with their newborn. Moreover, Baby-Friendly USA promotes skin-to-skin care shortly after birth, because of benefits that include stabilization of the infant's temperature and facilitation of initial breastfeeding. However, when performed as part of rooming in, unsupervised skin-to-skin care may contribute to bed-sharing, a practice specifically discouraged by the American Academy of Pediatrics.4Moon R.Y. SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment.Pediatrics. 2011; 128: 1030-1039Crossref PubMed Scopus (221) Google Scholar In 2014, Thach reported on a survey of medical examiners that identified 15 cases of unexplained deaths or near-deaths of infants at a mean age of 24 hours of life.5Thach B.T. Deaths and near deaths of healthy newborn infants while bed sharing on maternity wards.J Perinatol. 2014; 34: 275-279Crossref PubMed Scopus (29) Google Scholar In more than one-half of these cases, the mother fell asleep during or after breastfeeding. This report raised the important question whether bed-sharing, a practice that is discouraged at home, can be safely done in the hospital without medical supervision. These early events are now referred to as sudden unexpected postnatal collapse (SUPC), a rare subset of sudden unexplained infant deaths (SUID, defined as the sudden and unexpected death of a baby <1 year old). SUPC is apnea or cardiorespiratory failure occurring in an otherwise-healthy term newborn, usually in the first 24 hours of life, and during the initial skin-to-skin contact, with prone positioning, or with the first attempt to breastfeed. The incidence has been estimated as 2.6-133 cases per 100 000 newborns.6Feldman-Winter L. Goldsmith J.P. Safe sleep and skin-to-skin care in the neonatal period for healthy term newborns.Pediatrics. 2016; 138: e1-e10Crossref Scopus (125) Google Scholar Even with educational efforts, falling asleep while breastfeeding or holding a newborn during skin-to-skin care is a hazard after sleep deprivation and/or the use of narcotic analgesics associated with birth. Moreover, maternal fatigue and reduced monitoring have been reported to contribute to infant falls during rooming-in.6Feldman-Winter L. Goldsmith J.P. Safe sleep and skin-to-skin care in the neonatal period for healthy term newborns.Pediatrics. 2016; 138: e1-e10Crossref Scopus (125) Google Scholar The effect of 24/7 rooming-in on neonatal SUID is extremely important yet poorly understood. Although Baby-Friendly USA does not actively support bed sharing in its Ten Steps, it does not expressly discourage the practice. In a recent analysis of 20 years of Centers for Disease Control and Prevention (CDC) data from 1995 to 2014, Bass et al found that although overall rates of SUID in the first year of life fell, rates of neonatal (within the first month of life) SUID increased from 9% to 10% in 1995 to 11% to 13% by 2014.7Bass J.L. Gartley T. Lyczkowski D.A. Kleinman R. Trends in the incidence of sudden unexpected infant death in the newborn: 1995-2014.J Pediatr. 2018; 196: 104-108Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar Much of this increase occurred between 1995 and 2000. Of the neonatal SUID events, 29% occurred in the first 6 days of life and 15% on the first day of life. Overall, this translates to ∼125 SUPC events annually in the US, with ∼40% occurring in babies born preterm at <35 weeks of gestation.7Bass J.L. Gartley T. Lyczkowski D.A. Kleinman R. Trends in the incidence of sudden unexpected infant death in the newborn: 1995-2014.J Pediatr. 2018; 196: 104-108Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar Although SUPC in infants born at term is a rare cause of neonatal mortality, it deserves particular attention because it may be largely preventable. Bass et al did not directly link rates of neonatal SUID to any specific practices in or out of the hospital, but the authors suggested that safe sleep practices should be emphasized as part of their prevention.7Bass J.L. Gartley T. Lyczkowski D.A. Kleinman R. Trends in the incidence of sudden unexpected infant death in the newborn: 1995-2014.J Pediatr. 2018; 196: 104-108Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar In this volume of The Journal, Bartick et al also report CDC data and found that between 2004 and 2016 (a shorter and later time frame than examined by Bass et al), the adoption of skin-to-skin care as a part of Baby-Friendly practice increased substantially in the US and in Massachusetts.3Bartick M. Boisvert M.E. Philipp B.L. Feldman-Winter L. Trends in breastfeeding interventions, skin-to-skin care, and sudden infant death in the first 6 days after birth.J Pediatr. 2020; 218: 11-15Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar During the same time frame, data from the CDC and Massachusetts Department of Health showed a decrease in the prevalence of SUID in the first 7 days of life (ie, SUPC).3Bartick M. Boisvert M.E. Philipp B.L. Feldman-Winter L. Trends in breastfeeding interventions, skin-to-skin care, and sudden infant death in the first 6 days after birth.J Pediatr. 2020; 218: 11-15Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar,8Egan J. Bartick M. Linked birth-death file, ICD-10 Codes R95, W75, R99, age <6 days. Massachusetts Department of Public Health, Boston (MA)2019Google Scholar Their data suggest this decrease was at least partly due to a statistically significant drop in preterm deaths, but overall the trends in SUID prevalence over their 13-year study period appear similar to the report by Bass et al.7Bass J.L. Gartley T. Lyczkowski D.A. Kleinman R. Trends in the incidence of sudden unexpected infant death in the newborn: 1995-2014.J Pediatr. 2018; 196: 104-108Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar Both investigators attempted to examine the proportion of these early deaths that were directly attributable to accidental suffocation. Although both studies noted an increase in reported accidental suffocation over time, the specific rates are difficult to compare, as the age groups studied were different (<28 days for Bass et al vs <7 days for Bartick et al), and there continue to be concerns over inconsistent reporting and attribution, in part because there are not standard 10th revision of the International Statistical Classification of Diseases and Related Health Problems codes for these events. If a support program based on exclusive breastfeeding during the newborn period has unintended adverse effects, it is reasonable to consider whether alternative approaches are safer or more effective. To that end, in this volume of The Journal, Bass et al extend their thinking about the possible consequences of Baby-Friendly to examine which aspects of early maternal support lead to successful long-term breastfeeding.2Bass J.L. Gartley T. Kleinman R. Outcomes from the Centers for Disease Control and Prevention 2018 Breastfeeding Report Card: public policy implications.J Pediatr. 2020; 218: 16-21Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Are all of the Ten Steps required, or are some more important than others? Are there early outcomes that predict long-term success? Others have reported that as a system-level intervention, Baby-Friendly accreditation has not been shown to have an independent effect on the duration of any or exclusive breastfeeding and that implementation of individual steps within the Baby-Friendly Health Initiative, rather than accreditation itself, may have a bigger influence on rates of breastfeeding.9Patnode C.D. Henninger M.L. Senger C.A. Perdue L.A. Whitlock E.P. Primary care interventions to support breastfeeding: updated evidence report and systematic review for the US Preventive Services Task Force.JAMA. 2016; 316 ([Erratum in: JAMA. 2016;316:2155]): 1694-1705Crossref PubMed Scopus (89) Google Scholar Bass et al provide 2018 CDC Breastfeeding Report Card data that suggest that even in states with low rates of Baby-Friendly hospital accreditation, high rates of breastfeeding initiation after birth appear to predict success in sustained breastfeeding during infancy. The next task should be to determine how best to accomplish this important milestone for more mothers. Although the Bartick and Bass studies provide somewhat different perspectives on these challenging questions, both share the goal of improving breastfeeding outcomes while avoiding harm. In the hospital, a balance needs to be struck between encouraging and supporting a mother and avoiding system-based practices that inadvertently increase risk to the infant. There is growing support for an individual, tailored approach to promoting breastfeeding duration.1Flaherman V. Von Kohorn I. Interventions intended to support breastfeeding: updated assessment of benefits and harms.JAMA. 2016; 316: 1685-1687Crossref PubMed Scopus (12) Google Scholar All medical personnel need to be familiar with the evolving data supporting best practices for breastfeeding support. Trends in Breastfeeding Interventions, Skin-to-Skin Care, and Sudden Infant Death in the First 6 Days after BirthThe Journal of PediatricsVol. 218PreviewTo determine if implementation of skin-to-skin care and the Baby-Friendly Hospital Initiative (BFHI) contributes to sudden unexpected infant death (SUID) and asphyxia in the first 6 days after birth. Full-Text PDF Outcomes from the Centers for Disease Control and Prevention 2018 Breastfeeding Report Card: Public Policy ImplicationsThe Journal of PediatricsVol. 218PreviewTo compare the impact of Baby-Friendly designation vs rates of in-hospital breastfeeding initiation on breastfeeding outcomes at 3, 6, and 12 months postdischarge. Full-Text PDF