Here at Infant Feeding Support we are champions of all safe infant feeding methods; breastmilk and infant formula are both excellent sources of nourishment for babies and that goes for whether they’re delivered by bottle, boob or tube.  However a new family chooses to feed their baby, the most important thing is that everyone gets the very best, science-based support.  We want to be sure that any health care incentive that crosses a new parent’s path is held to the highest standards and demonstrably foregrounds the mental and physical health and wellbeing of families and babies. Above all, we want to roll up our sleeves and get stuck in to make sure that this happens and so responding to the World Health Organisation’s (WHO) public consultation on the revised Baby Friendly Hospital Initiative (BFHI) bounced directly to the top of our to-do list.

If you’re not familiar with the BFHI, it’s a programme set up by UNICEF and the WHO with the aim of increasing breastfeeding rates.  The programme advises ten key steps that are intended to help parents to initiate breastfeeding and improve overall breastfeeding rates. The initiative was launched in 1991 and has been running since then in over 152 countries, including the UK. The majority of maternity units (91%) and health visiting services (85%) across the UK are now working towards Baby Friendly accreditation, and new neonatal and children’s centre standards have been introduced to help services improve care.

UNICEF and the WHO provide guidelines on the BFHI and presented their draft revised guidelines for public consultation in October 2017.  We sent in a full response and because there was so much to get our teeth into we’ve summarised the key points from our response in this tl;dr version!

Read on to discover what we at IFS UK feel are the good, the bad and the ugly aspects of the revised BFHI guidelines.


Removes recommendation to avoid pacifier use

In previous years the BFHI Ten steps have recommended that pacifiers, or dummies, are avoided for the first few weeks of a new baby’s life so that they can’t interfere with breastfeeding. This revision reviewed the evidence, or in this case lack of evidence, for pacifier avoidance and nipple confusion and recommended that because there was insufficient evidence to support the point, it shouldn’t be there. We commended this.

Requests the reinstatement of better monitoring

In the UK we haven’t had a really thorough infant feeding survey (IFS) since 2010. The infant feeding survey was an absolute goldmine of information on how families fed their babies, which services they used and how they felt about their experiences. As well as being really rigorously conducted, it used comparable methods in each 5 year survey wave so the results could be used to assess progress over time in a rigorous way. It is absolutely not replaceable by the Public Health England data on just 6-8 week ‘any breastfeeding’ outcome as this is in no way as detailed or rigorous as the IFS was. If we want to get to grips with infant feeding in the UK then the IFS is a really important tool and so we strongly supported the request that monitoring returns.  Furthermore, we really want to see monitoring extended to several measures of infant health that are not actually included in the BFHI consultation (call us keen) but which are so important if we’re to understand how and where breastfeeding support is helping people and where it can be improved.


The document fails to acknowledge criticism of BFHI

While this document presents research into the effectiveness of the BFHI in a very positive light, it fails to acknowledge less positive and critical research or the limitations of research presented. We strongly believe that if you want to move forward and inspire confidence in your approach then you absolutely must meet constructive criticism head on. That might mean a humble mea culpa, it might mean a compromise or it might mean pistols at dawn, whichever you choose, it’s important to do it.  We felt that the BFHI consultation document was sorely lacking in this area.

No evidence for targets

The document provides no evidence for the BFHI target of 90% early initiation and exclusive breastfeeding. In the UK, 81% of parents initiate breastfeeding, with 69% exclusively breastfeeding at birth.   Without considering the contraindications to breastfeeding such as breast surgery, HIV+, other physical, mental or personal reasons why families choose to formula feed, this target may be physically impossible and therefore have adverse consequences.  In addition, in circumstances where exclusive breastfeeding is hindered by problems such as delayed onset of lactation, attempts to achieve a facility target of 90% may well create substantial problems with the readmission of undernourished infants.

Little consideration of parents who choose to supplement or formula feed

There are points over the course of the BFHI document where formula feeding or supplementing parents are considered.  However, we felt that the guidelines leave potential providers to walk an impossible line between describing formula as a ‘last resort’, ‘medical necessity’ and ‘discouraged’ and respecting a mother’s preference. We requested that far more guidance is included on how this balance can be achieved.

We also felt it was unclear how care givers can reconcile statements such as “Mothers should be discouraged from giving any food or fluids other than breast milk, unless medically indicated” with those such as “Families must receive quality and unbiased information about infant feeding. Facilities providing maternity and newborn services have a responsibility to promote breastfeeding, but they must also respect the mothers’ preferences and provide support for mothers to successfully feed their newborn in the way they choose.”

Given that in the UK substantial proportions of mothers are likely to have problems establishing sufficient milk production, if only temporarily, we suggested that BFHI modify its guidance to be clear that mothers wishing or needing to supplement should be supported to do so safely. Ideal guidance for UK-like settings would ensure that healthcare professionals and families receive consistent messaging, being clear that full nutritional adequacy for the baby is essential at all times and that where mother’s milk is insufficient, safe supplementation can and should be provided to meet those needs.


Lack of adherence to the highest standards of evidence

Every single one of us expects that guidelines and policies in relation to health will be safe for those who come into contact with it and that they will be based on an unbiased assessment of the overall, highest quality scientific knowledge that we have at the time. Because of this it is vital that we all use these review processes to hold outputs to account. This issue for Infant Feeding Support is not personal, it’s not ideological and it’s not about point scoring; it’s about safety. We were therefore utterly shocked by the lack of evidence underpinning some key recommendations and statements in the consultation document.
Probably the clearest and least controversial example of this was the use of a dated and underpowered study on infant formula to support a point about gut microbiota.  Other examples include evidence that is weak and/or conflicting in the area of scheduled feeding vs. infant led and when the best time to supplement an infant may be.  At best, this questionable use of evidence fails to inspire confidence in BFHI and looks a bit silly, but at worst it’s really dangerous to new families and babies.

Overinterprets data on gut microbiota

The BFHI consultation document posits that formula supplementation “significantly alters the intestinal microflora” and to support this assertion references a study from 1977 that did not look at any objective infant health outcomes. The significance on infant health of changes in gut microbiota are entirely unclear; the microbiome is influenced by multiple factors (including methodology) and there is not yet a general consensus on what a ‘normal’ microbiome is due to the individual variation in composition. We are concerned that a single, very small study using outdated methods and with little relevance to current practice (with regard to the type of formula used and its preparation) is influencing global policy on infant feeding.


Guidance on scheduled vs baby-led breastfeeding doesn’t follow the evidence

Scheduled feeding “is not recommended” by the BFHI. However, a recent review conducted on their behalf did not find any high quality evidence comparing baby-led and scheduled breastfeeding, and recommended no changes to current practice without robust research.  We’re not sure then why the BFHI insist that scheduled feeding is not recommended when even their own research doesn’t support that.  While we aren’t advocating for scheduled feeding per se, it’s important that BFHI recommendations follow the evidence and the policy guidance should acknowledge this.

Lack of clarity on guidance for supplementation

Supplementation is strongly discouraged within the guidelines due to fears that it will affect the newborns ability to suckle and stimulate milk transfer, although no evidence is provided to support this theory.  Data shows that even when parents receive excellent breastfeeding support and give birth in a BFHI hospital, a high proportion of mothers still experience a high rate of delayed onset of lactation. Therefore, a high proportion of babies may need supplementation, if only temporarily, to avert problems associated with insufficient intake. By suggesting that supplementation is withheld until babies are unwell (“medically indicated”), we feel that the guidelines have the potential to cause harm.  Nowhere in the report did the BFHI address the evidence that early pre-emptive supplementation of babies who lose 5% or more of their birth weight doesn’t seem to interfere with later breastfeeding success, and indeed may even increase breastfeeding later on, nor the fact that supplementation reduces maternal anxiety and may improve a mothers breastfeeding confidence.

No guidance on preventing adverse outcomes

It is surprising that the guidance does not include specific recommendations regarding the prevention of adverse outcomes as a result of insufficient milk intake such as excessive weight loss, jaundice and/or hypernatremia.

There was a lot to get our teeth into and such a short consultation period that unfortunately, we were unable to address every instance of questions around the evidence base, or really even raise all of the issues that we would have liked. We had to focus on our key and – we believe totally achievable – goal of the adoption of an Infant Feeding Policy that accurately represents the available evidence on maternal and infant outcomes, supports judicial use of supplementation in the early days postpartum and provides formula feeding parents with as much guidance and support as their breastfeeding peers.

We look forward to reading the fully revised guidelines and hope that UNICEF and the WHO are open to listening to our suggestions and are truly on board with creating a policy that both Baby AND Family Friendly.

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