Hundreds of babies die each year as a result of the Baby Friendly Hospital Initiative

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What if I told you that hundreds of babies die each year in industrialized countries from a problem that could be easily prevented by better patient and provider education?

You’d jump at the chance to fix the problem, wouldn’t you?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]In industrialized countries, aggressive breastfeeding promotion kills far more babies than it saves.[/pullquote]

What if I told you that a group of providers has a personal stake in perpetuating the problem and therefore won’t let it be treated?

You’d be horrified, right?

So let me tell you that hundreds of babies die preventable deaths each year as a result of the Baby Friendly Hospital Initiative (BFHI). And lactation consultants and lactivists are actively perpetuating the problem by ignoring these deaths.

The problem is so serious and widespread that it it has results in a new diagnosis: sudden unexpected post-neonatal collapse, the unexpected death of an otherwise healthy infant in the first hours or days of life.

Herlenius wrote about the problem in Europe in Sudden Unexpected Postnatal Collapse of Newborn Infants: A Review of Cases, Definitions, Risks, and Preventive Measures, reporting on 400 cases of collapse.

Such incidents are increasingly common in Europe in response to the adoption of so-called “baby friendly” policies:

Our summary of published reports indicates that even if still rare and with varying reported incidences, SUPC might occur more frequently than indicated in recent surveys. Even the lowest incidence numbers, if extrapolated on the 5 million annual births in the European Union, would result in some 500 SUPC cases and 150 newborn unexpected deaths yearly. Most of them are likely preventable.

How can we prevent these deaths? The first step is to acknowledge the role of the BFHI. That’s just what Flaherman and Von Kohorn in Interventions Intended to Support Breastfeeding Updated Assessment of Benefits and Harms and Bass et al. in Unintended Consequences of Current Breastfeeding Initiatives  published in JAMA in October 2016 recommended.

Not surprisingly, professional lactivists reacted to the editorials with a wall of denial embodied in a flurry of Letters to the Editor.

Melissa Bartick complained that studies that show the effectiveness of BFHI were excluded. Flaherman and Von Kohorn easily dismantle her complaint.

When considering the difference between studies included in the systematic review and those excluded, there are 2 important concepts to consider: confounding and generalizability. Confounding is an important
threat to internal validity for observational studies. In this case, confounding can occur when an increase in breastfeeding is attributed to the BFHI intervention when, in reality, it is caused by another factor…

Generalizability refers to the external validity of a study, an assessment of how applicable the results of the study are to patients and populations… Excluding a study such as PROBIT from the USPSTF review does not mean that the findings are not generalizable to some populations, only that they are not generalizable to the United States.

…[T]he good-quality evidence available that is applicable to the United States indicates that the BFHI is not beneficial for the general US population. This fact, along with the growing evidence for possible harm associated with some of the steps of the BFHI and the large number of effective individual-level interventions to promote breastfeeding, leads us to conclude that US institutions should focus on
implementation of the individual-level interventions identified by the USPSTF as effective.

Bass and colleagues address the denial expressed by other Letters in a compelling response.

Gardner et al comment that, under the BFHI Guidelines … mothers are fully informed of the benefits of breastfeeding and supportive practices… However they do not require that mothers also be informed of the important safety risk of late skin-toskin care identified by the AAP guidelines or the established benefit that a pacifier confers to prevent sudden infant death syndrome.


Boyd et al state that they were unable to document any deaths … before 28 days of life in New York City between 2012 and 2014 when they implemented BFHI designation in several facilities. This is not surprising given … that there intervention took place in only 8 birthing facilities in a city that has 50 hospitals with maternity services.

And most devastating of all:

Ferrarello characterizes sudden infant death syndrome in newborns as “exceedingly rare,” a position that other respondents also implied… [N]ational data on sudden unexpected infant death for US infants for 2003-2013 reveal that … there were 1421 [deaths] in the first 6 days of which 666 occurred on the first day of life… These compelling data provide a perspective on the potential magnitude and significance of the problem, which … should encourage government … as well as concerned breastfeeding advocates to focus on alternative effective strategies to promote breastfeeding safely.

If the statistics from the US and Europe are correct, babies continue to die preventable deaths every week as a result of rigid adherence to the BFHI. If this were about science, BFHI proponents would be rushing to modify the tenets of the BFHI.

But it’s not about science; it’s about business. The BFHI is a money maker for its proponents including the organizations that support it and the individuals who are employed as a result. Paraphrasing Upton Sinclair: It is difficult to get a woman to understand something, when her salary depends on her not understanding it.

It’s not just about business; it’s also about magical thinking. Lactivists, suffering from a severe case of white hat bias, insist that breastfeeding must be perfect and that all efforts to promote it must be perfect, too. Neither is true.

Lactivists can’t identify any term infants whose lives are saved by breastfeeding yet pediatricians and neonatologists can point to hundreds of lives lost each year to efforts to promote breastfeeding. It hard to imagine a more scathing indictment of lactivists in general and the Baby Friendly Hospital Iniative in particular than that.