Fellow physicians, why are we letting the Baby Friendly Hospital Initiative harm our patients?

danger tapes, danger sign

No one truly knows how hard a doctor works on behalf of patients than another doctor.

I understand how obstetricians struggle to make the right decision on when and how to deliver a baby to maximize the health of both infant and mother. I know what it’s like to confront at a worrisome fetal monitor tracing, unable to determine whether it represents real fetal distress but having to act anyway. I’ve lived the gut churning terror of a shoulder dystocia. I’ve been woken out of a deep sleep, snapped to awareness and raced to save a woman who showed up on the hospital doorstep hemorrhaging from a massive abruption, desperately hoping I’m not too late to save the life of her baby, too.

We give our all in service to our patients. Then we hand them over to the lactation lobby that harms both babies and mothers.

We and our pediatric/neonatology colleagues give our all in service to our patients. Then, too often, we hand them over to the lactation lobby that harms both babies and mothers. I’m referring, of course, to the so-called Baby Friendly Hospital Initiative designed to promote breastfeeding.

But wait, I hear you say. Doesn’t the conventional wisdom tell us breast best?

If you are as old as I am, you probably remember when the conventional wisdom was that routine episiotomies were best, that routine hormone replacement therapy for menopause was best, that routinely putting babies to sleep on their stomachs was best.

All too often the conventional wisdom is wrong and this is another case. Routinely pressuring all women to breastfeeding exclusively is wrong. Routinely withholding pacifiers and infant formula is wrong. Closing well baby nurseries and routinely forcing 24/7 rooming in is wrong.

How wrong?

This wrong:

Taken together, these papers demonstrate that insufficient breastmilk is common (up to 15% of first time mothers), formula supplementation makes successful breastfeeding more likely, pacifiers prevent SIDS, extended skin to skin contact lead to babies falling from their mothers’ hospital beds or suffocating while in them, and the latest results from the PROBIT studies show no impact on IQ at age 16. In addition, we know that the leading cause of jaundice induced brain damage (kernicterus) is breastfeeding.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The BFHI is a creation of La Leche League; it’s a full employment plan for its leaders allowing them to monetize the information they previously gave away for free.[/pullquote]

So wrong that exclusive breastfeeding is now the LEADING risk factor for newborn hospital readmission, accounting for literally tens of thousands of hospital readmissions for dehydration, jaundice and failure to thrive each year.

And those benefits we were taught about in medical school? Nearly all have been debunked.

It’s been 5 years since the publication, Is Breast Truly Best? Estimating the Effects of Breastfeeding on Long-term Child Health and Wellbeing in the United States Using Sibling Comparisons by Colen and Ramey that found the purported benefits of breastfeeding nearly all disappeared with corrected for confounding variables like socio-economic status and ethnicity.

A recent paper, Is the “breast is best” mantra an oversimplification?, is a comprehensive summary of breastfeeding research and concludes that the benefits have been overstated and the risks ignored.

The evidence for infant breastfeeding status and its association with health outcomes faces significant limitations; the great majority of those limitations tend to overestimate the benefits of breastfeeding. Nearly all evidence is based on observational studies, in which causality cannot be determined and self-selection bias, recall bias, and residual confounding limit the value or strength of the findings.

And there is growing evidence that the BFHI is harmful to mothers as well as babies:

The literature that does investigate harm consistently finds that women who have difficulty breastfeeding or choose formula feeding report feelings of inadequacy, guilt, loss of agency, anxiety, and physical pain during breastfeeding that interferes with 1) their ability to bond or otherwise care for their infant and 2) competing work obligations…

Why have we been promoting breastfeeding so aggressively?

The BFHI is a creation of La Leche League and is essentially a full employment plan for its leaders, allowing them to monetize the information they previously gave away for free.

…[T]he BFHI was crafted in close conversation with individuals from La Leche League’s inner circle. First, early work by UNICEF and the WHO to develop the BFHI includes language which reproduces key components of La Leche League’s commitments…

[I]t’s also possible to trace the influence of individual policymakers from La Leche League in the 1970s to UNICEF in the 1980’s…In fact, the extensive connections between La Leche’s leadership and the WHO and UNICEF are well documented in the archival record of the League. These collections detail the involvement of the organization’s leadership, including its president Marian Thompson …

At the same time, LLL was engaged in an effort to monetize breastfeeding support, creating the lactation consultant credential.

The International Board of Lactation Consultant Examiners® (IBLCE®) was founded in March 1985 using a $40,000 loan from La Leche League International as start-up funding…

These factors of consumer demand, scientific evidence and practical clinical skills converged to create an ideal climate for the new profession…

Not exactly. The heart of the BFHI program — the Ten Steps to Successful Breastfeeding — were operationalized BEFORE there was any scientific evidence to support them.

It was not until nearly a decade after the birth of the program, in 1998, that the WHO published a review of scientific evidence in support of the Ten Steps. Their review of the scientific literature at that point served not to inform or influence the design of the BFHI but instead to defend the initiative as it had been initially drafted.

Think about that: a program designed by LLL to be staffed by its members was implemented without ANY scientific evidence to support it. It’s no wonder then that the BFHI has ended up harming our patients.

Fellow physicians, we have the power to protect our patients from the BFHI and we should use that power. The BFHI is a private organization; they can be removed from hospitals altogether or they can be forced to amend their guidelines to put preventing harm to babies and mothers first.

You work so hard to ensure the health of every baby and every mother. Please don’t let the lactation lobby continue to harm them.