The ‘breast is best’ policy backlash
This story is not an argument against breastfeeding. My party line, after reading a lot of the research and speaking to a number of experts, is that breastfeeding is truly wonderful if you can make it happen but not of significant consequence if you can’t. For those who have access to clean water, formula can be a healthy choice.
This is also not an argument against supporting women in their breastfeeding efforts. New moms anticipating a seamless, euphoric process are often surprised to discover that feeding newborns is hard and rarely goes as planned. Breastfeeding requires education and damage control, and the sooner this is offered to pregnant women and new moms, the better the chance they have of successfully breastfeeding — if that’s what they choose to do.
What this story is, then, is a look at whether our current methods of providing support are working for families.
Over the past couple of years, a growing number of doctors and nurses have begun to question the current strategy. They’re worried that the near single-minded focus on breastfeeding often causes hospital staff to overlook risky behavior, unintentionally putting babies and mothers in harm’s way.
‘Fed’ is best
Dr. Christie del Castillo-Hegyi gave birth to her son in 2010 at the same Albuquerque, New Mexico, hospital where she worked as an emergency room doctor. The delivery was fairly textbook, and when del Castillo-Hegyi left the hospital a few days later, she had little cause for concern. Her baby was latching well, and so she followed the lactation consultant’s recommendation to keep him on the breast with the hope of encouraging her milk to come in.
Two days later, she returned to the hospital, concerned that her son’s fussiness was a response to starvation. Despite his significant weight loss, she was sent home and told to keep him on the breast. Eager to make breastfeeding work, she obeyed orders.
A day later, her son seemed to mellow out, and she presumed he was doing better. Instead, he had extreme dehydration and starvation, something they would discover at the emergency room the following day after her listless son became nonresponsive. He was given formula and stabilized, but it was still too late. Four days without food had caused brain damage, leading to cognitive disabilities that will affect him for the rest of his life.
Del Castillo-Hegyi has her regrets. In hindsight, she can view the events as an emergency room doctor and wonder why she didn’t insist that her child be monitored with the same level of care she would have given her patients. But at the time, she was a new mom, tired and scared, and so she took the lactation consultant’s word for it.
“The whole idea of ‘the baby looks fine’ is very dangerous. [Failing to monitor glucose levels] can kill a child or alter the rest of their life,” she said. “Complications from exclusive breastfeeding are so common and so devastating, I can’t understand why [glucose levels] aren’t universally checked” when there is reason to suspect that a child might be starving.
In 2016, del Castillo-Hegyi paired up with Jody Segrave-Daly, a newborn nursery and newborn intensive care unit nurse and certified lactation consultant, to form Fed is Best. The nonprofit is aimed at helping fill in the gap in breastfeeding education by teaching parents the signs of hypoglycemia, jaundice and dehydration and encouraging them to supplement with formula whenever necessary.
Although there are no studies documenting the rate at which newborn starvation and dehydration happens, there are more than enough anecdotes demonstrating the need for parents to be educated about the symptoms.
One American study found that roughly one in five women had insufficient milk supply three days after childbirth, leaving a considerable number of babies at risk for these conditions. On its website, Fed is Best points to studies showing that 10% of vaginally delivered and 25% of cesarean-delivered, exclusively breastfed babies lose a potentially dangerous amount of weight in the first days of life, 10% to 18% of babies experience starvation jaundice from insufficient milk intake, and 10% of exclusively breastfed babies experience hypoglycemia.
In addition to public education, Fed is Best is trying to prevent starvation-related complications through advocacy. These efforts are often met with resistance. In September, del Castillo-Hegyi and her team had a meeting with the World Health Organization to address some concerns about the way the current practices of breastfeeding promotion can inadvertently lead to starvation and dehydration.
“I said, ‘Does the WHO have any plans to inform moms of the risk of insufficient breast milk so she can identify starvation in her baby?’ And the answer was ‘No, our experts had not identified that as a problem.’ I was stunned into silence,” del Castillo-Hegyi said. “They told me that lactation consultants are trained to look for convulsions and lethargy. But [by the time those appear], it can already be too late.”
WHO, along with UNICEF, is behind the Baby-Friendly Hospital Initiative, which began in 1991 as an effort to promote breastfeeding worldwide. It now exists in 165 countries and is run in the States by Baby-Friendly USA.
Nearly a quarter of birthing facilities in the United States are designated as baby-friendly. In order for a hospital to receive this certification, it must follow 10 steps, which include a ban on pacifiers and the avoidance of formula or having babies sleep in nurseries unless medically necessary. (The initiative promotes the practice of “rooming-in,” or babies sleeping next to their moms, which can encourage breastfeeding.)
“The Baby Friendly Hospital Initiative snuck into the back door of modern medicine. There is no safety data,” Segrave-Daly said. “When we have a policy, we expect checks and balances. Can you imagine if they would implement a policy in [another field of medicine] and they told us to follow this protocol and there is no safety data?”
At the United Nations-affiliated World Health Assembly this spring, the US delegation reportedly opposed a breastfeeding resolution supported by most other countries. The United States’ motivation remains unclear. It could be that it was at the behest of formula companies, whose sales ostensibly might increase with less breastfeeding promotion. Or it could be that the US delegation is concerned with the well-being of mothers and babies. It could also be both.
Caitlin Oakley, a spokeswoman for the Department of Human Health Services, said in a statement that the “issues being debated were not about whether one supports breastfeeding” but about protecting “women’s abilities to make the best choices for the nutrition of their babies.”
Giving moms choices need not mean skipping the breastfeeding education and handing them samples of formula shortly after birth. In an ideal world, Health and Human Services gets this.
“Fed is Best acknowledges and opposes the history of aggressive and predatory marketing of formula in the developing world. This lead to serious complications for babies who ingested contaminated [by polluted water] and diluted formula,” del Castillo-Hegyi said, adding that Fed is Best has no political affiliation. “However, there are times when formula is necessary and it should be available to mothers.”
The risks of a one-size-fits-all approach
In 2016, pediatrician Joel L. Bass published a paper in JAMA Pediatrics about the increased risk of sudden unexpected postnatal collapse, a condition in which a healthy-seeming newborn stops breathing and often requires resuscitation, at Baby-Friendly hospitals.
The problem, he explains, is that the requirement for skin-to-skin contact between mother and child after birth and throughout the hospital stay can lead to unsafe conditions for the newborn. Postpartum moms are often exhausted and may not be in a good state to safely hold their children.
He has other concerns: The pressure to room-in can pose risks, as it increases the chance that a tired mom will attempt to feed her baby in bed and accidentally drop or suffocate the child. The ban on pacifiers is ill-conceived, considering that research shows they don’t decrease breastfeeding rates, but they do decrease the risk of sudden infant death syndrome.
Lastly, Bass questions the ban on formula, on account of the fact that there is no evidence that formula use early on leads to decreased breastfeeding rates. In fact, studies have found that early formula use boosts breastfeeding rates in the long run by giving new moms a chance to relax and allow their milk to come in.
Since he published the paper, a number of prominent medical organizations have expressed similar concerns. The American Academy of Pediatrics pointed to the risks of mandatory skin-to-skin policies; the US Preventive Services Task Force released a review in which its findings casts doubt on the Baby-Friendly Hospital Initiative’s effectiveness in boosting breastfeeding rates (others have reached similar conclusions), and an accompanying editorial said individualized interventions to encourage breastfeeding are preferable to one-size-fits-all ones like the initiative.
The Joint Commission, an independent nonprofit that accredits and certifies nearly 21,000 health care organization and programs in the United States, released a paper on the connection between breastfeeding practices and infant falls.
In April, WHO announced new guidelines in which it has removed the pacifier and nipple restriction. It also made more room for countries to adopt them as they see fit. “The strict interpretation of how the step should be applied is, in many cases, left more to national discretion than [before],” it says.
“The Baby-Friendly model, while well-intentioned, just didn’t turn out the way they thought it would,” said Bass, who’s optimistic that change is afoot. “These things don’t happen quickly, but I think you can’t escape the increasing data.”
Trish MacEnroe, executive director of Baby-Friendly USA, said she is aware of the concerns, and her organization plans to address some of them at an expert panel it is convening in August. The organization is also considering shifting its approach to training, with an increased emphasis on making sure lactation consultants are skilled at counseling and communication.
“Our message is not a one-size-fits-all message, and there is not a one-size-fits-all answer. I want [lactation consultants] to listen to each and every mother,” MacEnroe said. “Our goal is not to make mothers feel guilty.”
MacEnroe believes that some of the onus for reform is on health care providers, who should continue to make improvements to how breastfeeding support is practiced in their workplaces. “We call upon hospitals to create multidisciplinary committees, tasked with overseeing auditing of the various practices … and finding new ways forward.”
But some doctors wonder whether the Baby-Friendly USA certification is necessary in the first place. Dr. Enrique Gomez-Pomar, a neonatologist who published a critical review of the initiative in the Journal of Perinatology in February, thinks hospitals or even states could provide better breastfeeding support on their own.
He said the roadblocks to breastfeeding in his home state of Mississippi, where women associate breastfeeding as something “poor people do,” are far different from those found in other parts of country. A mandatory, one-size-fits-all approach just doesn’t make sense.
“Mothers are being forced to do stuff they don’t want to do,” he said.
What about the mothers?
Gomez’s concerns for mothers is shared by the Royal College of Midwives in the UK, which changed its guidelines this month to ensure that those who make an informed decision not to breastfeed should be respected.
One would hope that such a statement would be redundant in 2018. But unfortunately in the world of breastfeeding, this isn’t often the case.
I am one of the many moms I know who felt more bullied than bolstered by lactation consultants. As a result, I avoided supplementing in the early days of my first son’s life, despite the fact that my child was screaming and my milk clearly wasn’t coming in. The emotional fallout of this experience was heavy and overcast the first couple of months of our time together. A recent study out of the UK found that unmet expectations surrounding breastfeeding are a major contributor to depression in new moms.
I know that, broadly speaking, women can’t have it all. But perhaps, within the relatively narrow confines of breastfeeding education, we can. Imagine if we were told the whole truth, without judgment, and were given choices to proceed how we see fit. What if we could expect to be supported in our efforts feed our children without the fear that we are putting them, or ourselves, at risk?
About the author: Elissa Strauss writes about the politics and culture of parenthood.