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Breastfeeding is a natural biological process that has many benefits for human infants, children, and mothers. The promotion and preservation of successful breastfeeding during the first 2 years of life and beyond is a public health issue that can have long term positive effects on global health and survival, nutrition goals, as well as the economy and environment. In this course we will discuss strategies that nurses can use to promote successful breastfeeding and a baby friendly hospital environment, based on CDC guidelines and other relevant evidence.

Introduction   

While the barrier to breastfeeding vary globally, in the United States, there were several generations of mothers and babies where the full benefits of breastfeeding were not known and formula feeding was advertised an an equal or superior option. This, along with a rising number of hospital births and increased interventions that interfere with first feedings, created a sort of loss of “the village” of support that helped women breastfeed successfully, and significant effort has been required to repair this breach in a biological norm over the last few years.

As more and more evidence has emerged about the benefits, both long and short term, of breastfeeding, there has been a shift in focus surrounding the newborn period and goals to return babies to their mothers and foster successful breastfeeding relationships has become the forefront of maternal/infant healthcare (1).

We now know that what takes place during an infant’s first hours of life and how the first few feedings are approached has a substantial impact on the overall success and longevity of the breastfeeding journey (10). When possible, immediate skin-to-skin for baby and mother and an uninterrupted attempt at first feeding within the first hour of life should be prioritized over any routine care of the infant, visitation with other family members, or other unnecessary or non-time-sensitive hospital interventions for mother or baby.

Because of varying levels of education among staff and differing protocols that were previously in place, the Baby-Friendly Hospital Initiative was developed to help standardize and maximize best care of newborns and promotion of successful breastfeeding across the world (10).

Upon completion of this course, the reader will be able to:

1. Recognize the global implications of successful breastfeeding on health, the economy, and the environment
2. Discuss the current recommendations for exclusivity and longevity of breastfeeding
3. Recognize the steps to implementation of the Baby-Friendly Hospital Initiative (BFHI)
4. Discuss the implications of the International Code for Marketing Breast-Milk Substitutes (ICMBS) and
5. Understand how to protect and promote successful breastfeeding relationships as a healthcare provider.

Current Practice

The mid 20th century saw the rise of hospital births as the safest and preferred way to give birth in developed countries and, at the same time, human-milk substitutes like formula gained popularity and were marketed as easy, convenient, “trendy,” and even superior to breast milk. With a higher than ever number of women giving birth in hospitals and feeding their babies formula, babies and mothers were often separated after birth, with babies staying in the hospital nursery for long periods of time and receiving feedings from nurses or other family members. This also mirrored the rise in feminism, and formula gave women more opportunity to be present outside of the home.

Even if a mother still chose to breastfeed, it was believed at the time that babies should be weighed, examined, bathed, and swaddled immediately after birth, often then being handed off to another family member so that the mother could “rest.” Many of these practices were not based off of any science at all and, unknowingly, many barriers to successful breastfeeding were created (1,5).

In the late 80’s and early 90’s, scientists began really exploring the benefits of breastmilk and the breastfeeding bond and a shift towards breastfeeding education and returning mothers to this natural form of feeding began. Many leaders in healthcare recognized that those first few days of life in the hospital would need a major overhaul if breastfeeding goals were to be met, and in 1991, through the efforts of World Health Organization (WHO) and United Nations Children’s Fund (UNICEF), the Baby Friendly Hospital Initiative was born (1).

In over 3 decades since it began, the 10 step process (along with recommendations for the marketing of breast-milk substitutes) has created more than 20,000 Baby Friendly hospitals/birthing facilities across 150 countries (1). More than 28% of births in the United States take place in a Baby Friendly hospital each year, and this number only continues to grow (1).

With educated staff members equipped to provide patients with the help and information necessary to create confident mothers, these Baby Friendly facilities have helped increase the national rate of breastfeeding initiation (83.9% in 2019), continuation at 6 months (56.7%), and 12 months (35%). While these numbers still have a long way to go to reach WHO and UNICEF goals, they are increasing steadily and are overall significantly higher than even just a few years ago (4). In 2009, for example, the rate of breastfeeding initiation was 76.1%, continued breastfeeding at 6 months was 46.6%, and at 12 months the rate was 24.6% (3).

Each year, evidence on breastfeeding outcomes supports the continued implementation and maintenance of the Baby Friendly Hospital Initiative.

Global Implications: The Benefits of Breastfeeding

It is widely known that “breast is best,” yet many people do not understand the full extend of just how powerful a substance breastmilk truly is. This unique human product is custom made for each individual infant, providing them with the exact nutrients, calories, antibodies, and other ingredients necessary for optimum health, growth, and development. It provides infants with the energy and nutrition needed for not only physical growth, but also neurological growth. It helps prevent hunger, undernourishment, and obesity (8).

Breast milk contains antibodies and immune properties that keep infants healthy and help prevent serious illness and even death during the first few years of life. Half of diarrhea illnesses and a third of respiratory infections in infants are due to inadequate breastfeeding and it is estimated that improved breastfeeding practices globally could prevent 820,000 childhood deaths per year (8).

Breastfeeding up to 12 months of age could reduce childhood obesity by 13% and type 2 diabetes by 35% (8). It is also known that breastfeeding has maternal benefits and duration of breastfeeding is inversely related to the occurrence of breast cancer in mothers. WHO estimates that 20,000 breast cancer related deaths could be prevented each year by increased breastfeeding rates (8).

In addition to the astounding health benefits of breastmilk, there are many economical benefits of increased breastfeeding rates. Women who formula feed their infants are absent from work more often than their breastfeeding counterparts due to increased rate of illnesses in their children. This not only decreases their productivity at their jobs, which is money lost for the company, but has a negative impact on their family income.

Healthcare costs are also increased for these mothers as they seek more frequent acute care for their children (8). Long term neurological benefits in breastfed children has been shown to create more productive and higher-earning adults as well; a study in Brazil showed that income was 33% higher for adults who were breastfed for at least 12 months as children compared to those with less or no breastfeeding (9).

Baby Friendly Hospital – “Environmental Impact”

Environmentally, breastfeeding is also the best choice for infant feeding practices, as it is a non-polluting, sustainable, and natural food source for infants. The production, distribution, and use of formula creates greenhouse gases and waste on a very large scale (8).

With all of these benefits combined, the global impact of widespread breastfeeding is huge and demonstrates without question the need to promote and protect breastfeeding for all women and their infants.

The Baby Friendly Hospital Initiative: Standards for Hospitals and Birthing Centers to Improve Breastfeeding Goals

It is well known that the first few hours and days of an infant’s life are the most crucial time for establishing a successful breastfeeding journey. With a majority of babies being born in hospitals or birthing centers, the standards of care and the support of staff play a critical role in a mother’s experience both in the early period of breastfeeding and long term. The Baby Friendly Hospital Initiative is a 10 step plan designed to standardize breastfeeding support and care in maternal-infant health care settings and help reach worldwide breastfeeding goals.

Have a Written Breastfeeding Policy.

​The first step of the Initiative is multifaceted. Facilities must have a written policy regarding breastfeeding practices and this policy must be frequently communicated to both staff and patients; it should be well-integrated into the culture of the facility. Specifically, it is recommended that 80% of staff can identify at least 2 components of the Initiative upon random questioning (10).

The details of the policy should be evidenced-based and align with current WHO and UNICEF recommendations, as well as support their goals. The policy must comply with the International Code of Marketing of Breast-Milk Substitutes (which will be discussed in more depth later on).

And finally, the policy must outline how data will be collected to track the progress of the program and how adjustments to implementation will be made accordingly. WHO specifically requires that facilities track rates of breastfeeding initiation and the exclusivity of breastfeeding during the hospital stay (10).

Train Staff in Skills Needed to Effectively Implement the Policy.

The goals of the facility’s policy can only be accomplished if the staff on the frontlines of patient care are well trained, knowledgeable, and effective educators and supporters of breastfeeding.

Training is important to ensure that all staff members give consistent messages and it helps streamline a patient’s experience even with changing shifts and a variety of staff members encountered during one hospital stay. Staff should be educated on basic communication techniques, facts about breast milk and breastfeeding, the proper way to assess a feeding, how to adjust and suggest changes during a feeding where mother or baby is struggling, and help troubleshoot common breastfeeding issues/concerns (10).

Discuss the Benefits of Breastfeeding with Pregnant Women and Their Family Members.

​In order to make the most informed decision about infant feeding, women should be given information and education about breastfeeding before the baby is born. They should be given time to explore options, ask questions, and think about their choices before the monumental event of birth has occurred. For birthing facilities that also manage antenatal care, information on breastfeeding should be added to prenatal visits early on. For facilities that do not provide any prenatal care, staff members should branch out into the community and work with local clinics and primary care settings to strengthen their prenatal breastfeeding education (10).

This counseling should be tailored to each patient and family and any unique circumstances they may have. Ideally, the first infant feeding discussion would be during the first trimester so that there is still plenty of time to answer questions or revisit the topic as desired by the mother. One-on-one discussion, written information or pamplettes, and the option for classes or support groups should be included (10).

Mothers and families should be educated on the benefits of breastmilk on health, growth, and development for baby as well as health benefits for the mother. They should also receive information about feeding cues, the importance of initiating feeding within the first hour of life, skin-to-skin contact, and other important points that mothers may wish to include in a birth plan (10).

Facilitate Immediate Skin-to-Skin Contact After Birth and Encourage Initiation of Breastfeeding Within the First Hour of Life.

​Babies should be placed prone on their mother’s chest immediately following delivery and this contact should be uninterrupted for that first hour of life whenever possible (10). Skin-to-skin contact helps to regulate temperature, heart rate, and breathing for baby and is shown to maximize oxytocin release and bonding for both mother and baby (2).

Preterm or low birth weight infants, who are at particular risk of poor temperature regulation, benefit greatly from this practice. The current standard after cesarean delivery is for baby to be placed under a warmer until surgery has concluded, however emerging evidence indicates that as long as mother and baby are medically stable, skin to skin immediately after delivery should still be implemented and maintained that same beneficial effects as skin to skin after vaginal delivery. This practice increased mother-satisfaction with the birth experience after c-section as well (2).

Not only does this close contact assist with body temperature regulation, but it also increases oxytocin secretion and milk production, and facilitates early initiation of breastfeeding. The nutrient-rich colostrum baby receives during the first few feedings is full of important antibodies and gives the baby health benefits beginning almost immediately after birth if first feeding is not delayed. There is very little actual volume received, but frequent feedings and nipple stimulation will eventually lead to mother’s full milk volume coming in (10).

Show Mothers How to Initiate and Maintain Breastfeeding and How to Navigate Common Barriers. ​

While a natural process, breastfeeding does not always come naturally to infants or mothers and practice is needed as the two get to know each other. Practical support of mothers through information, demonstration, and encouragement/emotional support is very important to the success of breastfeeding. Specific topics to educate mothers on include feeding cues, positioning baby, hand expressing milk, nipple care, and signs of an adequate feeding/satisfied baby (10).

Do Not Give Breastfed Babies Food or Drink Other Than Breastmilk, Unless Medically Indicated. ​

Frequent feeding during the first few days and weeks of life is imperative to establishing milk supply; the more the baby is at the breast, the more a mother’s body is stimulated to make milk. If a baby is given supplements, such as formula, then a feeding at the breast is missed and milk supply may suffer. There are also no foods nutritionally superior to breastmilk during the first 6 months of life.

There are a few medically indicated circumstances when formula or supplementation may be recommended for the baby’s health, but these situations are rare and should be determined by a pediatrician or provider directly overseeing baby’s care (10). Severe breast milk jaundice, true inadequate milk supply, or an allergy or intolerance to breast milk that does not resolve with maternal dietary changes. Poor staff knowledge, limited resources, and limited staff time are not good excuses to recommend formula (10).

Practice Rooming-In and Minimize or Eliminate Separation of Mothers and Babies.

Infants and their mothers should be in the same room as each other day and night following delivery. This allows bonding and helps mothers to learn to recognize feeding cues and respond quickly when the baby indicates hunger.

Recent evidence suggests that mothers who practice rooming in have a greater milk supplier earlier on, have longer duration of breastfeeding, and higher rates of breastfeeding exclusivity than mothers who were separated from their infants. These women felt more empowered at discharge and had more positive feelings and fewer negative or depressive feelings about their breastfeeding experience as well (5).

If babies and mothers do need to be separated during a routine stay, this separation should be limited to one hour. There are of course situations when rooming in is not possible, such as when baby or mother are ill or unstable following delivery. However, the routine use of nurseries to give mothers time to rest or to assess and vital infants should no longer be part of maternity wards (10).

Encourage Feeding On-Demand and Help Mothers Recognize Feeding Cues. ​

Frequent and spontaneous breastfeeding is imperative to establishing a good milk supply and mothers should be encouraged to feed their babies whenever they are giving cues of hunger, rather than restricting them to a schedule. Breastfed babies cannot be overfed and should be allowed access to the breast on an as desired basis. Early recognition of feeding cues is important as well, as babies latch more easily and are less frustrated when they are not in distress. Cues such as rooting, sucking on hands, and licking lips should be responded to before infants start crying, which is a late hunger cue (10).

Discourage the Use of Artificial Nipples, Bottles, and Pacifiers. ​

During the first few days and weeks of breastfeeding, when good habits are being established, the use of artificial nipples should be discouraged. Once breastfeeding is well established, there are no strong opinions on restricting them, but until that time they should be avoided. Pacifier or bottle use can lead to reduced nipple stimulation and resulting poor supply, confusion for babies regarding the proper method of sucking to receive milk, increased hygiene risk, masking or unknowingly “holding-off” hunger cues (10).

Coordinate Outside Support Groups and Services So That Mothers and Babies Will Have Continued Support Upon Discharge. ​

Excellent support and care during hospital admission for mother and baby will mean little if there is no continued support upon discharge. Breastfeeding relationships change as baby grows and matures, new problems may arise, mother may become exhausted or lack confidence, and the best solution for almost all of these issues is a good support system. Mothers should be given information on where to call or go for professional lactation services as well as support groups or meetings with other lactating mothers. Follow up phone calls or appointments within the first week of discharge are strongly encouraged (10).

The International Code of Marketing of Breastmilk Substitutes

Throughout the BFHI, it is discussed that formula or other substitutes should not be given to breastfeeding babies unless medically indicated. However, in a capitalist society where marketing goals are to draw in as many customers as possible, no matter the health risks of the product involved, it was quickly realized that the way formula was advertised and viewed in our society created many barriers to successful breastfeeding.

An exhausted and insecure mother trying to breastfeed her crying baby in the middle of the night might be looking through her feeding information from the hospital and see a pamphlet of a peacefully sleeping baby being laid in a crib while the mother sets aside an empty formula bottle and think “That looks much better than what I am doing here!” Or a new mother may wonder, “If breast milk is so good for my baby, why did my pediatrician’s office give me this sample basket of formula?”

To combat these potential issues, WHO created the International Code of Marketing of Breastmilk Substitutes which places restrictions on formula companies and any facility wishing to achieve Baby Friendly status.

The ICMBS mandates that (2):

1. Participating facilities may not advertise formula or other breast milk substitutes.

2. Healthcare facilities may not give free samples or supplies related to bottle feeding.

3. Facilities cannot give free or low-cost formula.

4. Marketing personnel cannot contact pregnant or breastfeeding mothers through mail, shopping displays, direct contact, or other means to offer samples, products, or information about formula.

5. Formula companies cannot offer gifts or free samples to healthcare workers.

6. Advertising for formula cannot contain words or pictures idealizing infant feeding.

7. Information provided to healthcare workers about formula should be science and fact based only. Marketing cannot play on emotions.

8. All labels on formula must contain a disclaimer about the costs and hazards of artificial feeding in comparison with breastfeeding.

9. Products must be FDA approved for quality and safety.

10. Products must include storage and safe preparation information on labels.

Widespread Promotion of Breastfeeding

In addition to adherence with all of the above criteria, healthcare workers caring for lactating women and their children are encouraged to embody an overall supportive and enthusiastic attitude when it comes to breastfeeding.

They should aspire to generate a widespread understanding and acceptance of breastfeeding, help to correct misconceptions, and normalize a very natural biological process.

They are recommended to do this through attitudes, actions, words, and even by supporting breastfeeding-friendly legislation when possible.

Case Studies

Beth is a 24 year old first time mother who is admitted to the hospital in active labor. Beth has received regular prenatal care and has had an uncomplicated pregnancy. She knows a little bit about breastfeeding but no one has really discussed it with her at her prenatal visits besides giving her a few pamphlets. She has a friend who breastfed for 6 months but her mother and two sisters all formula fed their infants so she has few breastfeeding resources. Still, she has decided she would like to try it.

Due to some complications and failure of labor to progress, she is taken to the OR for a c-section. After delivery, the baby is placed under a warmer, dried, swaddled and brought over for Beth to see as her surgery is being completed. The father holds the baby until they are all taken to a recovery room. Family members come in to see and hold the baby and after about 2 hours, Beth thinks the baby seems hungry and she would like to try breastfeeding.

Her nurse has not received any training about breastfeeding since an initial refresher when she was hired to the unit 2 years ago, but together they manage to get the baby to latch and after 15 minutes of feeding, the baby seems satisfied and falls asleep.

Mother and baby have several more successful feedings over the next few hours. That night, an exhausted Beth puts on her call light to ask the nightshift nurse for help as the baby has been crying for nearly an hour and cannot be set down. The baby is frantic at the breast, rooting but refusing to latch for more than a few seconds at a time.

The nurse suggests offering an ounce or two of formula to help calm the baby, reassuring that everyone will be much happier if they can just get some sleep. Exhausted and discouraged, Beth agrees. The baby takes 2 oz of formula from a bottle and falls asleep, content. In the morning, Beth is back to breastfeeding on demand, approximately every 2 hours, and things go fairly smoothly.

By afternoon, Beth would like to take a shower. When she come out after 15 minutes, the baby’s father says that baby was crying and seemed hungry but he held her off with a pacifier.

When the new parents and baby are ready for discharge, they are sent home with a basket of sample formula given to all new babies.

At the baby’s first pediatrician appointment 2 days later, Beth has lost a lot of her confidence and admits that she has been giving formula from the sample basket in the night when she feels the baby is getting up too often. She is referred to a lactation consultant for further help with latch and feedings and her pediatrician gives her a list of local breastfeeding support groups.

The baby gains weight well and is still most often breastfed over the next 3 months, with 1-2 formula supplements per day. By the baby’s 4 month well child check, Beth is back to work and has lost a lot of her supply due to infrequent pumping and has decided to wean and switch to all formula.

While Beth did have a few months of breastfeeding with her baby, this case study is far from an ideal situation and fell short of WHO’s goals for breastfeeding duration and exclusivity. There are many places in this case where interventions from the BFHI could have resulted in more favorable outcomes, starting with her prenatal education. It is indicated that Beth wants to breastfeed but does not feel that she has much knowledge or support, giving her a very shaking foundation to start.

Conversations with her obstetrics provider at any of her prenatal appointments, local classes, and contacts for support groups would go a long way to increase Beth’s preparedness and confidence before the baby is even born. While her c-section was unplanned, a birth plan that included immediate skin-to-skin (or better yet, a hospital that integrates this automatically) would have improved bonding, first feeding, and milk production for Beth and is entirely possible, even with a c-section delivery.

This lack of skin to skin also delayed the timing of the first feeding which should ideally be within the first hour. Properly trained staff could have helped compensate for these issues and helped Beth feel confident in her breastfeeding knowledge and practical application as well as helped her learn to read baby’s cues. Staff that suggests formula is is never acceptable and likely did quite a bit of damage to Beth’s confidence level, making her feel that her milk supply or feeding technique is poor enough that she needed a supplement. Recommending formula should only be done by a provider in a medically indicated situation.

The use of pacifiers and a gift of formula just further complicate the situation. The referral to a lactation consultant and support groups, while a good effort by her pediatrician, is delayed from the recommendation and Beth should have already been set up with these resources before leaving the hospital.

If this facility did ever wish to become a Baby-Friendly institution, they would need to first look at scenarios like this as they are collecting data and forming their policy to see where they are going wrong and how they can better support their breastfeeding mothers and infants. Each of these mistakes do not seem like very large issues individually, but when compiled into one entire experience for a new mother, it is a recipe for failure.

Moving Forward: The Future of Breastfeeding & Baby Friendly Hospital Environments

Evidence continues to support the Baby Friendly Hospital Initiative and its success is demonstrated in the increased number of mother’s initiating breastfeeding, as well as longer averages of breastfeeding duration.

Reports suggest that the Initiative has had a positive impact on women in disadvantaged groups as well; racial minorities, low SES, rural location or poor access to healthcare, etc (6). It is well documented that the training level of healthcare professionals working with lactating mothers is directly related to the overall success of the program, therefore current and continued staff training is paramount (6).

Since its inception in the late 80s/early 90s, the BFHI has made a profound impact on the care of breastfeeding infants and their mothers as well as the staff who care for them. But the work is far from over.

WHO goals continue to push for even more facilities to join the BFHI and for even greater increases in the number of infants breastfed at birth, 6 months, 12 months, and beyond. With so much potential for global health from one biological act, it is easy to see why so much emphasis has been placed on the promotion, protection, and support of breastfeeding.

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