Breastfeeding initiatives can have unintended consequences

By Will Boggs MD

NEW YORK - Successful breastfeeding initiatives can have unintended consequences, some of them worrisome, according to a new report.

"It is standard practice in all modern pediatric centers to support and promote breastfeeding as the preferred method of feeding newborns as the advantages are so well established," Dr. Joel L. Bass from Newton-Wellesley Hospital in Newton, Massachusetts, told Reuters Health by email.

"While breastfeeding itself is beneficial and certainly safe, some of the recently mandated breastfeeding practices and policies introduce unnecessary risk," he said.

Among those unintended consequences, Dr. Bass and colleagues write in a viewpoint article online August 22 in JAMA Pediatrics, are reports of sudden unexpected postnatal collapse (SUPC) in association with the skin-to-skin practice associated with breastfeeding.

This practice, along with breastfeeding exclusivity and 24-hour rooming in, can inadvertently result in a potentially exhausted postpartum mother being persuaded to feed her infant while she is in bed overnight, when she is not physically able to do so safely.

The Ten Steps to Successful Breastfeeding of the Baby-Friendly Hospital Initiative also discourage the use of pacifiers, which may interfere with the development of optimal breastfeeding. Yet the use of pacifiers has been found to protect against sudden infant death syndrome (SIDS).

"Stress, exhaustion and pressure, which some parents may experience in hospitals that rigidly enforce certain practices to comply with certification or regulatory measures, is not helpful and in fact interferes with the natural process of breastfeeding," Dr. Bass said.

"Having said that, there is no doubt that some health care providers have become extremely committed to certain practices and may have a real problem accepting that some of the practices they have promoted may actually cause harm," Dr. Bass said. "However, as with every aspect of medicine we sometimes need to reverse direction."

"In the case of Baby Friendly 10 steps we are facing the added challenge of regulatory and major public health agencies who have committed to some practices which will need to change," he said. "It is our hope that this article will help them understand the need to modify their recommendations in order to safely support their goal to promote breastfeeding."

"Physicians should focus on the importance of supporting breastfeeding mothers safely," Dr. Bass concluded. "We would hope they would advocate for constructive change in public policy to supplement their efforts."

In a related viewpoint essay, Dr. Joan Younger Meek from Florida State University College of Medicine, Tallahassee, and Dr. Lawrence Noble from Icahn School of Medicine at Mount Sinai, New York, acknowledge these unintended consequences while focusing on the benefits of the Baby-Friendly Hospital Initiative (BFHI).

"We universally say that we support breastfeeding, but we need to do a better job of actually eliminating the barriers that women face in being successful at breastfeeding, by better prenatal education, hospital care that supports breastfeeding practices, trained health care providers, breastfeeding supportive workplaces, and paid maternity leave," Dr. Meek told Reuters Health by email.

"We also need to recognize that there are great disparities in our breastfeeding rates, with the African American rates being the lowest," she said.

Studies have linked implementation of BFHI with a 49% increase in exclusive breastfeeding and a 66% increase in any breastfeeding, Dr. Meek and Dr. Noble say.

To reduce the risk of SUPC, they recommend careful observation during the postpartum period, whether the mother is giving skin-to-skin care, breastfeeding, bottlefeeding, or even just holding her infant.

"Mothers who have had cesarean deliveries or who are on pain medication especially need close monitoring," Dr. Meek said. "Ideally, another family member in the room could help to monitor both mother and baby, but if this is not possible, the nursing staff need to be vigilant about checking on these dyads."

"I would want physicians to understand that we can make the changes that provide better maternity care practices that support mothers and babies in breastfeeding, while also making sure that babies receive safe and careful monitoring," Dr. Meek said.

"When the baby leaves the hospital, the mother will be providing the care. The hospital environment provides an opportunity to provide education to the mother about caring for her baby, breastfeeding her baby, and safe sleep for her baby, while there are support staff available," she said.

"Instead of abandoning the demonstrated benefits of the BFHI, promoting safe and effective assessment of babies should complement the implementation of the Ten Steps to Successful Breastfeeding," Dr. Meek and Dr. Noble write.


JAMA Pediatr 2016.

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