Your Responses

I am a midwife with privileges at a BFI hospital. I am disappointed to see excessive amounts of formula being fed to term babies with and without risk factors for hypoglycemia. My most recent experience was a term baby with several risk factors and who demonstrated initial hypoglycemia, who was given 28 mL formula every two hours after delivery until blood sugar stabilized. The baby's mother was instructed not to put the baby to the breast, despite her desire to breastfeed and ability to independently latch the baby. The parents were instructed to keep the baby wrapped up rather than placed skin to skin and the mother was not supported to stimulate the breasts through hand expression or pumping at this time. This approach, which favours excessive amounts of formula over evidence-based interventions such as skin to skin or breastfeeding support in favour of long term infant feeding outcomes, does not account for neonatal physiology, CPS guidelines, or parent choice about infant feeding.

This is not the only experience I have had of nursing staff at this hospital practicing non-evidence based and non-breastfeeding friendly practice. The unit protocol for monitoring of hypoglycemia (which is applied to LGA, SGA, IGDM, and any babies who experienced significant resuscitation, ie. more than 20% of infants) maintains that parents are not to feed babies when they are demonstrating hunger cues, but to wait until after the nurse has taken the baby's blood sugar (every 2 hours). This is contrary to the CPS guidelines on hypoglycemia, which recommend that "frequent (on demand) breastfeeding should be encouraged for at-risk infants, and, if they are being formula-fed or supplemented, the volume of enteral intake should be adjusted based on an infant’s size, chronological age, and gestational age." I hope that BFI will investigate and revoke their status if they are not found to be upholding the expected standards.

- 2020-07-02

Our Response

Thank you for your submission. It is wonderful to hear of your knowledge and support of the Baby-Friendly Initiative and there are certainly many important reasons for not giving supplements to any baby unless there are medical indications. Putting baby skin-to-skin immediately after birth until at least the end of the first feed or for as long as the mother desires, feeding on cue, and keeping mother and baby together can go a long way in preventing hypoglycemia in newborns by minimizing crying, keeping baby warm and enabling responsive, cue-based feeding. If the baby is unable to feed effectively, it is important for mothers to be able to hand express their colostrum for their baby. It is the best supplement!

Step 2 of the BFI 10 Steps and WHO Code Outcome Indicators for Hospitals and Community Health Services states: Ensure all staff, health care providers and volunteers have the knowledge and skills necessary to implement the infant feeding policy. BFI designation is based on outcomes that are measured during an External Assessment by a team of qualified assessors. Facilities are expected to maintain practices that are consistent with the Ten Steps and submit a BFI Interim report that describes any changes in practice and current breastfeeding rates every 2 years. BFI designation is valid for 5 years.

Although a facility achieved BFI designation at a point in time, sometimes practices change for a variety of reasons. One common reason is staff turnover and practices that are not evidence based can start being introduced (or reintroduced).  Delayed orientation, a lack of continuing education and refreshers, and even employee self appraisals and the development of learning goals all play a role in maintaining the implementation of BFI practices. It sounds as if you are a great advocate for your clients and it can be very frustrating when mothers are given care or information that hinders their ability to breastfeed exclusively.

The goal of BFI is to have a minimum standard of care that is improved over time. To maintain BFI designation, a healthcare facility must be assessed every 5 years.  It sounds as if the hospital you are working in has a great core of people that are passionate about providing the best standard of care for their patients. We suggest that you share your concerns with them and perhaps even consider becoming involved in a BFI workgroup or committee at the hospital. You would be a valuable addition and could help make a positive impact on the care perinatal patients receive.

The Provincial Authority for The Baby-Friendly Initiative

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