A Proposal for Policy Makers Implementing Baby-Friendly Care

As of January 2014, the Joint Commission mandate requires U.S. hospitals to measure exclusive breastfeeding. Unquestionably, feeding babies only breastmilk ranks highest of Baby-Friendly practices associated with exclusive breastfeeding postdischarge. Yet, the best strategy to implement the 10 Baby-Friendly Steps must take into account the diverse needs of all mother–infant dyads, including the most obviously vulnerable (such as preterm infants), as well as those one does not even suspect there may be a problem. Here is a proposal, not yet validated, but reasonable and based on current research and described in greater detail in an earlier publication in Breastfeeding Medicine. ¹

The success of this proposed plan (or any effective implementation plan) must include three ingredients: prevention, availability, and sustainability. Although this may sound intuitively obvious, these ingredients run counter to conventional practice.

1. Prevention. What must we prevent? Two major problems: the first is sending mothers home who will not produce enough milk to feed their babies; the second is sending babies home who risk complications related to not getting enough breastmilk.

A robust milk supply is the single most important factor affecting duration and exclusivity of breastfeeding in every population. Milk production is highly time sensitive and depends on the early, frequent, and effective removal of colostrum, beginning in the first hour. Early milk removal “programs the breasts,” if you will, and determines a mother's milk production potential, even up to 8 weeks later.

For example, a mother who expresses milk within the first hour after birth not only expresses four times more than the mother who begins in hours 2–6, but she will produce 130% more milk by the third week. ² With, insufficient milk production being the most common reason for mothers to discontinue breastfeeding earlier than planned, the first key ingredient of the plan is prevention, as opposed to what now currently occurs—delaying interventions until problems develop.

2. Availability. Very quickly, little problems, perhaps unrecognized, become big problems, less remedial and more time-consuming to fix. Every mother needs skilled, accountable bedside help around the clock. Our current practice relies heavily on episodic, problem-oriented, specialized care (by a lactation consultant) for only a restricted number of beneficiaries. This may result in too few doing too little too late.

3. Sustainability. Breastfeeding support, especially early on before problems get too far downstream, can be simplified and relatively easy to teach and learn. Yet, there is the misperception among professionals (nurses and doctors) that breastfeeding support is complicated and complex. With a paradigm shift, nurses can be elevated to skilled providers of critically important care, and lactation consultants can leverage their contribution to successful breastfeeding outcomes by training the bedside nurses. With daily usage of these skills, nursing competence increases, and the time required from the specialist and the need for formal training are reduced.

So, respecting the constraints of time, skills, and hospital resources, I would like to suggest a three-step plan for implementing Baby-Friendly bedside care for each and every dyad from the moment of birth:

1. Adopt a basic Baby-Friendly Hospital breastfeeding policy along with consensus and commitment among the providers and stakeholders to implement steps 2 and 3.

2. Provide bedside nurses a focused, streamlined curriculum with core competencies that are critical only to the first 3 days. An organized approach, focusing on three objectives, has been referred to as the A,B,Cs of breastfeeding. The simple mnemonic “A, B, C” can be used to remember the three main objectives: A=attachment (assisting a mother–baby dyad with breastfeeding); B=breastmilk production (the American Academy of Pediatrics and the World Health Organization recommend hand expression as a simple, risk-free technique for every new mother to stimulate production, relax the pressure on perfecting the baby's skills, and soften and empty the breasts when other options are less effective or unavailable); and C=caloric/nutritional parameters (simple indicators of normal and adequate intake).

3. Conduct daily bedside rounds with the three key participants (mother, her bedside nurse, and a lactation consultant). The daily tutoring of nursing skills cultivates competence and accountability. This is the lynch pin for the sustainability of the plan.

During these rounds, the focus is on the A,B,Cs. Participants determine what skills require additional tutoring and how, where, and by whom this instruction will be offered. This could include the lactation consultant teaching the bedside nurse how to help the mother, offering the mother a group breastfeeding class taught by both nurses and lactation consultant/specialists, or visual aids. Here is an opportunity to utilize new technologies. Although educational videos have traditionally been a keystone in training staff and mothers, more sophisticated interactive electronic simulation tools need to be developed. Such tools, similar to those used to train cardiac surgeons, obstetricians, and paramedics, could assist nurses with teaching new mothers the “A-B-Cs” of breastfeeding in a focused, culturally sensitive way.

In summary, we need a critical mass of skilled, accountable bedside nurses to maintain a preventative, available, and sustainable program to allow the magic of Baby-Friendly care to flourish. With the momentum for hospitals to adopt Baby-Friendly practices, this is the perfect time for a bold change.