Our Comments on New Postnatal Care Guidelines from NICE

We recently commented on new postnatal care guidelines that are being developed by NICE (National Institute for Health and Care Excellence). We read through many pages of evidence reviews and supporting documents and submitted extensive comments, which can be read below. You can join us in discussing the guidelines on Twitter.

Guideline: People have the right to be involved in discussions and make informed decisions about their care, as described in NICE’s information on making decisions about your care. Parents and carers have the right to be involved in planning and making decisions about their baby’s health and care, and to be given information and support to enable them to do this, as set out in the NHS Constitution and summarised in NICE’s information on making decisions about your care.

Comment: We question whether infant feeding guidelines are in line with the principles of shared decision making and making informed decisions. All families are not being given all information on different feeding methods. Your own evidence review (T) showed that women want information on formula feeding antenatally, but the committee disregarded this, concluding that it was ‘not feasible’ to give all women information on formula. Another evidence review (S) showed that women ‘appreciated the flexibility of mixed feeding’, but there is no guidance relating to it here. Indeed, the feeding guidelines are divided into ‘Breastfeeding’ and ‘Formula Feeding’, which doesn’t represent the lived reality of most families in the UK, who do both or switch at some stage.

While the guidelines touch on some breastfeeding complications, parents are not being told how common these are or how severe they can be. A recent review of the literature, which sought to quantify the health effects of different infant feeding methods, calculated that for every 71 exclusively breastfed babies, one is readmitted to hospital in the first month of life, primarily due to dehydration, failure to thrive, excessive weight loss or hyperbilirubinemia (Wilson and Wilson, 2018). They also calculated that for every 13 exclusively breastfed babies, one loses greater than 10% of their birthweight. While it is unclear how these numbers needed to harm calculations apply in the UK context, we know that infant readmissions for feeding complications and jaundice more than doubled between 2006 and 2016 (Keeble and Kossorova, 2017). Parents are told none of this.

Parents are not being told that, as your research uncovered (Evidence Reviews P, Q, R, S), there is scarce evidence for what interventions work to resolve breastfeeding problems and so there may be no solution to their problem. On the contrary, we were told that if we got the right support we would be able to breastfeed. This led some of us to spend money on lactation consultants (often midwives or health visitors who also hold NHS roles), only to be advised to see cranial osteopaths, have tongue-ties cut privately or have repeat visits with the lactation consultant without effect. There is a considerable industry happy to take parents’ money to provide ‘breastfeeding support’. Our healthcare professionals have a duty to inform us about the evidence base for any recommended supports they give and a realistic appraisal about the likelihood of their effectiveness and what risks they might involve.

Finally, parents are told about the benefits of breastfeeding without a true picture of the state of the evidence. They are not told that many of these benefits draw from correlational studies rather than experimental research, which can establish causal relationships between health-related behaviours (e.g. infant feeding method) and health outcome. We would like to see figures for absolute benefits and risks of each feeding method (only where there is evidence of a causal relationship) and an honest appraisal of the uncertainties in the current literature. We would also like to encourage open and frank discussion about the ways that families navigate feeding babies, including sharing feeding responsibilities between parents and with other family members. This may be particularly pertinent where sleep deprivation is a particular risk (e.g. for parents with a vulnerability to mental illness).

Before transfer from the maternity unit to home care:

Observe at least 1 effective feed.

We would like to see evidence for the effectiveness of infant feeding observation schedules at detecting and promoting suitable interventions to prevent feeding-related difficulties, including insufficient intake, insufficient breast drainage, low supply, excessive weight loss, poor weight gain, jaundice, hypoglycaemia, hypernatremic dehydration, breastfeeding-related pain, mastitis, prolonged feeding times, overly frequent feeding and any other relevant physical and mental health factors impacting babies and parents.

Arrange the first postnatal visit by a midwife to take place between 12 and 36 hours after transfer of care from the place of birth or after a home birth.

We point the committee to the fact that infant readmissions for jaundice and feeding complications more than doubled between 2006 and 2016 (Keeble and Kossorova, 2017). Many of our babies were readmitted for complications from under-feeding after we were encouraged and supported to persist at exclusive breastfeeding in hospitals practicing the Baby Friendly protocol. We question whether the safeguards in these guidelines, such as timing the first midwife home visit to potentially 36 hours after discharge, are enough to prevent babies suffering unnecessarily from excessive weight loss, dehydration, jaundice and other complications of under-feeding.

We advocate for clearer guidance as to the content of this visit, preventative measures taken, including weighing babies, and how best to use this visit to prevent adverse outcomes, such as readmissions to hospital as a consequence of under-feeding, or excessive maternal stress and sleep deprivation because of feeding difficulties.

We also advocate that parents be told how to supplement breastfeeding with formula, should they be worried that their baby is not getting enough milk. Some of us had the experience of babies becoming extremely hungry in this time period and were advised that frequent crying and feeding is normal. Our healthcare professionals offered ‘reassurance’ that amounted to little more than encouraging us to ignore our instincts and our babies’ communication that they were still hungry after frequent and long breastfeeds. This caused immense distress to us and to our babies. In some instances, we were to learn that our babies had not been getting sufficient milk, resulting in admissions to hospital.

It seems reasonable to us to inform parents how they can supplement breastfeeding with formula feeding, should they feel it is necessary or something that they might wish to do so, and that this does not need to spell the end of breastfeeding. Reassuring data suggests no association between modest formula supplementation and the timing of breastfeeding cessation (Flaherman et al., 2019b). Other data suggests that mothers who perceive themselves to have low milk supply are more likely to have biological markers of insufficient milk supply (Murase et al., 2016).

We would be interested in the committee’s opinion as to whether the risks of supplementing if a mother misperceives low milk supply are greater than the risks of not supplementing if she correctly perceives herself to have low milk supply. Our perspective as mothers is that it is wholly unacceptable for a hungry baby to wait for milk and that we should know how to supplement breastfeeding with formula in the event of suspecting our babies are not satisfied with breastfeeding alone. We believe this would reduce maternal stress and lead to a more relaxed, enjoyable and sustainable approach to breastfeeding. Most importantly, it would prevent our babies suffering from hunger because we have been advised to persist with exclusive breastfeeding regardless of our baby’s hunger cues. Indeed, we question how encouraging mothers to doubt their perception about their baby’s hunger can possibly be considered ‘responsive feeding’.

Communication with Women

While we acknowledge that aspects of this provision relate to healthcare of the postnatal woman and should be addressed to her, we wish to point out that for many of us, caring for the baby in the early days and weeks was a responsibility shared with our partners. Therefore, we suggest that this section would relate more to the realities of UK families and be more inclusive if it was about communication with families or parents, rather than with women. The focus on women here seems to perpetuate a position where caring for the baby, especially feeding, is the primary responsibility of the woman.

Information should support shared decision making and be:

Individualised and sensitive

As parents who fed our babies in different ways, we do not find the guidelines on infant feeding to be individualised or sensitive. The implication is that exclusive breastfeeding is something that should be ‘encouraged’ by healthcare providers.

Your evidence review (Q) showed that many families are finding ways to ‘share the load’ by bottle feeding, which chimes with the experience of many of our members. We feel that the guidelines and the evidence reviews, by suggesting parents need to be informed on other ways partners can bond with babies and ways to avoid introducing formula, in fact undermine and stigmatise the way families are choosing to manage the demands of caring for a small baby by sharing feeding. This cannot be seen as personalised care.

We would like to see consideration of a wider range of possibilities for feeding babies. For example, expressing milk for some feeds or feeding a baby a combination of formula and breastmilk. Although the current advice is to avoid giving any formula to a breastfed baby, this is not advice that the majority of families follow. One recent study suggests that the addition of a modest amount of formula is not associated with earlier breastfeeding cessation (Flaherman et al., 2019b).

Families need to be aware of all methods available to them and to feel able to attend to their own needs and values (e.g. for sleep, to reduce stress, to have a break, to share responsibilities, fulfil responsibilities to other children or family members, or pursue personal interests) and to make decisions that best meet their particular needs.

Information should support shared decision making and be:

Evidence-based and consistent

This matches what we found when searching the literature. The latest Cochrane review for managing breastfeeding-related nipple pain found insufficient evidence to make recommendations (Dennis et al., 2014), and we were unable to identify any similar review of interventions to manage difficulties with latching or maternal report of low milk supply.

The guidance on practical support seems to rely heavily on Baby Friendly Initiative (BFI) guidelines, even though your own quality assessment (Evidence Review F) found that these guidelines did not score highly, e.g. ‘Recommendations are quite vague and different options are not discussed’. In general, the guidelines reviewed in your search ‘scored poorly (<70%) in the “applicability” domain’ (Evidence Review F). Therefore we question whether the infant feeding guidelines here can be truly considered ‘evidence-based’ and whether they can be practiced consistently.

The lack of evidence that breastfeeding support and interventions can prevent or resolve common breastfeeding problems must be transparent to women. Only then can they make an informed decision about whether to avail themselves of these services. Healthcare workers must be honest with us about the uncertainty as to how effective this advice is likely to be at resolving breastfeeding-related problems or helping to make breastfeeding a sustainable long-term way to feed a baby.

Additionally, acknowledgement ought to be made of the full range of families’ feeding experiences and the variety of ways families navigate sharing early infant care. This would include how some sustain exclusive breastfeeding if desired and how others find mixed feeding or formula feeding more suited to their families’ needs.

At each postnatal contact, ask the woman about her general health and whether she has any concerns…Topics to discuss may include:

Fatigue

We are aware of a growing field of sleep medicine and the importance of night-time sleep, consistency and circadian rhythms for adults. We would like greater clarity for parents and those supporting them to recognise when sleep deprivation is a clinical concern that warrants treatment in its own right. This might be through practical problem-solving to ensure parents maximise their opportunities to sleep, behavioural sleep interventions for adults adapted to the postnatal period, or, in some cases, prescribed medication. Given the growing recognition of the effectiveness of psychological interventions for insomnia (e.g. CBT-I), we propose a future research direction might be to examine how these can best be utilised to support parental sleep in the early postnatal period.

For many of the mothers among us, sharing feeds with another person at night was essential to our self-care and our physical and psychological wellbeing. It allowed us to get a block of sleep of several hours, which was impossible to get if we were the sole provider of food to the baby. We do not see that ‘discussing’ fatigue with women without putting all practical solutions on the table (i.e. introducing a bottle in the evening, mixed feeding or formula feeding) is helpful. Indeed, it may contribute to the idea that it is ‘normal’ and should simply be battled through.

Sleep deprivation is a significant risk factor for physical and mental illness, stress, anxiety, mood disturbance, irritability, inflexible thinking, relationship tensions and more. It has zero benefits. It must be taken seriously. When it comes to making decisions about infant feeding and the possibility of sharing feeding responsibilities, particularly at night, any benefits of exclusive breastfeeding must be weighed up against the risks of sleep deprivation for women who are experiencing breastfeeding as fatiguing.

Measure weight and head circumference of babies in the first week and 25 around 8 weeks, and at other times only if there are concerns.

We point the committee to the fact that infant readmissions for jaundice and feeding complications more than doubled between 2006 and 2016 (Keeble and Kossorova, 2017). Many of our babies were readmitted for complications from under-feeding after we were encouraged and supported to persist at exclusive breastfeeding in hospitals practicing the Baby Friendly protocol. We question whether the safeguards in these guidelines, such as weighing once at an unspecified time in the first week, are enough to prevent babies suffering unnecessarily from excessive weight loss, dehydration, jaundice and other complications of under-feeding. We would ask the committee to consider the one intervention we are aware of that prevents early readmissions: early limited formula supplementation (Flaherman et al., 2013, 2018b, 2019a; Straňák et al., 2016).

For advice on identifying and managing jaundice, see the NICE guideline on jaundice in newborn babies under 28 days.

While the guideline here refers to other NICE guidelines on managing jaundice, which are outside the scope of these comments, we would highlight that, in our experience, parents are not being clearly informed: a) that exclusive breastfeeding is a leading risk factor for jaundice, b) of other factors that increase their baby’s risk of jaundice (e.g. mode of delivery) and c) that supplementation can be used as a preventative measure if babies are at risk of jaundice.

As parents, we experienced distressing readmissions for jaundice, and endured anxiety and upset as we watched our newborn babies go through phototherapy treatment that could have been avoided through supplementation. We would again point the committee towards the fact that readmissions for jaundice more than doubled between 2006 and 2016 (Keeble and Kossorova, 2017) and we would ask them to consider whether present safeguards are enough to prevent this.

We stress again that the only intervention that has strong support for preventing jaundice is early limited formula supplementation (Flaherman et al., 2018b). At a minimum, parents should be aware of the possibility to reduce the need for phototherapy and a readmission for jaundice by supplementing breastfeeding with formula, so they can make their own informed decision. We would like to see greater clarity regarding when introducing supplementary formula to babies who have been exclusively breastfed is considered clinically necessary.

Before and after the birth, discuss the importance of bonding and emotional attachment with parents, and explain the different ways that they can bond with their baby.

Given the lack of evidence found for benefits or harms of any interventions relating to bonding (Evidence Review O), we find it concerning that the committee makes such heavy-handed recommendations about promoting bonding and emotional attachment. As parents, we found such recommendations to undermine our confidence and be anxiety-inducing, intrusive and unhelpful, especially in the stressful postnatal period. We found that bonding happened when pressure was taken off us and we were given space to develop our relationships with our babies. We think it is important for healthcare providers not to overstep healthcare provision into interference with family life. In our experience, such interference can cause unnecessary worry and stress and lead to distrust of healthcare providers

Encourage parents to value the time they spend with their baby as a way of promoting emotional attachment.

We could find no evidence in the evidence reviews that families are not valuing the time with their babies and need to be reminded of this! We think it is important for healthcare providers not to overstep healthcare provision into interference with family life. In our experience, such interference can undermine parental confidence, cause unnecessary worry and stress and lead to distrust of healthcare providers. We also question whether advising parents on what to value is in line with NICE principles of personalised care: ‘This requires healthcare professionals to recognise the individual, and for services to be tailored to respond to the needs, preferences and values of the patient’.

Please respect the unique and individual ways that emotionally responsive and loving families find to connect with each other. Please refrain from overstepping the role of healthcare provider with overly prescriptive advice not grounded in solid evidence of health benefits. We suggest that communicating trust in parents and their ability to find their own ways to bond and relate to their baby would be respectful, reassuring and confidence-boosting for families.

Skin-to-skin contact

The most recent Cochrane review into the effects of skin-to-skin highlights methodological weakness in the trials, but recommends skin-to-skin on the basis of relatively weak evidence of benefit and lack of evidence of harm (Moore et al., 2016).

We point the committee towards recent reports suggesting rare but potentially catastrophic risks of skin-to-skin, including sudden unexpected postnatal collapse and newborn falls (Bass et al., 2017; Goldsmith, 2013). We also point towards the recent HSIB report into SUPC occurring when babies are in skin-to-skin contact (HSIB, 2020). This highlighted the need to ensure optimal positioning of the baby to protect their airway, as well as monitoring babies’ skin colour, tone and temperature while in skin-to-skin. We also suggest that parents should be advised about safety issues related to skin-to-skin contact at home, such as the effects of medications, sleep deprivation or other factors that might impact on parental alertness and how to ensure optimal positioning and keep babies safe while in skin-to-skin contact.

We also point out that the benefits of skin-to-skin as communicated in antenatal education are often considerably exaggerated in comparison to the benefits identified in systematic reviews of the literature, such as the 2016 Cochrane review. While many families enjoy skin-to-skin, we should not be under pressure to practice it with information from our trusted healthcare providers that exaggerates the health effects of having or not having skin-to-skin contact. We stress again, that family members find their own unique and intuitive ways to connect with each other. Healthcare providers should avoid interfering with family life with prescriptive guidelines that are not based on solid evidence of significant health impact.

Discuss with parents the potentially challenging aspects of the postnatal period that may affect bonding and emotional attachment, including:

Feeding

As parents, many of us found that when exclusive breastfeeding turned out to be extremely difficult, painful, or involved excessive sleep deprivation, frequent feeding and infant readmission, this contributed to difficulties with bonding with our babies. Bottle feeding provided a solution. For some, breastfeeding was straightforward and enjoyable. For others, combining breastfeeding and formula feeding or expressing milk were important aspects of how we fed our baby, cared for ourselves and build a nurturing family environment for our whole families.

It is clear to us that if a feeding method is painful, stressful or exhausting, it will not be good for bonding, but if it is working, is convenient and creates a relaxed atmosphere, it can contribute to bonding. However, the present guidelines present exclusive breastfeeding as always superior due to selected health benefits. Meanwhile, mixed feeding is not included, and formula feeding is presented as something that parents will need special help to bond if doing. As parents who fed and bonded with our babies in different ways, we do not find this situation acceptable. It is frankly insulting to suggest that parents who decide to formula feed will need additional help with bonding.

Listen carefully to parents’ concerns about their baby’s health and treat their concerns as an important indicator of possible serious illness in their baby.

We do not believe the committee’s approach to breastfeeding difficulties, such as low milk supply and problems with latching, meets its own standard here of taking women seriously when they raise concerns about their baby’s health. Evidence Review Q talks about ‘a perceived lack of satiation by the baby’ and seems to undermine women’s decisions to introduce formula when a baby is unsettled or there is anxiety about weight gain, rather than support them. We do not know what possible evidence the committee can have that shows these women were wrong in their assessment of their baby’s satiation. However, we can point the committee towards evidence that shows that women who ‘perceived’ low supply were significantly more likely to exhibit biochemical evidence of less progress towards mature lactation (Murase et al., 2016).

We suggest that all parents who intend to breastfeed should be aware of the possibility of under-feeding and that they should be educated about how to supplement breastfeeding with formula, if they deem this necessary or desirable for any reason.

Acknowledge the emotional, social, financial and environmental impact of feeding choices.

We do not understand what is meant by the ‘environmental impact’ of feeding decisions and we could find no evidence in any evidence reviews of where this recommendation comes from or on what the environmental impact of different feeding methods is. We do not believe it is a healthcare provider’s role to advise parents on making better ‘environmental’ choices.

Be respectful of parents’ choices.

We do not believe the present guidelines enable healthcare providers to be respectful of feeding choices. The guidelines present benefits of breastfeeding without acknowledging that exclusive breastfeeding is not a reasonable choice for many families. They do not acknowledge mixed feeding. They suggest only families committed to formula feeding receive info on formula (although your own Evidence Review T showed that families wanted this). The committee seems concerned about parents sharing feeding by bottle feeding and so advises that partners should be told of other ways to bond with baby.

It is clear that where evidence was not found, the committee rested on an ethos very much in line with the Baby Friendly Initiative. We point the committee to specific Baby Friendly guidelines that stigmatise formula feeding and are not respectful of parents’ choices:

– Formula is withheld from parents unless ‘medically necessary’

– Healthcare providers should ‘remain steadfast in their messaging about the superiority of breastfeeding’ when providing information to parents about formula feeding

– No information or positive images of bottle feeding should be on public display

– Formula feeding shouldn’t be discussed antenatally in the presence of women who are planning to breastfeed

– Referring to formula feeding as ‘artificial feeding’. (UNICEF UK, 2014)

Current policy in the UK reduces parental choice. For example, we are not aware of any NHS hospital that has a newborn nursery that parents can choose to use should they wish. Rather, a policy of rooming-in is enforced, requiring a mother to assume 24-7 care of her newborn, regardless of her physical or mental condition after the birth of her baby. This is part of the Baby Friendly Initiative approach, which sees rooming-in as conducive to breastfeeding.

A recent Cochrane review found only one trial, which was deemed to be low quality of evidence, suggesting that rooming-in might increase the rate of exclusive breastfeeding in the days after birth, but not the proportion of babies breastfeeding at six months of age (Jaafar et al., 2016). Its conclusion was that there was insufficient evidence to support or refute the practice. A more recent meta-analysis drew the same conclusion (Ng et al., 2019). Given that the evidence is equivocal, we propose that enforcing this on all families, regardless of their wishes or needs, is a violation of patient autonomy. Given the potential benefits of being able to use a newborn nursery during the postnatal hospital stay if a mother feels unwell or needs to rest, this should be an option available to families.

Before and after the birth, discuss breastfeeding and provide information and breastfeeding support.

We do not believe the guidelines can properly support UK parents or reflect their reality if they separate breastfeeding and formula feeding in this way. Your own evidence reviews found that parents felt unprepared for the realities of breastfeeding and for formula feeding if it was not planned, and that they did not feel informed about supplementation (Evidence Reviews P, Q, R, S).

As parents, we would like to see ‘infant feeding’ information (rather than ‘Breastfeeding’ and ‘Formula Feeding’ information) presented to all families antenatally, and postnatally if needed, so that they can make a fully informed choice about what will work best for them and so they can be prepared if things don’t go to plan. We would like to see mixed feeding acknowledged as a good option.

Explain to women that breastfeeding has benefits.

We do not believe this unbalanced presentation of benefits of breastfeeding is in line with NICE’s idea of personalised information. Different feeding methods have different benefits for different families. There is far more uncertainty in breastfeeding research than is acknowledged here and causation cannot be proven for the majority of these benefits, so selling breastfeeding to parents as having vast benefits for all babies is misleading. We would like to see parents presented with accurate and understandable information and statistics on the absolute benefits and risks of different feeding methods antenatally. This must include risks associated with exclusive breastfeeding, such as excessive weight loss, jaundice and dehydration (Flaherman et al., 2018a; Tarcan et al., 2005).

In the postnatal period, when families are already feeding their baby, we do not believe it is acceptable for this information to be delivered in an unsolicited way by healthcare providers. We also point to a recent qualitative study which found that some women felt desperate to stop breastfeeding but under pressure to continue (Ayers et al., 2019). We find it unacceptable that parents are being told about the benefits of breastfeeding in an overstated way, without acknowledgment that these benefits must be weighed up against the risks, including the risks of continuing to breastfeed through painful, stressful and unhappy breastfeeding experiences. Conversations about the health effects of infant feeding decisions need to be scientifically balanced and responsive to the experiences and needs of families in the postnatal period.

Healthcare professionals caring for women and babies in the postnatal period should know about how to encourage and support women with common breastfeeding problems.

Your evidence reviews (P, Q, R, S) found no evidence for interventions to increase breastfeeding rates and were vague on what practical interventions actually help to solve breastfeeding problems. This matches what we found when searching the literature. The latest Cochrane review for managing breastfeeding-related nipple pain found insufficient evidence to make recommendations (Dennis et al., 2014), and we were unable to identify any similar review of interventions to manage difficulties with latching or maternal report of low milk supply.

Your guidance on practical support seems to rely heavily on Baby Friendly Initiative (BFI) guidelines. However, your own quality assessment (Evidence Review F) found that these guidelines did not score highly, e.g. ‘Recommendations are quite vague and different options are not discussed’. In general, the guidelines reviewed in your search ‘scored poorly (<70%) in the “applicability” domain’ (Evidence Review F).

Therefore, we question how effective healthcare providers can be at resolving common breastfeeding problems and whether parents are being properly informed about this. Your evidence review (Q) found that women were not informed about supplementation. We would point the committee to recent evidence from randomised controlled trials that demonstrated that early limited supplementation with formula does not increase breastfeeding cessation but does reduce babies’ risk of readmission to hospital with feeding-related complications (Flaherman et al., 2013, 2018b, 2019a; Straňák et al., 2016). We do not feel the guidelines adequately equip healthcare providers to recommend supplementation or families to understand that it does not necessarily mean an end to breastfeeding.

We are concerned in general about a seeming lack of awareness in the guidelines about the severity and frequency of breastfeeding problems. As parents, we found breastfeeding problems to be far from trivial blips, but to contribute to serious mental health issues, infant readmissions, excessive sleep deprivation and not enjoying time with our babies. We question whether the guidelines empower healthcare providers to take a compassionate and person-centred approach if the severity of these problems is not taken seriously and if they are motivated to ‘encourage’ women to maintain breastfeeding, rather than discussing all options with parents so they can make a decision according to their needs.

We also point to a recent qualitative study which found that some women felt desperate to stop breastfeeding but under pressure to continue (Ayers et al., 2019). We find it unacceptable that parents are being told about the benefits of breastfeeding in an overstated way, without acknowledgment that these benefits must be weighed up against the risks, including the risks of continuing to breastfeed through painful, stressful and unhappy breastfeeding experiences. Conversations about the health effects of infant feeding decisions need to be scientifically balanced and responsive to the experiences and needs of families in the postnatal period.

Recognise the emotional impact of breastfeeding.

We fail to see how healthcare providers can help parents by discussing the emotional impact of breastfeeding, while the solutions parents are finding are viewed as ‘barriers to breastfeeding’ (Evidence Review Q: Facilitators and Barriers to Breastfeeding). Your own evidence review (Q) shows that families are finding ways to deal with the difficulties of the postnatal period by sharing feeding, but the committee appears to see this as a problem.

We also think it is important to note that a recent review of the Baby Friendly Initiative suggests adverse effects of the current approach on maternal mental health and emotional wellbeing (Fallon et al., 2019). We know of no study specifically examining the emotional and mental health effects of current policies regarding infant feeding. Given substantive qualitative evidence highlighting negative experiences, we suggest that the psychological impact must be a priority for research. Evidence is needed to reform current policies and practice in ways that promote the emotional wellbeing of families in the postnatal period.

Give breastfeeding care that is tailored to the woman’s individual needs.

We do not believe care can be tailored to the woman’s individual needs if it is considered ‘breastfeeding care’ rather than infant feeding support, in which introducing formula is a sensible solution to dealing with difficult problems and may help her to continue some breastfeeding.

Provide information, advice and reassurance about breastfeeding, so women know what to expect, and when and how to seek help. Topics to discuss include:

Expressing breast milk (by hand or with a breast pump) as part of breastfeeding and how it can be useful

We feel that any guidance about introducing expressing into a feeding routine needs to take into account a woman’s need to sleep and take care of other needs. As parents we found practices like this, which introduced another step into the process of feeding, were recommended with no acknowledgement of what they entailed and proved harmful to our wellbeing and in some cases to contribute to postnatal mental illness.

For example, the NICE guidelines on faltering growth recommend expressing milk between each breastfeed. As babies feed frequently, this leaves little time for sleep or indeed, anything else, which puts a great deal of pressure on the woman and has obvious potential to be detrimental to her physical and mental health.

Provide information, advice and reassurance about breastfeeding, so women know what to expect, and when and how to seek help. Topics to discuss include:

Pain when breastfeeding and when to seek help

We would suggest that ‘when to seek help’ is when the woman is suffering and needs pain relief or a solution to the problem, not when a healthcare professional deems she should.

We are concerned by a lack of seriousness around women’s pain in the evidence reviews, which told some harrowing stories. Evidence Review Q found that women feel the need to persevere through breastfeeding pain, that they sometimes dreaded the next feed, or it impacted on their bond with their baby.

We urge the committee to consider why women are feeling the need to endure pain. Is this connected to the promotion of breastfeeding and the promise that breastfeeding support can resolve all issues (Evidence Review S)? We would point the committee to the fact that neither the evidence reviews nor the latest Cochrane review found evidence for interventions to help with pain (Dennis et al., 2014). Health professionals must be honest with women about the lack of evidence for what might help with pain and accept a woman’s autonomy to decide she is no longer willing to persist with painful feeding. Where a woman is experiencing painful feeding that is not quickly resolved by current supports, any benefits of breastfeeding must be weighed up against the risks of persistently painful feeding.

Provide information, advice and reassurance about breastfeeding, so women know what to expect, and when and how to seek help. Topics to discuss include:

Fatigue and strategies to manage it

In our experience as parents, we know of only one intervention that is effective at treating fatigue in the postnatal period: sharing feeds with another person, especially at night. This allows a mother to potentially get a block of sleep of several hours that she cannot get if she is the sole provider of food to the baby. We do not see that ‘discussing’ fatigue with women, without putting all practical solutions on the table, is helpful, indeed it may contribute to the idea that it is ‘normal’ and should simply be battled through. Since excessive sleep deprivation is a risk factor for postnatal mental illness, normalising it can be harmful.

Provide information, advice and reassurance about breastfeeding, so women know what to expect, and when and how to seek help. Topics to discuss include:

The disadvantages and advantages of supplementary feeding with formula milk

Regarding disadvantages of supplementation, we would point to recent evidence from randomised controlled trials that has demonstrated that early limited supplementation with formula does not increase breastfeeding cessation but does reduce babies’ risk of readmission to hospital with feeding-related complications (Flaherman et al., 2013, 2018b, 2019a; Straňák et al., 2016). Another recent paper found up to 4 fl oz formula per day was not associated with earlier cessation of breastfeeding, suggesting combination feeding is a viable long-term possibility for those that wish to do so (Flaherman et al., 2019b).

We would also point to the committee’s own evidence reviews that showed that women ‘appreciated the flexibility of mixed feeding’ (S) and that many families are finding ways to thrive by sharing feeding (Q).

A practitioner with skills and competencies in breastfeeding management should assess breastfeeding to identify and address any concerns.

We question whether there is an overstating of what practitioners can do to ‘address’ breastfeeding concerns. Your evidence reviews (P, Q, R, S) found no evidence for interventions to increase breastfeeding rates and were vague on what practical interventions actually help to solve breastfeeding problems. This matches what we found when searching the literature. The latest Cochrane review for managing breastfeeding-related nipple pain found insufficient evidence to make recommendations (Dennis et al., 2014), and we were unable to identify any similar review of interventions to manage difficulties with latching or maternal report of low milk supply.

Observe a feed within the first 24 hours after the birth, and at least 1 other feed within the first week.

We question whether the safeguards in these guidelines, such as observing a feed once in the first 24 hours and at another unspecified time in the first week, are enough to prevent babies suffering unnecessarily from excessive weight loss, dehydration, jaundice and other complications of under-feeding.

If there are ongoing concerns, consider:

Other action, such as improving positioning and attachment to the breast, giving expressed milk, or assessing for tongue-tie.

The committee seems unconcerned by intractable breastfeeding problems here and what will happen if they do not resolve. There seems to be very little consideration of the baby’s need to eat and more of a focus on breastfeeding as an outcome in itself.

Why is supplementation with formula not one of the options here? Even if a woman wishes to keep breastfeeding, we would point to recent evidence from randomised controlled trials that has demonstrated that early limited supplementation with formula does not increase breastfeeding cessation but does reduce babies’ risk of readmission to hospital with feeding-related complications (Flaherman et al., 2013, 2018b, 2019a; Straňák et al., 2016).

Where is the evidence that positioning and attachment, expressing breastmilk and tongue- tie assessment or surgery impacts breastfeeding problems? We are still awaiting the results of an RCT looking at whether tongue- tie surgery improves breastfeeding continuation. Clinical recommendations should not come in advance of research evidence that allows their likely benefits and harms to be understood.

Before and after the birth, discuss formula feeding with parents who are considering or need to formula feed.

All parents need all information on all options in order to make an informed decision about what method might work for them and should things not go to plan. As your evidence review shows (T), families want information on formula feeding antenatally, not only if they plan to formula feed. We find it unacceptable that despite this, the committee concludes that families shouldn’t be given the information on formula feeding.

Many women plan to breastfeed but find it harder than they had anticipated, as your evidence review found (Q). Many families do both. Feeding information and support needs to be flexible. It needs to acknowledge that plans change, no decision is set in stone and that families are not ‘breastfeeding families’ or ‘formula feeding families’.

The fact remains that the vast majority of babies in the UK will receive some formula at some point in their lives. Therefore, this information is required by the vast majority of parents. Withholding this information is senseless, potentially causing needless confusion about what milk to purchase, how to prepare formula safely and how to keep feeding equipment clean.

Information about formula feeding should include:

The differences between breastmilk and formula milk

Despite the fact that parents want more info antenatally and are not given it, these guidelines suggest healthcare providers offer information postnatally that cannot possibly be helpful and can only be stigmatising. We fail to understand the rationale for a healthcare provider telling a family who are successfully formula feeding, in an unsolicited way, the ‘differences between breastmilk and formula’.

Please do not patronise us. We want only the absolute benefits and risks of each feeding method in a balanced way and then we can make our own autonomous decisions.

Information about formula feeding should include:

For women who are trying to establish breastfeeding, how introducing formula feeding can affect breastfeeding success.

An assumption runs through the guidelines that early supplementation with formula will spell the end of breastfeeding. None of the evidence reviews dealt with this question, seeing it outside of the scope. It appears the committee have relied entirely on Baby Friendly guidelines, despite grading them low on quality. We would point to recent evidence from randomised controlled trials that has demonstrated that early limited supplementation with formula does not increase breastfeeding cessation (Flaherman et al., 2013, 2018b, 2019a; Straňák et al., 2016). Other recent evidence suggests modest supplementation of formula is not associated with earlier cessation of breastfeeding (Flaherman et al., 2019b).

Face-to-face formula feeding support should include:

Positions for holding a baby for bottle feeding and the dangers of ‘prop’ feeding

We suggest that when supporting families to formula feed, the emphasis should be on what they need and should avoid being overly prescriptive about positions for holding a baby for bottle feeding. Recognising the risks of prop feeding, we query why this is not communicated to all parents regardless of their feeding intentions because the majority of them will bottle feed at some point.

Face-to-face formula feeding support should include:

How to bond with the baby when bottle feeding, through skin-to-skin contact, eye contact and keeping the number of people feeding the baby to a minimum

Nowhere in your evidence reviews did you find evidence that parents who formula feed need info on how to bond with their babies. Nor did you find that skin-to-skin, eye contact and minimising the number of people feeding a baby are predictive of better outcomes.

Your evidence reviews (Q) showed that parents are finding ways to survive the newborn period by sharing bottle feeding. We find it unconscionable that these guidelines problematise this and shame parents who make use of their support network by involving older siblings, grandparents and other close family members or friends to feed their babies.

We would also appeal to common sense and state here: it is in fact easier and more comfortable to make eye contact with a baby while bottle feeding than while breastfeeding!

We believe that this recommendation is simply stigmatising information lifted directly from Baby Friendly Initiative guidelines (which your evidence reviews rated low on quality, including for involvement of patients).

Face-to-face formula feeding support should include:

Advice about other ways that partners and family members can comfort and soothe babies

As parents, we find the implication here, as well as its supporting rationale, deeply disturbing. Many of us benefited from sharing feeds with our partners and, in some cases, it was vital to safeguard our mental health. We recognise many of the experiences of the families cited in Evidence Review Q, where sharing the load of feeding was a way to survive the newborn period. We are horrified that the guidance appears to stigmatise and problematise partners feeding their own babies and enjoying it. We question whether these guidelines genuinely wish to support new families or are in fact aimed at increasing exclusive breastfeeding rates.

We also question what advice should be given to parents, since the evidence reviews presented no data on how babies can be comforted and soothed. Most of us find ways to do this intuitively, based on our own experiences, personalities and in response to our baby’s unique personality and temperament. We believe this is the stuff of evolving, nurturing, organic family attachments and cannot and should not be prescribed. Where there are considerable bonding difficulties (e.g. due to severe mental illness or developmental trauma/attachment-based disorders), this requires highly specialist assessment and intervention beyond the remit of universal primary care services.

For parents who are thinking about changing from breastfeeding to formula feeding, support them to make an informed decision.

Parents are not in a position to make an informed decision about infant feeding because information about formula feeding and what to expect from breastfeeding is withheld antenatally. Nor are they given a balanced, accurate depiction of the absolute benefits and risks of infant feeding decisions.

However, by the time they are thinking of switching from breastfeeding to formula feeding, they are likely to be in a distressing situation that is impacting their wellbeing and mental health, and this is not the time to be discussing risks and benefits of different options. While a mother is potentially struggling with excessive sleep deprivation, pain, mental health difficulties or a baby suffering the complications of under-feeding, it is vital that healthcare providers step back. Parents must be allowed to make a decision about whether to stop trying to breastfeed, in accordance with their own needs and priorities and without the pressure of a public health agenda.

We would be happy to offer the committee our experiences of the realities for many families, and to explain why for many of us continuing exclusive breastfeeding was not a reasonable option.

Discuss lactation suppression with women if breastfeeding is not started or is stopped, breastfeeding is contraindicated for the baby or the woman, or in the event of the death of a baby… Topics to discuss include:

The possibility of becoming a breast milk donor.

As parents, we find the idea of this information being presented without soliciting it to be insensitive, lacking in compassion and potentially coercive – putting pressure on women to be altruistic during potentially difficult circumstances. Also, to donate breastmilk requires introducing expressing into a woman’s routine, which may add pressure at a difficult time.

Responsive feeding means feeding in response to the baby’s cues. It recognises that feeds are not just for nutrition, but also for love, comfort and reassurance between the baby and mother.

The guidelines perpetuate a position where feeding is firstly the mother’s responsibility. While we recognise that breastfeeding disproportionately impacts women, as parents we take the view that feeding is the responsibility of all involved parents and guidance should take into account and address both.

We also think conflating feeding with bonding is deeply unhelpful and not accurate. Parents are constantly responding to and interacting with their baby and their cues that they need feeding, to sleep, to be cuddled, to be played with or given space. It is wrong to give the impression that how a baby is fed is the be all and end all of healthy attachments and family relationships.

Research Recommendation: What support with breastfeeding do parents of twins or triplets find helpful?

Given that the evidence reviews (P, Q, R, S) found no evidence for interventions to increase breastfeeding and were vague on what breastfeeding support involves, we suggest a good research recommendation would be: What interventions can help with common breastfeeding problems for all parents who want to breastfeed?

As for parents of multiples, we think the question should be rephrased as what practical support they might need, with infant feeding and otherwise. Families with triplets will be especially likely to share care and support each other with feeding, possibly with additional family members’ involvement. The idea of encouraging mothers of triplets to exclusively breastfeed shows a staggering lack of understanding of the realities and of basic compassion. However, if mothers of multiples wish to breastfeed, a realistic option would seem to be mixed feeding, which is not covered in these guidelines.

The committee noted that observing a feed before transfer is already current practice in settings that are UNICEF Baby Friendly Initiative (BFI)-accredited, but many providers in England do not have this accreditation.

We would like to point out that it was in Baby Friendly facilities, or those working towards accreditation, that we experienced unsafe and coercive care, where staff seemed motivated to keep us exclusively breastfeeding at all costs. Many of us experienced readmissions with our babies for excessive weight loss, dehydration and jaundice in the first few days after discharge. We have since discovered rates of readmissions of this kind more than doubled between 2006 and 2016 (Keeble and Kossorova, 2017).

We would urge the committee to investigate Baby Friendly’s safety data and what evidence they are using to base their guidelines upon, before assuming that they are the gold standard.

The committee discussed the importance of allowing sufficient time for discussions so that it is easier for women to understand and absorb the information, which may also mean that they are more likely to follow the advice.

We find the language here deeply patronising. We question why the committee believes that women have trouble understanding information. We also question whether it is a healthcare professional’s role to get women to be compliant, or simply to give information that then may or may not be taken on board. The goal should be to inform so that we can make our own decisions, not follow the advice and do as we are told!

According to the committee’s experience, breastfeeding can also improve self-esteem in some women.

Citation needed! We would point out that healthcare providers who denied our lived experience, encouraged us to keep breastfeeding despite distressing complications and delivered stigmatising policies around formula feeding had an adverse effect on our self-esteem.

The committee may be interested in the psychological literature that highlights that the pursuit of high self-esteem can be problematic. To achieve it, people must feel special and above average. Needing to feel better than others to feel good about ourselves can lead to bullying, competitiveness and prejudice. Indeed, we suggest that the quest to achieve self-esteem through breastfeeding may well be a key contributing factor to the conflict and sometimes viciousness that features in infant feeding discussions. That healthcare professionals could be contributing to the creation of a cultural environment in which a mother’s self-esteem is contingent on her breastfeeding success should provoke self-reflection and soul searching.

We propose that an ethos of compassion should be the bedrock of infant feeding policy and culture. In such an environment, the challenges and suffering that families experience as they feed their babies would be acknowledged without becoming a judgement on their identity or ‘performance’ as a mother or their relationship with their baby.

Such a culture would recognise that having a baby is a tender and challenging time for most people. Far from being alone or abnormal in our struggles, or feeling stigmatised for our decisions, whatever they may be, we would see ourselves as a community, supporting and nourishing a diversity of families, each of whom navigates the joys and challenges of family life in unique ways. We also propose that in an environment where social comparisons and judgements are replaced with mutual respect, compassion and kindness, there would be more widespread acceptance of breastfeeding in public places and of older babies and children. And lastly, but by no means least, the emphasis in feeding babies would be on kindness – on ensuring first and foremost that babies’ nutritional needs are met and no baby or parent should ever suffer the fear and distress of an early readmission that could have been prevented. Families would feel able to feed their babies in whatever way best meets the physical and emotional needs of all family members.

The evidence also showed that varying experiences with breastfeeding can have an impact on the woman’s emotional wellbeing, and women often need reassurance and encouragement to gain confidence.

As parents struggling with difficult, painful and exhausting breastfeeding experiences and thinking about stopping, we experienced reassurance and encouragement as gaslighting. Healthcare providers not acknowledging our lived experience and normalising our suffering had an adverse impact on our emotional wellbeing. In support of our own experiences, we point the committee towards a recent review of the Baby Friendly Initiative that showed adverse effects on mothers’ wellbeing and mental health (Fallon et al., 2019).

We suggest that there is a need for reflection on how the current policy of promoting exclusive breastfeeding and withholding information about formula feeding is affecting families.

There was good evidence about what information and support parents who formula feed find helpful, so the committee used the evidence together with their knowledge and experience to make the recommendations.

There was good evidence (Evidence Review T) that families wanted more information antenatally on formula feeding. However the committee rejected this finding and decided that this was not ‘feasible’.

Many of us went into the postnatal period unprepared for the breastfeeding problems we experienced and clueless when we needed to switch to formula. Unfortunately, the separation of the present guidance into two camps (Breastfeeding and Formula Feeding), the refusal to give all parents all the information antenatally and the complete absence of mixed feeding as an option means it is likely other parents will have similar experiences. Indeed, a recent review of the Baby Friendly Initiative in the UK found that women reported a sense of cluelessness about formula feeding and a lack of information and support available (Fallon et al., 2019).

For women, their partners and their babies, this is a major life event that means considerable emotional and physical adjustment. It applies to all births but is perhaps most marked for those having their first child. Healthcare professionals have the responsibility to help families adjust to their new life.

Your evidence reviews (Q, T) showed that many families are finding pragmatic ways to adjust to the demands of the postnatal period and, in our words, ‘survive it’. Like us, many of the families surveyed shared feeding responsibilities using bottles. Unfortunately, we feel the present guidelines undermine choices parents make around feeding. We feel that steering families down one feeding path and undermining the reasoning behind other choices is not helping them adjust to their new life, is outside the remit of healthcare providers and is not supportive. There are many ways to be a loving, nurturing family.

This guideline was written with the hope that healthcare professionals can use it to provide consistent and high-quality care, while taking into consideration each family’s individual situation and needs, in order to reduce morbidity and mortality and to support families in this new phase.

While the guidelines refuse to accept that exclusive breastfeeding is not a reasonable option for many families, while they refuse to celebrate the ways families are finding to cope in the postnatal period (including mixed feeding and sharing feeding responsibilities), while they downplay the severity of common breastfeeding problems, they are not taking into consideration each family’s individual situation and needs. Reading these guidelines, we feel that, once again, families are being let down by the people we rely on to provide us healthcare at this most vulnerable time.

The committee has failed to identify high-quality evidence that early supplementation can prevent morbidity, including high-quality randomised trials demonstrating that early limited supplementation can prevent readmissions (Flaherman et al., 2013, 2018b, 2019a; Straňák et al., 2016). We propose that it looks as though the committee are more concerned about breastfeeding rates than they are about feeding complications and their effects on babies and parents. The committee’s own evidence review showed that women want information about all feeding methods but the committee concluded that this was not feasible. We look forward to the committee reconsidering its position and responding to the needs of parents, which their own evidence reviews identified.

References

Ayers, S., Crawley, R., Webb, R., et al., 2019. What are women stressed about after birth? Birth 46, 678–685. https://doi.org/10.1111/birt.12455.

Bass, J., Gartley, T., Kleinman, R., 2016. Unintended Consequences of Current Breastfeeding Initiatives. JAMA Pediatr.170 (10):923–924. https://doi.org/10.1001/jamapediatrics.2016.1529.

Dennis, C.L., Jackson, K., Watson, J., 2014. Interventions for treating painful nipples among breastfeeding women. Cochrane Database Syst. Rev. 12, CD007366. https://doi.org/10.1002/14651858.CD007366.pub2.

Fallon, V., Harrold, J., Chisholm, A., 2019. The impact of the UK Baby Friendly Initiative on maternal and infant health outcomes: a mixed-methods systematic review. Matern. Child Nutr. 15 (3), e12778. https://doi.org/10.1111/mcn.12778.

Flaherman, V.J., Aby, J., Burgos, et al., 2013. Effect of early limited formula on duration and exclusivity of breastfeeding in at-risk infants: an RCT. Pediatrics 131 (6), 1059–1065. https://doi.org/10.1542/peds.2012-2809.

Flaherman, V.J., Schaefer, E.W., Kuzniewicz, M.W., et al., 2018a. Health care utilization in the first month after birth and its relationship to newborn weight loss and method of feeding. Acad Pediatr 18 (6), 677–684. https://www.academicpedsjnl.net/article/S1876-2859(17)30566-1/fulltext.

Flaherman, V.J., Narayan, N.R., Hartigan-O’Connor, D., et al., 2018b. The effect of early limited formula on breastfeeding, readmission, and intestinal microbiota: a randomized clinical trial. J. Pediatr. 196, 84–90. https://doi.org/10.1016/j.jpeds.2017.12.073.

Flaherman, V.J., Cabana, M.D., McCulloch, C.E., et al., 2019a. Effect of early limited formula on breastfeeding duration in the first year of life: a randomized clinical trial. JAMA Pediatr 173 (8), 729–735. https://doi.org/10.1001/jamapediatrics.2019.1424.

Flaherman, V.J., McKean, M., Braunreuther, et al., 2019b. Minimizing the relationship between early formula use and breastfeeding cessation by limiting formula volume. Breastfeed. Med. 14 (8), 533–537. https://doi.org/10.1089/bfm.2019.0055.

Goldsmith, J., 2013. Hospitals should balance skin-to-skin contact with safe sleep policies. AAP News. 34 (11) 22. Available from: https://www.aappublications.org/content/34/11/22. Accessed date: 27 November 2020.

HSIB, 2020. National Learning Report Neonatal collapse alongside skin-to-skin contact. Available from: https://www.hsib.org.uk/documents/238/hsib-national-learning-report-neonatal-collapse-alongside-skin-to-skin-contact.pdf. Accessed date: 27 November 2020.

Jaafar, S., Ho, J., Lee, K., 2016. Rooming‐in for new mother and infant versus separate care for increasing the duration of breastfeeding. Cochrane Database Syst. Rev. 8, CD006641. https://doi.org/10.1002/14651858.CD006641.pub3.

Keeble, E., Kossarova, L., 2017. Focus on: Emergency hospital care for children and young people. Available from: https://www.nuffieldtrust.org.uk/files/2018-10/1540142848_qualitywatch-emergency-hospital-care-children-and-young-people-full.pdf. Accessed date: 27 November 2020.

Moore, E.R., Bergman, N., Anderson, G.C., Medley, N, 2016. Early skin‐to‐skin contact for mothers and their healthy newborn infants. Cochrane Database Syst. Rev. 11, CD003519. https://doi.org/10.1002/14651858.CD003519.pub4.

Murase, M., Wagner, E.A., Chantry, C., Dewey, K.G., Nommsen-Rivers, L.A, 2017. The Relation between Breast Milk Sodium to Potassium Ratio and Maternal Report of a Milk Supply Concern. J Pediatr. 181:294-297.e3. https://doi.org/10.1016/j.jpeds.2016.10.044.

Ng, C., Ho, J., Lee, Z., 2019. The effect of rooming-in on duration of breastfeeding: A systematic review of randomised and non-randomised prospective controlled studies. PLOS. https://doi.org/10.1371/journal.pone.0215869.

Straňák, Z., Feyereislova, S., Čern., M., et al., 2016. Limited amount of formula may facilitate breastfeeding: randomized, controlled trial to compare standard clinical practice versus limited supplemental feeding. PloS One 11 (2), e0150053. https://doi.org/10.1371/journal.pone.0150053.

Tarcan, A., Tiker, F., Vatandaş, N.S., et al., 2005. Weight loss and hypernatremia in breast-fed babies: frequency in neonates with non-hemolytic jaundice. J. Paediatr. Child Health 41 (9–10), 484–487. https://doi.org/10.1111/j.1440-1754.2005.00688.x.

UNICEF UK, 2014. Guidelines on providing information for parents about formula feeding. Available from: https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2018/02/Guidelines-on-providing-information-for-parents-about-formula-feeding.pdf. Accessed date: 27 November 2020.

Wilson, J., Wilson, B.H., 2018. Is the “breast is best” mantra an oversimplification? J.Fam. Pract. 67 (6), E1–E9. Available from: https://www.mdedge.com/clinicianreviews/article/166932/pediatrics/breast-best-mantra-oversimplification. Accessed date: 27 November 2020.

Leave a Reply Cancel reply