Garber et al have questioned the lack of “balancing measures” in our quality improvement intervention, Best Fed Beginnings (BFB).1 Their concerns include potential complications related to inadequate breast milk supply, outpatient breastfeeding rates, “cosleeping” (which we interpret as bed-sharing), and breastfeeding itself.
Increased rates of exclusive breastfeeding in the hospital is a desired outcome of the BFHI and was a desired outcome for the BFB improvement intervention along with achieving Baby-Friendly (BF) designation. There is convincing evidence that breastfeeding rates improve after BF designation.2 As part of the BFB project, we did include patient experience as a balancing measure. These data were captured as part of the BF mother audits and strategically included discussions about patient safety, including bed-sharing and additional newborn outcomes. Hospitals individually used the results of the audits to inform their improvement efforts and to ensure that their processes and system redesigns did not suboptimize the experiences of mothers. In consideration of reducing the reporting burden to hospitals, hospitals were required to do the audits, report internally, and to only report out qualitatively what they were learning from the results. We agree that it would be interesting for a future collaborative to add balancing measures related to safety that are reported and tracked.
As indicated by a recent Cochrane review by Smith et al,3 the World Health Organization’s recommendation of exclusive breastfeeding for the first 6 months of life is supported by the best evidence. Furthermore, this evidence-based review clarified that there is no evidence to support the provision of water or glucose water as a method to prevent hypoglycemia, hypernatremia, or hyperbilirubinemia, and this additional fluid does not support increasing the duration of breastfeeding. The BFHI, as guided by the Ten Steps to Successful Breastfeeding, does not preclude the use of infant formula for medical indications such as newborns who demonstrate a need for enteral feeding when their mother’s own milk is unavailable. Thus, deviations from exclusivity for medical reasons are already built into the structure of the intervention. After controlling for sociodemographic variables, evidence supports wide variability between hospitals in exclusive breastfeeding rates at discharge, suggesting that supplementation is often not related to medical indications, and quality improvement efforts such as the BFHI are warranted.4
Finally, it is correct to point out that “cosleeping” was not reported in this initiative. Cosleeping is not a measure associated with the BFHI; however, some questions about safe implementation of the Ten Steps in the United States have been raised as the number of hospitals gaining BF status has grown exponentially in the United States in recent years. Recently, the American Academy of Pediatrics (AAP) developed a Clinical Report to provide guidance to facilities and practitioners involved in the BFHI.5 Safety should be a key element in implementation of the Ten Steps.
CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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- Copyright © 2017 by the American Academy of Pediatrics