November 2017, VOLUME140 /ISSUE 5

Re: Balancing Breastfeeding Promotion

  1. Matthew D. Garber
  1. Pediatric Hospitalist, University of Florida College of Medicine–Jacksonville
  1. Alan R. Schroeder
  1. Pediatric Intensivist/Hospitalist
  1. Valerie Flaherman
  1. Preventive Medicine Physician

We read with interest the quality report by Feldman-Winter et al1 in which they described their efforts to increase breastfeeding initiation and exclusive breastfeeding rates by helping hospitals achieve Baby-Friendly Hospital Initiative (BFHI) designation. Not only did they track and improve BFHI, they also tracked and improved rates of overall and exclusive breastfeeding. We applaud their success but note an important omission: a lack of balancing measures. All interventions bring both intended and unintended consequences, and quality improvement scientists have the responsibility to track the benefits but also the potential risks of their interventions. Balancing measures are integral to quality improvement, yet we note a lack of balancing measures in this report and in the breastfeeding promotion literature in general, including the United States and international articles associated with the BHFI. Candidate measures could include some of the well-described complications that occur when breast milk supply is inadequate, including hypernatremic dehydration and hyperbilirubinemia,2 both of which can trigger hospital readmission and, in rare cases, severe morbidity. Additionally, given the results from 1 large study in which breastfeeding rates at 1 month were lower in hospitals with BFHI certification3 and from another small trial in which limited amounts of formula supplementation were associated with better long-term breastfeeding success,4 outpatient breastfeeding rates would be another useful metric. Evaluating cosleeping (which is associated with breastfeeding and potential asphyxiation) is another possibility. Although the net benefit of breastfeeding is certain, the magnitude of benefit has been questioned by recent cluster randomized trials,5 making an objective measurement of potential risks even more important.


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  • CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.