Why “Fed Is Best” is Flawed?
“Breast is best” … wait, no, it’s just the way mammals feed their infants.
“Fed is best” … well obviously. The alternative is pretty dire.
So where did this terminology spring from and why is it unhelpful in discussing infant feeding?
Obviously everyone wants babies to thrive and survive. In countries like Australia, almost all babies are initially put to the breast and most parents express the intention to breastfeed. This is partly why the “Breast Is Best” slogan hasn't been used to promote breastfeeding for many years. However, in countries like the United Kingdom, initiation remains low and ongoing breastfeeding rates are among the lowest in the world. The slogan isn't helpful in that environment either, because other social factors are involved, not just parent's awareness of why breastfeeding matters.
Professor Amy Brown, author of several books about breastfeeding and early parenting - including Informed Is Best and Breastfeeding Uncovered - is a Welsh psychologist. She is a Professor of Child Public Health at Swansea University who specialises in maternal and child health, particularly nutrition. She campaigns to bring about better support for women who want to breastfeed and to improve the UK public's attitude towards breastfeeding in public. Amy’s research has explored how the slogan “Breast Is Best” has negative impacts on parent’s decisions around infant feeding.
Global breastfeeding rates are important: 800 000 infant lives are lost each year due to lack of breastfeeding.
The Baby Friendly Hospital Initiative (BFHI), also known as Baby Friendly Initiative (BFI), is a worldwide programme of the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF), launched in 1992 in India following the adoption of the Innocenti Declaration on breastfeeding promotion in 1990. Since then, hospitals around the world have worked towards the goal of providing services which protect, promote and support breastfeeding.
Facilities can gain accreditation as a BFHI hospital by reaching and maintaining policies at management and patient care levels:
Critical management procedures
1a. Comply fully with the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions.
1b. Have a written infant feeding policy that is routinely communicated to staff and parents.
1c. Establish ongoing monitoring and data-management systems.
2. Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding.
Key clinical practices
3. Discuss the importance and management of breastfeeding with pregnant women and their families.
4. Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth.
5. Support mothers to initiate and maintain breastfeeding and manage common difficulties.
6. Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated.
7. Enable mothers and their infants to remain together and to practise rooming-in 24 hours a day.
8. Support mothers to recognize and respond to their infants' cues for feeding.
9. Counsel mothers on the use and risks of feeding bottles, teats and pacifiers.
10. Coordinate discharge so that parents and their infants have timely access to ongoing support and care.
The program also restricts use by the hospital of free formula or other infant care aids provided by formula companies and recommends that when formula is medically needed, it should be given in a small cup or spoon, rather than a bottle and should only be used to supplement breastfeeding.
As of 2011, approximately 15,000 facilities in more than 152 countries had been inspected and accredited as "Baby-Friendly." The number of accredited hospitals has continued to grow. As of 2019, a survey found that 28% of the hospitals in the US were registered as Baby Friendly. Australia has similar numbers while countries like New Zealand and Scotland have achieved almost universal access.
“Fed Is Best” is described as being a push-back at the “Breast Is Best” mantra. However, it was actually born of one mother’s experience of establishing breastfeeding in 2016. Dr. Christie del Castillo-Hegyi, herself an emergency room doctor, believes the focus on exclusive breastfeeding in the BFHI hospital her child was born in led to dehydration. She has suggested this led to multiple developmental challenges including autism spectrum disorder (ASD) and ADHD. Her experience led her to create a global movement to position infant formula with equity to breastfeeding. The idea has been embraced by other parents whose breastfeeding journey has not been exclusive and resonated with parents who choose not to breastfeed for reasons of their own.
Any parent of a child experiencing a health crisis will feel anger and fear. And likely seek answers to the question of how it might have been prevented. The problem here though is the wrong enemy has been identified. And the wrong hero declared.
In the early days of life, babies are designed to live on colostrum, before the milk transitions into what we might think of as breastmilk. When mother and baby are kept together with skin-to-skin as much as possible from birth, encouraged to breastfeed frequently and assisted to achieve optimal attachment of baby to breast, the baby will meet their current needs - as well as establish the breastmilk supply to meet their ongoing needs. BFHI policies are put in place to enable breastfeeding to be learned in a supportive and skilled environment with health professionals guiding the family through the learning process.
I do not know Dr del Castillo and do not know the finer details of her experience, although I have read her story as published online. She identifies “newborn jaundice, hypoglycemia and severe dehydration due to insufficient milk intake from exclusive breastfeeding in he first days of life” as leading to her child’s neurological disabilities.
Clearly, if a baby is not getting sufficient breastmilk in the first week, the signs of effective milk transfer will be not be observed and the expected output will not be present:
Day 1: At least 1 wet nappy and a sticky green-black bowel motion.
Day 2: At least 2 wet nappies and a soft green-black bowel motion.
Day 3: At least 3 wet nappies and greenish-brown bowel motions.
Day 4: At least 4 wet nappies with pale/clear wee (urine) and lighter greenish-brown or brown-yellow bowel motions.
Day 5 and beyond: 5 or more wet nappies with pale/clear wee (urine) and 3 or more mustard-yellow soft or liquid bowel motions.
Delayed Onset of Lactation
There are known risk factors for milk production to be delayed after birth and health professionals would have identified these and put strategies in place to overcome them. Ideally a milk bank will be available to provide donor milk to support the infant until the maternal supply catches up with demand. Hand expressing and cup feeding would be introduced to give additional colostrum to the baby and attention paid to achieving a good latch. And yes, if required, infant formula will be made available, with informed consent from the parents.
BFHI has been around a long time now and has led to increases in the establishment of breastfeeding globally. However, where mothers and babies are discharged with limited access to ongoing support with maintaining breastfeeding, into a community where direct marketing of infant formula to parents is permitted by law and a return to the paid workforce can be measured by days or weeks, rather than months or years, it is going to be harder to meet global guidelines.
Health guidelines are just that. Not targeting individuals but the overall community. Most of us know we should be eating less saturated fat, more fibre, more fresh fruits and vegetables and less processed foods. Yet in Australia, an affluent country with a strong history of growing our own produce and having an abundance of choice in fresh fruit and vegetables in all but the most isolated communities, only four per cent of men eat the recommended intake of fruit and vegetables.
“Fed is Best” dismisses the importance of breastfeeding as a health issue for our wider community. It plays down the need for society to do better at providing services to help families meet these infant feeding guidelines. Parents need to be making fully informed decisions a every point of caring for their children’s health, including a full risk assessment of introducing infant formula into the gut of an exclusively breastfed baby.
“Fed is Best” makes it harder to advocate for milk banks being available to all infants who need them - just as they are in Brazil and Norway. In Australia, public milk banks only provide donor milk to infants in NICU. For mothers with delayed onset of lactation, the only option is informal milk sharing - not always supported in a hospital setting. The World Health Organization recommends the use of donor breastmilk before resorting to infant formula.
“Fed is Best” dilutes the need for mothers to have paid parental leave to recover from childbirth and establish breastfeeding. The USA ranks at the bottom when it comes to paid maternity leave - with ZERO weeks mandated. Australian mothers receive 18 weeks at 42.4% of their usual payrate, the UK 39 weeks at 39.8% and New Zealand 22 weeks at 47.5%. In Norway, mothers receive 96% of their normal pay for 18 weeks. One in four mothers in the US might need return to paid work within two weeks of giving birth.
Every child has a birthright to their mother’s breastmilk. It is not a lifestyle choice. It is not an optional extra. Breastfeeding is a basic human right which governments should invest in to minimise the cost of preventable health conditions in later life.
Every mother has the right to feed their baby their own breastmilk. When challenges arise, they should receive personalised one-to-one support from IBCLC qualified lactation consultants in hospital and in the home. This should be fully-funded so that income is never a barrier to breastfeeding.
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