Baby Friendly Hospital Initiative History

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Baby Friendly Hospital InitiativeHistory

• 1982 UNICEF Director, James Grant launched
  initiative known as the child survival
  revolution, or GOBI plan
• 'G' for growth monitoring
• 'O' for oral rehydration therapy
• 'B' for breastfeeding
• 'I' for immunization

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Baby-Friendly Hospital Initiative

• 1991 WHO/UNICEF
• Ten steps to successful breastfeeding
• Today 14,500 hospitals in 125 countries
• 34 US hospitals

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Baby Friendly HospitalWhat are the Ten Steps?

• Write breastfeeding policy.
• Train all health care staff.
• Inform all pregnant women.
• Initiate breastfeeding within an hour of birth.
• Show mothers how to breastfeed.
• Give infants nothing but breastmilk.
• Practice "rooming in."
• Encourage breastfeeding on demand.
• Give no artificial teats or pacifiers.
• Establish breastfeeding support groups.

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Effects ofBaby Friendly Initiative

• JAMA 2001 Jan 285(4)413-420
• Promotion of Breastfeeding Intervention Trial
  (PROBIT)
• 30 hospitals, randomized to receive Baby-Friendly
  training, or to continue their routine practices
• 17,000 mother-baby pairs
• Followed for 1 year

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PROBIT Results
Exclusive breastfeeding at 3 months Any breastfeeding at 12 months BFHI 43.4 19.7 Control 6.4 11.4

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Baby-Friendly Hospital Initiative Reduction in
Infections and Allergies
GI Infections Atopic Eczema BFHI 9.1 3.3 Control 13.2 6.3

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Maternity Care PracticesImplications for
Breastfeeding
DiGirolamo, Grummer-Strawn, and Fein, BIRTH 282,
94, June 2001

• Surveyed 1085 women who intended to breastfeed
  for more than 2 months
• Assessed 5 Baby-Friendly practices
• Breastfeeding initiation
• Supplements
• Rooming-in
• Breastfeeding on demand
• Pacifiers

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Percentage of women who stopped breastfeeding
before 6 weeks, by specific hospital practices
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Percentage of women who stopped breastfeeding
before 6 weeks, by number of Baby-Friendly
Hospital Initiative practices they experienced
STOPPED BF
Number of Baby-Friendly Practices Reported
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BFHI Improves Breastfeeding Initiation Rates in
a US Hospital Setting

• Boston Medical Center
• inner-city teaching hospital
• 1800 births per year
• 15-bed Level III NICU
• primarily poor, minority, immigrant families
• Implemented Baby-Friendly policies over a 3-year
  period
• Reviewed 200 randomly selected medical records
  from each of the 3 years

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BFHI IMPLEMENTATIONEFFECTS ON BREASTFEEDING
TRENDS
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Effect on Rates of Breastfeeding of Training for
the BFHI

• Controlled, non-randomised study
• 4 hospitals in southern Italy (group 1)
• 4 hospitals in central/northern Italy (group 2)
• Implemented Baby-Friendly training
• Collected data before and after training

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Breastfeeding Rates at Discharge and Three
Months
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Narcotics during LaborEffects on Newborns

• Given IV or IM in Labor
• Decrease alertness
• Lower neurobehavioral scores
• Inhibit suckling
• Delay effective feeding
• Nissen 1995, Crowell 1994, Matthews 1989,
  Hodgkinson 1978, and other studies

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Studies specific to breastfeeding Crowell 1994

• 48 healthy term infants
• All mothers received local or pudendal anesthetic
  at delivery
• 26 also received analgesia in labor (butorphanol
  or nalbupine)
• Measured time to effective feeding
• Effective feeding defined as 3 consecutive IBFAT
  scores of 10-12

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Time To Successful BF By Analgesia And Time Of
First Feed



To breast within 1 hour
To breast after 1 hour
No analgesia or given less than 1 hour before
birth
6.4 hours (n 8)
49.7 hours (n 19)
Analgesia given more than 1 hour before birth
50.3 hours (n 9)
62.5 hours (n 7)
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Studies specific to breastfeeding Riordan 2000

• Studied 129 term infants born vaginally
• Scored Infant Breastfeeding Assessment Tool
  (IBFAT) while in hospital
• Measured duration at 6 weeks

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Types of Labor Pain Meds in Riordans Study

• Epidurals
• Bupivacaine with fentanyl
• IV Analgesia
• 25-50 mg meperidine
• 5-10 mg nalbuphine

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Breastfeeding Score by Labor Medication Group
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Any effect on BF duration?

• No effect, measured at 6 weeks in Riordans study
• Halpern (Birth 1999) also reported no effect on
  duration at 6-8 weeks

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Effect on Lactogenesis

• Hildebrandt JHL 1999
• 46 primips and 81 multips
• Mothers reported time of sensation of milk coming
  in
• Mean time in entire group was 50 hours
• Multips 45 hours
• Primips 59 hours

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Effect of labor pain meds on lactogenesis, contd

• Multips who delivered vaginally without
  medication had the shortest time to lactogenesis
  (44 hours)
• 6 hours longer if cesarean section
• 11 hours longer if primip
• 13 hours longer if sedative or pain medication
  given during labor

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Labor AnalgesiaDisturbs Newborn Behavior

• Ransjo-Arvidson (Birth 2001) studied 28
  mothers-babies
• Group 1 no analgesia
• Group 2 pudendal block
• Group 3 epidural or pethidine or more than one
  type of analgesia

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In Groups 2 and 3

• Infants massage-like hand movements were less
  frequent
• Fewer infants touched the nipple with hands
  before suckling
• Fewer infants made licking movements and sucked
  the breast
• Average time to first feeding was more than 150
  minutes (compared to 79 minutes in Group 1)

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Significance of hand motions

• Newborns use their hands as well as their mouths
  to stimulate oxytocin after birth

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Early post-birth events and oxytocin

• Baby crawls to breast
• Opens and closes hands
• Massages the breast
• Hand movements cause as high an oxytocin rise as
  sucking

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Skin-to-skin encourages oxytocin release

• OXYTOCIN
• Promotes milk
• Promotes mothering behaviors
• Alleviates pain

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Oxytocin in the bloodstream

• Released with nipple stimulation
• Released in surges, lasting about 1-2 minutes
• Contracts muscle cells
• Causes uterine contractions, causing involution
• Causes contractions of the muscle cells
  surrounding alveoli and ducts in the breast,
  causing milk let down or milk ejection reflex

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Second Stage and Early Post-birth Events and
Oxytocin

• Ferguson's Reflex Physiologic response triggered
  by the fetal presenting part stimulating stretch
  receptors located in the posterior vagina at
  around 1 station. Stimulation causes release of
  oxytocin, naturally augmenting pushing.
• Mother has another oxytocin surge AFTER babys
  shoulders are delivered

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Oxytocin effects

• Opposite of fight or flight response
• Lowers heart rate
• Lowers blood pressure
• Lowers blood cortisol
• Affects metabolic actions
• Contracts pyloric sphincter
• Releases insulin and cholecystokinin

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Oxytocin in the brain affects social behavior

• Women who have high levels of oxytocin
• Produce more milk
• Breastfeed longer
• Are more tolerant of repetitious, boring tasks
• Demonstrate more social behavior better
  listeners
• Women become more social and retain those traits
  if they continue breastfeeding

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Oxytocin as Pain-Relief

• Stimulates endorphins
• Increases pain threshold

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Endorphins in Colostrum

• 2x higher than mothers blood level
• Elevated endorphins may contribute to
• postnatal adaptation
• overcoming stress of labor and birth
• postnatal development of biologic functions

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Endorphins in Human Milk

• Mothers who delivered vaginally had higher levels
  of endorphins in their milk than mothers who had
  elective c-section

• Preterm mothers had higher levels than term

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Breastfeeding is analgesic in newborns

• Pediatrics 2002 Apr109(4)590-3
• 30 full-term, breastfed infants
• Intervention group - held and breastfed by their
  mothers during heel lance and blood collection
• Control group experienced the same test while
  swaddled in their bassinets
• Crying and grimacing were reduced by 91. Heart
  rate was also substantially reduced by
  breastfeeding

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The Most Important Factors for Lactogenesis Stage
II

1. Prepared mammary epithelium
2. Progesterone withdrawal
3. Maintained plasma prolactin
4. Removal of milk within an undefined interval
   after birth

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Days Postpartum
Neville et al, Ped Clin N Am, Feb 2001
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Milk volume
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Importance of nipple stimulation
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Early initiation of breastfeedingis associated
with

• Earlier establishment of effective sucking and
  feeding (Righard 1990)
• Temperature stability (Britton 1980)
• Higher blood sugar (Hawdon 1992, Yamauchi 1997)
• Increased stooling, decreased jaundice (Yamauchi
  1990)
• Longer duration of breastfeeding (DeChateau 1977,
  Salariya 1978, Taylor 1986, Yamauchi 1990)

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Unrestricted breastfeedingis associated with

• Less engorgement (Hill 1994)
• No increase in nipple soreness (DeCarvalho 1984)
• Less jaundice (DeCarvalho 1983)
• Stable blood sugar (Hawdon 1992, Yamauchi 1997)
• Faster onset of mature milk (Salariya 1978,
  Yamauchi 1997)
• Less weight loss, faster weight gain (DeCarvalho
  1983)

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Can You?

• Describe one effect medications given to the
  mother during labor can have on her newborn or on
  breastfeeding
• Identify the effect of early post-birth
  skin-to-skin contact and breastfeeding on
  maternal hormones and on breastfeeding outcomes
• Name at least 5 of the 10 Steps to Successful
  Breastfeeding from the Baby Friendly Hospital
  Initiative