Webchat with the directors of UNICEF's Baby Friendly Initiative

Unicef breastfeeding initiative

Sue Ashmore and Carmel Duffy from UNICEF joined us at MNHQ in November to answer your questions on infant feeding and support for breastfeeding in the NHS, as well as the Baby Friendly Initiative, peer support groups, co-sleeping and longer breastfeeding. 

Sue Ashmore is programme director of the UNICEF UK Baby Friendly Initiative, which works with the NHS to ensure a high standard of care for pregnant women and breastfeeding mothers and babies.

Carmel Duffy is deputy programme director of the UNICEF UK Baby Friendly Initiative, responsible for the development and monitoring of education and training. Carmel has recently been involved with developing a specialised course for health professionals working in neonatal units that emphasises the importance of breast milk as part of a family-centred approach to care.

Baby Friendly InitiativePeer support groups | Improving information offered by HCPs | Education and support | Support for formula feeding mothers | Special circumstances | Longer breastfeeding | Co-sleeping

Baby Friendly Initiative

Letter Qtruthsweet: I'm really interested in the Baby Friendly Initiative as a breastfeeding peer supporter, as well as a breastfeeding mother who has been an inpatient at a hospital recently, and as a breastfeeding mother of an recent inpatient. My local hospital is aiming for Baby Friendly Status, and by all accounts the maternity team is on board. However, the rest of the hospital seems at best unaware, or at worst obstructive and hostile, to breastfeeding mothers and babies.

The inpatient wards seem bemused by breastfeeding past about six weeks and are unwilling or unable to allow dyads to remain together, or offer support for those who are separated to continue maintaining a milk supply. Although the children's ward is better and allows parents to stay, most staff are woefully under-informed about breastfeeding. 

Could it be emphasised that Baby Friendly Initiative should apply to the whole hospital not just Maternity/SCBU. Or am I misinformed? Is the BFI only for the neonatal period on the maternity wards? Are there plans to have as a requirement for BFI status? Something like 'pooling' breast pumps that could be used by any ward, or training staff in BFI so they could visit wards other than Maternity ones, etc?

Letter ASue: Nice to talk to a peer supporter. I think my answer may leave you feeling a bit frustrated, so apologies in advance. We do only assess the maternity unit and to a lesser extent, the neonatal unit. Our hospital assessment tool is based on a global tool from the World Health Organization and UNICEF designed to assess the care of mothers and babies in the first days after birth.

We would love to take the standards into the areas you mention for all the reasons you describe, but don't have the resources to do so.

In the UK, we have taken the maternity standards and expanded these to cover community care for breastfeeding mothers, and have also developed standards for universities which educate midwives and health visitors. While we have a lot of supporters who do a lot for the initiative without financial reward (for which we are forever thankful!), our actual staff hours are quite small and mainly taken up with teaching and assessing. Developing and then running each accreditation programme is a very big undertaking and we have to be careful not to spread ourselves to the level that we are ineffective. 

Letter QGaelicsheep: I have given birth in two hospitals, one in England and one in Scotland, both of which have Baby Friendly status. In both hospitals I have received pretty poor breastfeeding support, which basically amounted to shoving the baby onto the breast and leaving me to it, and both times I have left hospital with cracked nipples. I am sure you will agree that those first few days are absolutely key to establishing successful breastfeeding, and leaving hospital with cracked nipples makes the subsequent days and weeks so much harder than they need to be.

What is UNICEF doing to ensure that hospital staff in Baby Friendly hospitals actually take on board the training they receive and provide decent support and advice to the mothers in their care, so far as resources permit?

Letter ASue: I am sorry to hear about your experiences and completely agree that it is not good enough. Your question is a really important one and I can only answer it properly by explaining how the assessment procedure works, therefore, I hope you don't find this too long winded.

Our assessments are based on interviews with staff, pregnant women and breastfeeding and bottlefeeding mothers. We also interview managers and check policies, guidelines etc. There are 41 criteria for the maternity assessment.

As an example, to assess whether the unit provides adequate support to mothers to help them position and attach their baby for breastfeeding, we will interview a random selection of relevant staff and ask them to describe how they would teach a mother. We look for all the key points in the right order and the communication skills needed. We then ask a random selection of mothers if they have been supported to learn how to position and attach, what this has consisted of and how they are doing now. We then check the written material provided, training curriculum for staff etc.

Obviously, if we had interviewed you, the unit would have failed on your interview because you weren't offered adequate support and you experienced cracked nipples. However, when we have interviewed the selection of mothers and staff, their answers are all fed into a scoring system and we come out with a percentage score for each criteria. Therefore, if we interviewed 40 mothers and 30 stated that they had had good care, the result would be 30 out of 40 = 75%.

The pass mark for most criteria is 80%, which means that 20% of staff can still have inadequate skills and 20% of mothers not get the care. This may seem lax, but you have to bear in mind that when units first start working towards Baby Friendly, initial internal audits can easily have scores of 20% or even less.

Once a unit is accredited, they are obliged to submit internal audit results each year and we provide them with an audit tool to do this. We carry out a standard reassessment after two years and then every one to five years after that, depending on how well they're doing.

We welcome feedback from mothers about accredited units and do get this quite regularly. We always discuss this with the unit concerned and offer them support to improve. If we get concerned about negative feedback, we can do spot checks, which are short-notice visits where we talk to a random selection of mothers.

Our external committee of experts, the Designation Committee, make decisions regarding who keeps and who loses awards. We do remove awards, but only when we run out of options to encourage improvements. The aim is always to improve care, not to be punitive.

Our ultimate aim is to enable the health service to provide Baby Friendly standards of care for all mothers, all of the time, and for this to happen it has to become the normal culture or 'just what you do'. Unfortunately, we started from a very low base in the UK. Before Baby Friendly, few health professionals had received any meaningful training on breastfeeding and policies and routines did not take breastfeeding into account at all.

Over the past 15 years there have been very large improvements and many people are now working really hard to improve care. When I hear stories like yours I could cry, but then I remind myself that there are around 900,000 babies a year born in the UK and thousands of health professionals are responsible for their care, so it was always going to be a big job!

Letter QLulumaam: How do I persuade the trust I doula at to get rid of the Nestlé-stuffed vending machines in the antenatal clinics and by the cafe? I don't think it sits well with Baby Friendly? I've brought it up at the Maternity Services Liaison Committee but nothing happened. I've spoken to the head of maternity and consultant midwife but nothing happened.

How further up the trust should I take it and is there any pro forma information that I can use? How can a unit be baby friendly and line the pockets of Nestlé?

Letter ACarmel: This is a tricky one. All healthcare facilities working towards Baby Friendly accreditation must adhere to the International Code of Marketing of Breast Milk Substitutes, which means that they cannot advertise formula milks, bottles, teats and dummies. Within healthcare facilities, this means there must be no leaflets, posters, pens, diary covers, weight charts etc produced by formula or bottle and teat manufacturers given to mothers or used in healthcare premises.

The purpose is to ensure that only accurate and unbiased information, free from the influence of commercial marketing, is used. This does not stop families from receiving information regarding bottle feeding - UNICEF and the Department of Health produce material to support good practice.

Nestlé is a multinational company which produces a vast range of products. It produces infant formula but not in the UK (we are, of course, aware of all the issues relating to their marketing of this in developing countries). This means that Nestlé products fall out of the remit of the UK Baby Friendly standards and so we do not prohibit the sale of products such as coffee or chocolate in healthcare premises. However, the international boycott of Nestlé is run by Baby Milk Action, and you may want to contact them for further information at www.babymilkaction.org.

Letter Qflyingzebra: Do you have any tips to help us distinguish the midwives who think they know something about breastfeeding from the midwives who actually know something about breastfeeding? That's not meant to be a facetious question, by the way, but I've been badly letdown on the breastfeeding front by midwives who are absolutely confident that they know what they're talking about, even though they are wrong!

Letter ASue: Hmmm, you could politely ask them? I appreciate that this would have to be sensitively done though. There are some things you can look out for though - UNICEF Baby Friendly run a breastfeeding management course designed to give midwives and health visitors the basics they need and we also run a train the trainer course to help trusts develop their own staff training. Obviously in-house training is only as good as the person running it, but in many places it is fantastic. Some of the voluntary organisations run very good training too. Baby Friendly also has an accreditation programme for university courses, so you could ask newly qualified staff if they trained in an accredited university.

Remember, though, that acute staff shortages leave many midwives and health visitors very, very pressured and that it isn't their fault as individuals if they have been given no opportunity for training, many would dearly love to attend.

If you are not happy with the standard of care you receive, could we make a plea that you let the organisation know. I know this is hard when you have just had a baby, but it is really important. We at Baby Friendly spend a lot of time trying to persuade reluctant NHS managers to take this seriously. Some are fantastic, but I can't remember the number of times we have been told that it is not a priority. The profound effect of poor care for breastfeeding on mothers, babies and their families is often not understood higher up the hierarchy.

Letters of complaint from mothers are taken very seriously and are responded to and monitored. You could ask what training the staff have had, what progress has been made towards Baby Friendly accreditation and what plans there are get the unit to full accreditation. If you go to the awards section of the Baby Friendly website you can see what progress has been made in individual units and there is a mechanism by which you can write a letter to the Chief Executive. If the unit is fully accredited please can you let us know and we will take it forward.

Letter QSuzikettles: I gave birth in a Baby Friendly hospital and the midwives were very supportive of breastfeeding - really, they were. However, midwives were few and far between, and trying to support many women and babies. The consistent people on the ward were healthcare assistants, and they weren't supportive (it wasn't explicit - but you could tell that their attitude was "just give them a bottle and us all a break"). One woman in particular acted almost as a gatekeeper to the midwives, but my requests for help with latching did not merit disturbing the "very busy" midwives and I left hospital with my nipples in shreds and what turned out to be the start of a very nasty infection.

How much emphasis is put on getting all staff on board when Baby Friendly status is awarded? And how is this checked up on to ensure it's not all lip-service?

Letter ASue: There are several issues here. First is the acute shortage of midwives in the NHS. The birthrate has risen in the UK over the past decade, but this has not been matched in terms of funding or increased staffing for the maternity services and this was not a well-staffed service to start with. As an ex-midwife myself, my heart goes out to all those desperately trying to do a decent job in such circumstances. 

However, I do take your point about the variability of support and enthusiasm for breastfeeding. We assess many hospitals and community services every year and know that one individual can make or break breastfeeding for mothers and that we are a long way from a harmonious service. Also we mustn't forget mothers who bottle feed here, they too need education and support which is not always consistent or even available.

I think we need to see this as a process. The fact that you have both seen supportive and knowledgeable staff demonstrates that they exist. In fact, there are now many thousands of health professionals who understand the importance of breastfeeding and the basics of how to make it work and that is a tremendous leap forward. In the early 1990s it was so few, they generally all knew each other!

However, we are still living in one of the most entrenched bottle feeding cultures in the world and health professionals are part of that culture. Not all are educated yet and not all are convinced even when they have had education. Some have such issues from their personal experience that it is too painful to admit that there is any value in breastfeeding. Some fear the loss of power if mothers are so much more important to babies than the 'qualified' professional, many are really worried about putting too much pressure on mothers to breastfeed – note how they are accused of this very regularly in the media.

Unfortunately, stories like yours are much too common. While we see evidence of some exemplary care in maternity units throughout the country, we do also hear stories like yours which saddens us but makes us more determined to keep on pushing for improvements in care. Your wonderful community midwife is an example of how just one person can turn things around and I am so glad that you found that support. The gatekeeper on the ward, however, is an example of how just one person can also jeopardise breastfeeding and it is why it is crucial that education and training is mandatory for all staff involved with caring for mothers and babies – and that includes doctors who have little or no breastfeeding education during medical training.

Baby Friendly requires that all staff are educated according to their role. The more this happens, the better care will be. In our experience it doesn't matter who gives the care, it is the quality that counts. If shortages of midwives and health visitors mean that healthcare assistants are asked to give care, so be it - as long as they are properly trained. More trained staff equals more breastfeeding mothers, which equals, more understanding of breastfeeding which equals a more breastfeeding friendly culture.

Letter QBollocksToThis: Increasingly, maternity units are discharging postnatal women within very short timescales, sometimes just six hours after delivery. And in many areas, daily midwife visits until day ten are a thing of the past, with some women seeing a midwife only once or twice within that period. How can this possibly be compatible with the BFI? What are your thoughts on NHS-funded breastfeeding counsellors visiting daily instead, for those mothers who wish support?

Letter ASue: Meeting Baby Friendly standards is very hard when postnatal care is so stretched. However, our job at UNICEF is to define adequate, evidence-based care and then work with the health service to find ways of providing that care. We are not defining excellent care as the 'icing on the cake' - rather, we are defining basic, safe care (more the cake board) and so stand very firm against watering down definitions of 'good enough' to fit into current political climates.

It's interesting, and I think this can be very helpful to NHS staff and managers. When the bottom line of an acceptable standard is defined, then ways of meeting that standard can be explored. I have had a number of visits recently where unacceptable holes in service (not necessarily just related to breastfeeding) have been identified and action plans drafted to address them as a result of working towards Baby Friendly accreditation.


Peer-support groups

Letter QIndith: How do you think we can change the problems encountered by so many women on the wards when trying to breastfeed? Much of the time the midwives would like to help but they simply cannot devote an hour to sit by a mother and help her feed, as a mother can be given a bottle to feed her child and the woman in labour needs the midwife more.

A group of us trained as peer supporters a while ago and there has been a lot of talk about getting us on the wards to sit with mothers, but there seems to be a lot of inaction and red tape. It seems we are far from it, which is a shame as while peer supporters may not be able to sort out more severe problems, I do believe that they can take the load off the midwives by just being there to hand-hold and chat to.

Letter ACarmel: There are a number of maternity units in the UK who have successfully brought peer supporters into the wards to offer additional support to breastfeeding mothers. I am more than happy to put you in touch with some of these hospitals so you can get more information about the process involved. If you can, email the helpdesk at bfi@unicef.org.uk

Hopefully, we will be able to help. I appreciate it can be frustrating when you feel that there is a lot of red tape and bureaucracy but hospital trusts also have a responsibility to ensure that both you and the mothers are protected and therefore there does need to be a certain amount of red tape. Good luck though.

Letter QGaelicsheep: A number of NHS areas are training groups of peer supporters. Is there any evidence as to how effective these peer supporters are with improving breastfeeding rates/success in those areas?

Letter ACarmel: There is evidence that peer-support programmes can work really well and we do know that health professional input alone is not enough to give mothers all the support they may need to continue breastfeeding. The evidence suggests that it is a 'package' of care that is needed - good hospital care, good NHS community care and then interventions to provide mothers with on-going support.

Peer-support programmes are primarily designed to provide the ongoing support. Their success depends on how they are run. Some have been extremely successful, while others less so. The Baby Friendly Initiative for the community requires that the programmes are audited and evaluated regularly and then changed if they are not meeting mothers' needs.

We do have some concerns about the fact that there is no national standard for either the training provided for peer supporters or the remit they have within their role. We worry that in some areas there is a huge amount of responsibility placed onto peer supporters and there may not be the support available for them should things go wrong.

Health professionals should have ultimate responsibility for women in their care and if peer support is provided there should be robust systems in place to protect everyone involved including the peer supporter. We also worry that in the current economic climate health chiefs could see peer support as a cheap option which could potentially leave them more vulnerable.


Letter QSparklePffftBANG: Most women do start breastfeeding but then the figures fall off at six weeks - why do you think that is? Is it lack of support to people who want to breastfeed, or people placing more emphasis on the first couple of feeds, either because they are in hospital with expectations to fulfil, or because they believe the benefits of colostrum are worth it, but then don't want to continue? What can be done about it?

Also, what can I do, as a breastfeeding mum, to help? I have trained as a peer supporter, don't think I would be much good as a counsellor, but would love to get involved somehow?

Letter ACarmel: It is really sad to see such a huge drop off in breastfeeding at six weeks, and even sadder to know that many of the women who stop breastfeeding did not want to but were forced to because of problems such as pain or poor milk supply which could have been prevented had they received the right support.

As Sue says in response to another question, women will succeed if just one person really believes they can do it and that belief along with skilled and knowledgeable support is often sadly missing. It is wonderful that you have trained as a peer supporter because just by believing in women you can do so much to help. Go for it!


Letter QTigerfeet: I and many of the other mums from our local group recently completed training and are now active peer supporters at our weekly support group. We now outnumber the non-peer supporters attending the group but we're really struggling to recruit new members. We are working hard to publicise the group but we seem to be finding it very hard to overcome the breastfeeding equals a boob-wielding-nutter myth. Do you have any ideas that might kick start our recruitment drive?

Letter ACarmel: It definitely is important to meet women in the antenatal period, as it's good to have a friendly face when you first turn up at a new group. I have found this to be useful in the past. Hopefully, your local midwives and health visitors can also help promote your groups and give out friendly fliers. My experience is that these groups do tend to start off slowly but feedback from people who have attended is the best publicity there is. I am not sure how long you have been running but be patient and they will soon see you as the measured sensible people that you are and be queuing up outside your door!


Letter QSerendippy: If you failed at breastfeeding the first time round, how can you convince me to try again a second time? I thought it was going to be easy as it is natural, everyone does it, etc, but failed completely. Now I am worried that next time I will be too afraid of failing - and the pain and guilt that goes with it - to try. I had people at the end of a phone last time, but I think I needed someone there in person. Would you recommend paying for someone private? 

Letter ASue: I would want to debrief with you exactly what happened and look at where things could have been different and then discuss with you your options for this baby. It would be worth finding out whether your maternity unit has an infant feeding adviser and asking for an appointment to talk to her, she can help you make a plan. There may also be a peer support programme in your area and again you could ask to talk to someone from the programme. Another alternative is to ring the NCT helpline or the National Breastfeeding Helpline.

Even if you don't breastfeed you can still enjoy skin contact with your baby – see Carmel's answer on care for bottle feeding mums.


Improving information offered by health professionals

Letter Qscrappydappydo: I would like to know how we 'educate' health visitors, in particular, on breastfeeding. I've been reduced to tears in the past and had one tell me she was shocked that I was 'still' breastfeeding, that I was over-feeding and encouraged me to switch to formula to monitor the amount my daughter was feeding. How can we ensure that health professionals have access to the best updated advice?

Letter ACarmel: It is such a shame that there are still some health professionals who think that follow-on milk is superior to breast milk. It just makes you see how effective the milk company advertising is. The law regulating the advertising of formula milks is much weaker than the International Code of Marketing and this is the reason there are adverts for follow-on formula on our television sets.

A MORI poll conducted by UNICEF and the NCT found that many mothers thought they had seen adverts for infant formula rather than follow-on milks and the companies use the promotion of follow-on milks to advertise their company name. It comes back to education, however, and your question illustrates just how important it is for health visitors to attend breastfeeding training so that they can appreciate the importance of breast milk beyond the six-month period.

Letter Qneenz: I tried to help a friend of mine to breastfeed her second child. I went to visit her in hospital 24 hours after the birth and she said the baby was latching on OK. The midwife came in and asked whether the baby had had a wee. When my friend said no, the midwife said if she didn't, they'd have to give her formula. I was shocked and felt that what was needed was for mum and baby to spend some time alone, skin to skin and feeding. My friend stopped breastfeeding the next day, sadly. Was the midwife correct with her advice or not?

Letter ACarmel: I'm sad to say that the advice was not correct. Firstly, the midwife should have observed a breastfeed if she was concerned about whether or not the baby was feeding effectively. Sometimes it is difficult to determine whether a baby has weed in the first 24 hours especially if he or she has also pooed a lot of dark meconium into the nappy. While urine and poo are important indicators of whether a baby is getting enough breast milk, they are part of a wider picture and the midwife should have conducted a full feeding assessment rather than undermine your friend's confidence with such a throwaway remark.

Letter Qneenz: Thanks for your answer, and I hope you don't mind a follow-up question. In situations where midwives are 'pushing' formula on mums when it is not necessary, how does that fit in with BFI and is it OK for the hospital to be giving away the formula for free? How many days should a BFing mother get post-birth before she is told to give the baby formula now because they aren't getting enough breast milk?

Letter ACarmel: No mother should be left in a situation where problems with feeding are discovered way down the line. The Baby Friendly standards are that mothers are helped with breastfeeding until they are confident to do so. From January, one of our standards will be that when mothers are discharged from hospital they have a discussion and are provided with information on how to recognise that feeding is effective and where to seek help if they have a problem.

A further feeding assessment should be carried out again at day five or six, and again at the handover to the health visitor. Most breastfeeding problems are preventable with good support and when we read about stories in the media about babies being readmitted to hospital because of dehydration, it is often breastfeeding that is portrayed as the problem when the reality is that no one has picked up on feeding problems earlier and put practices in place to overcome them.

Letter QDinahrod: To get access to good breastfeeding support was quite difficult for me. There was so much that conflicted - about cup feeding, syringe feeding, expressing, and with latching. The midwife told me I was doing everything right, but my baby dropped 10% of his birth-weight and there was talk about readmittance to hospital (not great if you have other children to care for). No wonder mothers see bottle feeding as the easier option.

Letter ASue: Conflicting information is one of the commonest complaints from breastfeeding mothers. Sometimes this is because the situation changes and the health professional is responding to this, but unfortunately sometimes it is because of a lack of training which leaves the health professional not sure what to do next. See our previous responses re our work to improve training and practice within the maternity services.

I do have a great deal of sympathy for mothers who just feel it is easier to bottle feed when they have faced problems as you describe. Our job is to keep working to improve the service so that this is far less common and then mothers will be in a position to make an informed and free decision whether or not to breastfeed.

Currently, it is not much of a choice if you are in a position where you feel you have to stop because it just isn't working and there is no one able to support you to carry on.


Letter Qcrikeybadger: What single thing would reduce the high rate of women who give up breastfeeding without really wanting to? Also, with public sector funding cuts, aren't the training courses (like the BFI ones) going to be one of the first things to go?

Letter ACarmel: This is a complex issue and it is difficult to come up with one single factor. However, from our point of view education is key to ensuring healthcare staff provide support and up-to-date evidence-based information to mothers. The spending cuts are a concern, but we would hope that health chiefs would recognise that a small investment in training staff to support breastfeeding will result in big improvements in long-term public health with accompanying cost savings to the NHS.

Our university award ensures that student midwives and health visitors receive in-depth breastfeeding education throughout the course. There is interest from a number of universities but we would like to see all university midwifery and health visiting courses accredited as Baby Friendly.


Promotion and education

Letter QLoveBeingAMummy: What do you think is needed to change the perception of women who think breastfeeding is gross, but that the highly processed milk from another animal is 'normal'? 

Letter ASue: This is a complex question - the UK has one of the most entrenched bottle feeding cultures in the world and this results in all of us seeing bottle feeding all the time and considering bottle feeding as the normal or default way to feed a baby. Breasts on the other hand are associated with sex (to put it bluntly).

Therefore, it's hardly surprising that some women have the reaction they do to breastfeeding. To turn this around is a big job, but not impossible. First, we need to ensure that the women who want to breastfeed are enabled to be successful. Therefore, healt care practices need to improve, with better policies and training as described by UNICEF, and new mothers need more support to carry on breastfeeding.

The research shows that mothers are more likely to breastfeed if there is one person in their lives who believe that they can do it, that is why peer-support programmes, support groups etc are so important, especially for women who live in areas where few people breastfeed. 

We also need to make education for breastfeeding in the antenatal period better and more accessible to the women least likely to breastfeed. You can't make an informed choice if you don't have clear and unbiased information to assist you. Once more mothers are breastfeeding, then it will become better understood and less strange to the women around them. Also there will be fewer mothers out there who have horror stories connected to their breastfeeding experience, putting off their family and friends.

Then we need to think about how breastfeeding is portrayed in the media. Social marketing campaigns have been shown to be successful in changing attitudes and I think we also need to tighten the law. It is illegal to advertise formula milk and yet the companies get around the law all the time, giving out misleading information and seductive adverts to make bottle feeding look like the sensible / normal choice to make.

Letter Qsungirltan: It seems as if there are women who want to breastfeed, and will do it hell or high water, then there are women who don't want to, no matter what. However, in the middle there are women who are open to giving it a go but when they have problems breastfeeding they seem to be let down by midwives and health visitors, when they should be referred to specialist support. Do you think breastfeeding support (counsellors, latch-on groups, peer supporters) should be explained and promoted to all new mothers?

Letter ACarmel: Yes, it is really important that breastfeeding women are provided with the contact details of breastfeeding support both locally and nationally. There is a wealth of knowledge and experience out there and we should all be working together to improve services and support for women. One of the Baby Friendly standards is that women are provided with information on what support is available and how to contact that support before they are discharged from hospital so that they are aware of the help available.

Support for formula feeding mothers

Letter QFatcontroller: There is clearly a lot being done by Baby Friendly and others to support breastfeeding mothers. Is anyone looking out for bottle feeding mothers?

Letter ACarmel: The Baby Friendly Initiative wants all mothers to receive a high standard of care, regardless of feeding intention. If a mother has made a fully informed decision to bottle feed we would encourage her to hold her baby in skin-to-skin contact after birth so that she and her baby can enjoy all the benefits associated with skin contact.

We then encourage mothers and babies to remain together so they can learn to interpret feeding cues. It is important that mothers are provided with information on how to make up bottles of formula as safely as possible and we check to ensure that this has been done during assessment. However, there is so much more that can be done to support bottle feeding mothers. It is important for babies that they are not bottle fed by a wide variety of people and so we would encourage mothers (and fathers) to be the main feed givers of their baby. Holding baby close and making eye contact during feeds promotes bonding and social interaction for both bottle and breastfed babies. There is clearly a lot being done by Baby Friendly and others to support breastfeeding mothers.

Letter Qtabouleh: I feel that a key part of Baby Friendly should be proper information and advice about formula feeding: different formulas, how to feed and most importantly, preparation. Your website has the only decent leaflet about formula - so well done for that. But why on why can that information not be properly explained to parents?

Why do healthcare professionals fail to explain that formula is not sterile, and that to make it safe it needs to be made with water which is 70°C? Nor explaining properly the alternatives to making a fresh bottle each time? 

Your own leaflet on this page is rubbish I'm afraid - it is five years old and it fails to mention that to get water at  70°C it needs to be boiled and left for 30 minutes - it also fails to mention that there are some safe alternatives to making fresh.

And as for the leaflets in other languages - well, some of them do not mention the  70°C at all. I emailed Baby Friendly in mid-July and was told: "I have spoken with our website and resources editor and we are getting all of our leaflets updated over the course of the summer."

I feel passionately about safer infant feeding - and working towards higher breastfeeding rates is part of that, of course. But at the moment where we are living in a formula feeding culture - let's make sure that healthcare professionals can give advice on how to actually safely feed formula. That should be easy. Then get on with increasing knowledge of breastfeeding. Please can I have your thoughts on safer formula feeding?

Letter ACarmel: Thank you for your kind comment about our recent leaflet. Like you we believed that the information available for mothers who are formula feeding was really patchy and much of it out of date. We want to ensure that all mothers however they choose to feed their babies receive appropriate information to enable them to feed as safely and effectively as possible and it is crucial that mothers are provided with the latest information on making up formula feeds.

I am sorry that you accessed some outdated material from our website. We are currently revamping the entire website and hope to make it the best breastfeeding website in the world so hopefully all outdated material will be removed when we make the change over.


Support for breastfeeding in special circumstances

Letter Qtwinsplus3: I've just found out I'm going now be finishing work at 8pm instead of 6pm one day a week. This means I won't be home until 9pm, but my twin daughters (aged one year and two weeks) are used to breastfeeding at 7pm before going to sleep. Work is fine for me to pump there, but my girls want the milk straight from me at bedtime. Any advice?

Letter ASue: This sounds really hard, I do sympathise. If you haven't already done so, it is a good idea to be aware of your rights as a breastfeeding mother. Follow this link for the Department of Health guidance on this.

It can be best not to try and replicate breastfeeding when mum is not there, especially with older babies like your girls. So if your partner gives them a drink in a cup and then offers cuddles, or stories, etc, they will start getting used to a mum routine and a Dad or partner routine. Most children quickly get used to it being different when mum is not around and life then gets easier.

Letter Qkveta: I wanted to ask if there is a similar initiative for workplaces, given that many women stop breastfeeding to return to work, and in the current economic climate, many more will be trying to get back into the workplace than they used to. I've been incredibly lucky to work at an institute which is very supportive of breastfeeding mothers - they have a 'lactation suite' (a room with comfy chair, table, sink, lockable door, and stack of trashy magazines - the only thing missing was a fridge for storage of expressed milk), a nursery on-site which encourages mothers to come and feed their babies when it's needed (the waiting list is shocking though) and great flexible working policies.

I am very aware that most workplaces do not offer anything like this level of support, and wondered if there was a mother-friendly initiative which could encourage workplaces to improve their support (obviously not just for breastfeeding mothers).

Letter ASue: Sounds like you are fortunate in your employer! Unfortunately, there isn't a Baby Friendly for workplaces, although I agree with you that it would be a good idea. Breastfeeding mothers returning to work do have certain rights though, and you can click here for more details.

Letter QHildathebuilder: I am the mother of a very premature baby. With babies in special care units, is there a way the NHS can balance the need for mothers who are breastfeeding to have time alone with their baby with the needs of the hospital? I would like to see something that can ensure privacy during ward rounds, and to help with the fact that there is not enough space to allow mothers of premature babies to stay in the hospitals.

Another idea would be milk banks, and loan pumps for those with a plentiful supply of milk to become milk donors, rather than spending the money on formula. Many premature babies' mothers want to breastfeed but are forced to use formula as it's easier to get the babies home. How can the NHS staff be encouraged to let the mothers take their babies home to really give breastfeeding a chance to get established?

Letter ACarmel: It is, as you say, so important for mothers to be able to have free access to their babies in neonatal units, and crucial that preterm and sick babies receive breast milk. Some experts believe that breast milk is as important (if not more so) than technology for the wellbeing and development of preterm babies.

We know this can be done, because there are neonatal units in Sweden where parents are encouraged to be with their babies at all times and they are encouraged to be fully involved with their care whilst being supported and supervised by the nursing staff. If parents are unable to be there for a period of time, other designated family members are encouraged to visit the units to offer comfort to the babies in their absence.

In this country there is at the present time a real drive towards encouraging family-centred care which promotes a more holistic approach to the treatment of babies in neonatal units. But you are right that there is still a long way to go. It is a real challenge for mothers to sustain milk production when their baby is preterm or unwell and they need additional support to help them succeed that this. Knowing that by providing breast milk they are contributing in a unique way to their baby's health is really important for mothers.

UNICEF UK has recently developed a specific course for staff working in neonatal units to help them improve their knowledge and skills and, therefore, improve standards of care within their hospital. We have also been really pleased to see some neonatal units take into consideration the importance of parental involvement when they have refurbished or built new units incorporating areas for parents to relax and stay overnight if they wish.

The European Association for Children in Hospital states that children in hospital should have the right to have parents or parent substitute with them at all times and that accommodation should be offered to all parents and they should be helped and encouraged to stay. Although this generally does apply to children on a paediatric ward, somehow it seems that neonatal units fall outside the directive and we should ask ourselves why this should be accepted.

Letter Qexplorerescueproject: I'm a breastfeeding peer supporter in a city that is working towards Baby Friendly accreditation. In the past few months, I have worked with eight women whose babies have been diagnosed by midwives as tongue-tied and yet there is no provision locally to rectify this.

I am aware that frenulotomy is not always the answer and that good breastfeeding support on attachment and positioning is vital. However, when the breastfeeding support has been provided, and women are still struggling, there is nowhere for them to go other than exclusively expressing or moving to formula milk.

The HCP Local Infant Feeding Guidelines state that NICE recommends snipping tongue-tie as an option, but this is contradicted by local clinical policy which is not to perform the procedure. It all seems pretty un-Baby Friendly to me. Does UNICEF have a view on tongue-tie and its potential treatment?

Letter ASue: Six or seven years ago, UNICEF Baby Friendly were a major supporter of the campaign to get frenulotomy accepted as a safe procedure to enable breastfeeding. We have come a long way since those days and now this procedure is accepted and carried out in many areas. We do share the concern you have hinted at - that in some cases it may now be being overused, with the procedure offered when support with positioning and attachment is what is needed. However, it is not helpful for it not to be offered at all.

Offering frenulotomy is not part of the Baby Friendly standards and so not something that we have much influence over on a local level. However, if you go to our website, you will find a list of places that do provide the service. In the absence of anything more local, your only option is to suggest mothers travel to the nearest centre to get the procedure carried out.


Longer breastfeeding

Letter QLeninGuide: Are we likely to see any initiatives around normalising natural-term breastfeeding? No one was more surprised than me that my first son went on, and on, and on. I had many wobbles and concerns over the four years he breastfed for, but it was clearly very important to him. He stopped more or less on his own in the end. It would have been so helpful not to have the six months/up to two years 'milestones' going around in my head.

Letter ASue: In the UK, only 2% of mothers exclusively breastfeed for the first six months as recommended by WHO and UNICEF, and the majority of mothers who stop in that time say that they would have liked to breastfeed for longer. With so far to go, your question feels more like a dream than a possibility. One of the problems we have whenever discussing or writing about longer breastfeeding is that there is very little evidence to support us, and the reason for this is that so few babies are breastfed for this length of time.

Logically, young children will only breastfeed if they want to and when they stop wanting to or lose the sucking reflex they stop. There is no convincing evidence of harm from longer breastfeeding, with the protests being largely cultural and a lot of 'common sense' reasons for continuing – antibodies provided to protect from infection, excellent nutrition, building a strong and loving relationship with mum, and giving both parents a highly effective way to help them calm fractious and tired toddlers.

Much breastfeeding evidence suggests that the longer breastfeeding goes on the greater the benefits. Maybe if we have success at enabling more mothers to successfully breastfeed in the first few weeks, some will carry on for longer and the studies can then be carried out and our gut instincts proved right.

Letter QGraceK: Will the initiative have some effect on the sudden change of emphasis that comes when your baby hits six months from "no food/just breast milk" to "why aren't you putting more effort into weaning/stuffing three meals a day into them"? This has happened to me in the last month when taking my daughter to be weighed. I was shocked by this sudden change in emphasis, and it must surely encourage many women to give up breastfeeding soon after six months, despite the fact that continued feeding would benefit both the mother and the child for months to come. 

Also, as someone with very inverted nipples, can I just mention that neither the NHS or NCT mentioned nipple shields to me. Luckily, my mother forewarned me, and a lovely nurse in special care (for my first daughter) got me one so that she could latch. We then fed happily with them for 22 months. Why does no one look at your nipples in antenatal care - even if you raise such concerns? Leaving it until you have a hungry baby and engorged breasts is no help to anyone.

Letter ACarmel: As an ex-health visitor who worked when mothers were advised to wean or introduce solids between four and six months (but in reality meant 16 weeks - I remember colleagues saying to parents "your baby will be 16 weeks on Monday and you will need to begin introducing baby rice" etc.) There was also a lot of concern that if solid food (what a misnomer – it was actually slush) was not introduced the 'window of opportunity' would be lost and babies would struggle to accept or tolerate foods. Thankfully the policy now recommends introducing solids at around six months, which makes so much more sense in that babies are definitely more developmentally able to deal with other foods.

However, old habits die hard and the pressure to quickly get babies on to three meals a day continues. Some health professionals worry about the baby's iron stores running out, as if this happens suddenly when the baby hits the six-month mark rather than it being a gradual process. Introducing other foods should not be treated like a science but should be part of a natural progression. Encouraging babies to experiment with tastes and textures when they show an interest is so much better than force-feeding them mush. And of course as you say, breastfeeding is still an important part of their diet throughout.

The Baby Friendly training programme for health professionals covers appropriate introduction of solids and since the introduction of the recommendation to introduce solids at six months, there has been more interest in this issue and health professionals are becoming better educated about this. However, again it is still patchy.

To answer your question about nipple shields – I am really glad that they worked for you but not everyone is so lucky. The problem is that they can reduce the amount of milk a baby gets from the breast because they limit the amount of breast tissue the baby takes into his/her mouth. As breastfeeding works on a supply-and-demand basis, this can then lead to reduced milk production and the cycle continues.

We don't check nipples in the antenatal period anymore, because babies are pretty good at working with what they have got. They don't have any preconceived ideas of what their mother's nipples should look like and if they have an opportunity to have unhurried skin-to-skin contact they can generally work out for themselves how to feed from big, small or even inverted nipples!

Letter QWelshCerys: I fed my youngest until his eighth year - of course only occasionally and he was enjoying a 'normal' diet the rest of the time. All well and good - and that was a few years ago. But at work the other day, talking to none other than a social worker, I heard her saying that she thought feeding an older child was unnatural and wouldn't hesitate to confront a parent who was doing so. Wow! She acknowledged it isn't against the law but saw nothing wrong with getting heavy about it, including interviewing the child in question. Hope this problem isn't endemic in a profession that yields so much power in many families' lives. What do you think about all this?

Letter ACarmel: One of the things we have observed over the years working in the very emotive field of breastfeeding is that everyone has an opinion and some people are very forceful in expressing their opinions. It is difficult to comment on a whole profession, as this may just be the views of one individual and one would hope that she would not have the power to act alone. It does seem strange that she would be concerned about something that is done in a loving and nurturing way when there are horrific stories of child abuse being conveyed in the media.



Letter QEauRouge: Do you think if the NHS changed their 'just don't do it' policy on co-sleeping and instead gave advice on safe co-sleeping, it would make a significant difference to breastfeeding rates?

Letter ASue: This is not an NHS policy per se, however, it has been adopted in some trusts.
Our position is that families should be given full information to enable them to decide how best to care for their baby at night. Bed sharing is associated with successful breastfeeding. However, there are certain circumstances when bed sharing is dangerous.

If parents are clearly informed of the benefits, risks and alternatives, then they are in a position to make up their own mind and do what is best for them and their child. Simply telling parents not to bed share is not evidence-based practice and also potentially dangerous. For example, a parent believes it is dangerous to bed share and so goes downstairs to feed their baby on the sofa, they then fall asleep on the sofa which is much more dangerous than if they had just stayed in bed. However, they don't know this, because staff in their local health service has been told to discourage bed sharing and so are terrified to talk about the issue for fear of being in trouble.

Our position is that parents should have a chance to discuss this and be given written information prior to leaving hospital; this should then be reinforced by the community team when they are at home. Staff should be trained to understand and explain this issue appropriately. Helen Ball did a Mumsnet webchat recently – have a look at that for more information.

Letter Qrubyslippers: I think the key to successful breastfeeding is making sure your expectations are on the mark. For example, it's very helpful for a midwife or health visitor to be able to reassure a mum that a baby feeding very frequently, and that cluster feeding is OK. And reassure you that it doesn't mean that your milk isn't enough or you need to top up.

I think we need to temper the idea that babies should go three hours between feeds, and then drift off to sleep in their Moses baskets. For me, co-sleeping was the key to successfully feeding in the early days. So can this be encouraged?

Letter ASue: I think you are spot on with your comments regarding frequency and patterns of feeding. We do cover this in some depth on our course and it is part of the Baby Friendly assessment. However, the belief that breastfed babies should feed at regular intervals and only a certain number of times a day persists. In the UK it is so part of our general belief about normal infant behaviour – all based on bottle feeding of course - that it has proved extremely difficult to get across that this is not how breastfeeding works.

I agree that if we could crack this misconception with both health professionals and mothers, we would be a long way to solving many perceived problems about breastfeeding. 

Last updated: 7 months ago