Implementation of the Ten Steps to Successful Breastfeeding Saves Lives.

The Baby-Friendly Hospital Initiative (BFHI), developed in 1991 by theWorld Health Organization and the United Nations Children’s Fund to improve maternity care practices andbreastfeeding rates, has been implemented globally in more than 152 countries. The core tenetsof theBFHIare theTenStepstoSuccessfulBreastfeeding, which have been endorsed by the American Academy of Pediatrics. A recentmeta-analysis of studiesevaluatingtheBFHI foundthat implementationof the BFHI increasedexclusivebreastfeedingby49%(95%CI, 33%-68%) and any breastfeeding by 66% (95% CI, 34%-107%).1Themeta-analysis reviewed29studiesthat found that the BFHI and its elements of hospital support increased breastfeeding in the first hour (relative risk = 1.11; 95% CI, 1.06-1.16), 51 studies that found that it increasedexclusivebreastfeeding in the first 5months (relative risk = 1.46; 95% CI, 1.37-1.56), and 47 studies that found that it increasedanybreastfeeding in the first 6months (relative risk = 1.40; 95% CI, 1.30-1.52). For optimal child health and development, the American Academy of Pediatrics recommends exclusive breastfeeding for about the first 6 months of life, followedbycontinuationofbreastfeeding forat least the first year of life.2 Increased duration and exclusivity of breastfeeding are most closely linked to improved maternal and child health outcomes. An analysis of the effect of 90%of infants being exclusively breastfed for 6months revealed that911 infantdeaths couldbesaved in the United States, most secondary to decreased sudden infant death syndrome.3 A recent metaanalysis revealed that improved breastfeeding globally would annually save 823 000 deaths in children younger than 5 years and 20 000 breast cancer– related deaths in women.4 In addition, it found that breastfeeding reduces morbidity and has an economic impact in improving the educational potential of childrenand their earnings as adults. Improvedbreastfeeding rates would reduce treatment costs by at least $2.45 billion annually in the United States alone.1 Breastfeeding prevents acute infectious diseases, decreases prevalence of obesity and type 2 diabetes, andpromotes optimal intellectual development in children,whiledecreasingmaternal riskofbreastcancerand ovarian cancer.4 These compellingbenefits support the premises that breastfeeding is a public health issue, breastfeeding promotion is a public health imperative, and breastfeeding support indeed saves lives. Breastfeeding initiation occurs in the maternity facility and requires an environment that supports and encouragesbreastfeeding.Baby-FriendlyUSA is theentity that designates maternity facilities in the United States thathave implemented theTenSteps toSuccessful Breastfeeding and follow the World Health Organization International Code of Marketing of Breast-Milk Substitutes. Facilities go through a process of selfassessment of compliance with the Ten Steps to Successful Breastfeeding and then follow quality improvement methods, using small tests of change, to modify their policies and procedures to improve compliance. With the support of funding from the Centers for Disease Control and Prevention and in accordance with the Surgeon General’s Call to Action to Support Breastfeeding, the number of births that occur in maternity facilities designated as Baby-Friendly increased from 1.79% in 2007 to 17.65% in June 2016, exceeding theHealthyPeople2020goalof8.1%.During that same period, national rates of initiation of breastfeeding increased from73.8%to80%,breastfeedingat6months increased from 41.5% to 53.9%, and exclusive breastfeedingratesat6months increasedfrom11.3%to21.9%, concurrent with the emphasis on implementation of Baby-Friendly practices and the assessment of Maternity Practices in Infant Nutrition and Care surveys conducted biannually by the Centers for Disease Control and Prevention.5 The Ten Steps to Successful Breastfeeding include development of a breastfeeding policy, education of all staff, and altering the paradigm under whichmaternity care is delivered. A key element involves allowing as muchuninterruptedcontactbetween thenewbornand familyaspossible,beginning immediatelyafterbirthwith skin-to-skin care and followed by continuous rooming in throughout the hospital stay. A meta-analysis of 34 randomized trials with 2177 participants revealed that earlypostpartumskin-to-skin contact increasedbreastfeeding rates, with no clear negative outcomes.6 In addition, skin-to-skin contact decreases hypothermia, hypoglycemia, and crying and promotes cardiorespiratory stability, especially in the late-preterm newborn. One study found that rooming in increased exclusive breastfeeding during the first few days of life.7 Suddenunexpectedpostnatal collapse is a rarebut potentially fatal event in otherwise healthy-appearing termnewborns.Mothersarenaturallyexhaustedandare at risk for falling asleep and/or dropping their newborn, especially after cesarean deliveries. The mother-infant dyad needs careful observation during the postpartum period, whether the mother is giving skin-to-skin care, breastfeeding, bottle feeding, or even just holding her infant. This is truewhether the infant is rooming in or is sent to themother for feedings. If themother is sleepy, the infant should bemoved to a separate sleep surface next to the mother’s bed. This can be done by hospital staff or by support persons. While pacifier use has been recommended as a means to decrease the risk of sudden infant death VIEWPOINT