Family, Feeding, Motherhood, Parenting

Impending WHO Breastfeeding Guidelines Are Putting Babies At Risk

The human race puts a huge amount of trust into The World Health Organisation (WHO). When it comes to guidance and advice for living a healthy lifestyle, us mere mortals refer to WHO as the oracle. WHO themselves state ‘Our goal is to build a better, healthier future for people all over the world. Working through offices in more than 150 countries, WHO staff work side by side with governments and other partners to ensure the highest attainable level of health for all people.’ Governments worldwide listen, trust and adhere to recommendations made by WHO.

When it comes to infant feeding, many governments have implemented their Baby Friendly Hospital Initiative (BFHI) guidelines on WHO’s Ten Steps to Successful Breastfeeding recommendations. Knowing that, you’d be forgiven for assuming WHO must be 100% confident in their panel of experts and make decisions based on up-to-date medical evidence. Shockingly, it has been revealed that when it comes to the nourishment of babies, this isn’t the case. It appears that during WHO’s review last year, the issue of breastfeeding complications weren’t raised as a ‘priority for discussion’. In fact, WHO officials reported that they have not specifically studied the complications from exclusive breastfeeding and have no studies or grants commissioned to monitor complications of the BFHI… and there was me stupidly thinking that any project of any size would have ongoing performance and means testing to ensure safety, relevance, outcomes etc. (on anything, let alone the health of our children!)

Let me introduce you to the Fed is Best Foundation (FIBF)… I can literally hear the groans from lactivists! On the 22nd September 2017, senior members of the Foundation secured a meeting with the top officials of the WHO Breastfeeding Program. Please believe me when I say that the FIBF aren’t a team of formula company advocates. They consist of experienced medical professionals who absolutely believe in the greatness of breastfeeding. But not at all costs. The Fed is Best Foundation are pioneers in promoting safe breastfeeding practices whilst highlighting the serious complications from accidental starvation of babies. These include dehydration, hyperbilirubinemia (jaundice) and hypoglycemia (low blood sugar) — known causes of infant brain injury and permanent disability. Within their meeting, the FIBF wanted to express their concerns about the complications arising from the BFHI Ten Steps and to ask what, if any, monitoring, research, or public outreach the WHO has planned regarding the risks of accidental starvation of exclusively breastfed newborns. It was during this meeting that the revelations unfolded.

I work closely with the FIBF. My support network has seen and heard the effects the BFHI and other breastfeeding campaigns have had on mothers and babies. My exposure to the emotional and physical trauma families have endured when trying to nourish their precious baby, means I am petrified of the further damage that will inevitably be caused from the publication from WHO.

When speaking to Sarah Norris, a representative from the UKFIB, she disclosed the shocking response from WHO when the Foundation offered their services, and other recruited experts in this field, in order to increase attention within the revised guidelines on prevention of complications. This would include patient education on the signs of newborn hunger and critical illness and the role of supplementation in preventing brain injury in underfed breastfed newborns. “The WHO officials stated that the revision process was well underway and that it was too late in the process to accept any new experts for this round of revisions. The officials did ask for a copy of the presentation given by the Foundation along with the list of supporting peer-reviewed references. They stated that experts present at the meeting may be invited for future revisions of the guidelines, although they noted the next cycle of revisions may be a few years away.”

She went on to say “We are appalled that WHO officials indicated being close to the end of the BFHI guideline revision process before final publication. The current draft revision does not include recommendations for educating mothers on the risk factors, signs and consequences of starvation from exclusive breastfeeding nor make mention of the prevention of brain injury and disability as the “medically necessary” rationale for supplementation.”

During the meeting Dr. Christie del Castillo-Hegyi, co-founder of the Foundation, asked the WHO directors, “Are there any plans within the WHO to inform mothers of the risks of brain injury from insufficient breast milk in order to make sure that they are aware when a child is critically ill at home, that supplementation can protect their child from brain injury?”

WHO acknowledged that they are aware of the complications, stating that the guidelines do include danger signs, such as “convulsions, being lethargic and not being able to feed,” to alert healthcare providers to intervene. However, according to the clinical evidence presented, those signs signify that brain injury is already present.[13,17,18] The BFHI guidelines, as written by the Academy of Breastfeeding Medicine, require informing patients of the risks of formula, but do not require health workers to inform parents of the risks of hospitalisation or brain injury from avoiding supplementation while exclusively breastfeeding. The guidelines offer no patient education on these danger signs for when critical conditions requiring supplementation occur at home.

As part of her role within the Foundation, Dr. del Castillo-Hegyi is a public speaker that presents data on the high rates of starvation-related complications from research conducted at BFHI-certified hospitals and the permanent disabilities that result. The following was presented to WHO and I strongly believe every mother should be aware of this information too:

• 10% of vaginally-delivered and 25% of cesarean-delivered exclusively breastfed (EBF) babies born at a BFHI hospital lose excessive weight of >10% in the first days of life.[1]
• 10-18% of exclusively breastfed newborns experience “starvation jaundice” from insufficient milk intake, according to the Academy of Breastfeeding Medicine jaundice protocol.[2]
• Jaundice, the majority from dehydration/underfeeding in exclusively breastfed newborns (approximately 86%) is the leading cause of newborn rehospitalisation in the U.S. and in the rest of the world and is a leading cause of perinatal disability.[3, 4, 5]
• Phototherapy-requiring jaundice increases the risk of long-term developmental disabilities including ADHD, cerebral palsy, seizure disorders, lower academic achievement and deficits in language, auditory, visual, sensory, motor, behavioral and cognitive deficits known as Bilirubin-Induced Neurological Dysfunction. [6-10]
• 10% of well-monitored exclusively breastfed babies undergoing the BFHI protocol develop hypoglycemia of less the 40 mg/dL within the first 48 hours. This rises to 23% in babies born to first-time mothers.[11]
• A glucose of less than 46 mg/dL within the first 24 hours of life has been associated with a 3.7- fold increased risk of brain injury on MRI and a 4.8-fold increased odds of lower motor, cognitive and language scores at 1 year of age.[12]
• Cognitive impairment can have lifelong effects as evidenced by a study of 1395 newborns showing that newborns who develop hypoglycemia of less than 40 mg/dL within the first hours of life had a 50% reduction in passing their fourth-grade proficiency test in literacy and math. A glucose less than 45 mg/dL resulted in a 38% reduction in passing the literacy test. Impairments persisted despite aggressive correction of the hypoglycemia. [13]
• 22% of motivated mothers intending to exclusively breastfeed who receive close lactation support experienced delayed onset of copious milk production which put her child at a 7-fold increased risk of excessive weight loss greater than 10%.[14]
• Exclusive breastfeeding at discharge has been associated with an 11-fold higher risk of rehospitalisation for underfeeding and dehydration.[15]
• 95% of hypernatremia, a form of severe dehydration that causes brain injury and increased mortality, occurs by 7% weight loss and at this time, over half of exclusively breastfed babies from a BFHI hospital lose greater than 7%.[16,1]
• 10.1% of babies born to one BFHI hospital system were hospitalised for phototherapy, over 10,000 babies in 3 years.[17]
• 1.1 million newborns a year develop severe jaundice. 114,000 of those newborns a year will die from that severe jaundice, the majority in resource-poor countries with insufficient healthcare resources to monitor the complications of exclusive breastfeeding.[18]

It’s important that I stress this article isn’t about scaring breastfeeding mothers. It certainly shouldn’t deter a mother-to-be from achieving an exclusively breastfed relationship with her baby. However, both myself and the FIBF are concerned that the secretariats of the guidelines are aware of the safety issues, namely the potential for brain injury and disability. It appears they are unwilling to inform the public about these complications, all of which can be prevented with guidelines that require monitoring of newborns for signs of hunger and supplementation of breastfeeding when those signs are present. We simply don’t understand why they would withhold education to new parents and professionals regarding the risks of newborn hunger and its outcomes.

Every member of the Fed is Best Foundation has experienced or witnessed the tragedies caused from underfeeding. They were heartfelt, literally moved to tears, when they retold their closing statement to WHO:

“The pressure to achieve exclusive breastfeeding is contributing to an epidemic of infant feeding complications, preventable hospitalisations, unrecognised brain injury, lower academic achievement and long-term disability. Publicly acknowledging the common problem of insufficient breast milk and the importance of supplementation to protect the brain can prevent millions of complications, hospitalisations and newborn injuries. We are asking the WHO to assist us in making infant feeding safe for all infants by ensuring that all babies have access to enough milk to preserve the integrity of their brain and vital organs. Being fully fed is a basic human right that is not currently met by the standard of care.”

A full report from the meeting between FIBF and WHO can be found here. You will also find the BFHI feedback from nurses, physicians and experts that work within paediatrics and maternity. Their reports may alarm you.

Astounded by what you’ve just read? Well, make your voice heard:

WHO is accepting comments on these guideline revisions until October 24, 2017. The Foundation urges health care providers, parents, and the public to demand that the WHO not place exclusive breastfeeding before infant safety in their guidelines and commit to informing parents of the real risks of insufficient feeding. Comments can be made on the WHO BFHI comments page or emailed to contact@fedisbest.org, to be forwarded to the WHO.

References:

[1] Valerie J. Flaherman, MD, MPH, et al., Early Weight Loss Nomograms for Exclusively Breastfed Newborns, Pediatrics, 2015 Jan; 135(1): e16–e23.
[2] ABM Clinical Protocol #22: Guidelines for Management of Jaundice in the Breastfeeding Infant Equal to or Greater Than 35 Weeks’ Gestation, The Academy of Breastfeeding Medicine Protocol Committee, Breastfeeding Medicine, Vol. 5(2):87-93.
[3] Janet H. Muri, et al. From the American Hospital Association: Reducing Avoidable Obstetrical and Neonatal Readmissions http://www.aha.org/content/11/PerinatalReadmissionscall1.pdf
[4] Lee BK, et al. Haemolytic and nonhaemolytic neonatal jaundice have different risk factor profiles. Acta Paediatr. 2016 Dec;105(12):1444-1450.
[5] Olusanya BO, Osibanjo FB, Mabogunje CA, Slusher TM, Olowe SA. The burden and
management of neonatal jaundice in Nigeria: A scoping review of the literature.
Niger J Clin Pract. 2016 Jan-Feb;19(1):1-17.
[6] Wei CC, et al. Neonatal jaundice and increased risk of attention-deficit hyperactivity disorder: a population-based cohort study. J Child Psychol Psychiatry. 2015 Apr;56(4):460-
[7] Maimburg RD, Olsen J, Sun Y. Neonatal hyperbilirubinemia and the risk of
febrile seizures and childhood epilepsy. Epilepsy Res. 2016 Aug;124:67-72.
[8] Hamdy NE, et al. Cerebral palsy in Al-Quseir City, Egypt: prevalence, subtypes, and risk factors. Neuropsychiatr Dis Treat. 2014; 10: 1267–1272.
[8] Hokkanen L, Launes J, Michelsson K. Adult neurobehavioral outcome of
hyperbilirubinemia in full term neonates-a 30 year prospective follow-up study.
PeerJ. 2014 Mar 4;2:e294.
[9] Wusthoff CJ, Loe IM. Impact of bilirubin-induced neurologic dysfunction on
neurodevelopmental outcomes. Semin Fetal Neonatal Med. 2015 Feb;20(1):52-57.
[10] El Houchi SZ, et al. Prediction of 3- to 5-Month Outcomes from Signs of Acute Bilirubin
Toxicity in Newborn Infants. J Pediatr. 2017 Apr;183:51-55.e1.
[11] Purnima Samayam, et al., Study of Asymptomatic Hypoglycemia in Full Term Exclusively Breastfed Neonates in First 48 Hours of Life, J Clin Diagn Res. 2015 Sep; 9(9): SC07–SC10.
[12] Emily W.Y. Tam et al., Hypoglycemia is associated with increased risk for brain injury and adverse neurodevelopmental outcome in neonates at risk for encephalopathy, J Pediatr., 2012 Jul; 161(1): 88–93.
[13] Kaiser JR, et al. Association Between Transient Newborn Hypoglycemia and Fourth-Grade Achievement Test Proficiency. JAMA Pediatr. 2015 Oct;169(10):913-21
[14] Dewey KG, et al., Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss, Pediatrics, 2003 Sep;112(3 Pt 1):607-19.
[15] Escobar GJ, et al., Rehospitalization for neonatal dehydration: a nested case-control study, Arch Pediatr Adolesc Med., 2002 Feb;156(2):155-61
[16] Uras, et al., Moderate hypernatremic dehydration in newborn infants: retrospective evaluation of 64 cases. J Matern Fetal Neonatal Med. 2007 Jun;20(6):449-52.
[17] Seske LM, et al. Late-Onset Hypoglycemia in Term Newborns With Poor Breastfeeding. Hosp Pediatr. 2015 Sep;5(9):501-4.
[18] Burns CM, Rutherford MA, Boardman JP, Cowan FM. Patterns of cerebral injury and neurodevelopmental outcomes after symptomatic neonatal hypoglycemia. Pediatrics. 2008 Jul;122(1):65-74.

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