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Baby-Friendly Hospital Initiative (BFHI)


The 4-D Pathway to Baby-Friendly Designation1

Discovery Phase: 

  • Register with Baby-Friendly USA in order to receive more information about the process.

  • Obtain CEO letter of support

  • Complete the self appraisal tool to determine the hospital practices and policies that need to be addressed in order to meet the requirements of the Baby-Friendly Designation.  The tool can be found at http://www.babyfriendlyusa.org/eng/docs/2010%20SelfApprTool.pdf

    Most maternity facilities will have already completed the mPINC (Maternity Practices in Infant Nutrition and Care) survey, which is an excellent gauge of adherence to Baby-Friendly practices.  The mPINC survey is administered by the Centers for Disease Control and Prevention (CDC) and is an assessment of maternity best practices.  All U. S. maternity facilities are asked to complete the mPINC assessment on an every other yearly basis.  A facility’s mPINC score is an excellent indicator of its readiness to become a Baby-Friendly.   More information on the mPINC survey can be found at: http://www.cdc.gov/breastfeeding/data/mpinc/index.htm

Development Phase

  •  Apply for Certificate of Intent

  • Form a Baby-Friendly Task Force

  • Develop a BFHI work plan. One of the functions of the Task Force should be to develop a comprehensive work plan to implement the Ten Steps to Successful Breastfeeding. Technical assistance is available from Baby-Friendly USA, which will review all plans before the facility moves to the Dissemination Phase. 

  • Develop a hospital breastfeeding policyIn 2010, the Academy of Breastfeeding Medicine has published a Model Breastfeeding Policy that can be used as a starting point. This protocol is the one used at Boston Medical Center and can be found at:  http://www.bfmed.org/Resources/Protocols.aspx; scroll down to Protocol 7. 

  • Develop a staff training curriculumGuidelines from Baby-Friendly USA suggest a minimum of 18 hours of training for all nursing staff who work closely with newborns and require that physicians be educated in the basics of breastfeeding management.  A guideline for curriculum content is available on the Baby-Friendly USA website at http://www.babyfriendlyusa.org/eng/docs/Topics%20for%20Staff%20Training.pdf

    Several excellent resources are available so that facilities do not have to develop their own training materials.  These include:

  • Develop prenatal/postpartum teaching plansBreastfeeding education should be included in routine prenatal and postpartum care for mothers eligible to breastfeed, and teaching should be documented in the medical record.

  • Develop a data collection planThis requires that all infant feedings be charted, which is an essential first step towards being able to measure a facility’s breastfeeding rates.  Charting infant feedings can be accomplished in a variety of ways depending on the availability of electronic medical record (EMR).  If EMR is available, it may be possible to collect information about how each patient was fed if daily feeding information is entered in the EMR in real time or if this data is recorded in an electronic discharge summary.  If charting is still done on paper, then initial data collection must be manual.  Facilities with paper charts need to decide whether to collect data on breastfeeding at discharge for every patient in a centralized database, or to do regular retrospective data collection on a sample of charts.  The new Perinatal Core Measures implemented by the Joint Commission in April 2010 require that maternity facilities collect information on exclusive breastfeeding rates at discharge; hence, collecting breastfeeding data satisfies JCAHO requirements.  More information is available at: http://www.jointcommission.org/core_measure_sets.aspx

Dissemination Phase: 

Facilities implement the plans they developed during the prior phase.

  • Train staffAll hospital staff (medical and non-medical) require training on how to implement the breastfeeding policies established as a part of the BFHI. 
  • Collect data on breastfeeding ratesImplement plan for collecting data on infant feedings as above so that breastfeeding rates can be calculated.

Designation Phase: 

  • Implement quality assurance program. Regular review of policies and breastfeeding rates is essential to maintaining compliance with Baby-Friendly practice.
  • Participate in readiness interview with Baby-Friendly USA staff
  • Participate in on-site assessment with Baby-Friendly USA staff.
  • Receive Baby-Friendly designation.  If a facility does not pass on its first assessment, it may apply for re-assessment once the identified problems have been resolved. 

Boston Medical Center’s Implementation of the Ten Steps to Successful Breastfeeding 

  1. Have a written breastfeeding policy that is routinely communicated to all health care staffThe Task Force modified its original breastfeeding policy in order to comply with the Baby-Friendly requirements.  In addition, a new policy was developed to eliminate routine distribution of pacifiers on the postpartum unit in order to comply with Step 9 of the Ten Steps.  The policy was communicated to staff through trainings and was incorporated into nursing competency requirements.  BMC’s Breastfeeding Policy was adopted as an official hospital policy and is available on the hospital website

  2. Train all health care staff in skills necessary to implement this policy.  At BMC, physician education was led by the Task Force co-chair, a pediatrician and International Board Certified Lactation Consultant, during grand rounds and monthly training sessions for all residents, interns, and medical students in the postpartum and neonatal intensive care units.  Nurse education was led by two pediatric nurse educators who created breastfeeding competency as a requirement for all pediatric and obstetric nurses.  Nurses were taught to administer breastfeeding classes.  For hospital personnel beyond the “front-line caregivers” (e.g., administrators, maintenance staff, interpreters, telephone operators, unit secretaries), Task Force members created “Reach and Teach” sessions to provide education on the health benefits of breastfeeding.  These sessions also provided an overview on the Baby-Friendly Hospital Initiative and offered an opportunity for discussion of breastfeeding issues specific to employee-patient interactionsTraining for new staff and house officers is ongoing.

  3. Inform all pregnant women about the benefits and management of breastfeeding.  Physicians and nurses inform pregnant women during prenatal visits, on admission, and throughout their hospital stay about the benefits of breastfeeding.  In addition, the importance of breastfeeding is highlighted in prenatal classes held at the hospital.  Written materials are also distributed; however, verbal communication about the value of breastfeeding is the preferred method of communication.

  4. Help mothers initiate breastfeeding within one hour of birth.  Newborn infants are placed skin-to-skin on their mother’s chest immediately after birth, instead of being taken away from the mother for initial nursing assessment, physician exam, and other care that can be performed later.  Skin-to-skin contact between mother and infant takes advantage of the newborn’s alertness and natural instinct to begin breastfeeding immediately after birth.  Labor and delivery nurses are trained to offer support for the mother to assist with position and latch and to offer positive reinforcement.  Beginning in 2010, the baby’s initial bath was delayed until 12 hours after delivery to further reduce separation between mother and infant, promote breastfeeding, and aid in mother-infant bonding.  This change has been well-received by parents, who are now able to participate in their infant’s first bath in their own room. 

  5. Show mothers how to breastfeed and how to maintain lactation, even when they are separated from their infants.  This step is very important for infants who are separated from their mothers after birth due to medical complications or who require transfer to the Neonatal Intensive Care Unit (NICU).  It can be challenging for new mothers in this situation to establish and maintain their milk supply.  All nursing staff, patient care assistants, and breastfeeding peer counselors are trained to assist women in the use of electric breast pumps.  The Pumps for Peanuts program provides an electric breast pump to mothers with infants in the NICU if their insurance does not cover this expense.

  6. Give newborn infants no food or drink other than breast milk (unless medically indicated).  Infants who are given breast milk and nothing else are more likely to breastfeed successfully.  A clear policy exists for when a breastfeeding mother requests formula supplementation.  The bedside nurse offers education about the benefits of breastfeeding and use of an alternate feeding method such as syringe is encouraged.  Expressed breast milk, when available, is used preferentially rather than formula.  The request for supplementation is documented in the patient’s chart along with the education that was provided.  Water and glucose water are never given.  Sucrose 24% oral solution is used in small volumes (less than 2 mL) prior to painful procedures such as phlebotomy or circumcision.

  7. Encourage breastfeeding on demand.  Mothers are taught to learn and respond to their infant’s individual hunger cues, as opposed feeding on a set schedule (e.g., every three hours).  Separations between mothers and infants are minimized

  8. Practice “rooming-in” to allow mothers and infants to remain together 24 hours a day.  Rooming-in facilitates feeding on demand.  Infants spend almost no time in the nursery, and examinations are routinely performed in the mother’s hospital room.

  9. Give no bottles or pacifiers to breastfeeding infants.  When needed for breastfeeding infants who have excessive weight loss or who are temporarily separated from their mother, supplementation with expressed breast milk or formula is encouraged via syringe rather than a bottle.  As noted above, when a breastfeeding mother elects to give her infant formula or expressed breast milk, an alternate feeding route rather than a bottle is recommended.  In addition, pacifiers are not routinely distributed on the postpartum unit.  A pacifier protocol was developed, approving pacifier use under the following circumstances: for infants in the Neonatal Intensive Care Unit (NICU); for infants exposed to opiates or other drugs in utero; and for painful procedures such as phlebotomy and circumcisions, after which pacifiers are discarded.  If the family chooses to bring a pacifier to the hospital, education is provided regarding the possible interference of pacifiers with breastfeeding.

  10. Foster the establishment of breastfeeding support groups and refer mothers to them at the time of discharge from the hospital or clinic.  Breastfeeding classes were initiated.  Classes were taught first by lactation consultants and then by staff nurses.  A telephone support line was created for new mothers to ask questions about breastfeeding after discharge.  In addition, peer counselors (women who have breastfed their own children) were hired and received special training to work with mothers before and after discharge.

Other Requirements of the Baby-Friendly Hospital Initiative

  • Forgoing free formula.  BMC does not accept free formula from manufacturers and instead pays market price for the formula that it provides to patients who request it and to infants whose mothers are not eligible to breastfeed.  BMC also pays fair market price for bottles and nipples that are usually supplied at no charge by formula manufacturers along with free formula.  In accordance with the hospital’s Conflict of Interest policy, formula company representatives are not allowed in the hospital.  Formula company advertising or free items are also banned, including formula company gift bags that are routinely distributed to new mothers in most hospital postpartum units.  For further information on formula company gift bags, please visit: www.banthebags.org

  • Promoting convenience.  BMC promotes the convenience of breastfeeding through four breastfeeding/breast pumping rooms in different sites around the hospital’s inpatient and outpatient facilities.

Keys to Success in Implementing the Ten Steps

  • Physician leadership in the formation of the task force and commitment to the Baby-Friendly initiative. It can be difficult to get the support of hospital administration, nurses, and other staff members if physicians are not involved with and supportive of breastfeeding promotion.   Identifying champions and allies in all clinical departments is crucial.

  • Representation of prominent staff from all relevant areas of the institution on the Task Force and involved in implementing Baby-Friendly practice. Identifying and including all stakeholders early in the process is critically important.  At BMC, the following departments were involved: Pediatrics, Obstetrics and Gynecology, Midwifery, Family Medicine, Nursing, Postpartum, NICU, Prenatal Services, Nutritional Services, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and local neighborhood health centers.  It is especially important to solicit the involvement of obstetrics and gynecology physicians and staff, as these individuals help to remove barriers at the time of delivery and ensure that newborns are put to the breast within one hour of birth.

  • Publicity of Baby-Friendly efforts including the opening of the breastfeeding/pumping room in a highly visible location in the hospital by a notable political figure, the female Lieutenant Governor of Massachusetts, with cake and ribbon-cutting and announcement in hospital newsletter.

  • Creation of a hospital environment that supports breastfeeding by:

    • displaying signs with the Ten Steps to Successful Breastfeeding throughout the hospital
    • displaying artwork of breastfeeding mothers throughout the hospital
    • removing formula videos, literature, and other promotional materials from the hospital
    • replacing formula company diaper discharge bags with BMC diaper bags
    • replacing bassinet formula cards with BMC bassinet cards
    • limiting accessibility by storing formula, bottles, and nipples in a centralized location that requires key card entry

Barriers to Implementation of the Ten Steps

  • Changing established cultural norms of formula feeding. Baby-Friendly advocates face challenges in promoting breastfeeding due to prevalent cultural norms and the negative influence of infant formula manufacturers on breastfeeding.  At BMC, as at other safety-net hospitals serving the urban poor, the expectation that babies will formula feed is difficult to counter.  Formula company advertising outside our walls is pervasive, and many mothers arrive to prenatal care with the assumption that they will not breastfeed.  Over more than a decade, we have seen great progress in breastfeeding initiation and more and more mothers who are committed to breastfeeding.

  • Difficulty in persuading hospital administrators to pay for formula. This initial request was met with resistance; however, once the actual formula usage was calculated, the amount that the hospital needed to purchase ended up being far less than originally estimated.2

1 An excellent introductory packet with FAQs is available from Baby-Friendly USA and can be accessed at http://www.babyfriendlyusa.org/eng/docs/2010%20Intro%20Packet.pdf.  A simple schematic of the 4-D Pathway is also available at: http://www.babyfriendlyusa.org/eng/docs/The%204-D%20Designation%20Pathway.pdf.  As noted above, BMC became Baby-Friendly in 1999, prior to the creation of the 4-D Pathway process.  At that time, the process of becoming Baby-Friendly was similar, but not identical to, the process that a candidate maternity facility would undertake today.  The requirements for Baby-Friendly designation have not changed.

2 Merewood A, Philipp BL. Becoming Baby-Friendly: overcoming the issue of accepting free formula. J Hum Lact. 2000 Nov;16(4):279-82.