Doctors write commentary saying an initiative designed to make hospitals safe for newborns might actually be endangering them.

A respected and widely adopted global initiative intended to save the lives of newborn babies may, in fact, be endangering them.

The Baby-Friendly Hospital Initiative (BFHI) was introduced in 1991 by the World Health Organization (WHO) and the United Nations Children’s Fund.

It was adopted by more than 152 countries, and meant to ensure that infants get the best and safest start in life.

Mounting evidence, however, suggests that the initiative may have unintended and dangerous consequences for newborns.

Those dangers include Sudden Unexplained Postnatal Collapse (SUPC), a severe illness that can potentially cause death within the first few days of life.

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Unintended consequences

Three Boston area pediatricians published a commentary on August 22 in JAMA Pediatrics titled “Unintended Consequences of Current Breastfeeding Initiatives.”

In it, they wrote that “rigid adherence to the Ten Steps to Successful Breastfeeding component of the Baby-Friendly Hospital Initiative may inadvertently promote potentially hazardous practices.”

Some of the initiative’s Ten Steps advise hospitals to promote immediate breast-feeding, ban pacifiers, and allow babies to sleep next to their mothers instead of in nurseries.

The doctors say, following those steps may lead to hazardous, and even fatal, issues for babies.

One of the physicians, Dr. Joel L. Bass, chair of the department of pediatrics at Newton-Wellesley Hospital, told Healthline that the Ten Steps themselves are not the cause of the problems.

“It is the manner in which BFHI criteria interpret compliance and the manner in which The Joint Commission and Mass Health [the combination, in Massachusetts, of Medicaid and the Children’s Health Insurance Program] have decided, despite objections from health professionals, to implement breast-feeding exclusivity,” he said.

These problems have been noted for many years, Bass said, but the connection to specific hospital practices “may not have been apparent.”

The first hours can be critical.

The pediatricians, in their JAMA article, looked at compliance with Step 4 — helping mothers initiate breast-feeding within one hour of birth:

“The guidelines state that all mothers should have continuous skin-to-skin contact with their baby immediately after birth until completion of the first feeding, and that skin-to-skin contact should also be encouraged throughout the hospital stay, a time period when direct continuous observation by medical care professionals is not likely to occur,” they wrote.

The authors cited a recent Cochrane Review, the highest standard for systematic reviews of primary research in human healthcare and health policy.

While they noted this review “provides evidence for the benefits of skin-to-skin care for healthy full-term and late pre-term infants for the first hour after birth, it also stipulates that mother and baby not be left unattended while skin-to-skin care takes place during this early period.”

Reports of SUPC, in association with the skin-to-skin practice, published over the past several years, have focused attention on the importance of this caveat, Bass said.

“SUPC includes both severe, apparent, life-threatening events (recently referred to as brief, resolved, unexplained events) and sudden unexpected death in infancy occurring within the first postnatal week of life,” the authors wrote.

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A baby’s sleep position can also be life-threatening.

Bass said SUPC is thought to be caused by the same factors that cause Sudden Infant Death Syndrome (SIDS) in older infants.

“In general, it is felt that a prone sleep position on a soft warm surface contributes to the development of hypoxia [deficient oxygen intake], which ultimately leads to systemic collapse,” he said.

European pediatricians have known about SUPC for years, Bass said. In 2013 a comprehensive, systematic review in Sweden documented 400 cases worldwide dating as far back as 1977.

“Most occurred during skin-to-skin care, with one-third of the events occurring in the first two hours after birth and the remainder in the subsequent week of life,” Bass said. “The review reported death in half of the cases and persistent disability in the majority of survivors.”

Bass and his co-authors — Dr. Tina Gartley, a pediatric hospitalist at Newton-Wellesley, and Dr. Ronald Kleinman, physician-in-chief at MassGeneral Hospital for Children — used a decade of Massachusetts Department of Health data, from 2004 to 2013.

During that period, 57 cases of SIDS were reported in the first month of life, of which 20 occurred during the first five days of life.

The communications office of the National Institutes of Health (NIH) told Healthline that the agency does not track SUPC statistics.

Neither do the U. S. Centers for Disease Control and Prevention (CDC), according to Richard Quartarone, the agency’s senior press officer.

“Currently there is no standard case definition or standardized system for reporting it,” Quartarone told Healthline. “We are unaware of any specific evidence that SUPC has increased over time or that these events are more common in hospitals with a baby-friendly designation. To date, CDC has not investigated a case of SUPC.”

Breast-feeding is important to the health and development of infants, including a reduced risk of SIDS, Quartarone said.

“CDC remains committed to supporting the safe implementation of evidence-based breast-feeding strategies for newborns in hospitals,” he said.

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Sleeping together

However, Bass and his colleagues warn that Steps 6 and 7, which emphasize breast-feeding exclusivity and 24-hour rooming-in, may also create risks.

“It is not uncommon for a mother and/or baby to be sleepy during this time,” Bass said. “If that happens, the baby may inadvertently fall from the mother’s chest during skin-to-skin contact [SSC]. Even if the mother is alert, the SSC position is inherently unsafe from the perspective of Sudden Infant Death Syndrome prevention. These risks can be mitigated by staff attention, including frequent measurement of vital signs.”

The pediatricians, in their commentary, added that “an overly rigid insistence on these steps in order to comply with Baby-Friendly Hospital Initiative criteria may inadvertently result in a potentially exhausted or sedated postpartum mother being persuaded to feed her infant while she is in bed overnight, when she is not physically able to do so safely. This may result in prone positioning and co-sleeping on a soft warm surface in direct contradiction to the Safe Sleep Recommendations of the National Institutes of Health.”

Co-sleeping also poses a risk for a newborn falling out of the mother’s hospital bed. Another possibility, the authors said, is that unsafe sleep practices modeled in the hospital may continue at home.

“Our suggestion to shift the focus of breastfeeding efforts to rates of initiation, rather than exclusivity, coupled with lactation support, is based on the most current evidence,” Bass said.

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Bass and his colleagues are also concerned about Step 9, the ban on pacifier use.

Compliance, they said, requires that mothers be educated repeatedly that pacifiers may interfere with the development of optimal breast-feeding.

“The evidence does not support this concept,” Bass said. “However, those who believe it, think it interferes with establishment of the milk supply.”

The timing of pacifier introduction may be critical.

“Because there is strong evidence that pacifiers may have a protective effect against SIDS, the American Academy of Pediatrics has suggested avoidance of pacifiers only until breast-feeding is established at approximately 3 to 4 weeks of age,” he said.

“The literature shows about a 50 to 60 percent reduction in SIDS with pacifier use,” Bass said. “The reason for this is not completely understood. But it is thought to be related to lowered arousal thresholds, modification of autonomic control, and/or maintaining airway patency [the relative absence of blockage] during sleep.”