BABY FRIENDLY HOSPITAL INITIATIVE (BFHI)

INTRODUCTION
The first few hours and days of a newborn’s life are a critical window for establishing lactation
and providing mothers with the support they need to breastfeed successfully. This support is not
always provided, as illustrated by a review of UNICEF data showing that 78% of deliveries were
attended by a skilled health provider, but only 45% of newborns were breastfed within the first
hour after birth (8, 22). Although breastfeeding is the biological norm, health professionals may
perform inappropriate procedures that interfere with the initiation of breastfeeding, such as
separation of the mother and infant; delayed initiation of breastfeeding; provision of prelacteal
feeds; and unnecessary supplementation. These procedures significantly increase the risk of
breastfeeding challenges that lead to early cessation. Families need to receive evidence-based
information and counselling about breastfeeding and must be protected from commercial interests
that negatively impact on breastfeeding.

GOALS OF BFHI
• To transform hospitals and maternity facilities through implementation of the “ten steps”.
• To end the practice of distribution of free and low – cost supplies of breast milk substitutes
to maternity ward and hospitals.
• BFHI has incorporated the international code of marketing of breast milk substitutes (1981)
and is aimed to protect and promote breastfeeding.
• Since the launch of initiative, more then 20000 hospitals in 156 countries in the world have
adopted it over the last 15 years.

KEY DATES IN THE HISTORY OF BREASTFEEDING AND BFHI

• 1979- Joint WHO/UNICEF meeting on infant and young child feeding, Geneva.
• 1981-adoption on the International Code of Marketing of Breast Milk Substitutes
• 1989- Protecting, promoting and supporting breast feeding. The special role of maternity
services.
- convention on the right of child
• 1990-world summit for children
• 1991-Launching of baby friendly initiatives
• 2000-WHO expert consultation on HIV and Infant feeding
• 2001-WHO consultation on the optimal duration of exclusive breastfeeding
• 2002-Endorsement of the Global strategy for infant and young child feeding by WHO
• 2005-Innocenti Declaration 2005 2007-Revision of BFHI document
• 2007-Revision of the BFHI document
TEN STEPS TO SUCCESSFUL BREASTFEEDING
1. Have a written breastfeeding policy that s routinely communicated to all health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding with a half hour of birth.
This step is now interpreted as;
- Place baby in skin to skin contact with their mothers immediately following birth for
at least an hour. Encourage mothers to recognize when their baby’s are ready to
breastfeed and offer help if needed.
5. Show mother how to breastfeed , and how to maintain lactation even if they should be
separated from their infants.
6. Give newborn infants no food or drink other then breast milk, unless medically indicated .
7. Practice rooming-in – allow mothers and infants to remain together—24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers ( also called dummies or soothers) to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on
discharge from the hospital or clinic.

Step 1. Have a written breastfeeding policy that is routinely communicated to all health care
staff.
Breastfeeding policy
It should be;
➢ Written in the most common language understood by the patient and staff
➢ Available to all staff caring for mothers and babies
➢ Posted or displayed in areas where mothers and babies are cared
Step 2. Train all health-care staff in skills necessary to implement this policy.
The health care staff should get practical training to implement 10 steps of breast feeding
They should be taught the skills needed to assist the nursing mothers for expression of breast milk,
correct positioning during breastfeeding
➢ Advantages of breastfeeding
➢ Risks of artificial feeding
➢ Mechanisms of lactation and suckling
➢ To help mothers initiate and sustain breastfeeding
➢ To assess a breastfeed
➢ To resolve breastfeeding difficulties
➢ Hospital breastfeeding policies and practices
➢ Focus on changing negative attitudes which set up barriers
Step 3. Inform all pregnant women about the benefits of breastfeeding.
During antenatal period mother should be informed and educated about:
➢ Benefits of breastfeeding
➢ Early initiation
➢ Importance of rooming-in(if new concept)
➢ Importance of feeding on demand
➢ Importance of exclusive breastfeeding
➢ To assure enough breast milk
➢ Risks of artificial feeding and use of bottles and pacifiers (50others, teats. nipples, etc.)
➢ Basic facts on HIV
➢ Prevention of mother-to child transmission of HIV (PMTCT) Voluntary testing and
counselling (VET) for HIV and infant feeding counseling for HIV+ women
➢ Antenatal education should not include group education on formula preparation

Step 4. Help mothers initiate breastfeeding with in half-hour of birth .

New interpretation of step 4 in the revised BFHI global criteria (2007)
“place babies in skin to skin contact with their mothers immediately following birth for at
least an hour. Encourage mothers to recognize when their babies are ready to breastfeed
and offer help if needed”.
Encourage mother baby bonding soon after delivery and encourage all mothers to initiate
breastfeed within an hour after birth. Mothers should be advised not to administer pre-
lacteal feed.
Early initiation of breastfeeding for the normal newborn-
➢ Increases duration of breastfeeding
➢ Allows skin-to-skin contact for warmth and colonization of baby with maternal organisms
➢ Provides colostrum as the baby's first immunization
➢ Takes advantage of the first hour of alertness
➢ Babies learn to suckle more effectively
➢ Improved developmental outcomes
➢ Keep mother and baby together
➢ Place baby on mothers chest
➢ Let baby start suckling when ready
➢ Do not hurry or interrupt the process
➢ Delay no-urgent medical routines for at least 1 hour
Step 5. Show mother how to breastfeed and how to maintain lactation, even if they should be
separated from their infants.
Mothers should be taught the art of breast feeding including position and technique of breast
feeding They should be taught the correct technique of expression of breast feeding or with the
help of breast pump
Supply and demand
➢ Milk removal stimulates milk production.
➢ The amount of breast milk removed at each feed determines the rate of milk production in
the next few hours.
➢ Milk removal must be continued during separation to maintain supply.
Step 6. Give newborn infants no food or drink other than breast milk unless medically
indicated.
There are rare exceptions during which the infant may require other fluids or food in addition to,
or in place of, breast milk. The feeding programme of these babies should be determined by
qualified health professionals on an individual basis.
Impact of routine formula supplementation
➢ Decreased frequency or effectiveness of suckling
➢ Decreased amount of milk removed from breasts
➢ Delayed milk production or reduced milk supply some infants have difficulty attaching to
breast if formula given by bottle.
❖ Acceptable medical reasons for use of breast-milk substitutes
Infant conditions:
Infants who should not receive breast milk or any other milk except specialized formula;
Classic galactosemia: A special galactose free formula is needed.
Maple syrup urine disease: A special formula free of leucine, isoleucine and valine is needed.
Phenylketonuria: A special phenylalanine free formula is required (some BF is possible, under
careful monitoring)
❖ Infants for whom breast milk remains the best feeding option but may need other food
in addition to breast milk for a limited period;
➢ Very low birth weight infants (less than 1500g)
➢ Very preterm infants (less than 32 weeks gestation age)
➢ Newborn infants at risk of hypoglycemia
Maternal condition ;
✓ Mothers who may need to avoid BF permanently-
❖ HIV infection
✓ Mother how may need to avoid BF temporarily:
❖ Severe illness that prevents a mother from caring for her infant
❖ Herpes simplex virus type 1.(if lesions on breast, avoid BF until active lesions have resolved).
❖ Maternal medications- sedating psychotherapeutic drugs, radioactive iodine – 131 better
avoided given that safer alternatives are available ; excessive use of topical iodine; cytotoxic
chemotherapy usually requires mother stop BF permanently.
Step 7. Practice rooming-in-allow mothers and infants to remain together 24 hours a day.
❖ Rooming-in--
- A hospital arrangement where a mother/baby pair stay in the same room day and night,
allowing unlimited contact between mother and infant
❖ Rooming-in for –
• Reduces costs
• Requires minimal equipment
• Requires no additional personnel
• Reduces infection
• Helps establish and maintain breastfeeding
• Facilitates the bonding process
Step 8. Encourage breastfeeding on demand.
Breastfeeding on demand:
• Breastfeeding whenever the baby or mother wants, with no restrictions on the length or
frequency of feeds.
On demand, unrestricted breastfeeding for-
• Earlier passage of meconium
• Lower maximal weight loss
• Breast-milk flow established sooner
• Larger volume of milk intake on day 3
• Less incidence of jaundice
Step 9. Give no artificial teats or pacifiers (also called dummies and soothers) to
breastfeeding infants.
- Pacifiers should not be given to the babies due to risk of Infection and non-nutritive sucking.
- Expressed breast milk should be administered through bowl and spoon but not feeding battles.
Alternatives to artificial teats
- cup
- spoon
- dropper
- syringe
Step 10. Foster the establishment of breastfeeding support groups and refer mothers to them
on discharge from the hospital or clinic.
Support can include;
- Early postnatal or clinic checkup
- Home visits
 - Telephone calls
- Community services
- Outpatient breastfeeding clinics
- Peer counselling Programmes
- Mother support groups Help set up new groups
- Establish working relationships with those already in existence
- Family support system

FOR RECOGNITION OF HOSPITAL AS BABY FRIENDLY

➢ A hospital that conduct a minimum of 250 deliveries per year can seek recognition after
implementation of the 10 steps for promotion of breast feeding a dually completed self
assessment form and registration form should be sent to BFHI Sectrate.
➢ The hospital and nursing home meeting all 10 criteria is visited by assessor for on the spot
check and to interview the mothers and health care staff. The assessor sends the report and
observation to BFHI Sectrate which is reviewed by the review committee for final
recommendation.
➢ The hospital fulfilling the National BFHI requirements are recognized as baby friendly. The
National Task Force organizes a public ceremony for presentation of BFHI certificate and a
logo. The hospital that are unable to fulfil the criteria for certification can reapply for it later
on after eliminating all short terms.

THE INTERNATIONAL CODE OF MARKETING OF BREAST- MILK

SUBSTITUTES
One of the tenets of the Baby-Friendly Hospital Initiative is that the marketing of breast-milk
substitutes, including infant formula, discourages mothers from initiating and/or exclusively
breastfeeding their infants. The International Code of Marketing of Breast-Milk Substitutes,
adopted by the WHO in 1981, calls for restrictions on the marketing of breast-milk substitutes,
infant feeding bottles, and teats. Hospitals and birthing centers wishing to attain and retain Baby-
Friendly designation must abide by the provisions of the International Code of Marketing of
Breast-Milk Substitutes.
Significant provisions of this code prevent hospitals and birthing centers from accepting free or
low-cost infant formula, providing free samples of infant formula to families, or advertising breast-
milk substitutes. Provisions of the International Code of Marketing of Breast-Milk
Substitutes require:

1. No advertising of breast-milk substitutes to families.

2. No free samples or supplies in the health care system.
3. No promotion of products through health care facilities, including no free or low-cost formula.
4. No contact between marketing personnel and mothers.
5. No gifts or personal samples to health workers.
 6. No words or pictures idealizing artificial feeding, including pictures of infants, on the labels
or product.
7. Information to health workers should be scientific and factual only.
8. All information on artificial feeding, including labels, should explain the benefits of
breastfeeding and the costs and hazards associated with artificial feeding.
9. Unsuitable products should not be promoted for babies.
10. All products should be of high quality and take account of the climate and storage conditions
of the country where they are used.

ROLE OF HOSPITAL ADMINISTRATIVE IN BFHI

• "Become familiar with the BFHI process
• Decide where responsibility lies within the hospital structure. This can be a coordinating
committee, working group, multidisciplinary team, etc.
• Support staff in decisions taken to achieve "Baby-friendliness"
• "Facilitate any BFHI-related training that may be needed
• Collaborate with national BFHI coordination group and ask for an external assessment team
when the hospital is ready for assessment
• Encourage staff to sustain adherence to the "10 steps", arranging for refresher training and
periodic monitoring and reassessment
• Establish the process within the hospital of working with the identified responsible body.
• "Work with key hospital staff to fill in the self- appraisal tool using the Global Criteria and
interpret results.

FURTHER STRENGTHENING OF BFHI

➢ The Global Strategy urges that hospital routines and procedures remain fully supportive of the
successful initiation and establishment of breastfeeding through the:
• implementation of the Baby-friendly Hospital Initiative
• monitoring and reassessing already designated facilities; and
• expanding the Initiative to include clinics, health center, and paediatric hospitals
➢ It also urges that support be given for feeding infants and young children in exceptionally difficult
circumstances,
• with one aspect of this being to adapt the BFHI by taking account of HIV/AIDS,
• and by ensuring that those responsible for emergency preparedness are well trained to
support appropriate feeding practices consistent with the Initiative's universal principles.
CONCLUSION
At the end all mothers can breastfeed successfully, which includes initiating breastfeeding with in
the first hour of life, breastfeeding exclusively for the first 6 months and continuing breastfeeding
( along with giving appropriate complimentary foods) up to 2 years of age or above.
REFERENCES
1. Subedi N. Health prospect 2012, Baby friendly hospital initiatives situation in Nepal. 2012;11
pp52-4.
2. World health organization nutrition baby friendly hospital initiatives 2018.
3.Philipp BL, Merewood A, Miller LW et al. Baby- friendly hospital initiative improves
breastfeeding initiation rates in a US hospital setting. Pediatric , 2001, 108: 677-681.
4. https://www.slideshare.net/smaxy/bfhi- 65805827