What are Acceptable Exceptions in a Breastfeeding Policy?

People who object to the Baby-Friendly Hospital Initiative (BFHI) often think that 100% of babies must be breastfed. That’s just not true. Although an effective hospital policy specifies ideal outcomes and actions, it also specifies desirable or at least acceptable policy exceptions. This is true for any policy — even non-hospital policies. With a breastfeeding policy, the trick is to clearly specify when the directive “give no food except breastmilk” isn’t appropriate.

Acceptable policy exceptions: five categories

It’s probably fair to say that that these exceptions fall into five categories:

• medical conditions that are incompatible with breastfeeding
• drugs that are incompatible with breastfeeding
• conditions that require more than the mother’s milk
• newborn pain
• maternal choices

You will need to address these more specifically in your policy, however.

If you are a breastfeeding expert, you probably already know specific examples in each of those five categories. So instead of listing examples, I want to address how to deal with the examples.

Choose your words carefully

Your words convey a level of detail that you may or may not want, so be careful.

Avoid “contraindicated”

Although it is widely used, I cringe when I see the word “contraindicated.” Why? Because “contraindicated” means, don’t ever do it. That doesn’t leave room for clinical judgment in individual situations, thus there’s no legal way to make an acceptable policy exception.

Use “risk-benefit”

There are very, very few situations where breastfeeding is completely contraindicated. Use the phrase, “risk-benefit,” or “risk-benefit ratio” instead. This allows for leeway with situations like maternal substance abuse.

It also allows for variations in medical conditions that are almost always incompatible with breastfeeding. For example, breastfeeding is strictly contraindicated for the classic form of galactosemia, but an infant may be born with variants of the condition, rather than the classic form, and breastfeeding may be a safe option.

Be wary of imprecise terms

The Baby-Friendly step is to “give no food or drink other than breastmilk.” But “breastmilk” is an entirely imprecise term! Instead, by invoking a very acceptable policy exception, you can steer clear of formula-feeding.

I use these terms:

• “mother’s milk” (milk from the baby’s own mother)
• “donor milk” (milk from a woman other than the mother)
• “human milk” (milk from the mother or a donor)

It is entirely possible that the mother’s milk may pose a risk to the baby (e.g., mother is HIV positive) but donor milk would pose no threat whatsoever. With the establishment of more and more donor milk banks, we need to use more precise terms.

BFHI was designed for healthy, full-term, average-for-gestational age (AGA) newborns. If a baby falls outside of those categories, hopefully donor milk will be used. But if a baby is born before term, or has a condition that necessitates more milk than a mother or donor can provide, formula, either as a replacement or supplement, is entirely acceptable.

Give a list of specific conditions

List specific conditions where the risks of exclusive breastfeeding outweigh the benefits. Avoid the temptation to make this list yourself. Instead, use the list from the Centers for Disease Control (CDC) as the backbone of your list of acceptable policy exceptions. This gives your list immediate credibility. It’s also a built-in mechanism for specifying the “currently” acceptable policy exceptions.  

Address pain and medical need

Products such as SweetEase™ are often offered to infants for a painful procedure. Most people don’t think of these being “medically indicated” for the procedure, but in fact, they are classified as such.

Research proves that newborns experience less pain when offered something sweet, when held, and when they suck during a painful procedure. Since breastfeeding qualifies on all counts, it should be offered as the primary method to address pain!

Maternal choice and informed choice

Sometimes, mothers just don’t want to breastfeed. You can’t force them to breastfeed. Nor should you.

Breastfeeding is a parenting decision, not a medical decision, and certainly not a hospital policy directive. Nonetheless, your hospital policy must address how to clearly and respectfully explain feeding options to parents. Write into the policy something that reflects the idea that the mother has made an informed choice. Should she be required to sign a written informed consent? I don’t know; that varies tremendously from hospital to hospital because the staff and the clients differ from hospital to hospital. Sort that out for yourself. 

When writing a hospital breastfeeding policy, it’s important to consider it from all angles, and that includes possible exceptions to the rule.

What acceptable policy exceptions are in your facility’s breastfeeding policy? Tell me in the comments below!