Questions and Answers

1. Given the BFHI 10 steps preclude offering formula unless for medical reasons, do you know what the protocol is to comply with the designation if a woman chooses/demands to formula-feed?
The goal of the BFHI is to ensure that women are provided with information, care and services that maximize their opportunities to establish and maintain exclusive breastfeeding i.e. to ensure that health care providers do not contribute to women not reaching their breastfeeding goals by in appropriate use of formula. The BFHI respects that all women will make an informed decision about feeding their babies, and requires that the hospital have an exclusive breastfeeding rate for healthy term babies from birth to discharge of 75%. Calculation of this rate is explained in this document from the BCC website.

• Babies supplemented with expressed breast milk or human donor milk are included in the exclusive breastfeeding category.

• If the exclusive breastfeeding rate is less than 75%, babies who have been supplemented with formula for medically indicated reasons (outlined by WHO/UNICEF, and anticipated to be a low % as the special care population of babies is excluded) may be added to this category. Many facilities keep formula in a locked cupboard where it is signed out by staff to encourage consideration of whether the supplement is really medically necessary. Formula is kept out of sight to create an environment where breastfeeding is the norm.

• The BFHI standards thus allow that 25% of healthy term babies may be either mixed feeding or exclusively formula feeding by parental informed decision. This would indicate that work can be done on the health promotion messages in the community, especially during prenatal care, to influence the intention and commitment of women to exclusively breastfeed from birth to 6 months, as per Health Canada and WHO recommendations.

Mothers who decide to formula feed receive the same standard of care as breastfeeding mothers i.e. skin-to-skin care to safely transition the infant after birth (blood sugar, heart, temperature and breathing stability) and help with infant feeding. Some babies latch by themselves during the skin-to-skin care period, and thus some mothers change their minds about formula feeding. The provision of information regarding the risks and costs of artificial feeding and the parents informed decision to use formula is recorded in the patient’s chart for medico-legal purposes. Mothers who elect to formula feed receive one-to-one education from staff on how to safely prepare, feed and store formula to safeguard their babies. The hospital provides formula that has been procured in an ethical way (according to the WHO International Code for the Marketing of Breastmilk Substitutes) for the mothers who need or want it during their stay in the hospital. Nofree samples or gift packs are sent home with the mother. The WHO Code protects formula feeding mothers by requiring minimum standards for the quality of artificial infant feeding products, and appropriate teaching by health professionals rather than marketing by company representatives.

The BFHI offers an evidence-based standard of care to all women, regardless of their choice of infant feeding methods, while working to ensure that staff are able to provide the information and help that will maximize breastfeeding outcomes.
2. I'm a lactation Consultant working in a hospital that is looking at the process of becoming BFHI. On completion of the self-appraisal tool we noticed many No's and the suggestion was to develop an action plan if this occurred. I was wondering if you have a sample of one that would be helpful in addressing the many NO's.
3. I am wondering if you have a work sheet for estimating the cost of infant formula used at the hospital. As well is there a more detailed information sheet re same other than the global criteria attached to Step 6. If I could have a response asap it would be greatly appreciated.
4. if a supplement is given for medical reasons, does that imply that an order is necessary?
5. Is informed consent needed only for parental request for formula and not for medical reasons?
6. Despite rooming-in, skin to skin and frequent hand expression, we continue to see mothers who are unable to express any colostrum and also babies who are not latching (same mothers without colostrum). I have looked many times at the acceptable critieria for supp and I still don't see a critieria that covers this situation.
7. The new Hospital will include retail outlets - which must comply to the BFI accreditation standards. I am wondering if there is a BFI document that might provide direction for our Business Innovative Services - to ensure that the retail outlets do not violate these standards.
8. Some family doctors offices have formula cans behind closed doors, not associated with advertising materials. These cans are sometimes given out to already established formula feeding families who have dire financial difficulties and are having trouble buying it, not to breastfeeding families or as "samples". Looking under Article 6.6 about donations or low cost supplies to health care organizations, I'm wondering if this practice is ok or not. Previously, I was under the impression it was appropriate to do it in this way. It would be a shame to throw out supplies for needy families if it is ok under the code, but as some of our offices strive to get the baby friendly designation, we want to follow the letter of the law.
9. When delivering one to one prenatal services, and have determined that the client has made an informed decision to feed breast milk substitues once her baby is delivered, is it appropriate to provide information on the safe preparation, storage and feeding of these?