Rebuttal to Dr. Amy Tuteur regarding Time editorial

This essay is reposted with permission from CHAMPSBreastfeed.org

Thirty years ago, every newborn infant born in a US hospital was separated from their parents at the time of birth. Rooming-in was not an available option. We know now that that this standard practice was not optimal for the mother or the infant. As a pediatrician, I am concerned by the implications of this article. The image used by Time Magazine depicts an “unsafe” practice: several newborns swaddled in basinets on their sides sleeping. This sleep position carries more the double the risk of SIDS compared to infants sleeping on their backs. In addition, the bassinets are positioned adjacent, in a row, which is a practice that is fraught with risk for nosocomial infections, and has implications for security, and privacy concerns, especially when viewed by the public as is often the case in US delivery hospitals.

Beyond the disturbing photo the subtitle is inaccurate. It is important to note that what is changing among maternity care hospitals is that mothers are now offered the opportunity to allow their newborn to share a room with them. This opportunity is not “forced” but protected, given that rooming-in not only does help breastfeeding, it is safer than sleeping separated from mom. In the past, mothers were forced to separate from their newborn infants and required to have their infants sleep separately in a nursery setting, where they were grouped with other infants. Rooming in is the recommended environment for all mothers regardless of chosen feeding method. The author repeatedly refers to rooming-in as unsafe but with appropriate guidance and monitoring it is not unsafe and is safer than sleeping in a nursery. Both mother and newborn continue to receive the same level of care and supervision. Rooming-in does not mean that the care of the newborn is delegated to the mother, however, rooming-in provides the mother the opportunity to participate in their own newborn’s care. This permits staff to do additional teaching and observation of parenting skills before discharge.

Rooming-in does not mean mothers cannot rest. In fact, studies show that mother’s sleep quality improves when her newborn is nearby, and sleep quantity does not diminish. Rooming-in is not a result of the “breastfeeding industry.” Rooming-in is not intended to promote breastfeeding, but rather to support breastfeeding for a mother who has chosen to breastfeed. Rooming-in does not promote bed-sharing, but breastfeeding often does occur in bed. Mothers are instructed to ask staff for assistance to help transition the newborn to a safe sleep surface, their bassinet, after feeding is complete.

It is unfortunate that the author believes Baby-Friendly is “deeply wounding” for those who choose to formula feed. Baby-Friendly offers the best care for mothers and babies irrespective of feeding method. Formula is still available in Baby-Friendly hospitals, but like any other medication it is not accepted as a free product nor distributed for free. Mothers are not given acetaminophen or ibuprofen free to use when they go home, but are likely to use these medications. The sole purpose of infant formula being given to delivery hospitals for free is to establish brand loyalty. Similar to other Pharmaceutical Research and Manufacturers of America (PhRMA) policies that are standard among hospitals, infant formula companies must follow the same set of guidelines. PhRMA code promotes the use of ethical standards, medical knowledge and experience to address individual patient needs and make sure they have access to appropriate medications. As a standard of care, the delivery of infant formula would fall under these PhRMA guidelines.

Regarding the author’s assertion of “What’s wrong with the BFHI?”:

1. The benefits of breastfeeding and risks of formula feeding are anything but trivial. The establishment of the infant’s immune system and properly functioning microbiome are reliant on an exclusively breastfed diet with profound and lifelong results. Even in first world countries the health outcomes and costs associated with not meeting the recommended timeframe of breastfeeding is estimated to be in the tens of billions of dollars per year for both maternal and childhood illnesses.
2. There is no “breastfeeding industry.” What we have is persuasive research evidence that mother-baby separation leads to increased supplementation and decreased duration of breastfeeding (for example NJ PRAMS data).
3. There are safety recommendations to ensure that mothers who are sedated or temporarily disabled due to delivery mode are provided with the assistance and support they need to care for themselves and for their newborns. The best way to think about rooming-in is a semi-private room where the mother and baby are sharing but both provided with skilled and continuous nursing.

Bradley Thach’s paper in the Journal of Perinatology (J Perinatol. 2014 Apr;34(4):275-9) drew attention to the conditions called, sudden unexpected perinatal collapse. While Dr. Tuteur suggests we know why these babies die or have perinatal collapse, we actually don’t know. While some of the deaths may have been related to accidental suffocation, there are no data to confirm or deny this association. Nevertheless, careful monitoring and safety considerations for mothers bringing babies into their beds is common sense. Mothers should be expected to use call bells when sleepy or having trouble transferring the newborn to the bassinet.

Rooming-in, and the BFHI, does not require being “privileged to have a partner” or money to pay for baby-sitting other children. As stated, rooming-in supports the most optimal arrangement for maternal rest and sleep quality.
Finally, the author is incorrect in stating that no one is preventing rooming-in. Indeed, most hospitals in the US do exactly that. They have routines that require babies are monitored for arbitrary yet mandated periods of time during some “transition” period. Rooming-in serves the needs of mothers and babies, regardless of feeding method, not the “breastfeeding industry” and does not lead to staff layoffs or reassignment of baby care to the mother.

Lori Feldman-Winter, M.D., MPH, is Professor of Pediatrics at Cooper Medical School of Rowan University and the Division Head of Adolescent Medicine at The Children’s Regional Hospital at Cooper University Healthcare in Camden, NJ.

Renée Boynton-Jarrett is a practicing primary care pediatrician at Boston Medical Center, a social epidemiologist and the founding director of the Vital Village Community Engagement Network.

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