Pamela Murphy asks if anyone has found a way to bring formula supplementation of breastfed infants on hospital postpartum wards under control, which got my attention because we are doing an internal audit on supplemental feedings in our supposedly Baby-Friendly unit at the moment and her question is very relevant for us too.

Heather Welford Neil responded: 
"The only thing that appears to work is for supplementation to be *recorded* in every individual case, for mothers not to help themselves to it, and for the HCP to record the reason, and to record that she has explained the risks of formula supplementation to the mother, and for the mother to sign that she understands the risk. 
'Maternal request' is not enough of a reason, and nor is 'doctor's orders' - it has to be more detailed than this.
When this sequence of notes is not carried out, then the HCP has to explain to her manager why."

I will add that a necessary factor for this scenario to work is a manager who is paying attention, actually cares, and is not afraid to speak to staff who need reminding of what policy says.  If staff know that no one will ever challenge them on it even if their practice is completely and blatantly at odds with current policies and procedures, they will do whatever suits them.  There needs to be just as diligent monitoring of feeding practice as there is for anything else the unit defines as essential, like hand hygiene.  

I'm guessing that an employee who always shows up ten minutes after shift has begun would be Spoken To, as would an employee who doesn't adhere to dress requirements, or an employee who doesn't document other aspects of care.  The leaders in the unit need to focus on supplementation, make sure everyone knows what the policy is and which indications for supplementation are acceptable, and then they need to monitor practice and REACT when procedure is not followed.

The argument that the mother requested a supplemental feed doesn't wash, and I really wonder how anyone can use it as an excuse, when you think of all the requests women have on postnatal wards, like 'peace and quiet' or 'the right to deny entry by anyone with a hospital ID card to the room where they are sleeping'  or 'meals of my own choosing when it suits me to eat' or 'consistent, evidence-based guidance about breastfeeding', things we don't bother about trying to satisfy at all.  Why should supplemental feeds be given freely when, unlike my other examples, they are demonstrably harmful because they lower the chances that the child will be exclusively breastfed, and shorten the period of exclusive breastfeeding if they are?

Rachel Myr
Kristiansand, Norway

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