The July 2017 report on BFB by Feldman-Winter et al is based on the premise that BF designation and breastfeeding exclusivity on the day of discharge from the birth hospital are appropriate criteria to ascertain the success of hospital support for breastfeeding. Neither breastfeeding rates after discharge nor adverse outcomes are included in the report. The World Health Organization evidence for the Ten Steps, the basis of BF designation, does not provide evidence that all of the 79 specific BF requirements (including 48 arbitrary numerical targets) are necessary or that strict breastfeeding exclusivity in the first days of life is an absolute precondition for subsequent breastfeeding success.1  It does demonstrate that implementation of steps 3, 5, and 10 (which involve lactation support before, during, and after hospitalization) is effective, a finding confirmed by the recent US Preventive Services Task Force report.2  Although the US Preventive Services Task Force includes evidence that populations with lower educational levels may benefit from BF, no researchers have ever compared the formal costly and complex BF designation process with the more straightforward approach of expending the same amount of funding toward expanding hospital lactation services. Of note, data from the 2016 Centers for Disease Control and Prevention (CDC) Breastfeeding Report Card reveal that states with the highest breastfeeding initiation rates (>90%) more consistently attained the US Healthy People 2020 Breastfeeding Objectives than states with the highest BF rates (>85%) (Table 1). This lack of long-term breastfeeding success is particularly important given the recent attention to certain sentinel events in the newborn. These include newborn falls and sudden unexpected postnatal collapse noted in association with some BF practices by the AAP3  as well as many other professional organizations worldwide. The unintentional consequences of skin-to-skin care (particularly when practiced unobserved beyond the early hours of life), inadvertent cobedding resulting from 24-hour rooming-in associated with strict breastfeeding exclusivity required by BF designation, and the ban on pacifier use are serious risk factors for these sentinel events.3,4  As the role of pacifiers in lowering the risk for sudden infant death syndrome is well established,5  notifying parents of this fact should have been required by the institutional review board rather than granting exempt status to this study. Future institutional review board decisions about BF research should also take into consideration AAP concerns about newborn falls and sudden unexpected postnatal collapse.3  Given the importance of breastfeeding and the severity of the associated sentinel events, it is critical that government policies promote only those practices that enhance breastfeeding in the safest and most effective manner, encouraging breastfeeding while minimizing risk. The focus should shift from process outcomes such as BF designation to an objective review of attainment of the Healthy People 2020 Breastfeeding Objectives. Current evidence indicates that to most effectively meet these national goals, hospitals should monitor breastfeeding initiation rates and emphasize provision of lactation support and safe sleep practices throughout the perinatal period.

TABLE 1

Healthy People 2020 Breastfeeding Duration Targets

% BF% Initiation (81.9%)6 mo (60.6%)1 y (34.1%)Exclusive 3 mo (46.2%)Exclusive 6 mo (25.5%)
>90% Initiation       
 Utah 7.9 94.4 (O) 
 Idaho 6.6 92.9 (O) 
 Oregon 32.4 92.5 (O) 
 Alaska 29.3 90.8 (O) 
 Hawaii 19.5 90.6 (O) 
 California 38.9 90.2 (O) 
 Minnesota 20.1 90.1 (O) 
>85% BF       
 Rhode Island 98.2 81.8 (X) 
 Delaware 85.8 74.6 (X) 
% BF% Initiation (81.9%)6 mo (60.6%)1 y (34.1%)Exclusive 3 mo (46.2%)Exclusive 6 mo (25.5%)
>90% Initiation       
 Utah 7.9 94.4 (O) 
 Idaho 6.6 92.9 (O) 
 Oregon 32.4 92.5 (O) 
 Alaska 29.3 90.8 (O) 
 Hawaii 19.5 90.6 (O) 
 California 38.9 90.2 (O) 
 Minnesota 20.1 90.1 (O) 
>85% BF       
 Rhode Island 98.2 81.8 (X) 
 Delaware 85.8 74.6 (X) 

Source: CDC Breastfeeding Report Card 2016. O, achieved target; X, below target.

1
World Health Organization Division of Child Health and Development
.
Evidence for the Ten Steps to Successful Breastfeeding
.
Geneva, Switzerland
:
World Health Organization
;
1998
2
Patnode
CD
,
Henninger
ML
,
Senger
CA
,
Perdue
LA
,
Whitlock
EP
.
Primary care interventions to support breastfeeding: updated evidence report and systematic review for the US Preventative Services Task Force
.
JAMA
.
2016
;
316
(
16
):
1694
1705
3
Feldman-Winter
L
,
Goldsmith
JP
;
Committee on Fetus and Newborn
;
Task Force on Sudden Infant Death Syndrome
.
Safe sleep and skin-to-skin care in the neonatal period for healthy term newborns
.
Pediatrics
.
2016
;
138
(
3
):
e20161889
4
Bass
JL
,
Gartley
T
,
Kleinman
R
.
Unintended consequences of current breastfeeding initiatives
.
JAMA Pediatr
.
2016
;
170
(
10
):
923
924
5
Hauck
FR
,
Omojokun
OO
,
Siadaty
MS
.
Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis
.
Pediatrics
.
2005
;
116
(
5
).

Competing Interests

CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.