How can it be safe to make newborns go without food for 48 hours?

The stories have been as shocking as they are tragic: dozens of babies who died or were left brain-damaged after errors by clinical staff at one of Britain’s biggest hospitals.

But among the appalling cases of negligence spanning a decade uncovered by an investigation into Nottingham University Hospitals NHS Trust, one stood out as particularly alarming – a baby boy, born in July 2019, who cried just once after birth, then fell silent, didn’t move or feed, yet was discharged by staff who said all was ‘normal’.

Earlier this month, his bereft mother said: ‘He never opened his eyes… He never moved, he didn’t lift his arm, a finger, a murmur.’

She tried to raise the alarm – yet both midwives and a junior doctor dismissed her concerns, and told her that only if he didn’t feed for 48 hours would they do anything.

The woman, in her 30s, and her son were then discharged with paperwork stating the newborn was ‘happy and content’, and that the midwife had seen him ‘both breastfed and bottle-fed’, which, the family now say was untrue.

A baby boy, born in July 2019, who cried just once after birth, then fell silent, didn’t move or feed, yet was discharged by staff who said all was ‘normal’. Pictured: Stock image

In the early hours of the following morning, back at the family’s Nottingham home, the baby stopped breathing.

His mother performed CPR and called an ambulance – but attempts to resuscitate him proved futile.

An independent investigation into the death, published last week, made note of the Trust’s so-called ‘reluctant feeder’ policy, which instructed staff not to intervene or offer a bottle of formula if a newborn doesn’t feed for up to 48 hours.

Such guidance was said to ‘ensure optimal breastfeeding support’ and avoid ‘unnecessary formula supplementation’.

An inquest found the baby died due to a respiratory problem normally seen only in premature babies, and may also have suffered an underlying metabolic condition.

It is unclear if not being fed played a role in his death.

Yet Nottingham University Hospitals NHS Trust has since changed its feeding protocol, shortening the delay to action, should a newborn not breastfeed, from 48 hours to just two.

The family’s legal case against the Trust is ongoing, and there have been calls for a public inquiry.

But perhaps equally worrying, many maternity units still abide by similar reluctant feeding guidance to the one now abandoned by Nottingham.

Figures published last week by the Health Select Committee revealed there are 1,000 preventable deaths among infants every year in British hospitals.

An independent investigation into his death made note of the Trust’s so-called ‘reluctant feeder’ policy, which instructed staff not to intervene or offer a bottle of formula if a newborn doesn’t feed for up to 48 hours. Pictured: Stock image

The committee, chaired by former Health Secretary Jeremy Hunt, made special mention of the pressure on women to have a natural birth.

Now campaigners are suggesting one ‘misguided’ hallmark of maternity care could explain some of these catastrophic failings: an ‘outdated obsession with breastfeeding’.

Dr Ruth Ann Harpur, a psychologist who runs lobby group The Infant Feeding Alliance, said: ‘Not giving a baby anything to eat for 48 hours might be unlikely to harm them, because newborns have reserves that allow them to go without feeding for this sort of time – but I struggle to see how it can be optimal.

‘I know of many women with babies who have ended up hospitalised with starvation-related conditions simply because midwives would do anything not to give them a bottle. I also know of cases where something serious has been missed because the midwives have been too preoccupied with breastfeeding.’

The taste of breast milk changes depending on what the mother has eaten, which may influence the baby’s food preferences as they get older.

As evidence for the failings of maternity wards’ breastfeeding regimes, Dr Harpur points to a 2017 Nuffield report that shows the number of infant hospital admissions for feeding-related problems, such as jaundice and dehydration, had doubled since 2006.

Since the early 1990s, hospitals have used various schemes to encourage mothers to opt for breastfeeding in response to the UK’s record-low rates – a hangover from the 1950s culture of medicalised childbirth, whereby formula was wrongly assumed to be superior.

One of them, the World Health Organisation-backed Baby Friendly Initiative, has been adopted widely and requires maternity wards to adhere to standards designed to keep women breastfeeding, should they want to, for up to six months.

This has been a huge success, credited for increasing the number of mothers who choose to breastfeed by at least 30 per cent.

And the health benefits are well proven – studies suggest breastfed babies are less likely than formula-fed counterparts to become obese in later life or develop allergies and gastrointestinal infections.

But amid the triumphs have been consistent reports of problems. Some mothers say breastfeeding is prioritised by maternity staff above all else – including both their and the newborn’s health.

Speaking to this newspaper, one mother told of being discharged from hospital after two days, despite her baby’s weight continuing to plummet.

Nottingham University Hospitals NHS Trust has since changed its feeding protocol, shortening the delay to action, should a newborn not breastfeed, from 48 hours to just two. Pictured: Stock image

The weight loss continued for five weeks at home, until against the health visitor’s advice she introduced bottles after noticing her baby had ‘protruding bones’.

Another was left traumatised after midwives attempted to latch their baby on to their breasts while they were fast asleep on a high-dependency unit recovering from a serious haemorrhage.

One mother from London said the pressure from midwives to breastfeed while she struggled to produce sufficient milk caused her to spiral into a severe depression that saw her being admitted to a psychiatric ward.

‘A problem I see commonly: the baby won’t feed but the staff say ‘Don’t worry, it’s normal’, then a few days later the baby has lost a dangerous amount of body weight and has to be readmitted to hospital,’ says Clare Byam-Cook, who has 30 years’ midwifery experience in busy London hospitals and is now a breastfeeding consultant.

‘It seems hospitals are more concerned about ticking the breastfeeding box than they are about healthy, happy parents and babies.’

For babies who do not feed easily within four hours of birth – termed reluctant feeders – the Baby Friendly Initiative advises ‘not feeling tempted to give formula feeds’ in the first 24 hours.

Guidance published by the British Association For Perinatal Medicine, which maternity wards use in combination with the Baby Friendly Initiative to set protocols, echoes this advice.

Mothers are encouraged to keep trying to express colostrum (a nutrient-rich early form of breast milk) either using a hand or the baby’s mouth, every two hours, or at least eight times in the first day.

Campaigners argue that waiting two days before giving them formula is too long – by that time mothers are often discharged home without support, where the situation can quickly worsen. But one hospital trust even extends the delay out to three days. Guidance published by The Royal Cornwall Hospitals NHS Trust states: ‘When babies are over 72 hours old and remain reluctant to feed it is appropriate to contact the Infant Feeding Team or Neonatal Team.’

Dr Helen Mactier, consultant neonatologist and honorary clinical associate professor at the University of Glasgow, said: ‘A baby who is not feeding by day three might well have something seriously wrong with them, and this needs proper investigating.’

Some studies have suggested a child’s IQ is slightly higher if they have been breastfed, although others have not found any link.

But why is there any delay at all in feeding a newborn baby?

According to the breastfeeding support network La Leche League, introducing a silicone bottle in the early days can drastically alter a baby’s sucking patterns, making it unfamiliar with the mother’s nipple and therefore less likely to latch on – dubbed ‘nipple confusion’.

Studies do support this concern. However, there is also research that shows nipple confusion is not a problem and that babies who are given supplemental formula milk in the 48 hours post-birth can actually help mothers continue breastfeeding in the weeks following.

In one 2018 study, three months after birth, 80 per cent of infants who were initially formula-fed went on to be breastfed exclusively, compared with fewer than half of those not given the supplementary help.

Another more recent study found exclusively breastfed newborns were more likely to lose significant amounts of weight six months after birth than those given a small amount of formula in hospital.

In recent years, research has shown that the Baby Friendly Initiative hasn’t been entirely beneficial. A 2018 University of Liverpool analysis of 11 studies of the scheme found, in some cases, it promoted ‘unrealistic expectations of breastfeeding,’ ‘did not meet women’s individual needs’ and ‘fostered negative emotional experiences’.

One mother for whom this rings true is 42-year-old Sue Haddon, from Guildford in Surrey. In 2016, her four-day-old daughter Rain was rushed to A&E after a health visitor spotted signs of malnutrition and a dangerous drop in body weight.

Sue had told midwives of her wishes to breastfeed, but when her first and only child was eventually delivered – after an excruciating five-day labour – it didn’t go as smoothly as she’d hoped.

‘I was completely exhausted, having had very little sleep for the best part of a week. I’d even started hallucinating,’ says Sue, a copywriter. ‘So when the midwives tried to get her to breastfeed a couple of hours after birth, with all their prodding and poking, it felt overwhelming and slightly terrifying. And it just wasn’t working, she wouldn’t latch on.’

The midwives tried again every two hours, using hand massaging techniques and bringing syringes to inject tiny amounts of extracted colostrum into Rain’s mouth.

Sue adds: ‘I could tell she wasn’t feeding properly, but there seemed to be no concern about this from the midwives.

‘And there was also no acknowledgment of the fact I desperately needed to sleep, or a conversation about whether exclusive breastfeeding was the best thing after such an ordeal.

‘The pressure to keep going with breastfeeding made me even more anxious and scared, so when I did try to sleep, eventually, my head wouldn’t stop spinning.’ She says that there was no guidance from staff about how she and her husband, Will, would feed Rain at home without the constant physical help from midwives.

The Haddons were discharged from the maternity unit on day three. But the following day a health visitor flagged several serious problems.

Sue says: ‘They told us to go straight to the hospital because she’d lost 13 per cent of her body weight since birth, had jaundice and was severely dehydrated. Basically, she wasn’t getting enough food.’

The couple were given an emergency referral to the paediatrics department where, Sue says, the approach was vastly different.

‘It was about feeding my baby in a way that would provide enough nutrition to keep her healthy and was sustainable for me and my husband,’ she says.

‘They immediately gave us a bottle of formula and we noticed a difference in Rain almost instantly. The jaundice cleared up in a day. A nurse told us they saw situations like ours almost every day.’

While her baby’s physical health problems resolved quickly, for Sue the repercussions of the ordeal on her mental health continued for years.

‘I was haunted by shame and guilt, feeling like I’d failed to feed my baby properly,’ she says. ‘It took a long time to make me realise that I hadn’t done anything wrong.’

Sue now campaigns for a more balanced approach to feeding. ‘It’s not that midwives didn’t offer me support to help breastfeed in hospital – they did,’ she says.

‘I just wish, when I was barely conscious, someone would have thought: maybe this isn’t the best, most sustainable thing for her in this current state.

‘My wellbeing, it seemed, simply wasn’t a priority.’

Speaking to The Mail on Sunday’s Medical Minefield podcast, paediatric nurse and breastfeeding consultant Lyndsey Hookway said it was vital the debate didn’t end up ‘pitting one form of feeding against another’, adding: ‘As soon as we start making the suggestion that a mother doesn’t have enough milk, or her milk is not good enough, or there’s something wrong with the composition or volume, that can have quite long-lasting detrimental effects on their wellbeing.’

However, Dr Heather Ryan, a GP and a member of campaign group the Infant Feeding Alliance, says: ‘Reluctant feeder policies focus on avoiding formula supplementation because there’s an idea that it’ll hinder long-term breastfeeding.

‘But there isn’t good evidence to support that. If a baby has lost an awful lot of weight in the first few days, or is having a lot of trouble feeding, then formula supplementation may be clinically indicated.

‘It’s absolutely right and proper we promote breastfeeding, and it should be the first choice if it’s possible. But there are plenty of mums who choose not to, or medically can’t do it, and I don’t think there should be the stigma attached to it.’

Read More: DailyMail

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