Abstract
Supporting optimal newborn nutrition and the positive maternal-infant relationship while encouraging safe sleep practices are essential components of maternal and newborn care in the hospital setting following birth. Breastfeeding is widely recognized as the best practice to support the nutritional needs and well-being of the infant, and recommendations have been developed by the WHO, the American Academy of Pediatrics (AAP), and the United States Centers for Disease Control to encourage and successfully support breastfeeding efforts before hospital discharge. The 10 Steps to Successful Breastfeeding, developed and promoted by the WHO, form the basis of the Baby-Friendly Hospital Initiative (BFHI) and have become the international framework for public health initiatives to promote breastfeeding. An evaluation of hospital performance implementing the 10 steps through the process of "Baby-Friendly Designation" (BFD) has been suggested by many breastfeeding advocates as the optimal pathway to attain the goals of the BFHI. However, the WHO has recognized that BFD may not be an appropriate goal in all settings, and indicated, as part of their updated 2018 guidance, that "facilities may make changes in their policies and procedures to obtain the designation, but these changes are not always sustainable, especially when there are no regular monitoring systems in place." In addition, unintended associated issues regarding newborn safety and maternal dissatisfaction with some of the 10 steps have emerged. This perspective discusses the challenges faced by hospitals attempting to implement the BFHI 10 steps and suggests potential solutions to make progress in those efforts with or without BFD and also the efforts needed to support formula feedings when appropriate.