The World Health Organization (WHO) and the United Nations International Children's Fund led the Baby Friendly Hospital Initiative (BFHI) since 1991 to improve infant feeding in birthing hospitals (WHO, 2017a). The BFHI was implemented to incentivize birthing hospitals to adhere to the Ten Steps to Successful Breastfeeding and comply with the Code of Marketing of Breast Milk Substitutes (WHO, 2017a). In healthcare and in childbirth care, much has changed in the past 25 years. There also have been significant advances in care for infants requiring intensive care at birth. As childbirth and healthcare have changed in the past 25 years, are the original 10 steps still applicable?

In 2017, the WHO released a crucial evaluation of the BFHI implementation over the past 25 years (WHO, 2017b). The WHO distributed the 2nd Global Nutrition Policy Review to 194 WHO member states during 2016 with a 60% (117/194) response rate (WHO, 2017b). The WHO interviewed breastfeeding and BFHI leaders in 22 countries from all six WHO regions (WHO, 2017b). Results of the report are alarming.

Based on data compiled from 168 countries, as of 2016, only 10% of infants are born in BFHI facilities (WHO, 2017b). This varies widely by region, with over 35% in the European region but less than 5% in Africa and Southeast Asia (WHO, 2017b). Many countries have not put in place effective reassessment processes. Hospitals do not maintain BFHI practices over time (WHO, 2017b). Based on this report, the WHO revised the BFHI significantly and offered a brief period for public comment in October 2017 (WHO, 2017a).

The new BFHI guidelines released in 2017 are significantly different than the original. They provide thorough detail with 258 references and an evaluation of existing evidence (WHO, 2017c). There are no longer only 10 steps. Substantial changes have been made, which are practical given the changes in healthcare since the original publication. The new guidelines include 15 steps organized under three guiding principles: 1) Immediate support to initiate and establish breastfeeding, 2) Feeding practices and additional needs of infants, and 3) Creating an enabling environment.

Of major interest is the specific language about teaching mothers how to express milk to maintain lactation in the event of maternal-infant separation. Additionally, they recommend nonnutritive sucking and oral stimulation for preterm infants who are unable to breastfeed directly. Bottle nipples are also no longer contraindicated and step 10 of the new guidelines states "feeding methods such as cups, spoons or feeding bottles and teats may be used during their stay at the facility" (WHO, 2017c).

Despite the WHO releasing the new guidelines, Baby Friendly USA who administers the BFHI program in the United States has released the following statement on their Web site "we are continuing to adhere to our current Guidelines and Evaluation Criteria and the current standards will remain in place for the foreseeable future. We encourage you to stay the course in implementing the current standards and will advise you if and when any official changes are made to the initiative" (Baby Friendly USA, 2017). They are convening an expert committee to review the guideline and "develop an implementation strategy."

The new WHO guidelines clearly state: "This guideline is an update of, and supersedes, the Ten Steps to Successful Breastfeeding, as published in a joint statement by WHO and UNICEF in 1989." Please take the time to read the new guidelines and recommend their adaption in all countries globally including the United States.

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