WHO and UNICEF issue new Guidance to promote breastfeeding in health facilities (11 April 2018)

The World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) have jointly issued revised guidance to promote breastfeeding in health facilities–> the Revised Baby Friendly Hospital Initiative (BFHI).

Background Information:

Breastfeeding is critical for achieving global goals on nutrition, health and survival, economic growth and environmental sustainability. WHO and the United Nations Children’s Fund (UNICEF) recommend that breastfeeding be initiated within the first hour after birth, continued exclusively for the first 6 months of life and continued, with safe and adequate complementary foods, up to 2 years or beyond.

Globally, a minority of infants and children meet these recommendations:

  • only 44% of infants initiate breastfeeding within the first hour after birth and
  • 40% of all infants under 6 months of age are exclusively breastfed.

At 2 years of age, 45% of children are still breastfeeding.

The risk of dying in the first 28 days of life is 33% higher for newborns who initiated breastfeeding 2–23 hours after birth, and more than twice as high for those who initiated 1 day or longer after birth, compared to newborns who were put to the breast within the first hour after birth.

The protective benefit of early initiation extends until the age of 6 months.

Inadequate breastfeeding practices significantly impair the health, development and survival of infants, children and mothers. Improving these practices could save over   820 000 lives a year.

Nearly half of diarrhoea episodes and one third of respiratory infections are due to inadequate breastfeeding practices. Longer breastfeeding is associated with a 13% reduction in the likelihood of overweight and/or prevalence of obesity and a 35% reduction in the incidence of type 2 diabetes. An estimated 20 000 maternal deaths from breast cancer could be prevented each year by improving rates of breastfeeding.

In 1989, WHO and UNICEF published the Ten Steps to Successful Breastfeeding (the Ten Steps), within a package of policies and procedures that facilities providing maternity and newborn services should implement to support breastfeeding .

In 1991, WHO and UNICEF launched the Baby-friendly Hospital Initiative (BFHI), to help motivate facilities providing maternity and newborn services worldwide to implement the Ten Steps. Facilities that documented their full adherence to the Ten Steps, as well as their compliance with the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly (WHA) resolution (the Code), could be designated as “Baby-friendly”.

The BFHI package was updated in 2006 after extensive user surveys, and relaunched in 2009. The updated package reflected the new evidence for some of the steps (steps 4 and 8 for example) and their interpretation, and specifically addressed the situation of women living with HIV. It included guidelines for “mother-friendly care” and described breastfeeding-friendly practices in other facilities and communities. Standards for providing support for “non-breastfeeding mothers” were included, as the initiative encompasses ensuring that all mothers, regardless of feeding method, get the feeding support they need.

Almost all countries in the world have implemented the BFHI at some point in time. Coverage within most countries has remained low, however. In 2011, it was estimated that 28% of all facilities providing maternity and newborn services had been designated as “Baby friendly at some point in time”. However, as of 2017, WHO estimated that only about 10% of babies in the world were born in a facility currently designated as “Baby-friendly”.

Key Messages:

The new guidance describes practical steps countries should take to protect, promote and support breastfeeding in facilities providing maternity and newborn services. They provide the immediate health system platform to help mothers initiate breastfeeding within the first hour and breastfeed exclusively for six months. The topic of each step is unchanged, but the wording of each one has been updated in line with the evidence-based guidelines and global public health policy.

Ten Steps to Successful Breastfeeding (Revised 2018):

1a. Comply fully with the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions.

1b. Have a written infant feeding policy that is routinely communicated to staff and parents.

1c. Establish ongoing monitoring and data-management systems.


2. Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding.


3. Discuss the importance and management of breastfeeding with pregnant women and their families.


4. Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth.


5. Support mothers to initiate and maintain breastfeeding and manage common difficulties.


6. Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated.


7. Enable mothers and their infants to remain together and to practice rooming-in 24 hours a day.


8. Support mothers to recognize and respond to their infants’ cues for feeding.


9. Counsel mothers on the use and risks of feeding bottles, teats and pacifiers.


10. Coordinate discharge so that parents and their infants have timely access to ongoing support and care.


Useful Links:

Link to the WHO news release announcing release of the updated guidance:


Link to the Revised BFHI guidance (English) [PDF]:


Link to the Revised Ten Steps to Successful Breastfeeding 2018:


Link to Infographics on the Revised BFHI guidance:


Link to WHO page on the Baby Friendly Hospital Initiative (BFHI):


Link to WHO’s 2017 Guideline document on protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services (English) [PDF]:



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