Of all the preventive activities a paediatrician can undertake, those that have the greatest impact on child health are vaccination and promotion of breastfeeding. The objectives set for the training of paediatric residents in breastfeeding should be very ambitious. Any breastfeeding lost through lack of training of professionals is a failure of the health care system. In Spain we have not up to now had any validated tool for estimating knowledge of breastfeeding. The rigorous study carried out by Gómez Fernández-Vegue and Menéndez Orenga1 offers us a valuable instrument for assessing paediatricians’ knowledge and skills in breastfeeding and will undoubtedly be very useful to supplement the training actions conducted in Spain on this subject.

All of us who work as child health professionals, and are therefore concerned with breastfeeding, have long had a validated, evidence-based, universally applicable tool which succeeds in increasing breastfeeding rates2: accreditation of our work centres under the Baby-friendly Hospital Initiative (BFHI), established in Spain as Iniciativa para la Humanización de la Asistencia al Nacimiento y Lactancia (IHAN-UNICEF). This initiative was launched by the World Health Organization (WHO) and UNICEF3 to encourage hospitals, health services, and especially maternity wards to adopt practices to protect, promote and support exclusive breastfeeding from birth to six months, and complementary foods up to at least 2 years of age. Spain has few accredited centres compared with other countries in our region (16 hospitals and one health centre), although in recent years numerous hospitals (70) and health centres (80) have initiated the process leading to certification. This greater interest in accreditation reflects greater concern among professionals to improve breastfeeding rates. In addition, 4 years ago IHAN (http://www.ihan.es) modified the accreditation procedure, which was adapted so that it could be completed in phases: Discovery, Development, Dissemination and Designation. This facilitates the process, as the objectives are attained gradually, stage by stage. The dissemination phase includes training for all professionals, and the questionnaire presented in this issue of Anales de Pediatría, whose authors collaborate with IHAN in the training of paediatric residents, is a valuable instrument which will undoubtedly facilitate the training offered to professionals and enhance its quality.

As the WHO report “Born Too Soon: Global Action Report on Preterm Birth”4 shows, the frequency of premature births is increasing; every year 15 million children are born prematurely in the world. Implementing cost-effective evidence-based measures, such as Kangaroo Mother Care and support for breastfeeding, could prevent half a million deaths every year. It therefore seemed reasonable that the WHO and UNICEF should decide to adapt BFHI to neonatal units (Neo-BFHI). Neo-BFHI focuses on supporting the breastfeeding of hospitalised newborns, who, being the most fragile patients, are also those that can most benefit from breastfeeding. Early, systematic, ongoing encouragement for mothers of children admitted to the neonatal unit to begin milk extraction is essential to achieve success not only in breastfeeding but also in the emotional support these mothers need. The main difference compared with the maternity floor is that most children in neonatal units are separated from their mothers. There are still very few centres with the resources to enable mothers to be with their children 24hours a day, which is what we should ideally be aiming for. The BFHI's Ten Steps to Successful Breastfeeding have been adapted for the situations in neonatal units and 3 basic principles have been included.5 The documentation for Neo-BFHI is now available at http://ilca.org/i4a/pages/index.cfm?pageid=4214.

We have clear evidence that the interest of professionals in initiating the accreditation process for a centre sometimes runs up against the obstacle of paying the assessment fees IHAN charges. The sole purpose of this payment is to obtain funds to defray the costs of the evaluation, the final phase of which involves several assessors visiting the health care institution for 2 or 3 days. Assessment of the 4 phases for a health centre represents a cost to the health care authorities of €1000, and €6750 for a hospital. There are certainly few actions in the health field with a more favourable cost-benefit ratio than the expense involved in accreditation compared with the demonstrated benefits in increasing the breastfeeding rate,6 which not only has a positive effect on the health of the child and of the mother, but also reduces parents’ absenteeism from work.

We all want a better, healthier life for our children. There are authors already reporting that the most frequent cause of acquired immunodeficiency is exposure to artificial formulas.7 Giving children priority attention is a sign of a developed country. It already seems to have been shown that breastfeeding is associated with higher IQ and greater capacity for social progress.8 Sometimes very complex strategies and high levels of financial investment are required to achieve improvement in certain areas. In the case of breastfeeding, however, we are fortunate: the strategies for change are not complex; they are based on widely available evidence and the cost to each institution is minimal. Greater sensitivity on the part of the public authorities will therefore help the commitment of professionals to achieve its ultimate objective.

Improving breastfeeding rates in Spain is a task in which everyone must play a part. We need a chain extending from the Ministry of Health and the Health Authorities of each Autonomous Committee, through the Learned Societies, to the professionals who are in direct contact with the women and children. In addition, breastfeeding can undoubtedly be supported through education and by controlling the marketing conducted around children and childhood, which constantly uses objects, symbols and words that question or undermine support for breastfeeding and sends mixed messages that reach parents at times of great vulnerability.

When it comes to breastfeeding, we can achieve a great deal with very little, and now, thanks to the knowledge assessment instrument presented in this issue of Anales de Pediatría, we can do even better.