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Breastfeeding Support in WIC
Erica Lamson MPH, RD, IBCLC Nutrition 526November 2012
About me… Mom to Hazel (7) and Sid (5)
both breastfed Graduate of MPH Nutrition
program Worked in WIC since 2005 IBCLC in 2011 Work for Community Action of
Skagit County WIC Program & Center for Public Health
Nutrition
About you… Name Program of study Any personal experiences with
breastfeeding?
Learning Objectives Describe how WIC promotes and supports
breastfeeding. Describe how to conduct an assessment in the
WIC setting. Identify at least 5 questions that assess
breastfeeding for the mother/infant dyad. Name at least 5 things that might impact
breastfeeding for the mother/infant dyad. List at least 3 resources for answering future
breastfeeding questions.
WIC breastfeeding support Access to breast pumps
Hospital-grade pumps for loan Single-user WIC ‘n Style pumps
Work or school Exclusively breastfeeding Baby > 8 wks
Single-user hand pumps
WIC breastfeeding support Access to skilled lactation
support International Board Certified
Lactation Consultants (IBCLC) Breastfeeding peer
counselors Trained WIC staff (RDs +
paraprofessionals) Referrals (MD, IBCLC, LLL,
etc) Hotlines and warm lines
WIC breastfeeding support Prenatal breastfeeding
classes One-on-one breastfeeding
education Postnatal breastfeeding
support groups
WIC breastfeeding support 2009 food package
changes Biggest food package for
fully breastfeeding moms
No formula issuance in first month for breastfed babies
WIC supports breastfeeding across the state Staff training State and local collaborations
with birthing hospitals Local funds designated specifically for
breastfeeding promotion State funds help support BCW Participation in local breastfeeding
coalitions
Changing the conversation“We’ve learned… that, ‘Oh, yeah, WIC. You’re the people who have the formula.’ And oh no, we’re really not. You take for granted that people know what WIC is. There’s a lot of folks out there that don’t know.”
-- Local WIC program coordinatorJanuary 2012
What is the effect?
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 201072%
74%
76%
78%
80%
82%
84%
86%
88%
Percent of Washington WIC Infants Breastfed at Birth (Initiation)
What is the effect?
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 201030%
32%
34%
36%
38%
40%
42%
44%
46%
48%
50%
Percent of Washington WIC Infants Breastfed at 6 Months (Duration)
Complexities WIC spends millions promoting &
supporting breastfeeding Formula is federally mandated part of
WIC food package Formula rebates
FY 2010 rebates saved $1.7 billion=1.9 million participants=20.5% of average monthly caseload
Complexities Association between WIC
participation and lower breastfeeding rates for initiation, exclusivity, & duration Jensen E. Matern Child Health J. 2012; 16:624-631 Racine EF, et al. Matern Child Health J. 2009;13:241-
249. Jacknowitz A, et al. Pediatrics. 2007;119:281-9. Ryan AS, Zhou W. Pediatrics. 2006;117:1136-1146
Self-selection based on desire/need for formula?
The changing landscape 2009 policy changes No formula in 1st month,
staff training, food pkg changes associated with higher rates exclusive breastfeeding Whaley SE, et al. Am J
Public Health. 2012; 102:2269-2273
Wilde P, et al. Am J Clin Nutr 2012;96:560-6.
The local perspective WIC moms have
Greater access to pumps
Greater access to skilled lactation support
May shift with ACA Full insurance coverage
for lactation services & devices
Questions / Discussion
Assessment in WIC Anthropometric
Weight/height Biochemical
Hemoglobin Dietary Psychosocial
Value Enhanced Nutrition Assessment (VENA)
Response to IOM report Dietary Risk Assessment in the WIC Program All women & children presumed at dietary risk
based on failure to meet Dietary Guidelines Goals
Expand purpose of nutrition assessment Eligibility determination nutrition education
Medical-nutritional assessment continues Streamline dietary assessment
Collect more relevant information to individualize nutrition services
VENA at the state level Each state chooses their own
assessment questions Assessment completed at
Yearly certifications Mid-year health assessments
Differ by client category PG, BF, PP, C, I
Each intended to ask about a specific risk
Breastfeeding Woman Assessment Questions1. How are you and the baby doing?2. How is breastfeeding going?3. In this or any previous
pregnancy, did you have any health or medical concerns, such as gestational diabetes and/or preeclampsia?
4. How many times have you been pregnant in the past two years?
5. Have you had any recent surgeries, such as a c-section?
6. Do you have any health problems or medical conditions?
7. Are you taking any medications?8. What vitamins or other dietary
supplements do you take?
7. Do you have any problems with your teeth or gums that affect how you eat?
8. How has your appetite been? Are there foods you avoid for any reason, including food allergies?
9. Do you eat things such as ice, dirt, clay, paint chips, or starch?
10.Do you smoke?11.Does anyone smoke inside your
home?12.When was the last time you drank
alcohol?13.When was the last time you used
drugs?14.Have you felt sad or depressed
recently?15.Is there anyone in your life who is
hurting you or your child(ren)?
Additionally VENA has… Shifted to more client-centered approach Process
Collect all information Wait to educate Begin dialogue about what she or he wants
and needs related to nutrition and health WIC Connects
Shift from basic nutrition assessment and education supporting behavior change
Ask and listen Thorough assessment
Helps you meet the client’s needs Saves you time
Get the full picture Sometimes things don’t come out neatly
or linearly – actively listen! Ask probing open-ended questions Seek to understand from the client’s
perspective
Assessment of the mother/baby dyad in WIC
Mom’s Health/ Nutrition
Labor
Length of Gestation
Baby behavior
LatchInterpersonal
Weight
Weight gain Ask:
What was your baby’s birth weight? (for newborn)
What was your baby’s discharge weight? (for newborn)
When was the last time your baby was weighed? What was that weight?
How many dirty and wet diapers per day? What color is baby’s stool (for < 1 wk old)?
Calculate weight gain Take weight and calculate:
Take today’s weight Calculate ounces gained per day
(today’s wt – last wt) / # of days elapsed Plot on WHO grid
Weight loss >7% of birth weight Meconium stools after day 5 < recommended # dirty/wet diapers per day
For newborns Breastfeeding needs a close look if 7% or
greater wt loss Diaper output = rough indicator of intake
AAP: Days 3-5 – 3-5 wet, 3-4 stools AAP: Days 5-7 – 4-6 wet, 3-4 stools
Immediate referral to MD if Lethargic, weak cry Skin less resilient after pinched Looks yellow (sign of jaundice) Eyes/mouth appear dry Sunken fontanel Fever
For older babies Rate of gain slows between 3 and 12
months If drops channels on grid, take a closer look
WHO growth grids Old CDC growth grids
Full feeding assessment How is breastfeeding going? Complementary foods introduced? Health history
Rules of breastfeeding management1. Feed the baby2. Protect mom’s milk production3. Fix the problem
Low milk production Feed the baby Determine cause
Poor latch insufficient milk removal Infrequent milk removal
sleepy baby pacifier use not responding appropriately to feeding cues
Medical problem insufficient mammary tissue hormonal disturbances Breast surgery/injury
Low milk production Fix the problem
Improve latch & milk transfer More frequent milk removal Use of pump Referral to MD for underlying health problems Encourage healthy diet Can provide information on galactogogues
Reliable info sources Encourage talking with MD Can’t recommend taking herbal or other
supplement
http://www.ilca.org/files/resources/HealthCareProviders/Galactogogue%20Dosage%20&%20Reference%20Table%20V2.pdf
http://www.ilca.org/files/resources/HealthCareProviders/Galactogogue%20Dosage%20&%20Reference%20Table%20V2.pdf
http://www.ilca.org/files/resources/HealthCareProviders/Galactogogue%20Dosage%20&%20Reference%20Table%20V2.pdf
Other info/references http://lowmilksupply.org/
http://www.breastfeedinginc.ca
http://kellymom.com/
Labor Ask:
How was your labor? (Usually, story follows freely.)
Very long, difficult labors Pain medication (epidural, fentanyl, etc) C-section
Birth practices & breastfeeding Stressful birth (physically or psychologically)
Increases cortisol Associated with delayed lactogenesis II
Medications Some studies show association between meds
& feeding effectiveness C-section
May make BF physically challenging Historically mother-baby separation, although
hospital practices changing
Reading baby behavior Ask:
Tell me about your new baby. How does she tell you she’s hungry? How does he sleep? When does she cry?
“He’s a really good baby. He sleeps a lot.”
“She only cries when she needs to eat.”
Beware the “good” baby
Poor Feeding
Jaundice
Sleepiness
CA Baby Behavior Campaign Teach parents to appropriately respond
to baby’s cues to avoid Overfeeding Unnecessary formula supplementation
Outcome Increased exclusive BF package issuance Combined feeding decreased (BF+formula) Fewer infants >95% wt-for-age in
intervention clinics
Heinig MJ, et al. Fit WIC Baby Behavior Study. Final Report. 2009. Available at http://www.nal.usda.gov/wicworks/Sharing_Center/spg/CA_report2006.pdf
CA Baby Behavior Campaignhttp://www.cdph.ca.gov/programs/wicworks/Pages/WICCaliforniaBabyBehaviorCampaign.aspx
Latch Ask:
How does it feel when your baby latches? Do you have damage (cracks, bleeding) to
your nipples? Without good latch
Mom hurts Baby doesn’t get milk Limited milk transfer low milk
production
Lots of ways to achieve latch
Laid back breastfeeding Reflexes work against BF in standard
positions Reflexes work with BF in laid back
position http://
www.biologicalnurturing.com/index.html http://www.breastfeedinginc.ca/content.
php?pagename=videos
Colson SD, et al. Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding. Early Human Development, 84(7), 441-449.
Length of gestation Ask:
Was your baby born on his due date? Early? Late?
Premature (<37 wks) Late preterm – (35-39 wks)
<34 weeks gestation Generally won’t see these babies in WIC
until closer to 37 wks gestational age Typical breastfeeding complications
Low milk production Less time for breast tissue development Mother-baby separation
Difficulty transitioning to breast Sometimes fortifying expressed breast
milk for higher kcals to support growth
34-37 weeks gestation Can be sneaky, pretend feeders
Look like they are latched and feeding well, but not transferring milk
Immature suckling pattern Need close monitoring Higher risk of high wt loss, slow gain,
high bilirubin
Interpersonal Ask:
How are you? No really, how are you? How do you think breastfeeding is going? What kind of support do you have?
How do they feel about your breastfeeding? What are your breastfeeding goals?
Interpersonal “I don’t know. This isn’t what I
expected.” “My doctor says that I shouldn’t stress
about the breastfeeding. It just doesn’t work for some people.”
“My mom thinks I don’t have enough milk.”
“My boyfriend wants to feed the baby.” “Can’t I just do both?”
Reality is… limited support High prevalence of single parent
households in WIC Brittainy
Three kids – ages 3, 18 months, and newborn
Partner involved, but doesn’t live in household and works 2 jobs
Financial pressure to be back to work by 2 wks postpartum
Reality is… need for income Often single earner or household
depends on her income Early return to work, <3 month
postpartum WIC supplies breast pumps, but…
Difficulty maintaining & establishing full milk production with early return to work
Unsupportive work environments & fear of job loss
Reality is… Stressful lives Depression and/or anxiety Associations between BF and depression
Do BF problems contribute to depression? Does depression contribute to less BF? Does successful BF protect against
depression, anxiety, & sleep disturbances?
All of the above?Kendall-Tackett. J Perinatal Educ. 2010;19(4):7-9. EditorialDennis CL & McQueen K. Pediatrics. 2009;123(4):e736-51Hamdan A & Tamim H. Int’l J Psychiatry in Med. 2012. 43(3);243-259.
Other realities… Less than optimal housing
Reluctance to breastfeed when no privacy Past/current abuse Focus on here and now, not abstract
future health We are a small voice among many
Friends/family info and opinions are more impactful
Mom’s health Collect & Calculate
BMI Health history
Diabetes Hypertension Hormonal disruptions (i.e. PCOS, thyroid,
etc.) History of breast surgery
Mom’s health
Obesity or high pregnancy weight gain Diabetes High blood pressure Polycystic ovarian syndrome (PCOS) Hypothyroidism Breast augmentation, reduction, injury, or
other surgery
Obesity & overweight Associated with delay in milk increase
(lactogenesis II) after birth Decrease prolactin response to suckling Concurrent medical conditions
Medical conditions Diabetes
Delayed milk increase after birth No differences in long-term production
between DM and non-DM moms Hypertension? PCOS
Risk of low milk production High level of individual variance
Medical condition Hypothyroidism
Risk for low milk production Breast surgery
Risk for low milk production Risk decreases with increasing years
since surgery Depends on surgical cuts and technique Reductions – generally greater impact on
milk production
Mom’s nutrition Ask:
How’s your appetite? Finding time to eat? Are you eating anything special to support
breastfeeding? Are you avoiding any foods because you
are breastfeeding?
Note: WA WIC assessment = limited diet quality questions
Mom’s nutrition Avoiding entire food groups Extreme dieting Rapid weight loss Unhealthy diet
Mom’s nutrition Rules of thumb
Counsel toward good diet, similar to other life stages
Slow, steady weight loss > 1500 kcals/d
Common questions Q: What can I eat to increase my milk
production? A: Healthy diet with adequate protein,
whole grains, low fat dairy, lots of fruits/veg, limit excess fats/sugars. Drink to thirst. Follow internal hunger cues.
Protein, iron, iodine, n-3 fatty acids, B vitamins, calcium, zinc all have been associated with good milk production
Marasco L. Lactogenic Foods for Milk Production. Oct 2012
Lactogenic foods Foods that might help and won’t hurt
(with good breastfeeding management) Whole grains – high fiber/roughage used
in dairy industry Barley, oats, quinoa
Traditional foods – sesame seed, green papaya, chicken soup, seaweed soup, tinola soup, torbangun soup, hops, brewer’s yeast, barley water, malunggay
Common questions Q: My mother-in-law says not to eat
broccoli, beans, etc, etc. because it makes the baby gassy. Is that true?
A: Probably not, although there is evidence that undigested proteins can pass into milk and cause allergic response in baby – eczema, bloody stools, fussiness, etc. Try NOT to eliminate healthy foods. (Don’t go down that path unless it’s really indicated.)
Moving the conversation forward Respect where she is right now Don’t hold her to your ideal Success is helping her get from A to B
Even if you want her at Z Your job is to provide information and
support, NOT to be responsible for her decisions
Questions / Discussion
Breastfeeding is normal feedingBest possible, ideal, optimal, perfect. Are you the best possible parent? Is your home life ideal? Do you provide optimal meals? Of course not. Those are admirable goals, not minimum standards. Let’s rephrase. Is your parenting inadequate? Is your home life subnormal? Do you provide deficient meals? Now it hurts. You may not expect to be far above normal, but you certainly don’t want to be below normal….
--Diane Wiessinger, “Watch Your Language”
Instead of… Benefits of
breastfeeding
Formula
Planning to breastfeed or formula feed?
Try… Risks of not
breastfeeding
Artificial baby milk
Assume that she will breastfeed
Change the conversation http://www.youtube.com/watch?v=7SM7Hvjqny4
Thank you!Erica Lamson MPH, RD, [email protected]@skagitcap.org