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, IBCLCelamson@uw.eduerical@skagitcap.org