Transcript No Cry For Help: Why Breastfeeding Support Services May
Starting Obesity Prevention in Infancy: The FitWIC Baby Behavior Project
M. Jane Heinig Jennifer Ba ñuelos Jackie Kampp Jennifer Goldbronn Luz Vera Becerra Kerri Moore
This project has been funded at least in part with Federal funds from the U.S. Department of Agriculture, Food and Nutrition Service. The contents of this publication do not necessarily reflect the view or policies of the U.S. Department of Agriculture, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government.
Results – Focus Groups (2003) “Breast is best.”
Health messages regarding breastfeeding were loud and clear “Helps them protect against viruses better, breastfeeding. It’s also very important for development of the brain and eyes.” “My mom breastfed my brothers and so that was something I wanted to do with my son because, you know, that special bond, and I feel there’s a bond and it’s healthier.” Heinig et al.
J Hum Lact
. 2006;22:27-38.
UCD Focus Groups (2003)
Many mothers reported that their infants were not satisfied when they followed guidelines We asked how could they tell?
Many of the mothers told us about their baby’s behavior Heinig et al. J Hum Lact. 2006; 22: 27-38.
UC Davis Focus Groups (2003)
Many mothers believe babies cry because of hunger (formula and cereal prevent hunger) “When I gave formula, the baby no longer cried and that is when I decided not to give him breast milk.” They think their babies will stay full longer if they are overfed “My baby used to wake up, but now I am giving him formula if he is already full and he no longer wakes up.” Heinig et al. J Hum Lact. 2006; 22: 27-38.
Results – Focus Groups (2003)
Mothers understand what is best, but many believe that their circumstances
force
them to make other choices Full, quiet, sleeping child is norm Mothers believe that health care providers/ support staff do not understand what they are experiencing “They don’t see what you’re going through. They are not there to see that you can’t do it and you keep trying. It’s like, ‘You try it.’ ” Heinig et al. J Hum Lact. 2006; 22: 27-38.
Feeding in Response to Baby Behavior
We found that mothers feel overwhelmed by crying and waking If breastfeeding, they start adding formula Add more formula, and more formula Start solid foods (cereal in the bottle) Add other foods and fluids Feed every time the baby makes noise
The Project
Study Design
3-year quasi-randomized educational intervention project (8 sites, 4 each in No. and So. Cal.) Year 1: Material development, staff training, and baseline data collection Year 2: Intervention period Year 3: Post-intervention data collection, write-up, and dissemination Concept: Create a
clinic environment
supporting positive caregiver-infant interactions Social marketing materials, staff training, handouts, classes, activities, incentives
Our Study Approach
Train staff to understand why babies behave the way they do Provide staff with tools (messages, methods, and materials) to help them feel safe and comfortable sharing baby behavior information with parents Use social marketing materials to tell parents that WIC is a place to learn about baby behavior
Handouts
Social Marketing Materials
Posters were created to advertise that new information was available Activities and games were available in the waiting areas to promote messages
All Sites Combined: WIC Food Package Selection
Increase in Excl BF Food Package Intervention = 6.3% (43% higher than baseline) Control = 2.3% Decreased formula use Reduction in cans of formula used while caseload increased 25 20 15 10 5 0
Change in EBF Food Package (0-6 mo)
Intervention Control Baseline Post
Exclusive BF Food Package by Age
30% 25% 20% 15% 10% 5% 0% 1 2 3 4 Infant Age (mo) 5 6 Intervention Control
Postpartum Participant Survey
BF with No Formula at 1 mo
35 30 25 20 15 10 5 0 * * Intervention Control English Spanish *p<0.05
Excluding those with self-reported initial medical or latch problems
Postpartum Participant Survey
Asks WIC for Advice
85% 80% * * * 75% 70% Intervention Control 65% 60% 55% 50% English Spanish *p<0.05
Postpartum Participant Survey
Likes going to WIC classes
80% * 70% 60% 50% * * 40% Intervention Control 30% 20% 10% 0% English Spanish *p<0.05
Infants >95
th
percentile wt/age
Attained weight for age > 95 th percentile 5-7 mo
20 18 16 14 12 10 8 6 10.7
14.4
4 2 0
N=339
Baseline
According to WHO growth standards NS
4.9
Post
N=411 *P<.01
Int Control
Baby Behavior at WIC and Beyond
California State WIC will use messages statewide Oregon State WIC staff has received training – looking to expand effort Presentations in AZ later this month Efforts ongoing to modify/ translate messages for Russian, Hmong, and Vietnamese populations
Opportunities for Collaboration
Efforts underway in Alameda County, Solano County, and Butte County to coordinate agencies to deliver baby behavior messages (as part of continuum of care) Hospitals Child Health and Disability Prevention Program Comprehensive Perinatal Services Program Black Infant Health Early Head Start Home Visitors Teen Parenting Programs
Supporting Informed Infant Feeding Decisions in the First 30 Days
Copyright 2009 UC Regents. All rights reserved.
“Just in Case” A Qualitative Study of Maternal Request for Hospital Formula 14 focus groups in English and Spanish (N=97) Study focused on maternal request for hospital formula for
healthy
breastfed infants Moms use formula in the hospital for many of the same reasons they use it at home
Reasons for Supplementation of Healthy Breastfed Newborns
Unrealistic expectations about newborns Lack of preparation for breastfeeding Formula seen as the only solution for breastfeeding problems Formula seen as the solution for baby behavior problems
Parents’ Unrealistic Expectations
“The imagined baby” 1 Parents’ prenatal construct of the baby Includes both hopes and fears Will be in conflict with the real baby Cultural norms have idealized the “quiet, full, sleeping” baby 2 1. Stern, Pediatrics 1998; 2. Heinig, JHL 2006
Support Strategies
Prenatally Ask moms about their expectations and address questions and concerns Gently break the bad news – parenting is tough Help moms build a support group for the first few weeks Share information about normal newborn behavior
Lack of Preparation for Breastfeeding
“She had a bottle because the milk wasn’t coming in right away.” “She was a big baby. She would wake up and need to be fed every 3 hours!” “I pumped and I got nothing.”
The Facts
Milk doesn’t come in right away 85% of mothers - milk comes in at 24-72 hours pp First time moms’ milk comes in later (avg. 70 hrs pp) than moms who have BF before (avg. 56 hrs pp) Colostrum is important too Early milk transfer to the baby varies
Early Milk Transfer to Infants Varies
900 800 700 600 500 400 300 200 100 0 1 2 3 4 5 Days Postpartum 6
Neville MC et al. Am J Clin Nutr 1988
7 8
The Facts
Newborns need to be fed very frequently Frequent feeds can help moms avoid engorgement May feed every 1-2 hours at first, varies widely Days 4 and 5 usually have the most feeds Several mothers thought that the amount pumped was equal to their production Pumps are not as effective as babies in extracting milk Colostrum can be difficult to obtain Too much early pumping can cause engorgement
Support Strategies
Make sure that moms know that their milk will come in after they leave the hospital and that it can take several days (must follow-up) Reassure them that colostrum is all newborns need Help moms to understand that babies need to eat frequently because they are so small Make sure that any mom who is pumping is properly trained and supported Limit pumping to those who need it
Breastfeeding Problems
Formula perceived as a “solution” to
breastfeeding
problems – few believed that initial difficulties could be fixed “He didn’t suck well, he rejected it right away.” “I was wondering why he didn’t want to take it. They told me as a first time mom that it was difficult to put him to breast.”
Percentage of Infants with Poor Suck
49 50 40 30 22 20 10 0 Day 1 Day 3
Dewey et al. Pediatrics 2003; 112: 607-619
.
14 Day 7
Support Strategies
Make sure that moms know half of all babies will not latch well on the first day but most babies get better quickly with practice (if not, they should call WIC) Make sure moms have resources if they have problems or questions
Behavioral Problems
Parents believed that formula would stop infant crying and promote sleep “Every time that I tried to breastfeed, he would have a tantrum, become really angry. So then I thought ‘Why? Why should I make him suffer?’” “We started the formula on the 2 never stopped crying.” nd day…since he “He wasn’t sleeping and was constantly crying and when I would get him to latch, there was nothing.”
The Facts
Newborn abilities vary widely Ability to control their bodies Range and regulation of states Social interaction skills Cues may be unreadable or conflicting When adults respond to baby cues, babies get better at using cues Sleep is erratic and light (lots of dreaming) Brazelton and many others; Poblano Int J Biol Sci 2008
Support Strategies
Help mothers understand why babies cry and wake Help them see the baby’s signs of dreaming and cues But, very important not to dismiss mothers’ concerns too quickly Some babies will be in trouble, sometimes it’s the “good” ones
Getting Back to Breastfeeding
What happens if a baby is supplemented in the hospital?
How can parents be supported to go back to exclusive breastfeeding?
After Supplementation Once babies were fed formula, some mothers believed their babies would not go back to breastfeeding “They gave him a bottle at the hospital anyway, so what did you expect?” “My thing is to continue to give him formula because that’s what he was used to and he’d take it…I kinda had to give in ‘cause I didn’t have another option.” Heinig et al.
J Hum Lact
2006;22:27-38. Heinig et al. J Hum Lact 2009
Support Strategies Don’t overemphasize “just one bottle” or “nipple confusion” Reassure moms that all babies can go back to exclusive breastfeeding with support Reassure moms that babies don’t “get used” to bottles when they are so young Half of all babies need a few days to learn to latch even if they’ve never had a bottle
After Supplementation Many mothers perceived that in-hospital supplementation represented a change in the feeding recommendation “They gave us huge bottles, but I really wanted to breastfeed.” “If the hospital uses it [formula], it must be better because they are up to par with research and everything.” Supplementation was often reported to be open ended No specific amount, no end date, no clear follow-up Heinig et al. J Hum Lact 2006;22:27-38. Heinig et al. J Hum Lact 2009.
Support Strategies Ask moms to clarify with the doctor Not a change in feeding recommendation?
How much and how long should supplements be given?
Let doctors know what you are hearing Ask them to consider “prescribing” supplementation Clear instructions of amounts, times, duration, follow-up
Parents’ Fears
Exclusive BF may seem overwhelming after supplementation Parents may fear removal of the supplement especially if there was a medical reason for the supplementation Some parents may fear removal of a supplement even if
another child
was the one with a medical problem Thomasgard M, Metz WP. J Dev Behav Pediatr. 1995;16(1):47-53. Boyce WT. Adv Pediatr. 1992;39:1-33 .
Support Strategies
Parents need a “safety net” just in case things go wrong Indicators that things are ok or not ok How will the baby look?
How will the baby behave?
Will there be obvious signs?
Phone numbers – who can they call and when are they available Action they can take until they reach you
Summary
Many moms use formula in the first 30 days because they are not prepared or informed WIC can help support mothers’ infant feeding decisions by helping them see “the door” and not feel forced to abandon their goals
The Big Picture
Baby Behavior at WIC is taught through: Social marketing materials – posters, games Counseling by trained staff Handouts Classes WIC has limited contact with a large diverse population Messages must be modified for other venues