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