Tope Awelewa MBCHB, MPH, IBCLC, FAAP

Temitope-awelewa@uiowa.edu

Clinical Assistant Professor of Pediatrics

University of Iowa

Iowa American Academy of Pediatrics (AAP)

Chapter Breastfeeding Coordinator

Learner Objectives

1. Understand why breastfeeding is a core component of the supplemental nutrition program for WIC

2. List indications for supplementation

3. Describe common breastfeeding problems in the first few weeks postpartum

4. Understand recommendations for preventive health care visits by the American Academy of Pediatrics (AAP)

5. Describe culturally sensitive care

Outline

• Breastfeeding and WIC

• The Infant’s feeding journey from the hospital

• Preventive care recommendations

• Providing breastfeeding care for a multicultural group of clients

Woman, Infants, and Children (WIC)

Special supplemental nutrition program to improve the health of

• low income pregnant women

• Postpartum women

• Breastfeeding (BF) mothers

• Infants and children up to the age of 5

WIC Breastfeeding Support• Breastfeeding promotion and support, priority in the Special Supplemental Nutrition Program

• Core component of nutrition services

• Mission of safeguarding health of low-income women, infants and children

• Breastfeeding rates improving among WIC participants nationwide

WIC breastfeeding data local agency report. Accessed https://www.fns.usda.gov/wic/wic-breastfeeding-data-local-agency-report

AAP Breastfeeding Recommendation

Exclusive breastfeeding (EBF)

for the first 6 months of life

Continue for at least the

first year of life, with

addition of solids

Thereafter, for as

long as mutually

desired by mother and child

Photo © Mary Boyd, MD, FAAP

AAP Pediatrics 2012;129;e827-41

Maternal Benefits

• Emotional bonding

• Rapid uterine involution

• Child spacing

• Lower rheumatoid arthritis

• Reduces obesity

• Reduced cardiovascular

disease risk

Picture from CDC breastfeeding website page

Maternal benefits

• Lowers risk of Type 2 diabetes mellitus • 4-12% less for each year of BF

• Reduces breast cancer risk • 4.3-28% less for each BF year

• Ovarian cancer 21% less for any BF vs. none

• Postpartum depression less for short term BF

Ip S et al: Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries, April 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/tp/brfouttp.htm

Infant Benefits

• Lower risk of leukemia, asthma

• Reduces risk of diabetes and childhood obesity

• Lower risk of Sudden Infant Death Syndrome

• Lower risk of necrotizing enterocolitis and diarrhea

• Reduced visits for ear and respiratory infections

Infant benefits vs. BF duration and exclusivity

• Acute otitis media 50% less with EBF 3-6 months

• Atopic dermatitis 42% less with EBF > 3 months

• Gastroenteritis 64% less with any breastfeeding

• Lower respiratory tract disease and hospitalization 72% less with EBF > 4 months

• Asthma 40% less with EBF > 3 months with positive family history

Ip S, Chung M, Raman G, et al. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Rockville, MD: Agency for Healthcare Research and Quality, 2007. http://www.ahrq.gov/clinic/tp/brfouttp.htmAAP Pediatrics 2012;129;e827-41

Benefits vs. Breastfeeding duration

Obesity 24% less with any BF Type 1 DM 30% less with BF > 3 months Type 2 DM 40% less with any BF vs. None Acute lymphocytic leukemia 20% less with BF >6 months

Acute myelogenous leukemia 15% less with BF >6 months

SIDS 36% less with any BF > 1 month

Ip S, Chung M, Raman G, et al. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Rockville, MD: Agency for Healthcare Research and Quality, 2007. http://www.ahrq.gov/clinic/tp/brfouttp.htmAAP Pediatrics 2012;129;e827-41.

Source: National Immunization Survey, Centers for Disease Control and Prevention, Department of Health and Human Services

0

10

20

30

40

50

60

70

80

90

Ever Breastfed Breastfed at 6 Months Breastfed at 12 Months

Pe

rce

nt

bre

astf

ed

Rates of any Breastfeeding by race among children born in 2014

Hispanic

Non-Hispanic White

Non-Hispanic Black

Non-Hispanic Asian

Non-HispanicHawaiian/PacificIslander

Non-Hispanic AmericanIndian/Alaska Native

Burden of Suboptimal Breastfeeding in the US

If 90% of US families could comply with medical recommendations to breastfeed exclusively for 6 months, the United States would save $13 billion per year and prevent an excess 911 deaths, nearly all of which would be in infants ($10.5 billion and 741 deaths at 80% compliance)

Bartick M, Reinhold A. The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis. Pediatrics. 2010;125:e1048.

Healthy People 2020

Healthy People Maternal, Infant, and Child Health 2020 Objectives:

http://www.healthypeople.gov/2020/topicsobjectives2020/objectives

Breastfeeding Initiation in Iowa

https://idph.iowa.gov/portals/1/Images/WIC/BF%20Rates.gif

BF Trend/WIC/Healthy People

WIC breastfeeding data local agency report. Accessed https://www.fns.usda.gov/wic/wic-breastfeeding-data-local-agency-report

30.9

12.9

31.7

13.2

26.9

7.7

27.5

11

81.9

46.2

0

10

20

30

40

50

60

70

80

90

Ever breastfed Exclusive BF

Percentage of Infants breastfed

WIC BF 2015

WIC BF 2016

IA WIC 2015

IA WIC 2016

Healthy people 2020 goal

Healthy People 2020 Objectives

• Increase the proportion of mothers who breastfeed their babies.

• Decrease the percentage of breast-fed newborns who receive formula supplementation within the first 2 days of life.

• Increase the percentage of live births that occur in facilities that provide recommended care for lactating mothers and their babies.

Contraindications to Breastfeeding

Infant with classic form of galactosemia

Maternal HIV, HTLV-I, HTLV-II in U.S.

Herpes simplex lesions (active) of breast

Mothers with active, untreated tuberculosis

Mothers receiving antimetabolite or chemotherapeutic agents

Mothers with active radioisotopes

Incompatible medications (rare)

Drugs and Lactation Database (LACTMED) (http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT American Academy of Pediatrics. Pickering LK (ed). Red Book: Report of the Committee on Infectious

Diseases, 28th ed., 2009.

Infant indications for supplementation

1. Hypoglycemia with breastfeeding

40% dextrose gel

2. Inadequate milk intake:

significant dehydration (poor feeding, lethargy)

Weight loss greater than 10% (day 5 or later)

weight loss greater than 75th percentile for age

Delayed bowel movements, meconium on day 5

Prematurity

Infant indications for supplementation

3. Jaundice Suboptimal breastfeeding begins 2–5 days, ongoing weight loss, limited stooling and voiding

Breast milk jaundice (20–25 mg/dL) for diagnostic and/or therapeutic interruption

4. Inborn errors of metabolism requiring macronutrient supplementation

ABM Clinical Protocol #3:Supplementary Feedings in the Healthy. Term Breastfed Neonate, Revised 2017. Ann Kellams, Cadey Harrel, Stephanie Omage, Carrie Gregory, Casey Rosen-Carole, and the Academy of Breastfeeding Medicine

Maternal Indications for supplementation

• Delayed secretory activation (day 3–5)

• Primary glandular insufficiency (less than 5% of women with lactation failure)

abnormal breast shape or growth during pregnancy

• Poor milk production with breast surgery

• Temporary separation of mother and baby without expressed breast milk available

• Excessive pain during feedings not resolved with interventions

Maternal Medications

• Commonly used medications are

compatible with breastfeeding

• Temporary cessation of

breastfeeding - chemotherapy

• Consider Risk-Benefit ratio

• Medication use in pregnancy vs.

medication use in lactation

Drugs and Lactation Database (LACTMED) (http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT)Hale T. Medications and Mothers’ Milk 2010, 14th ed.. http://www.ibreastfeeding.com/AAP breastfeeding toolkit slide

Newborn period in the Hospital

• Nursery admission for 2 to 3 days

• Neonatal intensive care admission

• Newborn exam, weight and Bilirubin check

• Breastfeeding, formula feeding, intravenous hydration

• Newborn hearing screen

• Newborn screening labs

• Critical congenital heart disease screening

Newborn Visit D3-5

• Parental plan for feeding

• Consider potential breastfeeding barriers

• Is breastfeeding going on well?

• Is baby gaining weight adequately?

• Is baby voiding well?

at least one wet diaper per day of life until day 6

• What is the stooling pattern and color?

Vitamin Supplementation

• Infants needing vitamin/Iron supplementation

Exclusively BF infant need 400 I.U of Vit. D daily by 2 weeks of age

Exclusively BF full term : Iron supplementation from 4 months before starting solids

Premature infants need Iron supplementation by 1 month of age

• Formula fed babies do not need vitamin supplementation

Pediatrician’s office in the first year

Immunization schedule

Newborn and hearing screen

Anemia and lead screening

How often do we follow up?

Developmental Screening

• Developmental surveillance

• Developmental screening

at 9, 18 and 30 months

• Autism screening at

18 and 24 months

Developmental Milestones

• Parents can track child’s milestones from age 2 months to 5 years with CDC’s checklists

Tips for encouraging child’s development

Find out what to do if you are ever concerned about how your child is developing

Download the app from the App Store or Google Play (search “CDC’s Milestone Tracker”) and learn more about the app at www.cdc.gov/MilestoneTracker

Infant and toddler feeding

Discontinue Bottle by 18 months of age

No bottle to bed by 12 months of age

Dairy (whole milk, breast milk, formula, yogurt, cheese): 16-20oz/day, max 24oz/day

3 meals with 1-2 scheduled snacks

Eats and drinks in chair for scheduled meals

Meals should be no more than 30 minutes

What does AAP say abut juice intake?

The American Academy of Pediatrics (AAP)recommends infants and children should be given milk or water instead of 100% fruit juice

If juice is given it is recommended to limit consumption to 4-6 ounces per day

Sugary drinks consumptionamong WIC participants

Methods: Data obtained through ReadNPlay for a Bright Future, a program advocating for healthy active living among families with young children

RESULTS: Up to 66% of mothers reported consuming at least one sugary drink daily, while 27.1% reported consuming 3 or more daily. About 69% of the total sample (n=226) was enrolled in WIC. Mothers reported infants consumed an average of 4.6 ounces of sugary drinks daily (range 1-15 ounces)

Juice Consumption Among Children Aged 9 to 24 Months Participating in Women, Infants, and Children (wic) Program. Alyssa Lovelace, Karen E. Schetzina, Gayatri Jaishankar. Pediatrics Jan 2018, 141 (1 MeetingAbstract) 587; DOI: 10.1542/peds.141.1_MeetingAbstract.587

WIC food package and diet quality

Methods: A total of 1197 children aged 2 to 4 years from low-income households were studied from before and after the policy implementation (using the 2003–2008 and 2011–2012 National Health and Nutrition Examination Survey. Healthy Eating Index–2010 (HEI-2010) was calculated using two 24-hour diet recalls

RESULTS: WIC food package revisions were associated with an adjusted average of 3.7 increased HEI-2010 points (95% CI, 0.6–6.9) for WIC participants compared with nonparticipants

Revised WIC Food Package and Children’s Diet Quality. June M. Tester, Cindy W. Leung, Patricia B. Crawford. Pediatrics May 2016, 137 (5) e20153557; DOI: 10.1542/peds.2015-3557

Common breastfeeding problems encountered in the

pediatrician’s office

Engorgement:

wet warm compress before feeding for 5 mins and cold compresses after feeding for 10-20mins

usually resolves in 24 hours. Signs of infection

Poor latch and nipple pain:

demonstrate good latch and correct positioning

protect sore nipples, triple base ointment

Poor milk supply and jaundice:

assess milk supply and weight gain

frequent feeds and pumping if supplementing

Case study 1• Alex is a 7-month-old boy brought in by his mother • His weight plotted on the CDC Growth Chart decreased from 85th percentile at 4 months to the 15th percentile

• He was born full term after a vaginal delivery, exclusively breastfed, with introduction of solid foods at around 5 months

• She is able to pump while at work. He has started solid food and has no feeding difficulties

• Mother’s Concerns: She has become concerned due to the attention being paid to her son’s weight. She would like to know what supplements either she or her son should be taking

• What advice would you give this mother?

Adapted from AAP Breastfeeding residency curriculum

Growth curve assessments

• Weight

• Length

• Weight for

length

• BMI

• Head size

Case study 2 Eric is a 3-day-old exclusively breastfed boy, born full term. He has been feeding every 3 hours. His last stool about 18 hours ago, was tarry

A transcutaneous bilirubin measurement at 24 hours places the baby at high risk jaundice level

The dyad had some problems with correct positioning and latch and once corrected, the baby’s stool output increased.

Mother’s concerns: Her nipples are cracked and bleeding. Her breasts are soft and it doesn’t seem as though her milk has “come in” yet. The baby does not seem as alert as she was the day before

What factors may be contributing to the baby’s jaundice?

Case study 3

• Kate, a 24-year-old new mother is in clinic for concerns about low milk supply

• The 7-week-old baby had gained weight well until the last 2 weeks when the mother noticed less wet diapers and a decrease in pumped breast milk

• A pre- and post-feeding weights showed low transfer of milk

• Her son now has a coordinated suck and swallow, however with asymmetric latch

• Mother’s concerns: The baby never seems satisfied unless he is breastfeeding. Her in-laws, who recently arrived to help with the baby, have encouraged her to stop breastfeeding

• What factors might influence breastfeeding? How might you counsel this mother?

Breastfeeding and racial disparities

• Breastfeeding rates are up but racial disparities exist

• Up to 15 percentage points difference between non-hispanic black and non-hispanicwhite infants in exclusive breastfeeding rates through 6 months

Anstey EH, Chen J, Elam-Evans LD, Perrine CG. Racial and Geographic Differences in

Breastfeeding — United States, 2011–2015. MMWR Morb Mortal Wkly Rep 2017;66:723–727. DOI:

http://dx.doi.org/10.15585/mmwr.mm6627a3

Source: National Immunization Survey, Centers for Disease Control and Prevention, Department of Health and Human Services

0

10

20

30

40

50

60

70

80

90

Ever Breastfed Breastfed at 6 Months Breastfed at 12 Months

Pe

rce

nt

bre

astf

ed

Rates of any Breastfeeding by race among children born in 2014

Hispanic

Non-Hispanic White

Non-Hispanic Black

Non-Hispanic Asian

Non-HispanicHawaiian/PacificIslander

Non-Hispanic AmericanIndian/Alaska Native

Cultural sensitivity in breastfeeding care

• WIC participant data for 2014

Blacks or African Americans constitute about 20.3 percent

American Indians or Alaskan Natives: 11.1 percent

Asian or Pacific Islanders : 4.1 percent

About 5.4 percent of WIC participants reported two or more races

Ethnicity data show Hispanics made up 41.6 percent of WIC participants

58.7 percent reported as white only

WIC Participant and Program Characteristics 2014. Final report. https://fns-prod.azureedge.net/sites/default/files/ops/WICPC2014-Summary.pdf

Five components of cultural competency

Cross cultural awareness

Cultural knowledge

Cultural skill

Cultural encounters

Cultural desire

Cultural awareness

• Sensitization of self to personal biases and prejudices recognizing effect on cross-cultural interactions

• Acknowledging and understanding differences vs. harmful practices

Campenha-Bacote, 1994

Cultural Knowledge

• Process of gathering more information about the belief system of clients

How different cultures and beliefs impact breastfeeding attitudes and practices

Complexity of culture

Culture

Ethnicity

Race

Nationality

Age

EducationGeneration

Location

Language

Religion

Socioeconomic status

Cultural Skill

• The process of carrying out a cultural assessment while avoiding being judgmental and stereotypical assumptions

Awareness of cultures of clients

Awareness of language and support services

Identify easy to understand messages

print, video, graphic, “easy-to-read”

Cultural desire

• Motivation to engage in the process of building cultural competence

Willingness to be open to others

Accept and respect differences

Willingness to learn from others

LEARN Model Cross cultural communication

Berlin E, Fowkes, WA. A teaching framework for cross-cultural health care. Western Journal of Medicine 1983;139:934–938. Available from: http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1011028&blobtype=pdf

Listen with empathy and understanding to parental perception of problem

Explain your perceptions of the problem

Acknowledge and discuss differences and similarities

Recommend plan

Negotiate plan

How can we help? Improve communication between physicians and the WIC office

Inform mothers of breastfeeding benefits

Provide disincentives to mothers to discourage supplementation

Provide incentives for exclusively breastfeeding mothers in the WIC program

Provide culturally appropriate care

Summary

• Breastfeeding is the preferred feeding

method

• Breastfeeding should be actively

supported and promoted by WIC programs

• Inform mothers of breastfeeding benefits

• Supplementation can mitigate successful

lactation

• Know indications for supplementation

• Understand perceived low supply vs

inadequate supply

References1. Breastfeeding and the Use of Human Milk Pediatrics Mar 2012, 129 (3) e827-e841; DOI:

10.1542/peds.2011-3552

2. AAP breastfeeding section resource kit

3. Juice Consumption Among Children Aged 9 to 24 Months Participating in Women, Infants, and Children (wic) Program

4. Alyssa Lovelace, Karen E. Schetzina, Gayatri Jaishankar. Pediatrics Jan 2018, 141 (1 MeetingAbstract) 587; DOI: 10.1542/peds.141.1_MeetingAbstract.587

5. Revised WIC Food Package and Children’s Diet Quality. June M. Tester, Cindy W. Leung, Patricia B. Crawford. Pediatrics May 2016, 137 (5) e20153557; DOI: 10.1542/peds.2015-3557

6. Anstey EH, Chen J, Elam-Evans LD, Perrine CG. Racial and Geographic Differences in Breastfeeding — United States, 2011–2015. MMWR Morb Mortal Wkly Rep 2017;66:723–727. DOI: http://dx.doi.org/10.15585/mmwr.mm6627a3

7. National Immunization Survey, Centers for Disease Control and Prevention, Department of Health and Human Services

8. Berlin E, Fowkes, WA. A teaching framework for cross-cultural health care. Western Journal of Medicine 1983;139:934–938. Available from: http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1011028&blobtype=pdf

References

9. Campinha-Bacote, J. (2003). The process of cultural competence in the delivery of healthcare services: A culturally competent model of care (4th ed.). Cincinnati, OH: Transcultural C.A.R.E. Associates.

10.Bartick M, Reinhold A. The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis. Pediatrics. 2010;125:e1048.

11.ABM Clinical Protocol #3:Supplementary Feedings in the Healthy. Term Breastfed Neonate, Revised 2017. Ann Kellams, Cadey Harrel, Stephanie Omage, Carrie Gregory, Casey Rosen-Carole, and the Academy of Breastfeeding Medicine

12.National Immunization Survey, Centers for Disease Control and Prevention, Department of Health and Human Services

13.WIC breastfeeding data local agency report. Accessed https://www.fns.usda.gov/wic/wic-breastfeeding-data-local-agency-report

14.WIC Participant and Program Characteristics 2014. Final report. https://fns-prod.azureedge.net/sites/default/files/ops/WICPC2014-Summary.pdf

Thank you!