Breastfeeding Support in WIC

1. Breastfeeding Support in WIC Erica Lamson MPH, RD, IBCLC Nutrition 526 November 2012

2. 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

3. About you… • Name • Program of study • Any personal experiences with breastfeeding?

4. 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.

5. 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

6. 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

7. WIC breastfeeding support • Prenatal breastfeeding classes • One-on-one breastfeeding education • Postnatal breastfeeding support groups

8. WIC breastfeeding support • 2009 food package changes • Biggest food package for fully breastfeeding moms • No formula issuance in first month for breastfed babies

9. 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

10. 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 coordinator January 2012

11. What is the effect?

12. What is the effect?

13. 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

14. 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?

15. 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 ClinNutr 2012;96:560-6.

16. 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

17. Questions / Discussion

18. Assessment in WIC • Anthropometric • Weight/height • Biochemical • Hemoglobin • Dietary • Psychosocial

19. 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

20. 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

21. Breastfeeding Woman Assessment Questions • How are you and the baby doing? • How is breastfeeding going? • In this or any previous pregnancy, did you have any health or medical concerns, such as gestational diabetes and/or preeclampsia? • How many times have you been pregnant in the past two years? • Have you had any recent surgeries, such as a c-section? • Do you have any health problems or medical conditions? • Are you taking any medications? • What vitamins or other dietary supplements do you take? • Do you have any problems with your teeth or gums that affect how you eat? • How has your appetite been? Are there foods you avoid for any reason, including food allergies? • Do you eat things such as ice, dirt, clay, paint chips, or starch? • Do you smoke? • Does anyone smoke inside your home? • When was the last time you drank alcohol? • When was the last time you used drugs? • Have you felt sad or depressed recently? • Is there anyone in your life who is hurting you or your child(ren)?

22. 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

23. 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

24. Baby behavior Assessment of the mother/baby dyad in WIC Mom’s Health/ Nutrition Labor Weight Interpersonal Length of Gestation Latch

25. 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 wkold)?

26. 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

27. For newborns • Breastfeeding needs a close look if 7% or greater wtloss • 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

28. 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

29. Rules of breastfeeding management • Feed the baby • Protect mom’s milk production • Fix the problem

31. 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

32. 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

33. http://www.ilca.org/files/resources/HealthCareProviders/Galactogogue%20Dosage%20&%20Reference%20Table%20V2.pdfhttp://www.ilca.org/files/resources/HealthCareProviders/Galactogogue%20Dosage%20&%20Reference%20Table%20V2.pdf

34. http://www.ilca.org/files/resources/HealthCareProviders/Galactogogue%20Dosage%20&%20Reference%20Table%20V2.pdfhttp://www.ilca.org/files/resources/HealthCareProviders/Galactogogue%20Dosage%20&%20Reference%20Table%20V2.pdf

35. http://www.ilca.org/files/resources/HealthCareProviders/Galactogogue%20Dosage%20&%20Reference%20Table%20V2.pdfhttp://www.ilca.org/files/resources/HealthCareProviders/Galactogogue%20Dosage%20&%20Reference%20Table%20V2.pdf

36. Other info/references • http://lowmilksupply.org/ • http://www.breastfeedinginc.ca • http://kellymom.com/

37. Labor • Ask: • How was your labor? (Usually, story follows freely.) • Very long, difficult labors • Pain medication (epidural, fentanyl, etc) • C-section

38. 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

39. 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.”

40. Beware the “good” baby Poor Feeding Jaundice Sleepiness

41. 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

42. CA Baby Behavior Campaignhttp://www.cdph.ca.gov/programs/wicworks/Pages/WICCaliforniaBabyBehaviorCampaign.aspx

43. 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

44. Lots of ways to achieve latch

45. 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.

46. Length of gestation • Ask: • Was your baby born on his due date? Early? Late? • Premature (<37 wks) • Late preterm – (35-39 wks)

47. <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

48. 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

49. 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?

50. 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?”