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Title: Breastfeeding%20


1
Breastfeeding Public Health 2008
2
Functions of Public Health
  • Assessment
  • Policy Development
  • Assurance

3
Levels of Influence in the Social-Ecological Model
Structures, Policies, Systems Local, state,
federal policies and laws to regulate/support
healthy actions
Institutions Rules, regulations, policies
informal structures
Community Social Networks, Norms, Standards
Interpersonal Family, peers, social networks,
associations
Individual Knowledge, attitudes, beliefs
4
Objectives
  • Students will be able to
  • Identify advantages to increasing breastfeeding
    rates in the population
  • List 2010 Healthy People goals for breastfeeding
  • Access population-based breastfeeding data and
    describe patterns of breastfeeding in the US
  • Apply evidence-based approaches to improve
    breastfeeding rates
  • Use knowledge about the physiology of
    breastfeeding to advocate for policies that
    support breastfeeding

5
Benefits of Breastfeeding
  • Health outcomes
  • Infant short term
  • Infant long term
  • Maternal
  • Economic
  • Environmental

6
Breastfeeding and the Use of Human MilkAmerican
Academy of Pediatrics, 2005
  • Human milk is species-specific, and all
    substitute feeding preparations differ markedly
    from it, making human milk uniquely superior for
    infant feeding.

7
Health Benefits for Infant AAP
  • Lowered risk of infectious diseases in both
    developed and developing countries diarrhea,
    respiratory tract infection, otitis media,
    bacterial meningitis, botulism, UTI, necrotizing
    enterocolitis, bacteremia
  • Enhanced immune response to polio, tetanus,
    diptheria, haemophilus influenza immunization
  • Possible lowered risk of sudden infant death
    syndrome
  • Possible lowered risk of diabetes (type 1
    2),leukemia, Hodgkin disease, lymphoma
  • Probable enhanced cognitive development
  • Provides analgesia to infants during painful
    procedures

8
Health Benefits for Mother AAP
  • Possible reduction in hip fractures after
    menopause
  • Less postpartum bleeding more rapid uterine
    involution
  • Reduced risk of breast and uterine cancer
  • Increased child spacing

9
Breastfeeding and Maternal and Infant Health
Outcomes in Developed Countries (Agency for
Healthcare Research and Quality, 2007)
  • Systematic reviews/meta-analyses, randomized and
    non-randomized comparative trials, prospective
    cohort, and case-control studies on the effects
    of breastfeeding
  • English language
  • Studies must have a comparative arm of formula
    feeding or different durations of breastfeeding.
    Only studies conducted in developed countries
    were included in the updates of previous
    systematic reviews.
  • Studies graded for methodological quality.

10
Limitations of Breastfeeding Outcome Studies
  • Definitions of breastfeeding misclassification
  • Lack of randomization confounding residual
    confounding
  • Wide range in quality of evidence

11
AHRQ Positive Findings for Infants
less in BF
Acute otitis media (exclusive BF 3-6 mos.) 50
Atopic dermatitis (exclusive BF 3 mos) 42
GI infection (infants breastfeeding) 64
Lower respiratory tract diseases 72
Asthma (in young children) no family hx, family hx 27, 40
Obesity 4, 7, 24
Type I diabetes 19, 27
Type 2 diabetes 39
Childhood leukemia 15, 19
Sudden Infant Death Syndrome 36
Necrotizing enterocolitis 4-82
12
AHRQ Equivocal or insignificant infant outcomes
  • Cognitive development in term or preterm infants
  • CVD
  • Infant mortality in developed countries

13
AHRQ Positive Maternal Outcomes
less in BF
Maternal Type II Diabetes (reduction in risk per year of lactation) 4, 12
Postpartum depression association
Breast cancer (reduction per year of lactation) 4.3, 28
Ovarian cancer 21
14
AHRQ Equivocal or insignificant maternal
outcomes
  • Effect of breastfeeding in mothers on
    return-to-pre-pregnancy weight was negligible
  • Effect of breastfeeding on postpartum weight loss
    was unclear
  • Little or no evidence for association with
    osteoporosis

15
Breastfeeding and Obesity Reviews Meta-analysis
  • Owen et al. Pediatrics. 2005
  • 61 studies
  • Odds ratio 0.87 (95 CI 0.85-0.89) for reduced
    risk of later obesity associated with
    breastfeeding compared to formula
  • Arenz et al. Int J obes relat metab disord. 2004
  • 9 studies met criteria
  • Odds Ratio 0.78, 95 CI (0.71, 0.85) protective
    effect of breastfeeding for obesity
  • Found dose response
  • Harder et al. Am J Epidemiol. 2005

16
Breastfeeding and risk of obesity
Does Breastfeeding Reduce the Risk of Pediatric
Overweight? CDC. 2007
17
Harder et al. Am J Epidemiol. 2005 (17 studies)
Length of Breastfeeding Odds Ratio for Risk of Obesity 95 CI
lt 1 1.00 0.65, 1.55
1-3 0.81 0.74, 0.88
4-6 0.76 0.67, 0.86
7-9 0.67 0.55, 0.82
9 0.68 0.50, 0.91
18
Breastfeeding Obesity Support for the Evidence
  • Secular trends
  • Trend for increased breastfeeding is opposite
    that for obesity
  • Dose Response
  • Some studies find, others do not
  • Plausible mechanisms
  • Changes in leptin production and sensitivity
  • Lower energy and protein intake in breastfed
    infants
  • Insulin response to feeding higher in formula
    fed infants
  • Differences in the feeding relationship
    self-regulation of energy intake
  • Changing composition of human milk during
    feedings

19
Dubois et al. Public Health Nutrition, 2003
  • Social inequalities in infant feeding during the
    first year of life. The Longitudinal Study of
    Child Development in Quebec (LSCDQ 1998-2002)
  • Social disparities in diet during infancy could
    play a role in the development of social and
    health inequalities more broadly observed at the
    population level.

20
Economic Costs of Formula Feeding(US
Breastfeeding Committee)
  • Families 2,000 for the first year
  • Employers loss of productivity, increased
    absence, more health claims
  • Health care 3.6 billion a year to treat infant
    illnesses, 331-475 per child for one HMO
  • Food assistance costs to support breastfeeding
    mothers in WIC are 55 the cost for providing
    formula

21
Environmental Benefits of Breastfeeding(ADA
Position Paper, 2005)
  • Human milk is a renewable natural resource.
  • Produced and delivered to the consumer directly
  • Formula requires manufacturing, packaging,
    shipping, disposing of containers
  • 550 million formula cans in landfills each year
  • 110 billion BTUs of energy to process and
    transport
  • Breastfeeding delays return of menses, increases
    birth spacing, limits population growth

USBC
22
Barriers to Breastfeeding (ADA Position Paper
2005)
  • Individual Inadequate knowledge, embarrassment,
    social reticence, negative perceptions
  • Interpersonal Lack of support from partner and
    family, perceived threat to father-child bond
  • Institutional Return to work or school, lack of
    workplace facilities, unsupportive health care
    environments
  • Community discomfort about nursing in public
  • Policy aggressive marketing by formula companies

23
Moses Lake Breastfeeding Data
24
Moses Lake Resident Survey (N 254)
Statements about the Community Agree Disagree
Babies in our community are more likely to be bottle-fed first 6 months 55.1 28.3
It is not customary to breastfeed a baby in public 61.0 26.4
Brzezney A. Unpublished Data (2003)
25
Moses Lake Resident Survey (N 254)
Statements about Worksites Agree Disagree
Workplaces in our community make it easier for mother to bottle-feed 61.4 21.3
Workplaces in our community make it easier for mother to breastfeed 8.7 67.3
(Barrier) Mothers dont want to breastfeedmothers must return to work 87.8 3.5
Brzezney A. Unpublished Data (2003)
26
Moses Lake Resident Survey (N 254)
Statements about Childcare Agree Disagree
(Barrier) Mothers dont want to breastfeedbaby starts attending day care 71.7 14.2
Brzezney A. Unpublished Data (2003)
27
Assessment
  • Rates of Breastfeeding and Exclusive Breastfeeding

28
(No Transcript)
29
Percent of U.S. children who were breastfed, by
birth year
Breastfeeding Among U.S. Children Born
19992005, CDC National Immunization Survey
30
The resurgence of breastfeeding at the end of the
second millennium (Wright and Schanler, J Nutr.
131, 2001)
  • Between 1971 and 1995 increase was for all
    groups.
  • Between 1984 and 1995 increase was in groups less
    likely to breastfeed (low income, low education,
    African American, WIC)
  • Early resurgence of breastfeeding concurrent to
    natural childbirth and womens movement in
    white well educated families

31
More recent increases associated with
  • Increased knowledge of the benefits of
    breastfeeding by professionals (AAP 1997)
  • Successful breastfeeding interventions -
    especially in WIC
  • 47 of US infants on WIC
  • early 90s brought increased WIC for
    breastfeeding promotion and increased maternal
    food package for BF

32
Healthy People Goals and Breastfeeding Data
33
National Immunization Survey
  • Random-digit--dialed telephone survey conducted
    annually by CDC
  • Nationally representative data
  • Breastfeeding questions first added in 2001
  • Data organized by birth cohort, not year of data
    gathering
  • 2004 data from 17,654 infants

34
Healthy People 2010 Increase the proportion of
mothers who breastfeed their babies
Goal US Base-line US 2004 WA 2004 WA 2005
Early post-partum 75 64 74 88 90
At 6 months 50 25 42 57 57
At one year 25 16 21 32 33
35
Does Breastfeeding Reduce the Risk of Pediatric
Overweight? CDC. 2007
36
Demographics of Breastfeeding (NIS 2004)
37
Percent of Children Ever Breastfed by State among
Children Born in 2004
National Immunization Survey, Centers for Disease
Control and Prevention, Department of Health and
Human Services
38
Percent of Children Ever Breastfed by State among
Children Born in 2005
39
Percent of Children Breastfed at 6 Months of Age
by State among Children Born in 2004
National Immunization Survey, Centers for Disease
Control and Prevention, Department of Health and
Human Services
40
Percent of Children Breastfed at 6 Months of Age
by State among Children Born in 2005
41
Percent of Children Breastfed at 12 Months of Age
by State among Children Born in 2004
National Immunization Survey, Centers for Disease
Control and Prevention, Department of Health and
Human Services
42
Percent of Children Breastfed at 12 Months of Age
by State among Children Born in 2005
43
New 2010 Breastfeeding Objectives added in 2007
  • To increase the proportion of mothers who
    exclusively breastfeed their infants through age
    3 months to 60
  • To increase the proportion of mothers who
    exclusively breastfeed their infants through age
    6 months to 25

44
Exclusive breastfeeding definition
  • Exclusive breastfeeding is defined as an infant
    receiving only breast milk and no other liquids
    or solids except for drops or syrups consisting
    of vitamins, minerals, or medicines

45
Exclusive Breastfeeding
US 2004 US 2005 WA 2004 WA 2005
Through 3 months 31 36 50 45
Through 6 months 11 12 23 21
National Immunization Survey, Centers for Disease
Control and Prevention, Department of Health and
Human Services
46
Rates of Exclusive Breastfeeding at 3 months
(NIS, 2004)
Maternal Education
Less than high school 24
High school 23
Some college 33
College graduate 42
Income/poverty ratio
lt 100 24
100 - 184 29
185 - 340 34
gt350 39
47
Rates of Exclusive Breastfeeding at 3 months
(NIS, 2004)
Education
Hispanic 31
White, non-Hispanic 33
Black, non-Hispanic 20
Asian, non-Hispanic 31
Other
Mothers age at birth of child
lt 20 17
20-29 26
gt 30 35
48
Percent of Children Exclusively Breastfed Through
3 Months of Age among Children born in 2004
National Immunization Survey, Centers for Disease
Control and Prevention, Department of Health and
Human Services
49
Percent of Children Exclusively Breastfed Through
3 Months of Age among Children born in 2005
(Provisional)
50
Percent of Children Exclusively Breastfed Through
6 Months of Age among Children Born in 2004
National Immunization Survey, Centers for Disease
Control and Prevention, Department of Health and
Human Services
51
Percent of Children Exclusively Breastfed Through
6 Months of Age among Children Born in 2005
52
AssuranceEvidence-Based Interventions
  • The CDC Guide to Breastfeeding Interventions, 2005

53
Six evidence-based interventions
  • Individual
  • Educating mothers
  • Professional support
  • Intrapersonal
  • Peer support/counseling programs
  • Institutional
  • Maternity care practices
  • Media and social marketing

54
Four Interventions Effectiveness not
established, encourage rigorous evaluation
  1. Use contermarketing techniques to limit the
    negative impact of formula marketing
  2. Improve the knowledge, skills and attitudes of
    health care providers re breastfeeding
  3. Increase public acceptance of breastfeeding
  4. Provide assistance to breastfeeding mothers
    through hotlines or other information sources

55
Policies to Support Breastfeeding
  • Key policy documents
  • Worksites
  • Healthcare
  • Legislation

56
Breastfeeding Policy Documents
1984   U.S. Surgeon Generals Workshop
1990   Innocenti Declaration, WHO and UNICEF
2000   Healthy People 2010 Objectives
2000   HHS Blueprint for Action on Breastfeeding
2001 US Breastfeeding Committee Strategic Plan
2003 WHO Global Strategy for Infant and Young Child Feeding
2003 WA State Nutrition Physical Activity Plan
57
Key Policy Documents Worksites
Global Strategy for Infant Young Child Feeding WHO/ UNICEF (2003) Innocenti Declaration WHO/ UNICEF (1990)
Women in paid employment can be helped to continue breastfeeding by bring provided with minimal enabling conditions. paid maternity leave, part- time work arrangements, onsite crèches, facilities for expressing and storing breastmilk and breastfeeding breaks. obstacles to breastfeeding within theworkplace must be eliminated
58
HHS Blueprint Worksites
  1. Facilitate breastfeeding or breastmilk
    expression at the workplace by providing private
    rooms, commercial grade breastpumps, milk storage
    arrangements, adequate breaks during the day,
    flexible work schedules and onsite childcare
    facilities.
  2. Establish family and community programs that
    enable breastfeeding continuation when women
    return to work in all possible settings.
  3. Encourage childcare facilities to provide
    quality breastfeeding support.

59
CDC Healthstyle Survey 2006 (Nationally
representative postal survey N5000)
Agree Neither agree/ Disagree Disagree
I believe employers should provide flexible work schedules, such as additional break time, for breastfeeding mothers 51 32 18
I believe employers should provide extended maternity leave to make it easier for mothers to breastfeed. 49 31 19
60
Healthstyle Survey, cont.
Agree Neither agree/ Disagree Disagree
I believe employers should provide a private room for breastfeeding mothers to pump their milk at work. 47 29 24
I would support tax incentives for employers who make special accommodations to make it easier for mothers to breastfeed. 30 34 36
61
WA Healthy Worksite Survey
  • Content Measures policies, environments to
    support healthy nutrition, physical activity,
    breastfeeding and to discourage tobacco use.
  • Population WA businesses with 50 employees,
    selected from WA Department of Employment
    Security.
  • Sampling Representative geographic sample across
    WA. 900 contacted, 540 responded.
  • Administration Fall 2005. 15 minute phone survey
    of HR managers, conducted by Gilmore. Repeat in
    2007.
  • Background DOH STEPS/CDNPA/Tobacco collaboration

62
Of the 400 Businesses with Female Employees lt age
of 50
  • 11 had a specific policy to support
    breastfeeding
  • 82 provided flexible scheduling to allow
    employees adequate break time to breastfeed or
    pump/express breast milk
  • 31 had a designated room or location (not
    counting bathroom stalls) for mothers to
    breastfeed or pump/express breast milk

63
Characteristics of Breastfeeding Rooms
64
Key Policy Documents Childcare
HHS Blueprint for Action (2000) WA State Nutrition Physical Activity Plan (2003)
Safe storage Follow mothers instructions Provide quiet and comfortable place for mothers Assure thatchild care facilities are breastfeeding friendly. Follow guidelines of Breastfeeding coalition of Washington.
65
Key Policy Documents Health Care
Global Strategy for Infant Young Child Feeding WHO/ UNICEF (2003) WA State Nutrition Physical Activity Plan (2003)
Virtually all mothers can breastfeed provided they have accurate information, and support within their families and communities and from the health care system. They should also have access to skilled practical help from, for example, trained health workers, lay and peer counselors, and certified lactation consultants Support King County model breastfeeding standards.
66
Key Policy Documents Health Care
International Code of Marketing of Breastmilk Substitutes WHO (1981) Innocenti Declaration WHO/ UNICEF(1990)
No facility of a health care system should be used for the purpose of promoting infant formula or other products Health workers should encourage and protect breastfeeding obstacles to breastfeeding within thehealth systemmust be eliminated every facility providing maternity services fully practices all ten of the Ten Steps to Successful Breastfeeding
67
HHS Blueprint Health Care System
  1. Train health care providers who provide maternal
    and child care on the basics of lactation,
    breastfeeding counseling and lactation management
    during coursework, clinical and in-service
    training and continuing education.
  2. Ensure that breastfeeding mothers have access to
    comprehensive, up-to-date, and culturally
    tailored lactation services provided by trained
    physicians, nurses, lactation consultants and
    nutritionists/dietitians.

68
Health Care System, cont.
  • Establish hospital and maternity center practices
    that promote breastfeeding, such as the Ten
    Steps to Successful Breastfeeding.
  • Develop breastfeeding education for women, their
    partners, and other significant family members
    during the prenatal and postnatal visits.

69
National Survey of Maternity Care Practices in
Infant Nutrition and Care (mPINC)
  • 2,546 hospitals, 121 birth centers in the 50
    states, DC, Puerto Rico
  • 35 questions 7 categories
  • labor and delivery,
  • breastfeeding assistance,
  • mother-newborn contact,
  • newborn feeding practices,
  • breastfeeding support after discharge,
  • nurse/birth attendant breastfeeding training and
    education,
  • structural and organizational factors related to
    breastfeeding

MMWR. June 13, 2008 / 57(23)621-625
70
http//www.cdc.gov/mmwr/preview/mmwrhtml/mm5723a1.
htmfig
71
mPINC Key Findings
  • 70 of facilities reported providing discharge
    packs containing infant formula samples to
    breastfeeding mothers
  • 88 of facilities taught the majority of mothers
    techniques related to breastfeeding
  • 24 of facilities reported giving supplements
    (and not breast milk exclusively) as a general
    practice with more than half of all healthy,
    full-term breastfeeding newborns

MMWR. June 13, 2008 / 57(23)621-625
72
Prospective Cohort Study to Compare Breastfeeding
Environments in Moses Lake and Centralia
73
Moses Lake Centralia
Moses Lake Centralia
Total participants 247 250
White 71 90
Hispanic 42 24
lt HS grad 25 24
WIC/MSS 69 75
Mean number of children 2.3 2.2
74
Hospital Policies
Moses Lake Centralia
Lactation consultant visited mother 45 30
Newborn given something other than breastmilk in hospital 57 55
Newborn given a pacifier 51 58
(p 0.002)
75
Moses Lake Moses Lake Centralia
Mother was given free formula 91 80 80
Mother given coupons for formula 82 76 76
p 0.003
76
Moses Lake Centralia
Mother referred to support group 20 14
Mother received follow-up on breastfeeding 29 40
p 0.025
77
State Breastfeeding Legislation
  • Breastfeeding in public 18 states give the right
    to breastfeed in any place it is legal to be
  • Employment 10 states encourage employers to
    support breastfeeding mothers
  • Jury duty 7 states exempt breastfeeding mothers
    from jury duty
  • Family law three states require breastfeeding
    status to be considered in divorce or custody
    decisions.

78
WA Breastfeeding Legislation
  • Amendment to indecent exposure law
  • A person is guilty of indecent exposure if he or
    she intentionally makes any open and obscene
    exposure of his or her person or the person of
    another knowing that such conduce is likely to
    cause reasonable affront or alarm. The act of
    breastfeeding or expressing breast milk is not
    indecent exposure.

79
WA breastfeeding legislation
  • Am employer may use the designation infant
    friendly on its promotional materials if the
    employer has an approved workplace breastfeeding
    policy addressing at least the following
  • Flexible work schedule, place to nurse/express
    with handwashing facilities and refrigerator
  • DOH to approve employers, but no funds to do
    this, so no worksites have been designated

80
CDC Breastfeeding Report Card 2007 Process
Indicators
US WA
Percent of live births occurring at facilities designated as Baby Friendly (BFHI) 3.31 8.97
Number of IBCLCs per 1000 live births 2.12 4.15
Number of state health dept FTEs dedicated to breastfeeding 81 1
81
CDC Report Card, cont.
US WA
State legislation about breastfeeding in public places 46 yes
State legislation about lactation and employment 14 yes
Presence of an active statewide breastfeeding coalition 43 yes
82
Levels of Influence in the Social-Ecological Model
Structures, Policies, Systems Local, state,
federal policies and laws to regulate/support
healthy actions
Institutions Rules, regulations, policies
informal structures
Community Social Networks, Norms, Standards
Interpersonal Family, peers, social networks,
associations
Individual Knowledge, attitudes, beliefs
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