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E Excerpts from Comments Received on the Institute of Medicine’s Website for the Workshop to Update the USDA National Breastfeeding Campaign From March to May 2011, a public website was set up (www.iom. edu/USDABreastfeeding) to provide input to the U.S. Department of Agri- culture’s Food and Nutrition Service about the Loving Support campaign. About 40 comments were received from health departments, hospitals, breastfeeding coalitions, WIC offices, and other settings. A sampling of the comments is reprinted below. They have been edited for length, in some cases with some minor copyediting. Question 1: How does FNS build on the success of the current Loving Support Makes Breastfeeding Work campaign to promote breastfeeding among WIC participants? From a medical school professor: Breastfeeding is an incredibly difficult skill to master. Doctors, midwives, and lactation consultants all offer conflicting advice about breastfeed- ing. There needs to be a consistent approach across disciplines, and it needs to be offered early—in the hours and days immediately after childbirth—and continued in the early weeks, and then support and encouragement needs to happen when mothers return to work. From a peer counselor: I think the current food instruments allowing for more food for breast- feeding mothers and their babies is wonderful. . . . I must add, however, 101

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102 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN that I don’t personally feel the breastfeeding package is big enough, meaning I believe even more food choices should be allowed for these mothers. From a WIC staff member: Expansion of early education/promotion with a focus on the use of materials that truly make a difference is one strategy for building on the success of the current campaign. Our aim was to develop an edu- cational kit that clearly communicated that WIC moms and babies are important and that breastfeeding is important, and this kit evidences that. All of the products contained in the kit are of the highest quality, effectiveness tested, and specifically targeted. We received the nicest compliment from a nurse/IBCLC who works with middle- and upper- income breastfeeding moms: “This kit looks like something we would give our moms.” And indeed the kit clearly communicates to each WIC mom, “You and your baby are important. So let’s talk about breastfeeding.” From a WIC nutrition/breastfeeding coordinator: In the Southwest region we have used the campaign with an FNS- sponsored workgroup to provide prenatal education bags for WIC participants. From a medical school employee: I believe the campaign needs to focus on clear, simple, concise mes- sages about breastfeeding that are at a reading level of participants targeted. Although technology and media, such as Facebook and tex- ting, are popular forms of communication, the message that exclusive breastfeeding is best for newborns still must be comprehended by the participants at a deeper level. From an IBCLC: Increase funding to hire more peer counselors in areas where there are none, and increase their availability to WIC clients (e.g., more hours, more activity) where programs are in existence. Provide support and funding for clinics to offer comprehensive prenatal breastfeeding classes and ongoing breastfeeding support groups. Fund at least one breast- feeding expert for every clinic and recommend that states hire IBCLCs.

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103 APPENDIX E Increase funding to allow for hospital and home visits by IBCLCs, when indicated. In order to increase access to skilled breastfeeding support, suggest clinics consider hiring non-licensed IBCLCs (meaning without a state license such as RN or RD) as well as licensed IBCLCs. The level of breastfeeding education and knowledge needed to pass the IBLCE exam is equal, so clinics would not be compromising care. Ad- ditionally, non-licensed IBCLCs may save the clinic money as they often will work for a lower salary. Promote the campaign in the community, especially to physicians and hospitals. Encourage hospitals to offer care that promotes early breastfeeding initiation and bonding. Provide ongoing breastfeeding education for peer counselors and WIC staff. Provide clients with access to comprehensive breastfeeding information, whether via print or online. Provide funding for current breastfeeding education materials, including videos and demonstration models that represent current knowledge of breast anatomy. Encourage clinics to develop relationships with community breastfeeding resources such as La Leche League, Black Breastfeeding Association, Breastfeeding USA, Mocha Moms, Attachment Parenting International, etc. From a peer counselor coordinator: The Loving Support curriculum is engaging and inspiring. It could be enhanced by more fully utilizing additional evidence-based materials, such as Breastfeeding: A Magical Bond of Love. From a peer counselor: By creating a net for moms who have no idea of how to find resources or do not even consider finding them. For many of them, the thought process begins when they are contacted by a peer counselor or some- one asks, “What are your breastfeeding goals?” Many times it is not on their radar until they are caught by this loving and supportive net! From a WIC state supervisor: Fund the WIC Peer Counselor Program so that there will be a minimum of one WIC Peer Counselor in every WIC local agency to provide peer- to-peer latch and position support to all WIC breastfeeding women. Ensure that all local agencies have competent professional authorities with certification to better support WIC participants toward successful breastfeeding up to and beyond 12 months postpartum.

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104 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN From a lactation consultant: My recommendation is to involve all the WIC participants’ fami - lies, friends, and their community. Stop giving away free formula to everyone. From a hospital staff member: Focus more on the hazards of formula as opposed to the benefits of breastfeeding. From a WIC client: Breastfeeding needs the support of pediatricians and nurses. I have too many friends who were unable to successfully breastfeed mostly because of the advice or recommendation of a doctor or nurse! Parents need to see more information on why breast milk is simply far superior to infant formula. I would like to see breastfeeding addressed on public television. If we run ads about the risks of drunk driving and smoking, why can’t we run ads about the benefits of breastfeeding? From a nutrition education coordinator: Add to the messages so that they appeal to grandmothers, fathers, etc. and make those people start thinking of breastfeeding as the first choice for feeding a baby. Add messages that can be used to promote breastfeeding to doctors, clinics, nurses, and hospitals as the first choice for feeding a baby. Include materials to help market mother/baby breastfeeding-friendly care protocols to the above audiences. From a peer counselor: Our peer counseling program has taken steps to network with the lo- cal lactation experts to bring better service to our clients. This includes hospitals, independent lactation consultants, schools, and home visit nurses. By collaborating with other community resources, we have been able to make more of a difference with our clients and in a speedier time frame as well. We have also utilized e-mail and text messaging with our clients who are interested. This has been especially helpful with our younger moms who are more comfortable with this method of communication.

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105 APPENDIX E From a WIC program: Have more specific examples and guidelines for referral to an IBCLC as the breastfeeding expert. The guidelines should be very specific with respect to the job functions of peer counselors. From a lactation consultant: To move this campaign along, there need to be more incentives for busi- nesses to participate willingly. Currently they are being “threatened” by new laws being passed where they have to comply with offering breastfeeding women time/space to pump. What if we offer the busi- nesses a way to hire an IBCLC consultant to help set up and provide ongoing support to their breastfeeding moms? From a WIC program: Review current requirements for breastfeeding peer counselors (BFPCs) to see if updating the qualifications would support women better by making it possible to expand the program. Our state developed on- line modules for BFPC training. If a national online training existed, it would provide more standardization, and accessibility to training would become more flexible. From a lactation program coordinator: Utilizing International Board Certified Lactation Consultants for educa- tion and support of breastfeeding has shown to result in better breast- feeding duration rates for areas. From a county health department: I would like to see more education focused on physicians and the mis- conceptions they have about breastfeeding as well as more emphasis on appetite and growth spurts and how to help the confidence of the mother regarding milk supply. From a breastfeeding counselor: I’ve been a breastfeeding counselor for 6 months. I really admire the title “Loving Support.” It’s when I sound a little less controlling and more interested in caring for WIC participants that I’m more successful.

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106 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN From a prenatal education coordinator Provide (1) consistent professional information/education for all breast- feeding families; (2) support using easily accessible lactation counselors; (3) physical space for lactating moms to pump at their place of work; (4) a healthy point of reference accepting breastfeeding mothers and babies in public places in our society; (5) education for the upcoming generation that breastfeeding is a healthy and normal method of feed- ing our babies; and (6) monetary support for various breastfeeding advocacy groups and agencies. From a breastfeeding coordinator: Continue to support the Peer Breastfeeding Grant. It has proven very successful in our small county. Make available free large posters of women breastfeeding in a wide variety of settings and in a wide va- riety of cultures. Make the sight of breastfeeding a normal, natural phenomenon. From a breastfeeding peer counselor manager: The standard would be that all pregnant participants without excep- tion (including those mothers who indicate that they don’t want to breastfeed) would have an educational contact with a breastfeeding peer counselor. From a social marketing consultant: My feeling is that you have a wealth of information about possible strategies that could be part of the campaign. But the first most impor- tant step for moving the campaign forward, in my opinion, is to do formative research and include testing of the current campaign materi- als in the formative research. The findings from the formative research will then allow the USDA to select the most appropriate strategies for the campaign, to select appropriate targets and messages, etc. I would then recommend creating a very straightforward logic model that lays out the goal and objectives of the campaign, the strategies you will use, and how you will measure success based on the outcomes you expect. The logic model, if very simple, will be an excellent educational tool for state and local programs.

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107 APPENDIX E From a medical center employee: Work out a way to include moms willing to pump and feed. There is a small number who cannot breastfeed due to past abuse histories, etc., and they should not be excluded. It can help them mend as well. Question 2: The original Loving Support Makes Breastfeeding Work campaign was launched in 1997. How can the campaign be improved to better meet the needs of current WIC participants? Specifically, what are key considerations for breastfeeding messages, communication tools (including social media), technical assistance for WIC staff, community partners and collaboration, and changes in laws, policies, and other initiatives? From a medical school professor: So many mothers stop breastfeeding when they return to work. Support for working mothers needs to happen—support in terms of offering materials, tips, guidance, and encouragement. Asking mothers if they are breastfeeding and if it is working is not enough—they may not real- ize that they are or are not doing it correctly. From a peer counselor: I was trained using the Loving Support module. While I feel it was sufficient, I must admit I thought it to be a bit “dated,” from the in- formation to the pictures. Also, more emphasis needs to be placed on new ways of communicating such as e-mail, text messaging, and social networking. That said, women still need to have real live communica- tion and contact with other moms, PCs, and LCs in a support group type setting. Whether it be at a clinic or elsewhere, I believe this is crucial to getting the breastfeeding numbers up and keeping them up. From a lactation consultant: Messages need to target today’s parents in terms of language and appearance—contemporary images, edgy messages, eye-catching de- signs. Campaigns need to be multi-faceted, tapping into social media platforms as a means of dissemination. The Text4Baby campaign by Healthy Mothers Healthy Babies is a good example. Expand the WIC Peer Counseling Program and integrate WIC programs and hospital services so that there is seamless care throughout the perinatal period. Change needs to occur not only among mothers, but also among em- ployers, healthcare facilities, schools, faith-based communities, and

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108 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN state, local, and federal governments, so materials need to be targeted but integrated. Too much time is spent telling people something they al- ready know. We need to focus instead on “You can do this. I can help.” From a WIC nutrition/breastfeeding coordinator: I feel that the word “support” for many moms is taken for granted. We make the law, we train WIC staff, we collaborate and do all these things, but when it comes down to it, in this society a breastfeeding mom still has to fight for her right to breastfeed. As individuals we may support breastfeeding, but as a society we do not “support” breastfeed- ing moms. From a medical school: Although computer technology is popular, I hope that that will not be the focus of this campaign, for we see too many women ignoring contact and interaction with their newborns while they use their cell phones or computers. Somehow the importance of putting children before technology needs to be stressed in this new campaign. From an IBCLC: So many mothers have difficulty breastfeeding in the hospital and in the early days. Strengthening messages about getting breastfeeding off to a good start would be incredibly helpful to mothers. Promote ways to make breastfeeding and working easier (tips for expressing milk, bringing baby to work, etc). Inform clients of their rights as employees. Encourage clients to advocate for themselves. Additionally, offer information targeted to specific communities, especially African American, Native American, and Hispanic. Online forums and webi- nars could be used to provide support to clients as well as to inform the community. Offer accurate info about breast milk storage and handling, amounts that breastfed babies take in bottles, normal infant behavior, needs of the breastfeeding mother, etc. Encourage staff to join or start area breastfeeding coalitions. Promote WIC breastfeeding services through church, community, and civic groups. Provide targeted breastfeeding promotional materials for fathers, grandparents, schools, employers, community leaders, and healthcare providers. Lack of ac- cess to accurate, comprehensive breastfeeding information is a barrier to breastfeeding, at least in my community. If every clinic could provide

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109 APPENDIX E a breastfeeding class specifically for clients who are returning to work or school, attending the class could be made part of the requirement for receiving a full-size double electric pump, too. From a peer counseling coordinator: Include guidance on and tools for social media use and etiquette (e.g., following HIPAA guidelines while using Facebook, YouTube, and Twit- ter) as well as guidance on how to go about building rapport and col- laborating with community partners. From a nutritionist: Breastfeeding peer counselors (with IBCLC) in hospital setting to work with moms on first-hour latch, more hands-on staff trainings, and aggressive media and ad campaigns to promote breastfeeding; also increasing community partnerships and collaborations may help. From a peer counselor: I am a huge advocate for using technology. Many moms will only con- nect on a text message agenda, and although many may argue that you just don’t have the same communication via texts, sometimes it is the only way to establish communication and provide that support that otherwise they would not be interested in. Establishing communication with lactation consultants at the hospitals where my clients deliver has made all the difference and has had a huge impact. From a WIC state supervisor: Provide more advanced training on resolving breastfeeding problems that WIC participants have. Simple, direct breastfeeding messages for WIC participants and the public, including the link to obesity. Social media focus on breastfeeding as the norm for feeding infants. Provide more education on the importance of skin-to-skin contact through the first six weeks to six months of life to stabilize preemies and enhance preemie and full-term infant health outcomes and growth. Better train- ing on breastfeeding problem resolution; funding/support for state breastfeeding coalitions. More laws and initiatives that support WIC breastfeeding women and infants.

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110 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN From a lactation consultant: Prepare women to survive the hospital experience. Most hospitals are a barrier to breastfeeding, as reported by the CDC in the mPINC survey. From a hospital staff member: The Health Care Act of 2010 made time and a place for pumping at work mandated in companies with 50 or more employees This should be shared with WIC participants. From a WIC client: I have to say that the key to my success was accurate information about milk production and babies, but also my mother-in-law works for a WIC program certifying women and children, and she breastfed 3 boys in her day. She came to my home to support me. We cannot give full support over the phone! How can we create a way for WIC staff to support mothers in their home? From a nutrition education coordinator: Key messages: Breastfeeding is the first and best choice in feeding a baby; ways to talk with their healthcare provider and delivery site about breastfeeding; go with more emotion-based messages, messages geared toward a generation of grandparents who chose not to breast- feed, etc. From a peer counselor: Our agency has been given Blackberries, which has made communica- tion with other WIC staff much more efficient. We also have the option of text messaging. This has been very helpful especially when clients deliver and are too overwhelmed for phone calls. We can send quick tips and guidance when necessary. Our teen moms have been much more receptive to this means of communication as well. From a breastfeeding coordinator: USDA needs to redefine breastfeeding. Breastfeeding should not be de- fined as a woman that breastfeeds once a day. If we are going to impact the populations that are most at risk, we need to send clear messages on the normalcy of infant feeding.

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111 APPENDIX E From a WIC program: Information that is factual and evidence-based allows the customer to make a more informed feeding choice. Breastfeeding messages that are more risk-based would be more effective; e.g., enumerate the risks of formula feeding. Encourage the use of social media applications such as Facebook and Twitter to connect with moms. In-person contact is great, but many moms are unable or unwilling to connect in that man- ner any longer due to time constraints or transportation issues. From a lactation consultant IBCLCs need to be reimbursed by insurance for their services. This is the key to increasing breastfeeding rates on all levels, especially among the WIC population, who can least afford the out-of-pocket cost of IBCLC assistance but need the help the most. From a WIC program: A “Text4Baby” format with exclusively breastfeeding messages for moms would be ideal. Any formal policy guidance for utilizing social media formats to support breastfeeding within WIC is appreciated. Breastfeeding messages need to be aimed at supporting duration and be targeted to the areas identified in the Surgeon General’s Call to Action. From a lactation program coordinator: I would like to see stronger language to include the International Board Certified Lactation Consultant’s role in promoting and support- ing lactation. From a WIC program: I think a key breastfeeding message might be not the benefits of breast- feeding but rather the hazards of formula feeding. Community part- ners: reaching out to middle school health classes. Changes in laws: healthcare reform and tax-deductable pumps would be a major step in the right direction. Make breastfeeding the norm. From a county health department: More emphasis on hospitals limiting formula offered, and increase Baby-Friendly Hospitals.

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112 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN From a breastfeeding coordinator: Make it a law that insurance companies have to cover a certain number of visits with an IBCLC after the baby is born so that if a mom needs help she can get it. Make it a law that formula bags are not allowed to be given out at hospitals. It is unethical, but now is the time to become Baby Friendly. Give personal-use pumps to each WIC mother the last month of her pregnancy. The cost is so much cheaper than formula and would save the government hundreds of dollars from just one doctor’s visit alone. Make lactation management an entire mandatory course for pediatricians, OB/GYNs, and family practice doctors, as well as labor and delivery nurses, NICU nurses, and registered dietitians. Get a celebrity to campaign it so that it can become more popular. From a breastfeeding counselor: Many issues crop up in regard to pumping and working, and many participants seem to know all about benefits, but I have trouble getting them to answer until it’s too late. From a breastfeeding coordinator: Put some teeth in the law. The small businesses and factories in our area all think they are exempt because pumping is a “hardship” on their business hours. Give WICs more money for IBCLCs and breastfeeding messages. From a breastfeeding peer counselor manager: Use Facebook and Twitter accounts to communicate with moms. Es- tablish a model workplace breastfeeding program in WIC. From a breastfeeding coordinator: I think that prenatal education should be a focus. I think it should be mandatory that all prenatal clients receive an instructional breast- feeding class regardless of whether they plan to breastfeed or not. Performance bonuses for peer counselors would be helpful in retaining effective peer counselors.

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113 APPENDIX E From a WIC project director: It would be helpful if more representation of breastfeeding moms for the promotional and educational materials included the populations that are least likely to breastfeed (African American women, blue-collar workers, and young teen moms). From a U.S. Public Health Service employee: Cell phones for breastfeeding peer counselors need to be funded. From an IBCLC: WIC mothers need the support to breastfeed most critically in the 1- to 3-day hospital stay. Mothers state their first WIC appointment is in two weeks, but they are losing heart to continue breastfeeding by day 2, especially if the hospital is not providing hour-to-hour bedside sup- port to help mom and baby be successful. How can WIC provide lov- ing support during the critical early hours and days of breastfeeding? Can phone communication or hospital visits be incorporated into the program? Can peer assignments develop a stronger bond prenatally? From a social marketing consultant: These questions are best answered through formative research. Wom- en’s circumstances haven’t changed all that much (still too busy, still embarrassed to feed in public, still pressured to bottle feed by family and friends). I think the world of technology, and how we communi- cate with target audiences is where the big change has occurred. We should inquire about preferred communications methods with audi- ences (WIC-eligibles, medical staff, employers of low wage earners, etc.) in the formative research. From a peer counselor at a county health department: The key is to go out into the community and make them aware. We can post as many posters as we want out there, but the better advertisement is word of mouth.

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114 UPDATING THE USDA NATIONAL BREASTFEEDING CAMPAIGN From a medical center staff person: Our WIC offices are different in their education, opinions, how they are run, and what they do to support moms. We need more consistency. From a WIC program director: There appears to be a shifting direction in the program. The concern: Are peer counselors intended to encourage and support mothers, and only directly address (counsel) low-risk issues? Or are they expected to also address more high-risk situations with a mother? I believe future changes in the Loving Support Program need to address the “scope creep” that can occur as the peer counselors get more experience and feel more confident in their “scope of practice.” Continuing educa- tion needs to remain limited to the “normal” breastfeeding condition. Understanding the WIC program does not enrich the peer counselor’s knowledge as much as understanding the same struggles that our cli- ents experience. The ideal peer counselor also does not need to be of a similar age as the WIC clients (usually under 30). Our experience has shown that an older woman can provide as much, or more, comfort to a young mother who is having problems. The peer counselor program needs to be more integrated with the WIC Program.