1. Supporting Breastfeeding in Child Care Settings Insert Presenter’s Name

2. This presentation was created through a collaboration among: Our Lady of the Lake Children’s Hospital American Academy of Pediatrics Greater New Orleans Breastfeeding Awareness Coalition Louisiana Breastfeeding Coalition Tulane’s Mary Amelia Center Volunteers of America/Partnerships in Child Care Louisiana Department of Health and Hospitals Office of Public Health - Maternal and Child Health Program The “Breastfeeding-Friendly Child Care Initiative” of the Carolina Global Breastfeeding Institute /UNC Gillings School of Public Health The Wisconsin Department of Health Services, Ten Steps to Breastfeeding-Friendly Child Care Centers Resource Kit Pilot centers in Baton Rouge Photos: Addie Imseis and the US Breastfeeding Committee

3. Agenda Introductions Pre-test Presentation Post-test/Review Evaluation

4. Supporting Breastfeeding in Child Care Settings © Addie Imseis and USBC, 2010 Pre-test

5. At the end of this presentation, participants should be able to: 1.Describe the historical, societal and social barriers to breastfeeding. 2.Understand the impact of breastfeeding on the health of women, infants, children, and society.

6. At the end of this presentation, participants should be able to: 3. Discuss the proper way to label, store and handle breast milk in the child care center. 4. Describe ways that a child care provider can support breastfeeding families.

7. Disclaimer This information is meant for the education of child care providers. It is not meant to take the place of any child’s own personal health care professional. Completing this training does not guarantee competency in infant feeding techniques. Child care providers are responsible for knowing their own center’s feeding policy and their own state regulations.

8. You can make a difference! As a child care provider you are an important part of each mother’s support system. ©USBC, 2010

9. Image from Larry Grummer-Strawn, PhD: CDC-USBC Bi-Monthly Teleconferences, Tuesday, February 8, 2011.

10. ACTIVITY Do you think breastfeeding is important? Why? Why not? © Addie Imseis and USBC, 2010

11. Infant feeding history Until the mid-1800s, almost all babies everywhere were breastfed. Wet nursing was the most common alternative. Substitutes often led to infections, malnutrition, and dehydration. Walker, M. Still Selling out mothers and babies: marketing of breast milk substitutes in the U.S.A. Weston, MA: NABA REAL, 2007.

12. Artificial feedings became more common about 100 years ago. 1870s – Nestle Infant Food $.50/bottle 1897 –Formula could be ordered from the Sears catalogue, but it was still expensive 1910 – Refrigerators became widely available 1920s and 1930s – Evaporated milk became available. It was recommended by physicians; it was cheap and became widely popular

13. Formula feeding became popular for modern society. 1950s – Commercial formulas, like Similac and Enfamil, became available. – Post World War II women wanted freedom and independence – Many more women left home to work – Feeding schedules became popular – Advertisements undermined breastfeeding 1970s – Only 25% of US babies were breastfed. Walker, M. Still Selling out mothers and babies: marketing of breast milk substitutes in the U.S.A. Weston, MA: NABA REAL, 2007.

14. Commonly believed myths

15. Getting rid of myths In most cases, a mother can provide breast milk even if: Her baby is premature. Her nipples are inverted. She has had a prior breast surgery. She smokes (even though she should be encouraged to stop). She has had an episode of mastitis. She does not eat a healthy diet. She is on a medication (it depends).

16. Getting back to “normal”… 1980s to present – Research keeps proving that breastfeeding is best for infant health and development – The best baby food throughout history is still the best.

17. Today’s formula is safer than it was 50 years ago, but it will never be…. “complete nutrition” “closer than ever to breast milk” Walker, M. Still Selling out mothers and babies: marketing of breast milk substitutes in the U.S.A. Weston, MA: NABA REAL, 2007. “premium”

18. ACTIVITY Human Milk Components Game What are the ingredients in human milk that make it the preferred food for babies? www.breastmilkcounts.com/educational-activities.html © Addie Imseis and USBC, 2010

19. Which are in human milk? Which are in formula? http://www.breastmilkcounts.com/breastfeeding-benefits.php

20. How does formula stack up?

21. Human milk cannot be replicated. The enzymes, antibodies, growth and disease fighting factors, and hormones found in human milk cannot be added to formula. © USBC, 2010

22. Each animal makes milk that is best for the development of their young. Human milk is the perfect food for human babies. It is the foundation for good health in early childhood, with benefits that last a lifetime. from -- www.ars.usda.gov/is/graphics/photos

23. Mother’s milk is “The Gold Standard.” Mother’s milk is more than food. Experts recommend: – Mother’s milk only for the first six months – Other foods added slowly after 6 months with breastfeeding continuing for at least the first year – Breastfeeding beyond one year, for as long as desired by mother and baby (there is no specific age by which a child should be weaned)

24. A well-built immune system leads to a healthier life. Breastfeeding helps babies develop a healthy immune system These effects on the immune system last a lifetime. Hanson, L. A. MD, PhD. Immunobiology of Human Milk: How Breastfeeding Protects Babies. Pharmasoft Publishing, 2004. © Addie Imseis and USBC, 2010

25. Breastfeeding lowers infections. Lower risk for: – Ear Infections – Colds and pneumonia – Diarrhea – Urinary Tract Infections – Bacterial Meningitis – Wide range of infectious diseases American Academy of Pediatrics, Work Group on Breastfeeding. (2005).Breastfeeding and the use of human milk. Pediatrics. 115(2), 496-501 United States Breastfeeding Committee. Breastfeeding and child care [issue paper]. Raleigh, NC: United States Breastfeeding Committee; 2002.

26. Breastfeeding reduces other diseases. Lower risk for: – Sudden Infant Death Syndrome – Types 1 & 2 diabetes – Lymphoma and Leukemia – Inflammatory Bowel Disease – Asthma and Eczema – Obesity – Dental disease American Academy of Pediatrics, Work Group on Breastfeeding. (2005).Breastfeeding and the use of human milk. Pediatrics. 115(2), 496-501 United States Breastfeeding Committee. Breastfeeding and child care [issue paper]. Raleigh, NC: United States Breastfeeding Committee; 2002.

27. Breastfeeding promotes bonding. Secure attachment in the early years influences mental health and functioning for a lifetime. Breastfeeding does not spoil a baby. Center on the Developing Child at Harvard University (2010). The Foundations of Lifelong Health Are Built in Early Childhood. http://www.developingchild.harvard.edu © Addie Imseis and USBC, 2010

28. ACTIVITY: What do you know about childhood obesity? Why did Michelle Obama choose this topic? www.letsmove.gov

29. Obesity is a modern epidemic with serious consequences. In the US: About 69% of adults are overweight or obese. About 12% of children age 2-5 are obese. Obesity puts children at risk for diabetes, heart conditions, self-esteem issues and many other health problems. www.cdc.gov/nchs/fastats/obesity-overweight.htm

30. Healthy eating must begin in early childhood. Children develop food preferences and eating habits very early in life. Overweight baby ↓ Overweight child ↓ Overweight adult © USBC, 2010

31. Obesity Prevention Begins with Breastfeeding! Breastfed infants self-regulate better (learn to eat when they are hungry and stop eating when they are full). Breast milk contains hormones and other substances which play a role in weight regulation. Formula feeding and early introduction of solids can increase the risk of childhood obesity. Lawrence, R. A. (2010). Does Breastfeeding Protect Against Overweight and Obesity in Children? A Review. Childhood Obesity, 6(4),193-197

32. ACTIVITY How do you think breastfeeding benefits the mother? © Addie Imseis and USBC, 2010

33. Breastfeeding benefits the mother. Decreased postpartum bleeding Reduces post-partum depression Earlier return to pre-pregnancy weight Reduces fertility and helps to space babies (no guarantee!) Lowers risk for breast and ovarian cancer Lowers risk for hip fractures and osteoporosis Fewer absent days when she returns to work/school American Academy of Pediatrics, Work Group on Breastfeeding. (2005).Breastfeeding and the use of human milk. Pediatrics. 115(2), 496-501 United States Breastfeeding Committee. Breastfeeding and child care [issue paper]. Raleigh, NC: United States Breastfeeding Committee; 2002.

34. Bonding also benefits mothers. Both mom and baby benefit from the special emotional bond that develops between a mother and her child during the process of breastfeeding. © Addie Imseis and USBC, 2010 Strathearn L, Mamun A, Najman, J and O'Callaghan, M. Does Breastfeeding Protect Against Substantiated Child Abuse and Neglect? A 15-Year Cohort Study. Pediatrics 2009;123;483-493

35. Breastfeeding benefits employers. Higher productivity Less missed work days Lower health care costs Increased loyalty to workplace Less employee turnover U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Support Breastfeeding. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General; 2011.

36. Not breastfeeding costs everyone. Formula-feeding families: – Spend $1,200–$1,500 per year for infant formula – Have more health insurance claims and more time off work due to baby being sick Society benefits when US mothers breastfeed: $13 billion dollars could be saved every year if more babies were exclusively breastfed Louisiana benefits: A total of $216,103,368 could be saved and 18 infant deaths prevented if 90% of LA infants were exclusively breastfed for the first 6 months of life Bartick, M. and Reinhold, A The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis. PEDIATRICS (doi:10.1542/peds.2009-1616) U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Support Breastfeeding. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General; 2011.

37. Breastfeeding is “Green.” No land needed for production No energy required (except the mom’s!) No pollution Less packaging Less disposal (cans, bottles, nipples) www.llli.org

38. MT WY ID WA OR NV UT CA AZ ND SD NE CO NM TX OK KS AR LA MO IA MN WI IL IN KY TN MS AL GA FL SC NC VA WV OH MI NY PA MD DE NJ CT RI MA ME VT NH AK HI Rates of Infants Ever Breastfed by US State (2012 data) Legend 55-64% 65-74% 75-84% ≥ 85% MT WY WA OR NV CA AZ SD NE CO NM TX OK KS AR LA MO IA MN AK IL AR WI IN TN MS AL GA FL SC NC VA WV OH MI ME NH NY PA VT KY ND ID UT

39. Breastfeeding rates in the U.S. (2012 data) 80.0% of US infants are “ever breastfed” 51.4% of US infants are still breastfeeding at 6 months 29.2% are exclusively breastfed at 6 months There are significant racial disparities http://www.cdc.gov/breastfeeding/data/nis_data/rates-any-exclusive-bf-socio-dem-2012.htm Percent %

40. Louisiana Breastfeeding Rates 49 th in the nation (2012 data) Percent % Source: http://www.cdc.gov/breastfeeding/data/nis_data/index.htm

41. Breastfeeding mothers need support from everyone! ©USBC, 2010

43. Louisiana Laws related to Breastfeeding A mother can breastfeed her infant in any place that a mother and her infant have a right to be (public or private). Child care centers cannot discriminate against breastfed infants.

44. ACTIVITY: Barriers to Breastfeeding What factors make breastfeeding more difficult for some women? © Addie Imseis and USBC, 2010

45. Top reasons US women stop breastfeeding physical discomfort (example: sore nipples) concerns about making enough milk going back to work or school taking care of other children Most mothers could overcome these challenges with the right support. Child care center support is important! Li, R., Fein, S.B., Chen, J., & Grummer-Strawn, L.M. (2008). Why mothers stop breastfeeding; mother’s self reported reasons for stopping during the first year. Pediatrics, 122, S69-S76.

46. Mothers need workplace support. Breastfeeding after returning to work requires effort and commitment. Employers benefit when they support breastfeeding. Federal law requires support for breastfeeding employees. http://www.womenshealth.gov/breastfeeding/employer-solutions/business-case.php

47. ACTIVITY: Supporting Breastfeeding in Child Care Settings What steps can a child care setting take to be more breastfeeding-friendly? © Addie Imseis and USBC, 2010 The “Ten Steps” are adapted from the “Breastfeeding-Friendly Child Care Initiative” of the Carolina Global Breastfeeding Institute /UNC Gillings School of Public Health

48. Ten Steps to a Breastfeeding-Friendly Child Care Center Step 1: Make a commitment to the importance of breastfeeding and share with staff. Step 2: Train all staff to promote optimal feeding for infants and young children. Handouts: Breastfeeding and Child Care: What Child Care Centers Can Do Our Center Supports Breastfeeding Sample Center Breastfeeding Policy

49. Scenario 1 A couple expecting their first baby in 2 months comes in to your center for a tour. The mother states that she might breastfeed, but she isn’t sure she’ll be able to. – What are some things that you can do as a child care provider to support her decision?

50. Ten Steps to a Breastfeeding-Friendly Child Care Center Step 3: Inform families about the importance of breastfeeding. Step 4: Provide children’s activities which normalize breastfeeding.

51. Scenario 2 A mother is nursing her infant in a chair in the corner of the infant room. Another parent sees this and expresses to you that she does not think it’s right for the nursing mother to be doing that in public. – What is your response?

52. Ten Steps to a Breastfeeding-Friendly Child Care Center Step 5: Ensure that all breastfeeding families are able to properly store and label milk for child care center use. Step 6: Provide a breastfeeding-friendly environment. Handout: Breastfeeding and Child Care - What Moms Can Do

53. Preparing and Storing Human Milk Use clean bottles specific to each infant Warm or defrost under running water or in bottle warmers. Microwaves should never be used! www.nrckids.org/CFOC3/PREVENTING_OBESITY/index.htm

54. Preparing and Storing Human Milk Each breast milk bottle or bag should have a label (that does not wash off) including the child’s name date/time the milk was expressed Washing hands is important. Gloves are NOT necessary when preparing formula or human milk (unless blood is visible in the milk). Accidental breast milk ingestion is low-risk. www.nrckids.org/CFOC3/PREVENTING_OBESITY/index.htm Handout: Breast Milk Errors & Mix-ups

55. Location TemperatureDurationComments Countertop, tableRoom Temperature (up to 77 ⁰ F or 25 ⁰ C) 6-8 hoursContainers should be covered and kept as cool as possible; covering the container with a cool towel may keep milk cooler. Insulated cooler bag5 ⁰ F—39 ⁰ F or –15 ⁰ C—4 ⁰ C 24 hoursKeep ice packs in contact with milk containers at all times, limit opening cooler bag. Refrigerator39 ⁰ F or 4 ⁰ C 5 daysStore milk in the back of the main body of the refrigerator. Freezer compartment of a refrigerator 5 ⁰ F or -15 ⁰ C 2 weeksStore milk toward the back of the freezer, where temperature is most constant. Milk stored for longer durations in the ranges listed is safe, but some of the lipids in the milk undergo degradation resulting in lower quality. Freezer compartment of refrigerator with separate doors 0 ⁰ F or -18 ⁰ C 3-6 months Chest or upright deep freezer -4 ⁰ F or -20 ⁰ C 6-12 months Human Milk Storage Guidelines http://cfoc.nrckids.org/StandardView/4.3.1.3 Handout: Human Milk Storage and Handling

56. Bottle-feeding tips: Hold the bottle horizontally with the infant upright Do not let the baby hold the bottle in the crib Never prop a bottle Feed one infant at a time Maintain eye contact and vocal communication www.nrckids.org/CFOC3/PREVENTING_OBESITY/index.htm Lactation Education Resources www.LERon-line.com 2011

57. Bottle feeding like breastfeeding Begin feedings when the infant provides EARLY hunger cues (sucking sounds, opening mouth, rooting, etc.) Don’t wait for baby to cry before feedings Crying = Late Cue Allow breaks for burping Allow infant to stop feeding when satisfied Handouts: Bottle-feeding like breastfeeding and Paced bottle-feeding a breastfed baby

58. Provide a comfortable nursing/pumping space. Private, quiet Comfortable Electrical outlet Sink for washing Footstool Pillow Water available © USBC, 2010

59. Scenario 3 A mother asks you if it would be possible for her to nurse her baby before she leaves him to go to work. What do you say? Where would you tell her to nurse the baby?

60. Ten Steps to a Breastfeeding-Friendly Child Care Center Step 7: Support breastfeeding employees. © USBC, 2010

61. Scenario 4 A toddler room teacher is returning to work after a 3-month maternity leave. She wishes to continue providing milk to her infant, who will be enrolling in the infant room. – What are some ways that your center can accommodate her?

62. Ten Steps to a Breastfeeding-Friendly Child Care Center Step 8: Develop a breastfeeding-friendly feeding plan with each family. –Allow infants to feed on cue (when they show early hunger signs: rooting, smacking, or sucking on hands) and to be breastfed when possible. Handout: Sample Center Infant Feeding Plan

63. Ten Steps to a Breastfeeding-Friendly Child Care Center Step 9: –Contact and coordinate with local skilled breastfeeding support. –Actively refer families who need breastfeeding support. Labreastfeeding support.org

64. Ten Steps to a Breastfeeding-Friendly Child Care Center Step 10: Stay up-to-date and continue learning about protection, promotion, and support of breastfeeding.

65. Support Breastfeeding! It is natural. It promotes healthy babies and mothers. It saves money. It contributes to a healthier community. Working mothers need the MOST support! Child Care Provider Support is Important. You can make a difference!

66. Other Opportunities for Centers NAPSAAC Well Ahead from Let’s Move Child Care

67. What is…. Nutrition And Physical Activity Self Assessment for Child Care

68. Timeline Self-Assessment Action Planning Workshop Delivery Technical Assistance Evaluate, Revise, and Repeat Month 1 Month 2 and 3 Months 4-6

69. For more information on NAP SACC contact Leslie Lewis at leslie.lewis@la.govleslie.lewis@la.gov

70. Well-Ahead is a wellness initiative started by the Louisiana Department of Health and Hospitals aimed at improving the health and wellness of Louisiana citizens DHH is working with worksites, hospitals, schools, child care centers, colleges/universities, and restaurants to help them meet wellness benchmarks Part of Well-Ahead is the designation of “WellSpots”

71. What is a WellSpot? A place or organization that has implemented voluntary, smart changes to make healthier living easier for Louisiana centers Places and organizations that meet certain criteria can be designated as a Level 1, 2, or 3 WellSpot Contact DHH for more information on how to become a WellSpot

72. For more information on Well Ahead contact Melissa Martin at Melissa.R.Martin@la.gov.

73. Supporting Breastfeeding in Child Care Settings Action Plans Post-Test Evaluations Certificates Thank you for your attendance and participation! For more information, visit www. louisianabreastfeeding.org