National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention *The findings and conclusions in this presentation are those of the authors and do not necessarily represent the views of CDC Marilyn Batan, MPH American Public Health Association Denver, CO November 9, 2010

Marilyn Batan: The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No relationships to disclose.

Acute Otitis Media Atopic Dermatitis GI (Non- specific) Asthma Type 2 diabetes Childhood Leukemia SIDsObesity AHRQ

Lack of knowledge Social norms Poor family and social support Embarrassment Lactation problems Employment and child care Health service related barriers 4

 In 2008, 71.3 percent of women with children were in the labor force.  ~12 million of the 19 million US children under the age of 5 are in some form of child care.  Pre-school aged children average ≥35 hrs/week in child care settings. 5

 Breastfeeding rates were significantly lower among infants who attended child care at 6 months. (Li 2005).  Infants in child care before 3 mo were 42% less likely to have been breastfed (Kim 2008).  Compared with children who had no child care arrangement, children who attended child care were breastfed for shorter durations (Benjamin 2009). 6

Regulation in place* No Regulation in place Delaware Dist. Columbia Benjamin et al. State and Regional Variation in Regulations Related to Feeding Infants in Child Care. Pediatrics. 2009: 124(1), *Consistent with CFOC Standards (2008) 7

 To examine the impact of child care provider’s (CCP’s) breastfeeding support on breastfeeding duration 8

 Largest US longitudinal study of mother- infant pairs  ~4900 pregnant women 18+ participated  Questionnaires completed almost monthly  3rd trimester through 1 yr postpartum 9

 Mothers ≥ 18 years of age when recruited  Singleton infant  Birth weight ≥ 5 pounds  Full term or near-term infants  Mother and infant healthy at birth  Infant has no long term medical condition that would affect feeding 10

Breastfeeding duration <<12 mo vs. ≥12 mo <<6 mo vs. ≥6 mo 11

1. Feed a mother’s pumped breast milk to her baby? 2. Allow mothers to breastfeed at the child care place before or after work? 3. Allow mothers to come in and breastfeed during their lunch or other breaks? 4. Thaw and prepare bottles of pumped milk if needed? 5. Keep extra breast milk in a freezer for use if they run out during the day? 12 At 3, 6, 9 and 12 months

 Individual CCP’s support over time:  Yes=Breastfeeding supported by CCP in at least one survey  No=Breastfeeding not supported by CCP in any survey  Cumulative breastfeeding support over time: # of “yes” answers X 100% # of valid answers (Yes or No)  Low breastfeeding support : <33.3%  Medium breastfeeding support: 33.3 to 66.6%  High breastfeeding support: >66.6% 13

Mother  Age, race, ethnicity  Education  Household income  Marital status  Breastfeeding Intention  Workplace supports breastfeeding 14 Infant  Sex  WIC Participant  Parity  Age when mother returned to work  Age when infants were first cared outside their home

 Bivariate Analysis:  Chi-square  T-test  Multiple Logistic Regression  Adjusted for all covariates 15

Month 3 (n=824) Month 6 (n=866) Month 9 (n=850) Month 12 (n=809) Private home with no other children 18%19%21%24% Private home with other children 34%15%16%17% Day care or child care 15%37%34%32% 16 *Column %’s do not add up to 100% because mothers could choose all that apply

N% Intended to Breastfeed % Ever Breastfed303385% Breastfed ≥6 months % Breastfed ≥12 months % 17

Total Sample n= 3,033 Babies cared in their own home n= 1,062 Baby cared outside their home n= 920 Final Sample for this study n= 526 Missing covariates n= 125 Missing f/u to neonatal survey n= Missing primary exposure variables n= 69 Infants who were cared for by mother n= 659 Missing data on breastfeeding outcome n= 45 Mothers who never breastfed n= 155

1 st Year 1)Feed pumped milk to baby78% 2) Allow mother to BF B/A Work86% 3) Allow mother to BF during lunch/breaks 85% 4) Thaw and prepare bottles of pumped milk 86% 5) Keep extra milk in freezer73% 19 *Column %’s do not add up to 100% because mothers could choose all that apply

MotherBF Duration <12 mo (n=436) BF Duration ≥12 mo (n=90) Marital Status* Yes 75%86% Workplace supports BF* Yes 83%96% Maternal Education* <=high school 16%4% some college 34%27% college grad 50%69% Infants’ median age in wks when first cared outside home* 15%25% *P<

% Breastfeeding ≥12mo Mothers with Support Mothers without Support 21 *P<0.05

%Breastfeeding ≥12mo Mothers with Support Mothers without Support 22 * *P<0.05

%Breastfeeding ≥12mo Mothers with Support Mothers without Support 23 * *P<0.05

%Breastfeeding ≥12mo *P<0.05 Overall Breastfeeding Support

% Breastfeeding ≥12mo Support AOR95 % CI 1)Feed a mother’s pumped breast milk to her baby 2.3*1.1 – 4.9 2)Allow mothers to breastfeed at the child care place before or after work – 3.5 3)Allow mother to breastfeed during their lunch or other breaks – 2.4 4)Thaw and prepare bottles of pumped milk if needed – 4.9 5)Keep extra breast milk in a freezer for use if they run out during the day – 2.4 Adjusted for breastfeeding intention and all other covariates

26 % Breastfeeding ≥12mo AOR95% CI Overall Support Low ref Medium – 9.4 High 3.9*1.3 – 11.8

Breastfeeding duration <<12 mo vs. ≥12 mo <<6 mo vs. ≥6 mo 27

 Sample is not nationally representative  All data are reported by the mother  Child care support only represents the perceptions of mothers 28

 Largest longitudinal study on infant feeding  Extensive questionnaire development  Short recall period  Relatively high response rate over time  Sample is well distributed throughout the US  Detailed data collection allows to control for a large range of confounding factors 29

 Mothers with CCP’s support to feed pumped milk were 2.3 times more likely to breastfeed ≥12 months.  Mothers of infants with high CCP’s breastfeeding support throughout the 1 st year were about 4 times more likely to breastfeed ≥12 months than those mothers with low CCP’s support  Multiple supports at the CCP are needed to improve breastfeeding duration 30

 More research is needed on child care provider supports and breastfeeding  Standards for the state to regulate breastfeeding support at child care facilities  Implementation guidance 31

Co-investigators:  Ruowei (Rosie) Li, MD, PhD  Kelley Scanlon, PhD Contact Information:  