Supporting Breastfeeding in Child Care Settings Insert Presenter’s Name

Agenda Introductions Pre-test Presentation Self-assessments Action Plans Post-test/Review Evaluation

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

Acknowledgments Ashley Lucas, MD and Kacie Sims, MD --Our Lady of the Lake Pediatrics Residency Program Marci Brewer, MPH –Louisiana Breastfeeding Coalition Susie Amick, RN, IBCLC, RLC, LCCE – East Jefferson General Hospital Caitrin Alb, MPH –Tulane Mary Amelia Women’s Center Students: – Stephanie Miles and Chi McKendall-Lewis

Acknowledgments Our Lady of the Lake Children’s Hospital American Academy of Pediatrics Greater New Orleans Breastfeeding Awareness Coalition (GNOBACC) Volunteers of America/Partnerships in Child Care – Gina Forsman and Janie Starks Louisiana Department of Health and Hospitals Office of Public Health - Maternal and Child Health Program Pilot centers and Reviewers Photos: Addie Imseis and the US Breastfeeding Committee

Acknowledgments Parts of this educational program were adapted from: 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

At the end of this presentation, participants should be able to: 1.Describe changes in infant feedings in the last three generations. 2.Understand the impact of breastfeeding on the health of women, infants, children, and society.

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 and help meet national goals for promoting health.

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.

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

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

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

Infant feeding history Until the mid-1800s almost all US babies (and babies around the world) were breastfed. Wet nursing was the most common alternative. Other 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.

When did formula-feeding become common? Mid-1800s – Cow’s milk became the alternative of choice, but led to infections and vitamin deficiencies 1869 – Leibig’s Soluble Infant Food sold for $1/bottle 1870s – Nestle Infant Food $.50/bottle 1897 –The Sears catalogue advertised formula, but it was still expensive

When did formula-feeding become common? Early 1900s – Some physicians recommended and sold infant formula 1910 – Refrigerators became widely available 1920s and 1930s – Evaporated milk used for feedings – Often recommended by physicians – Cheap – Became widely popular

Artificial feeding became popular. 1950s – Artificial Baby Milk available (Commercial formulas, like Similac, Enfamil) – Approved by some physicians – Infant feeding schedules became popular – Advertisements undermined breastfeeding – Many more women left home to work – Women wanted freedom/independence 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.

Commonly believed myths

Getting back to “normal”… 1980s to present – Research proves that breastfeeding is important for optimal health and development – Medical and government organizations recognize and publicize the importance of breastfeeding. The National Alliance of Breastfeeding Advocacy

Formula manufacturers often use false and misleading advertising to increase sales of their products. “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, “new and improved”

ACTIVITY Human Milk Components Game What are the ingredients in human milk that make it the preferred food for babies? © Addie Imseis and USBC, 2010

Which are in human milk? Which are in formula?

How does formula stack up?

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

Breastfeeding matters for babies. 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 --

Mother’s milk is “The Gold Standard.” Mother’s milk is more than food. Each mom has custom-made milk for her baby, which changes as he grows. 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

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, © Addie Imseis and USBC, 2010

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), United States Breastfeeding Committee. Breastfeeding and child care [issue paper]. Raleigh, NC: United States Breastfeeding Committee; 2002.

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), United States Breastfeeding Committee. Breastfeeding and child care [issue paper]. Raleigh, NC: United States Breastfeeding Committee; 2002.

Breastfeeding promotes bonding. Secure attachment in the early years influences mental health and functioning for a lifetime. Center on the Developing Child at Harvard University (2010). The Foundations of Lifelong Health Are Built in Early Childhood. © Addie Imseis and USBC, 2010

ACTIVITY: What do you know about childhood obesity? Why did Michelle Obama choose this topic?

Obesity is a modern epidemic with serious consequences. 18.4% of teenagers are obese 18.0% of children age 6-11 years are obese 12.1% of children age 2-5 years are obese Obesity puts children at risk for diabetes, heart conditions, self-esteem issues and many other health problems.

Obesity begins in early childhood. Help mothers prevent pregnancy-related risk factors for obesity: Tobacco exposure Excess weight gain in pregnancy Gestational diabetes High birth weight babies Low birth weight babies Mothers need support to stay healthy during pregnancy! © Addie Imseis and USBC, 2010

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

“I’m so excited about Let’s Move Child Care – because I know that childcare facilities and home-based providers can be a real building block for an entire generation of healthy kids.” First Lady Michelle Obama, June

Goals: – Increase physical activity – Reduce screen time – Serve healthy foods: fruits and vegetables – Serve healthy drinks: more water, less sugar – Support infant feeding (breastfeeding)

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),

A healthy infant leads to a healthy adult. Early childhood is a critical time period when the brain is growing rapidly and the baby’s body systems are being programmed. Early childhood health is the foundation for adult health. Center on the Developing Child at Harvard University (2010). The Foundations of Lifelong Health Are Built in Early Childhood.

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

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), United States Breastfeeding Committee. Breastfeeding and child care [issue paper]. Raleigh, NC: United States Breastfeeding Committee; 2002.

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;

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.

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 and 911 infant deaths prevented every year if 90% of babies were exclusively breastfed for the 1 st 6 months Bartick, M. and Reinhold, A The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis. PEDIATRICS (doi: /peds ) 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.

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

Breastfeeding rates in the U.S. 77% of US infants are “ever breastfed” Only 47% of US infants are still breastfeeding at 6 months

Louisiana Breastfeeding Rates 48 th in the nation Percent % Source: Centers for Disease Control and Prevention National Immunization Survey, Provisional Data, 2009 births.

Breastfeeding rates are the lowest among African American Women in Louisiana Percent % Source: Louisiana Risk Assessment Monitoring System (LaPRAMS)

Breastfeeding mothers need support from everyone! ©USBC, 2010

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. Child care centers cannot discriminate against breastfed infants.

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

Top 3 reasons women stop breastfeeding In the United States: – physical discomfort (example: sore nipples) – concerns about making enough milk – going back to work or school In Louisiana: – disliking breastfeeding – going back to work or school – taking care of other children 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. Louisiana Pregnancy Risk Assessment Monitoring System (LaPRAMS) data.

Other barriers to breastfeeding: Problems with latching Issues with breastfeeding attitudes/support Concerns about lifestyle (diet, smoking, personal freedom) Medical reasons Issues with milk pumping Infant self-weaning (infant losing interest, etc) Ahluwalia, I.B., Morrow, B., & Hsia, J. (2005) Why do women stop breastfeeding? Finding from the pregnancy risk assessment and monitoring system. Pediatrics, 116,

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. The US Department of Health and Human Services: The Business Case for Breastfeeding

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 “Ten Steps” are adapted from the “Breastfeeding-Friendly Child Care Initiative” of the Carolina Global Breastfeeding Institute /UNC Gillings School of Public Health

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

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.

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

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!

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. Handout: Breast Milk Errors & Mix-ups

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 Handout: Human Milk Storage and Handling

Human Milk Storage Guidelines (how long to keep milk for use) After a baby sucks on a bottle: 1 Hour Room Temperature: 6-8 hours Refrigerator: 5 days Deep Freezer: 6-12 months

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 Lactation Education Resources

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: Tips for Day Care Providers

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

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

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

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.

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.

Scenario 1 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?

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?

Scenario 3 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?

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?

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!

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