Copyright 2004, The Regents of the University of California Copyright 2004, The Regents of the University of California. All rights reserved. 2/25/04 Starting Obesity Prevention in Infancy: The FitWIC Baby Behavior Project M. Jane Heinig Jennifer Bañuelos Jackie Kampp Jennifer Goldbronn Luz Vera Becerra Kerri Moore This project has been funded at least in part with Federal funds from the U.S. Department of Agriculture, Food and Nutrition Service.  The contents of this publication do not necessarily reflect the view or policies of the U.S. Department of Agriculture, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government.

Results – Focus Groups (2003) “Breast is best.” Copyright 2004, The Regents of the University of California. All rights reserved. 2/25/04 Results – Focus Groups (2003) “Breast is best.” Health messages regarding breastfeeding were loud and clear “Helps them protect against viruses better, breastfeeding. It’s also very important for development of the brain and eyes.” “My mom breastfed my brothers and so that was something I wanted to do with my son because, you know, that special bond, and I feel there’s a bond and it’s healthier.” Key Point Among the participants, the health messages provided about breastfeeding were loud and clear. They had heard about many of the benefits of breastfeeding for infants. Read quotes. Heinig et al. J Hum Lact. 2006;22:27-38.

Copyright 2004, The Regents of the University of California Copyright 2004, The Regents of the University of California. All rights reserved. 2/25/04 UCD Focus Groups (2003) Many mothers reported that their infants were not satisfied when they followed guidelines We asked how could they tell? Many of the mothers told us about their baby’s behavior Heinig et al. J Hum Lact. 2006; 22: 27-38. 3

UC Davis Focus Groups (2003) Copyright 2004, The Regents of the University of California. All rights reserved. 2/25/04 UC Davis Focus Groups (2003) Many mothers believe babies cry because of hunger (formula and cereal prevent hunger) “When I gave formula, the baby no longer cried and that is when I decided not to give him breast milk.” They think their babies will stay full longer if they are overfed “My baby used to wake up, but now I am giving him formula if he is already full and he no longer wakes up.” Heinig et al. J Hum Lact. 2006; 22: 27-38.

Results – Focus Groups (2003) Copyright 2004, The Regents of the University of California. All rights reserved. 2/25/04 Results – Focus Groups (2003) Mothers understand what is best, but many believe that their circumstances force them to make other choices Full, quiet, sleeping child is norm Mothers believe that health care providers/ support staff do not understand what they are experiencing “They don’t see what you’re going through. They are not there to see that you can’t do it and you keep trying. It’s like, ‘You try it.’ ” Heinig et al. J Hum Lact. 2006; 22: 27-38.

Feeding in Response to Baby Behavior We found that mothers feel overwhelmed by crying and waking If breastfeeding, they start adding formula Add more formula, and more formula Start solid foods (cereal in the bottle) Add other foods and fluids Feed every time the baby makes noise

The Project

Copyright 2004, The Regents of the University of California Copyright 2004, The Regents of the University of California. All rights reserved. 2/25/04 Study Design 3-year quasi-randomized educational intervention project (8 sites, 4 each in No. and So. Cal.) Year 1: Material development, staff training, and baseline data collection Year 2: Intervention period Year 3: Post-intervention data collection, write-up, and dissemination Concept: Create a clinic environment supporting positive caregiver-infant interactions Social marketing materials, staff training, handouts, classes, activities, incentives

Our Study Approach Train staff to understand why babies behave the way they do Provide staff with tools (messages, methods, and materials) to help them feel safe and comfortable sharing baby behavior information with parents Use social marketing materials to tell parents that WIC is a place to learn about baby behavior

Handouts

Social Marketing Materials Posters were created to advertise that new information was available Activities and games were available in the waiting areas to promote messages

All Sites Combined: WIC Food Package Selection Copyright 2004, The Regents of the University of California. All rights reserved. 2/25/04 All Sites Combined: WIC Food Package Selection Increase in Excl BF Food Package Intervention = 6.3% (43% higher than baseline) Control = 2.3% Decreased formula use Reduction in cans of formula used while caseload increased

Exclusive BF Food Package by Age

Postpartum Participant Survey Excluding those with self-reported initial medical or latch problems

Postpartum Participant Survey * * * *p<0.05

Postpartum Participant Survey * * * *p<0.05

Infants >95th percentile wt/age Copyright 2004, The Regents of the University of California. All rights reserved. 2/25/04 Infants >95th percentile wt/age Attained weight for age > 95th percentile 5-7 mo * N=411 N=339 According to WHO growth standards NS *P<.01

Baby Behavior at WIC and Beyond California State WIC will use messages statewide Oregon State WIC staff has received training – looking to expand effort Presentations in AZ later this month Efforts ongoing to modify/ translate messages for Russian, Hmong, and Vietnamese populations

Opportunities for Collaboration Efforts underway in Alameda County, Solano County, and Butte County to coordinate agencies to deliver baby behavior messages (as part of continuum of care) Hospitals Child Health and Disability Prevention Program Comprehensive Perinatal Services Program Black Infant Health Early Head Start Home Visitors Teen Parenting Programs

Supporting Informed Infant Feeding Decisions in the First 30 Days Copyright 2004, The Regents of the University of California. All rights reserved. 2/25/04 Supporting Informed Infant Feeding Decisions in the First 30 Days Copyright 2009 UC Regents. All rights reserved.

Copyright 2004, The Regents of the University of California Copyright 2004, The Regents of the University of California. All rights reserved. 2/25/04 “Just in Case” A Qualitative Study of Maternal Request for Hospital Formula 14 focus groups in English and Spanish (N=97) Study focused on maternal request for hospital formula for healthy breastfed infants Moms use formula in the hospital for many of the same reasons they use it at home

Reasons for Supplementation of Healthy Breastfed Newborns Unrealistic expectations about newborns Lack of preparation for breastfeeding Formula seen as the only solution for breastfeeding problems Formula seen as the solution for baby behavior problems

Parents’ Unrealistic Expectations Copyright 2004, The Regents of the University of California. All rights reserved. 2/25/04 Parents’ Unrealistic Expectations “The imagined baby”1 Parents’ prenatal construct of the baby Includes both hopes and fears Will be in conflict with the real baby Cultural norms have idealized the “quiet, full, sleeping” baby2 1. Stern, Pediatrics 1998; 2. Heinig, JHL 2006

Support Strategies Prenatally Ask moms about their expectations and address questions and concerns Gently break the bad news – parenting is tough Help moms build a support group for the first few weeks Share information about normal newborn behavior

Lack of Preparation for Breastfeeding Copyright 2004, The Regents of the University of California. All rights reserved. 2/25/04 Lack of Preparation for Breastfeeding “She had a bottle because the milk wasn’t coming in right away.” “She was a big baby. She would wake up and need to be fed every 3 hours!” “I pumped and I got nothing.”

The Facts Milk doesn’t come in right away Colostrum is important too Copyright 2004, The Regents of the University of California. All rights reserved. 2/25/04 The Facts Milk doesn’t come in right away 85% of mothers - milk comes in at 24-72 hours pp First time moms’ milk comes in later (avg. 70 hrs pp) than moms who have BF before (avg. 56 hrs pp) Colostrum is important too Early milk transfer to the baby varies

Early Milk Transfer to Infants Varies Copyright 2004, The Regents of the University of California. All rights reserved. 2/25/04 Early Milk Transfer to Infants Varies Neville MC et al. Am J Clin Nutr 1988

The Facts Newborns need to be fed very frequently Copyright 2004, The Regents of the University of California. All rights reserved. 2/25/04 The Facts Newborns need to be fed very frequently Frequent feeds can help moms avoid engorgement May feed every 1-2 hours at first, varies widely Days 4 and 5 usually have the most feeds Several mothers thought that the amount pumped was equal to their production Pumps are not as effective as babies in extracting milk Colostrum can be difficult to obtain Too much early pumping can cause engorgement

Support Strategies Make sure that moms know that their milk will come in after they leave the hospital and that it can take several days (must follow-up) Reassure them that colostrum is all newborns need Help moms to understand that babies need to eat frequently because they are so small Make sure that any mom who is pumping is properly trained and supported Limit pumping to those who need it

Breastfeeding Problems Copyright 2004, The Regents of the University of California. All rights reserved. 2/25/04 Breastfeeding Problems Formula perceived as a “solution” to breastfeeding problems – few believed that initial difficulties could be fixed “He didn’t suck well, he rejected it right away.” “I was wondering why he didn’t want to take it. They told me as a first time mom that it was difficult to put him to breast.” Key Points Mothers in the study shared some details about who they felt was in control of the feeding relationship. Some mothers relied on their babies to guide their behavior (read quote). Others felt they lost control of the feeding relationship once family members or others had intervened and fed the baby something other than breast milk or formula. (read quote). Once the baby had received something else, they perceived that the baby was somehow “changed” and they could not go back to exclusive breastfeeding. Breastfeeding advocates should recognize that messages that “even one bottle” can prevent breastfeeding success can feed into this pattern of thinking.

Percentage of Infants with Poor Suck Copyright 2004, The Regents of the University of California. All rights reserved. 2/25/04 Percentage of Infants with Poor Suck Dewey et al. Pediatrics 2003; 112: 607-619.

Support Strategies Make sure that moms know half of all babies will not latch well on the first day but most babies get better quickly with practice (if not, they should call WIC) Make sure moms have resources if they have problems or questions

Copyright 2004, The Regents of the University of California Copyright 2004, The Regents of the University of California. All rights reserved. 2/25/04 Behavioral Problems Parents believed that formula would stop infant crying and promote sleep “Every time that I tried to breastfeed, he would have a tantrum, become really angry. So then I thought ‘Why? Why should I make him suffer?’” “We started the formula on the 2nd day…since he never stopped crying.” “He wasn’t sleeping and was constantly crying and when I would get him to latch, there was nothing.” Key Points Mothers in the study shared some details about who they felt was in control of the feeding relationship. Some mothers relied on their babies to guide their behavior (read quote). Others felt they lost control of the feeding relationship once family members or others had intervened and fed the baby something other than breast milk or formula. (read quote). Once the baby had received something else, they perceived that the baby was somehow “changed” and they could not go back to exclusive breastfeeding. Breastfeeding advocates should recognize that messages that “even one bottle” can prevent breastfeeding success can feed into this pattern of thinking.

The Facts Newborn abilities vary widely Copyright 2004, The Regents of the University of California. All rights reserved. 2/25/04 The Facts Newborn abilities vary widely Ability to control their bodies Range and regulation of states Social interaction skills Cues may be unreadable or conflicting When adults respond to baby cues, babies get better at using cues Sleep is erratic and light (lots of dreaming) Brazelton and many others; Poblano Int J Biol Sci 2008

Support Strategies Help mothers understand why babies cry and wake Copyright 2004, The Regents of the University of California. All rights reserved. 2/25/04 Support Strategies Help mothers understand why babies cry and wake Help them see the baby’s signs of dreaming and cues But, very important not to dismiss mothers’ concerns too quickly Some babies will be in trouble, sometimes it’s the “good” ones

Getting Back to Breastfeeding What happens if a baby is supplemented in the hospital? How can parents be supported to go back to exclusive breastfeeding?

After Supplementation Copyright 2004, The Regents of the University of California. All rights reserved. 2/25/04 After Supplementation Once babies were fed formula, some mothers believed their babies would not go back to breastfeeding “They gave him a bottle at the hospital anyway, so what did you expect?” “My thing is to continue to give him formula because that’s what he was used to and he’d take it…I kinda had to give in ‘cause I didn’t have another option.” Key Points Mothers in the study shared some details about who they felt was in control of the feeding relationship. Some mothers relied on their babies to guide their behavior (read quote). Others felt they lost control of the feeding relationship once family members or others had intervened and fed the baby something other than breast milk or formula. (read quote). Once the baby had received something else, they perceived that the baby was somehow “changed” and they could not go back to exclusive breastfeeding. Breastfeeding advocates should recognize that messages that “even one bottle” can prevent breastfeeding success can feed into this pattern of thinking. Heinig et al. J Hum Lact 2006;22:27-38. Heinig et al. J Hum Lact 2009

Support Strategies Don’t overemphasize “just one bottle” or “nipple confusion” Reassure moms that all babies can go back to exclusive breastfeeding with support Reassure moms that babies don’t “get used” to bottles when they are so young Half of all babies need a few days to learn to latch even if they’ve never had a bottle

After Supplementation Copyright 2004, The Regents of the University of California. All rights reserved. 2/25/04 After Supplementation Many mothers perceived that in-hospital supplementation represented a change in the feeding recommendation “They gave us huge bottles, but I really wanted to breastfeed.” “If the hospital uses it [formula], it must be better because they are up to par with research and everything.” Supplementation was often reported to be open ended No specific amount, no end date, no clear follow-up Key Points Mothers in the study shared some details about who they felt was in control of the feeding relationship. Some mothers relied on their babies to guide their behavior (read quote). Others felt they lost control of the feeding relationship once family members or others had intervened and fed the baby something other than breast milk or formula. (read quote). Once the baby had received something else, they perceived that the baby was somehow “changed” and they could not go back to exclusive breastfeeding. Breastfeeding advocates should recognize that messages that “even one bottle” can prevent breastfeeding success can feed into this pattern of thinking. Heinig et al. J Hum Lact 2006;22:27-38. Heinig et al. J Hum Lact 2009.

Support Strategies Ask moms to clarify with the doctor Not a change in feeding recommendation? How much and how long should supplements be given? Let doctors know what you are hearing Ask them to consider “prescribing” supplementation Clear instructions of amounts, times, duration, follow-up

Copyright 2004, The Regents of the University of California Copyright 2004, The Regents of the University of California. All rights reserved. 2/25/04 Parents’ Fears Exclusive BF may seem overwhelming after supplementation Parents may fear removal of the supplement especially if there was a medical reason for the supplementation Some parents may fear removal of a supplement even if another child was the one with a medical problem Thomasgard M, Metz WP. J Dev Behav Pediatr. 1995;16(1):47-53. Boyce WT. Adv Pediatr. 1992;39:1-33.

Support Strategies Parents need a “safety net” just in case things go wrong Indicators that things are ok or not ok How will the baby look? How will the baby behave? Will there be obvious signs? Phone numbers – who can they call and when are they available Action they can take until they reach you

Summary Many moms use formula in the first 30 days because they are not prepared or informed WIC can help support mothers’ infant feeding decisions by helping them see “the door” and not feel forced to abandon their goals

The Big Picture Baby Behavior at WIC is taught through: Social marketing materials – posters, games Counseling by trained staff Handouts Classes WIC has limited contact with a large diverse population Messages must be modified for other venues