1. 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.

2. 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.

3. 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: 3

4. 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:

5. 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:

6. 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

7. The Project

8. 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

9. 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

10. Handouts

11. 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

12. 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

13. Exclusive BF Food Package by Age

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

15. Postpartum Participant Survey* * *
*p<0.05

16. Postpartum Participant Survey* * *
*p<0.05

17. 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

18. 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

19. 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

20. 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.

21. 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

22. 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

23. 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

24. 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

25. 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.”

26. 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 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

27. 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

28. 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

29. 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

30. 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.

31. 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:

32. 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

33. 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.

34. 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

35. 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

36. 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?

37. 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: Heinig et al. J Hum Lact 2009

38. 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

39. 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: Heinig et al. J Hum Lact 2009.

40. 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

41. 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): Boyce WT. Adv Pediatr. 1992;39:1-33.

42. 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

43. 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

44. 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