FOLLOWUP REPORT: THE SURGEON GENERAL S WORKSHOP ON BREMTFEEDING & HUMAN LACTAnON

Transcription

1 FOLLOWUP REPORT: THE SURGEON GENERAL S WORKSHOP ON BREMTFEEDING & HUMAN LACTAnON Presented by he U.S. DWARTMEM OF HEALTH AND HUMAN SERVICES Pubic Heath Servtce Heafh Resources and Services Administration Bureau of Heath Care Deivery and Assistance Division of Materna and Chid Heath DHHS Pubkation No. HRS-D-MC 85-2

2 .. c Thk report was prepared ivith the assistance of the Nationa Centerfor Education in Materna and Chi!d Heath. 38th & R-Streets, N. W., Washington; D.C The Nationa Center is a resource center that responds to pubic and professiona inquiries in materna and chid heath. incuding human genetics. Estabished in the Nationa Center for Education in Materna and Chid Heath provides services under a grant from the Divkion of Materna and Chid Heath, Department of Heath and Human Services. U.S. NATIONAL MEDICINE 1 -\ 1 I : The oiigina drawing on the cover was done-by Bob Congi of Rochester, N.Y.

3 PREFACE Since the Surgeon Genera s Workshop on Breastfeeding and Human Lactation ast year, there has been a notabe renewa of interest and a resurgence of activity in promotion of breastfeeding. This may be attributed to the phiosophy of shared responsibiity which guided the panning committee in organizing the workshop. The workshop participants, representing many professiona and vountary organizations, were activey invoved in the workshop process of assessing the current status of breastfeeding pro-. motion in the United States and of deveoping recommendations and strategies to faciitate progress toward achieving the 1990 breastfeeding objective for the nation. The workshop recommendations have become a nationa agenda, with participant organizations providing eadership in disseminating the recommendations and encouraging their impementation. The Report of the Surgeon Genera s Workshop on Breastfeeding and Human Lactation, pubished in September 1984; has become a vauabe reference on the science and art of breastfeeding and a usefu panning guide for breastfeeding promotion efforts. The origina printing of 35,000 copies was quicky distributed by participant organizations, and a second printing has been done. This Foowup Report has been prepared to document efforts emanating from the workshop and to continue to disseminate information reated to breastfeeding promotion activies and accompishments. At the workshop four successfu modes to promote breastfeeding were presented. In the past year many additiona approaches have come to our attention. The purpose of this Foowup Report: Surgeon Genera s Workshop on Breastfeeding and Human Lactation is to recognize other usefu approaches, describe these approaches, and identify where they are being impemented. It is hoped that poicymakers, administrators, educators, heath care providers, professiona and vountary organizations, Federa agencies, empoyers, and others who read this Foowup Report wi gain new ideas that wi inspire them to further action. Information incuded in this report was submitted in response to requests made to the participants in the workshop; State Directors of Materna and Chid Heath; members of the Heathy Mothers, Heathy Babies Coaition; and Department of Heath and Human Services Regiona Heath Administrators. The responses were impressive and incuded descriptions of a variety of efforts such as egisation, poicies, resoutions, guideines, meetings, pubications, media campaigns, service deivery modes, support systems, and research, a of which are incuded in this report. ii

4 We are interested in your response to our ongoing efforts to disseminate information and stimuate action to reduce barriers to breastfeeding. Wi you pease take a few minutes to compete the questionnaire on the back cover of this pubication? We recognize and appreciate the new, renewed, and continuing work that is being done in support of improved. heath and nutrition for our nation s mothers and babies. Progress has been made, but many chaenges remain in our efforts to promote informed decisions by more women to breastfeed their babies. C. Everett Koop, M.D., Sc.D. Surgeon Genera *.. 111

5 CONTENTS INTRODUCTION... ACTIVITIES RELATED TO RECOMMENDATIONS OF THE SURGEON GENERALS WORKSHOP ON BREASTFEEDING ANDHUMANLACTATION PROFESSIONAL EDUCATION Task Forces/Work Groups/Committees... Poicies/Standards/Protocos/Curricua... Continuing Education... Professiona Consutation/Technica Assistance... Manuas/Guides/Educationa Materias... PUBLIC EDUCATION Media... Hard-To-ReachGroups... Promotion/Pubic Education Campaigns... Education Systems... Coordination/Sharing of Educationa Materias... Data Coection... HEALTH CARE SYSTEM Poicies/Standards/Protocos... Laws/Reguations... Mode/Demonstration Programs... Staff/Cient Education... Task Forces/Guides/Materias... SUPPORT SERVICES Teephone Caing Systems... Peer Support Groups... Breastfeeding Counseors... Nurse Foowup/Referra... Cinics/Casses... Institutiona Practices... Human Mik Banks iv

6 WORLD OF WORK Data Base Information/Education... g Institutiona Poicies... ;... Breast Pump Loan Programs... z: Mode/Demonstration Programs... RESEARCH Trend Data Determinants/Behaviors/Practices/Attitudes Physioogy/Nutrition/Other Aspects Interventions/Strategies NATIONAL AWARENESS CONTRIBUTORS...,,..., APPENDIX A-Task Force on Professiona Training in Lactation.. 38 APPENDIX B-Research on Human Lactation and Breastfeeding Supported by the Nationa Institutes of Heath, Department of Heath and Human Services APPENDIX C-Research on Human Lactation and Breastfeeding Supported by the U.S. Department of Agricuture.. 45 QUESTIONNAIRE C-III V

7 INTRODUCTION The Surgeon Genera s Workshop on Breastfeeding and Human Lactation was convened in Rochester, NY on June 11-12, Presented by the Division of Materna and Chid Heath in cooperation with the University of Rochester Medica Center, the workshop was directed toward the achievement of the 1990 nationa objective of increasing the number of women who breastfeed their infants and the duration of breastfeeding. Specific objectives of the workshop were: To review progress of past efforts, in both pubic and private sectors, to promote breastfeeding To assess the state-of-the-art reated to factors that enhance and those that inhibit breastfeeding and human actation To determine remaining issues To deveop strategies and recommendations in order to faciitate progress toward achieving the 1990 breastfeeding objective Workshop participants incuded many discipines serving different ethnic, cutura, and income groups in a wide variety of practice settings. Professiona and ay organizations; oca, State, and Federa governments; industry; and vountary groups were a represented. The Report of the Surgeon Genera s Wotkshop on Breastfeeding and Human Lactation was disseminated in October Six recommendations with suggested strategies to faciitate progress toward achieving the 1990 objective were presented to the Surgeon Genera. The recommendations were: Improve professiona education in human actation and breast feeding Deveop pubic education and promotiona efforts Strengthen the support for breastfeeding in the heath care system Deveop a broad range of support services in the community Initiate a nationa breastfeeding promotion effort directed to women in the word of work Expand research on human actation and breastfeeding The Division of Materna and Chid Heath of the Pubic Heath Service, in coaboration with other pubic and private agencies, encourages, supports, assesses progress, and evauates foowup action reated to the workshop recommendations. Efforts to increase the incidence and duration of breastfeeding in the United States were underway prior to the Surgeon Genera s Workshop. However, as a resut of the workshop, many of these efforts have been intensified and expanded. In addition, a significant

8 number of other activities have been initiated in direct response to the issues identified at the workshop, and strategies designed to promote breastfeeding, particuary in popuation groups with ow incidence of breastfeeding, have been impemented across the nation. This Foowup Report is presented to share information about the wide range of foowup action which emanated from the workshop. A arge voume of information about foowup action was received from a broad spectrum of individuas, agencies, and organizations. In order to ensure a report of reasonabe ength, it was possibe to incude ony exampes or iustrations of the scope of activities undertaken, and to present these in abbreviated or abstract form. The information is organized according to the recommendations isted above. Sections on Nationa Awareness and Contributors are aso incuded, as we as Appendices. It is hoped that the report wi stimuate the interest and increase the support of a who can have an impact on breastfeeding decisions and opportunities. The utimate goa is a continuing commitment to the promotion of breastfeeding and improvement of materna and chid heath.

9 ACTIVITIES RELATED TO RECOMMENDATIONS OF THE SURGEON GENERAL S WORKSHOP ON BREASTFEEDING AND HUMAN LACTATION PROFESSIONAL EDUCATION Recommendation: Improve professiona education in human actation and breastfeeding The improvement of didactic and cinica training in actation and breastfeeding, and the deveopment of skis in patient education and management of breastfeeding for a heath care professionas, were major goas of this recommendation. Concerns about the avaiabiity and quaity of professiona education reated to breastfeeding and actation incude: 1) the absence of appropriate curricua which recognizes the diversity of sociocutura and economic groups in the popuation as we as the roes/responsibiities of various heath professionas, 2) the inadequate funding for preparation of facuty to direct and provide training, 3) the unavaiabiity of educationa programs and resources to support the education of practicing professionas, and 4) the ack of appropriate invovement of accreditation and standard-setting bodies to assure the competence of heath professionas and others invoved in materna and chid heath care. Foowup on this recommendation is receiving priority in most parts of the nation, and significant steps have been taken to improve the education of a wide range of providers who can have an impact on breastfeeding decisions. These steps revove around the foowing major types of action: convening task forces, work groups, and committees to focus on professiona education; deveoping and promugating poicies, standards, protocos, and curricua to guide professiona action; offering continuing education to a wide range of heath care providers; providing professiona consutation and technica assistance to upgrade the knowedge and skis of heath professionas; and pubishing manuas, guides, and educationa materias for professiona reference. Seected exampes of each of the above types of action foow. Task Forces/Work Groups/Committees A nationa Task Force on Professiona Training in Lactation was convened in June 1985 by the University of Rochester Medica Center with support from the Division of Materna and Chid Heath, Department of Heath and Human Services to review the activities of professiona groups pursuant to this recommendation and to determine additiona efforts that need to be panned to improve professiona education in the areas of actation and breastfeeding. About 20 major professiona organizations and vountary agencies concerned with perinata heath, education of professionas, and standards of practice were represented. A mode poicy state- 3

10 ment, Promotion of Breastfeeding in the Context of Heath Care: Professiona Training Priorities, and a set of objectives were deveoped (see Appendix A). Task Force members agreed to a foowup strategy which caed for each organization to endorse the joint poicy statement or deveop one of its own, and to review the objectives, identifying specific actions to be undertaken by the organization to achieve them. It is expected that the task force meeting wi faciitate networking and resut in cooperative training programs. As wi be noted in the section on Pubic Education, many of the state and community coaitions organized to promote breastfeeding incude a work group or committee specificay concerned with professiona education. For exampe, one subcommittee of the Virginia Task Force on Breastfeeding is investigating continuing education opportunities reated to actation for heath care professionas in that state; the New York City Steering Committee to Promote Breastfeeding has a task group to focus on training of hospita staff; and one of the Montgomery County, MD Breastfeeding Coaition s committees focuses on professiona education of physicians. Poicies/Standards/Protocos/Curricua Not ony are Federa, State, and oca pubic agencies, nationa organizations, and vountary agencies deveoping new or additiona poicy statements, standards, protocos, curricua, and other types of guidance on breastfeeding, but they are aso taking positive action to ensure their dissemination and impementation. Iustrations of specific activities are given beow: The Division of Materna and Chid Heath, Department of Heath and Human Services issued a Regiona Program Guidance Memorandum on Breastfeeding Promotion Efforts to its regiona office staff members in Materna and Chid Heath, Primary Care, and the Nationa Heath Service Corps. The Division of Materna and Chid Heath aso sent copies of the Heathy Mothers, Heathy Babies Breastfeeding Packet to the State Directors of Materna and Chid Heath and to a regiona offices of the Department of Heath and Human Services for reference use of staff and for broad dissemination to their state and oca co-workers. Poicy and position statements reated to breastfeeding deveoped by many professiona organizations remain in effect. These incude issuances from the American Academy of Pediatrics, American Coege of Obstetricians and Gynecoogists, the Nationa Association of Pediatric Nurse Associates and Practitioners, and the American Pubic Heath Association. Other groups report that they are in the process of deveoping new, or additiona, poicy and position statements reated to breastfeeding. These incude the Nationa Perinata Association and The American Dietetic Association. The Tennessee Department of Heath and Environment deveoped 1) a protoco on providing support to breastfeeding mothers for use in oca heath departments, 2) esson pans on breastfeeding management in hospitas for use in training of hospita staff, and 3) guideines for enisting the support of oca heath care providers and heath professiona training programs. 4

11 The Steering Committee to Promote Breastfeeding in New York City deveoped a curricuum which specifies breastfeeding knowedge and skis necessary for hospita staff. It wi be used to train monitors and heath care workers invoved in impementation of New York State s new reguations supporting breastfeeding in hospitas. Their Guide to Promoting Breastfeeding in the Hospita wi be distributed widey by the State Heath Department. Heath Education Associates (PA) issued two new education aids designed to hep impement recommendations of the Surgeon Genera s Workshop. The Breastfeeding Teaching Box for In-Hospita Teaching is a box of teaching cards for instructor use in any setting in which mothers initiate breastfeeding. The Kit for Preventing Breastfeeding Probems and Eary Faiure provides compete instructions and materias for use in deveoping a teephone ca system to assist nursing mothers. Based on the reaization that many give up breastfeeding very easiy, the kit uses a triage mode to differentiate among women with different eves of interest and motivation in breastfeeding and to focus on providing practica hep to each woman as indicated. Famiy Medicine Center, Durham Heath Care, Inc. (NC) has incorporated didactic materia on actation and breastfeeding in the nutrition curricuum deveoped for its residency program. Future pans incude deveopment of a counseing component of the nutrition curricuum to increase competency of famiy physicians in counseing breastfeeding mothers. The first credentiaing exam for actation consutants was given in Juy 1985 in Washington, DC by the Internationa Board of Lactation Consutant Examiners. Continuing Education Positive steps are being taken in many states, oca communities, and agencies across the nation to provide in-service education in actation and breastfeeding to a wide range of care providers. In some states, educationa resources such as the Nationa Chid Nutrition Project (PA) and Heath Education Associates (PA) are utiized for workshops and conferences. These states incude: Caifornia, Idaho, Iinois, Maryand, Mississippi, Montana, New Hampshire, North Dakota, South Dakota, Vermont, and Washington as we as severa states in Department of Heath and Human Services Region VI. Often personne in neighboring states participate; for exampe, Maine sent staff to the New Hampshire workshop. In other states, the state heath agency works cosey with educationa institutions and various agencies to provide continuing education in actation and breastfeeding. Frequenty these continuing education courses invove one or more sessions incorporated into a broader topic on materna and chid heath; often the conference focuses soey on actation. States invoved in these activities incude: Aaska, Coorado, Connecticut, Georgia, Iowa, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Jersey, New York, Ohio, Pennsyvania, South Dakota, Utah, Washington, and Wyoming. Both pubic and private community agencies in various ocaities aso conduct in-service training for their own staff as we as that of other agen- 5

12 ties. For exampe, the nutrition staff of the Wiiam F. Ryan Community Heath Center (NY) participated in ongoing professiona conferences on breastfeeding education. In Indiana, the Rura Heath Activities Project and Margaret Mary Community Hospita sponsored a wofkshop. La Leche League reports the continuation of ong-standing professiona seminars for physicians, and the impementation of additiona educationa opportunities for heath professionas and breastfeeding counseors. Medica centers aso pay a key roe in sponsoring professiona education opportunities, often in cooperation with other groups. These incude the University of Rochester Medica Center (NY), Case Western Reserve University and Rainbow Babies and Chidren Hospita (OH), and Georgetown University Hospita s Department of Nursing (DC). Vountary agencies and professiona organizations contribute to upgrading the knowedge and skis of professionas. The March of Dimes Birth Defects Foundation and The American Dietetic Association incude actation and breastfeeding as important topics in their nationwide series of symposia for dietitians, nurses, and physicians, designed to address nutrition in perinata heath care incuding the short- and the ong-term support of critica and convaescing premature infants. Papers and sessions on breastfeeding are incuded in the annua meeting programs of such professiona organizations as the American Medica Women s Association, American Coege of Obstetricians and Gynecoogists, and the Nationa Association of Pediatric Nurse Associates and Practitioners. The twefth and thirteenth annua Seminars for Physicans on Breastfeeding sponsored by La Leche League nternationa were hed in Montrea, Canada in 1984 and in Washington, DC in Professiona Consutation/Technica Assistance In order to hep heath care providers deveop skis in patient education and management of breastfeeding, many agencies continue or are expanding their professiona consutation and technica assistance services to staff in a wide variety of practice settings. For exampe, the three-year demonstration project sponsored jointy by the Departments of Pediatrics, Obstetrics, and Community Heath of the Abert Einstein Coege of Medicine (NY), and supported as a Tite V Specia Project of Regiona and Nationa Significance, is designed to improve the incidence and duration of breastfeeding among ow-income women in the Bronx. A actation consutation team consisting of a nutritionist, nurse, and obstetrician provides consutation and education services in the three municipa hospitas in the Bronx and the eeven community heath centers that constitute the Bronx Committee for the Community s Heath. Whie members of the team provide consutation to mothers with breastfeeding probems, primary emphasis is given to education and training activities directed toward providers of care. The San Diego Lactation Program continues to provide intensive training and consutation to professiona care providers. For exampe, the Popuation Counci of New York utiized staff from the San Diego program for a day-ong workshop for key staff members of the municipa hospita system. This workshop consisted of on-site visits to seected hospitas to meet with staff and conduct bedside demonstrations of techniques to assist 6

13 mothers with breastfeeding. A foowup visit one year ater was made to the target hospita to address specific concerns of staff. Manuas/Guides/Educationa Materias A significant number of educationa materias designed for professiona reference and use were avaiabe prior to the Surgeon Genera s Workshop. Since the Workshop a renewed effort has been made to improve their dissemination and to deveop additiona materias to meet specia needs and fi existing gaps. Exampes of activities reated to this effort incude: The Heathy Mothers, Heathy Babies Coaition s Breastfeeding Promotion Packet was assembed with eadership from the American Academy of Pediatrics and contributions from seected Federa and State agencies and professiona organizations. Amost 2,000 copies of this educationa packet on breastfeeding have been disseminated nationwide. The packet incudes reprints of scientific artices on actation and breastfeeding; bibiographies of seected technica references and resource materias; sampe materias for cient education; a how-to guide to assist individuas, agencies, and communities to promote breastfeeding; and a ist of key organizationa contacts by state. In some states, materias in the packet have been made more widey avaiabe to heath professionas working within the state. The Nationa Chid Nutrition Project (PA) pubished A Guide 10 Breastfeeding - Principes, Practices and Probems. It is intended as a guide for medica professionas and others who work with expectant and new mothers. The Popuation Counci s Program for Appropriate Technoogy in Heath has deveoped Breastfeeding: A Nurse s Guide for use in conjunction with two cient bookets, A Mothers Guide to Breastfeeding and Su Guia de a Lactancia Materna. Intended for use by hospita staff and mothers, the bookets are designed to hep them initiate and maintain breastfeeding. Drawings and simpy stated messages are used to iustrate and expain breastfeeding. The United States Department of Agricuture, Food and Nutrition Service, with support from the Infant Formua Counci, pubished and disseminated Promoting Breastfeeding: A Guide for Heath Professionas Working in the WIC and CSF Programs. The guide is intended to provide a variety of ideas and successsfu approaches to hep staff be more effective in their efforts to promote breastfeeding among owincome women. The Nationa Center for Education in Materna and Chid Heath continues to make avaiabe the video-tape on breastfeeding from the nationwide teeconference entited Improving Nutrition for Mothers and Babies: A Research Update - Breastfeeding and Human Lactation. 7

14 PUBLIC EDUCATION Recommendation: Deveop pubic education an4 promotiona efforts There is a need to improve the avaiabiity and quaity of information and education about actation and breastfeeding as a norma process, a part of everyday ife, and the preferred method of infant feeding. Important aspects of this recommendation incude the deveopment and dissemination of accurate and consistent messages about breastfeeding, increased use of the educationa system and the media; coordination with professiona education; recognition and targeting of various economic, cutura, and ethnic groups; and encouragement of pubic officias and other eaders who can infuence community support for breastfeeding. A wide range of efforts have been stimuated by the workshop and impemented to improve pubic information and education about breastfeeding and actation. Incuded are activities designed to make more effective use of various media, improve targeting of hard-to-reach groups, deveop state and community promotion and pubic education campaigns, integrate breastfeeding information into education systems, coordinate and share educationa materias, and coect data to monitor changes in attitudes and behavior. Iustrations of these various activities foow. Media Increased use has been made of teevision, radio, newspapers, magazines, posters, fims, dispay ads, educationa materias, and other media to enhance awareness of breastfeeding as the norm and to encourage the deveopment of attitudes and behaviors that support it. For exampe, the Pubic Education Task Group, New York City Steering Committee to Promote Breastfeeding, competed a three-pronged strategy as the basis of a pubic information campaign. Incuded were a media effort composed of a subway poster, press conference, caravan of mothers breastfeeding on the subway with teevision, radio, and press coverage; a teephone information effort which provided counseing and referra; and an informationa pamphet for use in heath cinics and other service settings. A speakers bureau was organized, and resource materias were deveoped for use in pubic presentations during a city-wide Prenata Care Week program. An estimated four miion New Yorkers had some exposure to the two-month pubic information campaign in the fa of The Wisconsin Nutrition Project, Inc., deveoped two radio and two teevision pubic service annoucements to promote breastfeeding. The Tennessee Breastfeeding Task Force deveoped a pubic service annoucement to educate the pubic and encourage pregnant women to contact the heath 8

15 department for breastfeeding information, whie the North Jersey Community Union in Newark aso conducted a media campaign about breastfeeding. Actress Linda Kesey has formed a non-profit, organization, Metanoia (a Greek work meaning change of heart ), to foster a change on the part of miions of mothers around the word to choose breastfeeding. Metanoia has produced a 30-second pubic service announcement in Engish and Spanish to promote breastfeeding and wi have a to-free 800 teephone number which viewers wi be abe to ca for information. The pubic service announcement wi be avaiabe for use by states in their Heathy Mothers, Heathy Babies pubic information efforts. Posters and eafets for use in a wide variety of settings were deveoped by the New York State Heath Department in cooperation with the New York City Heath Department and the New York City Medica and Heath Research Association. The Heathy Mothers, Heathy Babies Coaition has continued to emphasize breastfeeding in its pubic education effort. Breastfeeding is the topic of one of a series of six posters and information cards deveoped for use in cinics serving ow-income pregnant women. Over a miion breastfeeding information cards in Engish and Spanish have been distributed to ow-income women. A student in the Department of Heath Education at Hunter Coege, New York City, is conducting a survey of women to evauate the effectiveness of different types of posters in getting the breastfeeding message to women. Videotapes to present information to cients were prepared by the Jackson County, IL pubic heath program and by Charity Hospita in New Oreans, LA. The atter tape was fimed in a cient s home, and a cient narrated the fim. Cosed-circuit teevision is made avaiabe to patients at the Kapioani Women and Chidren s Medica Center in Hawaii, and breastfeeding fims are shown daiy. Fims were aso prepared and disseminated to increase pubic education about breastfeeding. In Kansas, the State Department of Heath and Environment and the Kansas University Medica Center produced Breastfeeding in the 1980 s. The producers of a three-part educationa fim series on breastfeeding, Motion, Inc., offered a specia discount on fim orders received before March 31, 1985, in recognition of the Surgeon Genera s commitment to promote breastfeeding. The New Jersey State Department of Heath, with support from the Ford Foundation, deveoped a fim entited Liy s Choice for use with ow-income popuations. Outside My Mom: The Story of a Breastfed Baby is an 1 -minute audiovisua presentation avaiabe from the March of Dimes Birth Defects Foundation. It is avaiabe in coor sides or fimstrip with audio-cassette and comes with a teaching guide and pamphets for viewers. Other innovative activities reated to the use of media incude the deveopment of a guide, Starting a Teephone Support System for Breastfeeding Mothers, by the Wisconsin Nutrition Project, Inc., and the Aabama State Heath Department s use of speciay designed postcards. Maied to mothers of breastfed infants when infants are ten days, three weeks, and six weeks of age, the cards provided information designed to encourage continuation of breastfeeding. 9

16 New or additiona educationa materias on breastfeeding were deveoped by numerous organizations and agencies, and many took steps to expand the dissemination and use of existing materias. For exampe, the Missouri Division of Heath deveoped an information packet on breastfeeding for diabetics, whie the Naturist Society and the State Heath Departments in Aaska, Coorado, Iinois, Indiana, Minnesota, New York, Wisconsin, and Wyoming deveoped or provided for new materias on breastfeeding. The Utah State Heath Department initiated a periodic newsetter for a new mothers in the state, and it wi incude information on breastfeeding. The American Academy of Pediatrics, the Department of Heath and Human Services/Division of Materna and Chid Heath, the United States Department of Agricuture/Food and Nutrition Service, the Bayor Coege of Medicine/Department of Pediatrics, and The American Dietetic Association cooperated in the deveopment and dissemination of two pubications on breastfeeding-a Gift of Love and Breastfeeding: Baby s Best Start. The atter is written in both Engish and Spanish. Hard-To-Reach Groups Some of the educationa materias on breastfeeding described above were pubished in severa anguages to meet cient needs and in simpified formats for cients with imited reading skis. For exampe, the Popuation Counci of New York deveoped a new set of educationa mater,ia for women with imited reading abiity. Heping Mothers to Breastfeed, Program Strategies for Minority Communities, a guide edited by Judith D. Gusser and Caro A. Bryant, was pubished by the Lexington-Fayette County Heath Department (KY) and the University of Kentucky Coege of Medicine. Based on a breastfeeding promotion workshop supported by Ross Laboratories, the pubication incudes reports from peope directing successfu breastfeeding programs for ow-income mothers in severa rura communities and ethnic groups in widey scattered geographic areas. Forida has deveoped a poster to promote breastfeeding among its new refugee popuations. Many immigrants from deveoping countries view botte-feeding as the accepted method of infant feeding in the United States. The poster in Engish, Spanish, and Haitian Creoe versions says Discover the New American Way of Infant Feeding. In New York City, the Expanded Food and Nutrition Education Program aides acceerated their activities to promote breastfeeding among owincome women. Emphasis is given to recruitment of pregnant women, particuary pregnant teens, use of vounteers to provide a support network, and use of eafets and brochures adapted to cient needs. To provide prenata education for young parents in rura areas, the University of Wyoming deveoped tweve side-tape modues, one of which is on breastfeeding. Recognizing that grandmothers and other cose kin can be important support persons for new parents, the Internationa Chidbirth Education Association, Inc., has deveoped a eafet entited To the Grandmother of the Breastfed Baby. Grandmother casses offered during the prenata and postnata periods to hep cose kin earn current concepts of materna and infant care and nutrition are aso recommended. Such casses can update 10

17 grandmothers on new concepts and practices that have changed during the ast generation and can hep them deveop supportive attitudes and techniques. Many of the breastfeeding promotiona campaigns described ater in this section focus considerabe attention on hard-to-reach groups. The District of Coumbia s campaign, for exampe, is targeted for ow-income minorities who reside in the District as we as for oca professiona and paraprofessiona providers who deiver heath and socia services to these groups. Promotion/Pubic Education Campaigns One of the most interesting foowup activities was the initiation and expansion of coaition-type organizations in states and communities across the nation to mobiize community interest and support for breastfeeding. Foowing are a few iustrations of these organizing efforts. The Virginia Task Force on Breastfeeding currenty incudes representatives from heath departments and hospitas and wi be expanded to incude individuas from primary care centers and other interested groups. Three subcommittees are invoved in obtaining baseine data about breastfeeding promotion and education, investigating opportunities for continuing education avaiabe for heath care professionas, and reviewing the avaiabiity of support services and systems. The Georgia Breastfeeding Promotion Steering Committee incudes representatives from medica organizations, nationa foundations, and educationa institutions. Pans are underway to convene breastfeeding workshops for professionas and sponsor other promotiona activities. The District of Coumbia s Breastfeeding Promotion Campaign was aunched in September Individuas and organizations from the private and pubic sectors are cooperating to address barriers that interfere with the initiation and continuation of breastfeeding. Tennessee s Breastfeeding Promotion Task Force was organized to deveop a statewide breastfeeding education and promotion campaign. It is composed of representatives from the nursing, nutrition, and materna and chid heath divisions of the State Department of Pubic Heath. A technica advisory committee has been organized and incudes two private-practice obstetricians, the chairman of the Perinata Advisory Committee of the state chapter of the American Academy of Pediatrics, two university nursing professors, and a hospita nurse and actation counseor. A poicy etter stressing the importance of providing services that support breastfeeding has been issued to a oca heath departments in the state. A workshop, entited Promoting Breastfeeding in Massachusetts: Research Issues, Poicy Impications and Practica Strategies, was hed to set the groundwork for a statewide campaign. Organized by the Massachusetts Breastfeeding Promotion Task Force, the workshop was cosponsored by the Massachusetts Department of Pubic Heath, Boston University Schoo of Pubic Heath, Boston Area Heath Education Center, Department of Heath and Hospitas, and the Erna Yaffe Foundation. Numerous state, professiona, and vountary organizations were invoved. Conference proceedings wi be avaiabe in December Cities and counties in various geographic areas were aso active in promoting breastfeeding. For exampe, the La Crosse, WI Breastfeeding Task 11

18 Force, organized in 1982, has continued its efforts to work with oca hospitas, cinics, socia services, and Women, Infants, and Chidren programs to increase the incidence and duration of brgastfeeding. The Las Vegas, NV Perinata Coaition is working to invove the La Leche League in staff training and to modify hospita poicies which have discouraged breastfeeding. The Montgomery County, MD Breastfeeding Coaition has deveoped Guideines for Enisting Support of Loca Heath Care Providers and Heath Professiona Training Programs. Four committees have been estabished: Patient Education, Professiona Eduction for Physicians, Community Outreach, and Literature. The Steering Committee to Promote Breastfeeding in New York City continues to impement specific strategies to promote breastfeeding. The work of six task groups is we underway, and reports of some of their activities are discussed in other sections of this report. In addition to a of these state and oca coaition activities, Heathy Mothers, Heathy Babies state coaitions in Arizona, Caifornia, Maryand, and Montana reported a focus on the promotion of breastfeeding. Education Systems Limited efforts to integrate breastfeeding information into existing secondary schoo curricua and educationa programs and systems are being reported. The New York State Heath Department reported oaning fims on breastfeeding free of charge to schoos for famiy ife education courses. In Arizona, La Leche League members are invited to speak in some schoos. Primary care projects such as North Jefferson Heath Systems, Inc., Cayton, NY provide fims, informationa materias, and staff to ecture on breastfeeding in schoos. In addition, prenata and parenting casses conducted by a wide variety of heath agencies incude information on breastfeeding. Such agencies incude Cinica Sierra Vista (Lamont, CA), Northern Oswego County Heath Services, Inc. (Puaski, NY), San Juan Department of Heath and the Conciia De Saud Integra De Loiza, Inc. (PR), and the Anchorage Heath Department (AK). Coordination/Sharing of Educationa Materias Educationa materias on breastfeeding deveoped by such organizations as La Leche League, Internationa Chidbirth Education Association, the American Academy of Pediatrics, and The American Dietetic Association are utiized nationwide. In addition, information and materias avaiabe from industries such as Ross Laboratories, Mead Johnson, Wyeth Laboratories, and Gerber are aso used and adapted as necessary. Many oca heath departments report that they utiize materias from their respective state heath agencies. Data Coection It appears that more effort is being made to coect baseine data usefu in monitoring changes in attitudes and behavior reated to breastfeeding. States utiizing the automated data system of the Women, Infants, and Chidren program to monitor the incidence of breastfeeding are Aabama, Arizona, Coorado, Connecticut, Iowa, Kentucky, Maine, Montana, 12

19 Nebraska, New Jersey, North Caroina, Rhode Isand, Tennessee, and Wisconsin. Over 300 materna and chid heath agencies and primary care programs in the Department of Heath and Human Services Region VI have surveyed knowedge, attitudes, and practices among their cients. Maine, Caifornia, and Oregon report use of their state-wide newborn screening program data base to determine incidence of breastfeeding. In Maine, for exampe, a recenty initiated Newborn Breastfeeding Surveiance Program provides information on breastfeeding rates in Maine hospitas and about feeding practices of at east 90 percent of the newborns in the state. The Ross Laboratories Nationa Mothers Survey is conducted on an annua basis to track infant feeding practices in the United States. The data from the 1984 survey are schedued to be pubished in the December 1985 issue of Pediatrics. Surveys to assess practices and poicies were aso conducted by Aaska s State Department of Heath and Socia Services; Arizona s State Department of Heath; St. Louis, Missouri s County and City Women, Infants, and Chidren Advisory Counci; and Tennessee s State Department of Pubic Heath. The surveys obtained information from mothers, birth certificates, hospitas, heath programs, and other data sources. 13

20 HEALTH CARE SYSTEM Recommendation: Strengthen the support for breastfeeding in the heath care system Practices of the heath care team and poicies of heath care institutions do not aways refect concern for actation and the promotion of breastfeeding. In fact, frequenty they negate support for it. This recommendation deas with the need for breastfeeding promotion in ambuatory heath care settings as we as hospitas. The need for education for a members of the heath care team about the process and the advantages of actation in human reproduction and infant heath was emphasized. Adoption of institutiona poicies supportive of actation and breastfeeding and remova of disincentives to breastfeeding were recommended. Many supportive actions are aso reported under Professiona Education and Support Services. Five different strategies appeared frequenty to be used to strengthen the heath care system s support of breastfeeding. These incude: deveopment and promugation of institutiona poicies, standards, and protocos; modification or enactment of aws and reguations; impementation of mode or demonstration programs; education of staff and cients; and deveopment of task forces, guides, and materias. Exampes of each of these strategies foow. Poicies/Standards/Protocos Federa, state, and oca agencies report the deveopment, adoption, and dissemination of poicies, standards, and protocos designed to increase support for breastfeeding in the heath care system. Some exampes are given beow: The United States Department of Agricuture revised Efforts To Promote Breastfeeding in the Suppementa Food Programs, a fact sheet which describes federa requirements, pubications, and guidance avaiabe from the United States Department of Agricuture, cooperative efforts, and other usefu information. The Division of Materna and Chid Heath/Department of Heath and Human Services incuded breastfeeding promotion as a priority area for competitive grant appications for Fisca Year 1985 funding under the Materna and Chid Heath Improvement Projects category of Specia Projects of Regiona and Nationa Significance. In New Mexico, nutrition recommendations for actating women and infant feeding were incuded in a state nutrition manua. Breastfeeding: A Probem Soving Manua was aso deveoped by the nutrition staff of the state heath agency for use by nurses, nutritionists, and other heath professionas. 14

21 8 The Women, Infants, and Chidren and the Commodity Suppementa Foods Program State Pans and Poicies continue to emphasize breastfeeding as a priority among program goas. Connecticut, Minnesota, and Wisconsin Women, Infants, and Chidren programs require each oca agency to incude measures to promote breastfeeding in its annua pan. A poicy and procedure manua on breastfeeding for babies requiring newborn intensive care and other specia care was deveoped at the University of Kansas Medica Center. Poicy changes have been instituted to support breastfeeding of preterm and sick infants. Six Steps to Breast Feeding Promotion: A Handbook for Heath Care Professionas in Materna and Infant Care Faciities was deveoped by the Prenata and Postpartum Ambuatory Care Task Group of the Steering Committee to Promote Breastfeeding in New York City. The Suggested Guideines and Standards for Materna and Perinata Nutrition Care, which incudes breastfeeding, continues to be promugated by the Michigan Heath Department in cooperation with the Michigan State Medica Society and the Michigan Dietetic Association. A Mode Breastfeeding Poicy for Fu-Term Norma Newborn Infants was deveoped by the San Diego Lactation Program (CA), and a simiar poicy is in preparation by the Greater Southeast Community Hospita (DC). A Breastfeeding Promotion Poicy, issued by the Tennessee Department of Heath and Environment, is posted in every heath department cinic statewide. A Breastfeeding Promotion Handbook to assist oca heath departments with panning and impementing such efforts is being competed. The Arkansas Pubic Heath Association adopted the American Pubic Heath Association resoution on Breastfeeding Encouragement. 0 The Georgia Division of Pubic Heath, Office of Nutrition deveoped a position paper on breastfeeding. Guideines are aso being prepared and wi be distributed statewide as part of a practice manua. Quaity assurance standards for actation were deveoped by the Materna and Chid Heath Division, Indiana Department of Heath, and made avaiabe for use in a oca heath services. Laws/Reguations This particuar strategy has not been used extensivey, but severa states have undertaken activities reated to either changing existing aws and reguations, or deveoping new ones in order to infuence the heath care system to faciitate breastfeeding. Some of these activities are given beow: In New York State, breastfeeding reguations were issued as an amendment to the New York Hospita Code (see Support Services). In Massachusetts, there is a proposed amendment to the patients bi of rights to inform prenata and maternity patients about the heath benefits and techniques of breastfeeding and actation. The bi (S2269) is in the Senate Steering and Poicy Committee. In the Pacific Basin, a mode bii supporting the promotion of breastfeeding and adaptabe to each jurisdiction is being prepared for incusion in a breastfeeding packet, This effort is part of the focus on breastfeeding, a priority of the Pacific Basin Materna and Chid Heath Resource Center IS

22 at the University of Guam. This center is supported by Division of Materna and Chid Heath funds. Mode/Demonstration Programs Many agencies impemented a variety of mode or demonstration programs which provide continuous support, professiona consutation, cient counseing, and education. Descriptions of a number of these programs are mentioned beow: The Lactation Project at Oregon Heath Sciences University Hospita serves women who deiver their babies there as we as those referred by private physicians. The project incudes a actation cinic, inservice training of staff, consutation to staff and private physicians, teephone foowup of cinic cients, and prenata education which incudes breastfeeding. The Mode Breastfeeding Program of Tacoma-Pierce County Heath Department is supported by the Washington State Office of Materna and Chid Heath. Detais of this project are discussed under Support Services. The project Overcoming Constraints to Breastfeeding in Lower Socioeconomic Urban Groups has been continued by the Popuation Counci (NY). Focusing on factors over which hospita staff coud exert some contro, a Nursing Department Lactation Committee was deveoped in the hospita. Functions of the Committee reate to staff and patient education, reporting techniques, and deveopment of more consistent, quaity nursing care throughout the period of pregnancy, actation, and infancy. An interdiscipinary group meets on an ad hoc basis to examine impediments to breastfeeding as they reate to medica and nursing issues. Pans incude empoyment of a part-time actation counseor, a teephone hotine for nursing mothers, and training of a mutidiscipine staff. The three-year SPRANS Breastfeeding Project at Abert Einstein Coege of Medicine (NY) is described under Professiona Education. In addition to activities cited esewhere, a curricuum outine, Art and Science of Breastfeeding, and a form for prenata pediatric interviews have been deveoped. A joint breastfeeding promotion project of the Washington State Office of Materna and Chid Heath Services and the Seatte-King County Department of Pubic Heath is deveoping a system to promote breastfeeding that can be repicated statewide. Supported as a Tite V Materna and Chid Heath Improvement Project, the goas of the project are: to estabish a mode for increasing the incidence and duration of breastfeeding among ow-income and minority women that incorporates support for breastfeeding into the existing heath care deivery system; to provide breastfeeding education to pubic heath professionas throughout Washington; and to deveop breastfeeding education materias for statewide use. A mode of service wi be deveoped, impemented, and evauated at two sites that currenty have very ow rates of breastfeeding. A manua to assist others in the deveopment of simiar projects wi aso be written. A breastfeeding promotion project conducted by Renewabe Technoogies, Inc., in Butte, MT aims to deveop breastfeeding counse- 16

23 ing and support in the existing private materna and infant care system where virtuay a such care is provided in Montana. Heath care professionas (nurse, nurse-midwife, dietitian) wi function as breastfeeding subspeciaists who wi become sef-supporting independent practitioners in the existing private system. The cost of providing breastfeeding support services by a breastfeeding subspeciaist and the potentia for any reimbursement for payment of these services wi be determined. The piot project Materna and Chid Heath Modue has been initiated at Shady Grove Adventist Hospita (MD). The focus incudes change in hospita poicies, staff education, and a strengthening of referra and foowup. The Breastfeeding Promotion Program at Yeatman, Union-Sarah Medica Heath Centers, St. Louis, MO, invoves promotion, education, counseing, and support activities. An ad hoc task force was organized to expore the feasibiity of such a program and assist in its impementation. A prenata counseing protoco was estabished. A series of etters to the cient s famiy, incuding grandparents and fathers, was deveoped and many other actions impemented. A project reated to promotion of breastfeeding in the hospita setting was conducted by the Division of Chid and Famiy Heath, Department of Heath and Wefare, Canada. Another project invoved the deveopment of a counseing guide, Feeding Babies in the Eighties, for heath professionas. Staff/Cient Education A diverse group of heath care agencies took positive steps to improve the knowedge and skis of staff and cients invoved in the heath care system. Activities directy reated to this recommendation are aso discussed under Professiona Education, Pubic Education, and Support Services, and some are mentioned in the paragraphs that foow: The first step in a mutifaceted program for Aabama s heath department personne is in-service training on aspects of breastfeeding promotion. Five of the ten heath districts are focusing on increasing the incidence of breastfeeding. Significant numbers of community heath centers have stepped up their efforts to provide individua counseing and patient education, and to use prenata and chidbirth preparation casses effectivey for education regarding breastfeeding. Among such heath centers were the Oak Orchard Heath Center and Coney Isand Community Heath Center (NY), East Orange Famiy Heath Center (NJ), Cinica Adeante, Inc. (AZ), and Neponset Heath Center (MA). Nurses in the area of Ceveand Metropoitan Genera and Highand View Hospitas (OH) received training on the promotion of breastfeeding of high risk infants from the neonata nutritionist. The Hudson Headwaters Heath Network, Warrensburg, NY, provides a free pediatric visit for coupes before their baby is born. During this visit the pediatrician stresses the importance of breastfeeding. Information about breastfeeding is aso presented during the Lamaze casses sponsored by the Network. 17

24 Task Forces/Guides/Materias A variety of organizations and agencies, both individuay and in groups, have formed committees and have deveoped guides and other materias to improve the support for breastfeeding throughout the heath care system. A brief summary of these guides and other materias is given beow: A breastfeeding task force is being estabished by the Cincinnati Department of Heath and University Hospita (OH). This coaborative effort is expected to resut in an increase in the incidence and duration of breastfeeding in heath service faciities. The chart, Hospita Practices Which Infuence Breastfeeding Initiation, incuded in the Report of the Surgeon Genera s Workshop on Breastfeeding and Human Lactation, has been widey used by hospitas as a guide to assess hospita practices and identify areas in need of improvement. A handbook, Six Steps to Breartfeeding Promotion, has been prepared for heath care professionas in materna and infant care faciities by the New York City Steering Committee to Promote Breastfeeding. The committee s Faciity Task Group is panning a workshop to deveop strategies for decreasing institutiona barriers to breastfeeding. Numerous hospitas have prepared or adopted breastfeeding guideines, poicies, and education materias to improve in-hospita,and out-patient services reated to breastfeeding. These incude Brigham and Women s Hospita, Boston, MA, New Oreans Charity Hospita (LA), and many others. St. Luke%Roosevet Hospita Center Breastfeeding Committee (NY), composed of representatives from the departments of Pediatrics, Obstetrics, Nursing, Food Service and Nutrition, Pharmacy, and Socia Services continues its work. After three years of coordinated effort, its Breastfeeding Manua is ready to be pubished. Geared toward educating a hospita staff, it is a direct hands on reference and teaching too in Spanish and Engish. It wi be formay introduced to the staff at a breastfeeding conference.

25 SUPPORT SERVICES Recommendation: Deveop a broad range of support services in the community This recommendation focuses on the need for women to have access to the foowup support necessary to cope with questions and probems reated to actation and breastfeeding, both during hospitaization and foowing discharge from the hospita. Such support shoud: 1) emphasize the strengths of the famiy; 2) respect the variations found within different cutura, ethnic, and economic groups as we as ife styes; 3) offer a continuum of care for the mother and baby throughout the reproductive cyce and infancy; and 4) effectivey use community resources. Seven genera approaches seem to be used to deveop and ensure the avaiabiity of a range of community support services. These incude maintenance of teephone caing systems, deveopment of peer support groups, use of peer breastfeeding counseors and professiona actation speciaists, provision of nurse foowup and referra, sponsorship of breastfeeding cinics and casses, remova of institutiona barriers and improvement of institutiona practices, and the operation of human mik banks. Many of the activities reported under Professiona Education, Pubic Education, and Word of Work address the need for foowup support. Additiona exampes of activities targeted on the deveopment of community support services foow. Teephone Caing Systems One method of providing oca support for breastfeeding mothers is teephone foowup by staff or vounteers. A few exampes are given beow: The Nutrition Project, Inc. (WI) deveoped a new pubication, Starting a Teephone Support System for Breastfeeding Mothers. This guide provides step-by-step advice about how to estabish a buddy support system directed to ow-income breastfeeding mothers. Severa community heath centers aso provide for teephone contact. For exampe the Chares Drew Heath Center, Inc. in Omaha, NE provides for a teephone ca to the mother one to three days after hospita discharge and a home visit within the first week. For ongoing peer support, referras are made to the oca La Leche League. In Lamont, CA, Cinica Sierra Vista provides for a teephone foowup ca to breastfeeding mothers the first two days after discharge from the hospita. Ca are made by a nutrition aide. 19

26 The Miwaukee, WI Task Force on Breastfeeding maintains a teephone buddy support system using 40 trained vounteers to answer questions and assist with probems. Peer Support Groups One of the most widey avaiabe sources of support for breastfeeding mothers in oca communities is peer support groups. Some exampies of peer support groups and their activities are given beow: La Leche League continues to be a major resource for peer support in a arge number of communities in every state. Heath care providers in both the private and pubic sectors report working cosey with League groups to make referra arrangements that faciitate necessary support during actation. The Zanesvie Muskingum Prenata Cinic in Zanesvie, OH and the Vaey Heath Center in Yuma, AZ are exampes of such joint efforts. Pubic heath agencies and community heath programs are increasing their efforts to estabish support groups. In Georgia, for exampe, district heath departments are promoting the deveopment of such groups. A vounteer support system has been estabished in Eau Caire, WI, and it works cosey with oca hospitas, cinics, socia service agencies, and Women, Infants, and Chidren programs. The Appaachian Ohio Rura Heath Initiative Program sponsors group sessions on breastfeeding for women in the third trimester of pregnancy. The Catawba Pubic Heath District (SC) continues its monthy Nursing Mothers Support Group meetings, provides information through teephone contacts by vounteers, and recommends books and other materia on breastfeeding to be carried by bookstores and speciaty shops. A breastfeeding mothers support group in Sussex County, DE focuses on prenata patients and hospita obstetric patients. In Hamiton County, OH the Women, Infants, and Chidren program makes a sma ibrary of breastfeeding references avaiabe for cient use. The Deposit Heath Center in Deposit, NY utiizes the United Heath Services outreach worker for. home foowup to assist and provide support for breastfeeding mothers. In the southeast Queens area of New York City, Corne University Cooperative Extension s Expanded Food and Nutrition Education Program, in conjuction with the Nationa Back Women s Heath Project, is estabishing breastfeeding support groups. Many of these groups are composed of vounteers recruited from the Education Program s homemakers. They incude both Engish and Spanish anguage groups. It is expected that hospita maternity staff and Women, Infants, and Chidren program staff wi refer cients to the support groups. Metro Nursing Mothers was initiated in St. Pau, MN to provide professiona support and probem soving to both professiona persons and breastfeeding famiies. This non-profit organization hods weeky cinics in a church. Breastfeeding Counseors The avaiabiity of professiona and peer breastfeeding counseors is increasing as a source of support for mothers. Mentioned beow are some of these counseing services: 20

27 The Adams County, OH Women, Infants, and Chidren program uses private funding to support a part-time ay breastfeeding counseor to provide education and foowup services. She is avaiabe for home and hospita visits which are foowed up by phone and mai contacts. A simiar program in a arge Arizona hospita empoys La Leche League eaders as paid breastfeeding counseors six days a week to provide education and counseing. The North Centra Bronx Hospita has a Doua project funded by the New York State Department of Heath. The Doua works with new breastfeeding mothers individuay, participates in postpartum rounds and casses, provides teephone foowup, and heps famiies obtain other needed services. Two county heath departments in Maryand are invoved in a piot program for peer counseors. Protocos for the program were deveoped by a graduate student from Johns Hopkins University Schoo of Pubic Heath. The Riverside County, CA Women, Infants, and Chidren program staff deveoped a Lactation Counseor Manua. Materias from the Nationa Chid Nutrition Project (PA) aso incude a Counseor s Guide to Breastfeeding. Through a grant to the Rhode Isand Women s Heath Coective, the Rhode Isand State Department of Heath has supported a part-time person to train peer counseors who promote breastfeeding in the Hispanic popuation. Not a efforts to deveop peer counseing programs have been suc- cessfu. For exampe, the Waianae Coast Comprehensive Heath Center in Hawaii expored the possibiity of using Women, Infants, and Chidren program participants who were currenty nursing or had previousy breastfed their babies for six months or more as counseors. Whie 18 women agreed to become invoved, attendance at foowup training meetings was poor, and the project was dropped. Nurse Foowup/Referra One exampe of nurse foowup is the program of the Famiy Care Center of Carondeet in St. Louis, MO. It provides for prenata and postpartum home visits for each cient by the Materna Heath Nurse to discuss breastfeeding and other aspects of care. Referras are made to La Leche League for continuing support. As noted earier, the Chares Drew Heath Center in Omaha, NE aso provides for home visits and referras to La Leche League. In Forida, the North Centra Materna and Infant Care- Women, Infants, and Chidren project continues to offer home visits to newy breastfeeding women within the first weeks after hospita discharge. Settement Heath and Medica Services, Inc. in New York City provides a hospita visit by a nurse-midwife and a home visit, within 48 hours after hospita discharge, by a pediatric nurse practitioner to ensure that breastfeeding is proceeding we. Cinics/Casses The Tacoma-Pierce County Heath Department (WA) operates a Mode Breastfeeding Program supported by the State s Office of Materna and Chid Heath. Breastfeeding cinics are hed twice weeky, and chsses 21

28 are schedued monthy to promote breastfeeding, particuary among owincome women. A pediatric nurse practitioner is responsibe for the program. In addition to the cinics and casses that provide an opportunity to address common concerns of breastfeeding mothers and assist them in ocating community resources, she is avaiabe for teephone consutation and in-service education for heath professionas. She aso assists other oca heath departments through on-site consutation in deveoping simiar programs. In Wyoming, ongoing breastfeeding casses sponsored by county pubic heath agencies are in progress in 22 of the 23 counties. Specia casses are aso conducted for new breastfeeding mothers through cinics serving cients of the Women, Infants, and Chidren program. La Leche League has deveoped a new format of breastfeeding casses to be avaiabe for mothers who prefer this to the traditiona ongoing meetings. Institutiona Practices Two exampes of efforts to remove hospita barriers to breastfeeding are the Nationa Chid Nutrition Project (PA) program and the breastfeeding egisation enacted in New York State. Detaied descriptions of these efforts are given beow: Through a grant from the Ford Foundation, the NationaChid Nutrition Project has focused on removing hospita barriers to breastfeeding and strengthening the prenata and postpartum breastfeeding support network in hospitas where ow-income women deiver their babies. The Project s poicies and procedures, materias, and research findings have been compied into the Breastfeeding Promotion Guidebook which is avaiabe in Engish and Spanish. The guidebook served as the framework for three conferences in Chicago, Daas/Fort Worth, and Batimore. Teams of three to five persons representing hospita and ambuatory heath services were invited to the conferences. One objective was to stimuate these teams to work together in deveoping a coordinated breastfeeding promotion effort for women during pregnancy and throughout the actation period. The State of New York has recenty passed breastfeeding reguations to amend the New York Hospita Code. Under the new reguations, hospitas wi be required to provide instruction and assistance to each maternity patient who either chooses to breastfeed or is undecided about the feeding method for her infant. Each hospita with a maternity service wi be required to designate at east one person who is thoroughy trained in breastfeeding physioogy and management to be responsibe for presentation of an effective breastfeeding instruction program. Hospitas wi be required to carry out poicies and procedures such as: prohibiting the use of standing orders for antiactation drugs; assisting the infant to breastfeed immediatey foowing deivery, uness contraindicated; providing for the infant to be fed on demand; restricting suppementa feedings to those indicated by a medica condition of infant or mother; 22 and restricting distribution of discharge packs of infant formua to an in- dividua order by the attending physician or the specific request of the mother.

29 Human Mik Banks Human mik banks appear to be increasing in number. Besides serving as a source of human mik, many of the banks instruct mothers about improved techniques for expression and storage of mik. For exampe, the Hawaii Mother s Mik Bank provides training to heath professionas. The Mother s Mik Bank of San Jose (CA) has deveoped a manua for use by faciities desiring to set up human mik banks. The Community Human Mik Bank, Georgetown University Hospita (DC) issues a periodic Donor Newsetter to promote communication among donors and provide new information from staff. 23

30 WORLD OF WORK Recommendation: Initiate a nationa breastfeeding promor: directed to women in the word of work The focus of this recommendation is the importance of facii:;u~~,,,,, empoyed woman s opportunity to breastfeed. An increasing n -in\ti,,, women are invoved in schoo, job training, professiona educa:i,\t\, I (\I[ empoyment, and these mothers frequenty receive negative rnessa$i x.i\, II breastfeeding. Moreover, institutiona poicies and practices I I\, 1,. workpace, and the ack of appropriate support systems, often a<r.i\ I,,,, riers to successfu actation. Many individuas and agencies have reported that foowup tw 1,, workshop recommendation is being deferred unti a sound base LV 1 1u,1,, and professiona education has been estabished. However, severa I ~1 b&., I activities have been carried out to reach those who can in t,.,,,, breastfeeding decisions and improve opportunities for women in rhr \\,,,,, of work. These efforts are reated to improvement of the data base, III,,,, sion of information and education, review of institutiona poicies. I~~i~,,,, breast pumps, and deveopment of mode or demonstration program:, 1., ampes of such efforts foow. Data Base With support from a Ford Foundation grant, researchers at the I 11~, University Schoo of Nutrition have studied various aspects of WOIII~:~, empoyment and infant feeding. One survey of more than a thousam I,,., mothers investigated interactions between chidbirth, women s enip~,, ment, and infant feeding, with a specia focus on mothers who pan to 1,,,,, bine breastfeeding and working. Another survey invoved teephone ir~,., views of 81 working mothers who were sti breastfeeding their infant 5 i I ;,,,, months postpartum. This survey focused on factors responsibe for IJ,,.,, abiity to continue breastfeeding after eary postpartum return to wt,, 1 Neither of these studies has been pubished to date; however, a two-vc,t,,,,. book by researchers Zeitin, Schossman, and Conne, entited WIIII/~~,,. Empoyment and Eary Return to Work and Time Use of WOI{/,,,~ Mothers, is schedued for pubication in January Aso underw;r 7,,, Tufts is a study of empoyers attitudes toward new mothers and mater rrji, benefits. Information/Education A statewide organization, Wisconsin Nutrition Project, Inc., Y/I,~,.J, promotes breastfeeding and is an advocate for the nutrition and htab), needs of ow-income individuas, deveoped a 24-page iustrated guick,,i 24

31 Mother s Handbook-Combining Breastfeeding with Work or Schoo. It is avaiabe in Engish and Spanish. Another new book, Breastfeeding Success for Working Mothers, was written by Mariyn Grams, M.D. to assist working breastfeeding mothers. At the University of Nebraska Media Center, a socioogist who speciaizes in actation has discussed breastfeeding and materna empoyment in teevision and radio interviews, artices in severa professiona journas, and newsetters for parents and professionas. An increasing number of primary heath care programs in different geographic areas of the nation are providing information to mothers about maintaining breastfeeding after their return to work or schoo. For exampe, the Lyndon Baines Johnson Heath Compex, Inc., in Brookyn, NY provides educationa programs and counseing sessions for staff in six daycare centers and seven schoos to hep them support working breastfeeding mothers. The Syracuse Community Heath Center (NY) provides individua patient counseing, educationa materias in severa anguages, and support and advice from individuas who have successfuy combined breastfeeding and empoyment. At Segundo Ruiz-Bevis Neighborhood Famiy Care Center, Bronx, NY, breastfeeding for the working woman is incuded in the heath maintenance protocos deveoped for women and teenage girs. Institutiona Poicies The Task Group on Poicy and Legisation, one of six groups of the Steering Committee to Promote Breastfeeding in New York City, studied poicies in the workpace as they reate to the working woman s abiity to breastfeed. Objectives of the Task Group incude the formuation of breastfeeding promotion guideines and recommendations for corporations, unions, and heath professionas who work with these organizations. The pivota roe of the occupationa heath nurse in effecting change in the workpace to make it feasibe for working mothers to breastfeed was the subject of an artice, Promoting Prenata Care and Breastfeeding in the Workpace. Pubished in Occupationa Heath Nursing (February 1985), the artice emerged from the activities of the Steering Committee. Breast Pump Loan Programs To support continued breastfeeding among working mothers, mothers who are in schoo or training programs, and mothers who may need pumps because of iness, the Hamiton County (OH) Women, Infants, and Chidren program makes a imited number of breast pumps avaiabe for oan. In Boston, MA the Bank of Boston purchased eectric breast pumps for empoyee use, Mode/Demonstration Programs With support from a Tite V Materna and Chid Heath Improvement Project grant, the Nationa Chid Nutrition Project in Phiadephia, PA is conducting a breastfeeding project to increase the incidence and duration of breastfeeding among women, particuary working mothers, in three project sites in Department of Heath and Human Services Region III. The major objectives of the project are: 1) to provide mothers with sufficient information and support to enabe them to breastfeed successfuy, 2) to provide 25

32 continuing education for heath professionas to faciitate a positive attitude toward breastfeeding and working, and 3) to infuence work environments and day care settings that wi provide a supportive atmosphere for the working mother. The three-part strategy for this project incudes a materna breastfeeding education and support network comprised of oca women who have previousy breastfed successfuy and continued breastfeeding after return to work; a staff education component to provide information on breastfeeding, particuary on issues that reate to working women; and a program to faciitate changes in the chid care and empoyment settings to accommodate breastfeeding women who return to work. 26

33 RESEARCH Recommendation: Expand research in human actation and breastfeeding In order to improve the information base, estabish poicy, improve and target strategies, assess program effectiveness, and determine progress in achieving goas reated to the promotion of breastfeeding, an intensified nationa research effort with a broad range of research studies is essentia. This recommendation focuses on the need for basic studies, cinica studies, evauation of information studies, and prospective and ongitudina studies reated to breastfeeding. Athough research reated to actation and breastfeeding has received considerabe attention and support in recent years, the Surgeon Genera s Workshop reaffmed the importance and need for continued and expanded research efforts. Federa agencies within the Department of Heath and Human Services which support research in materna and chid heath, especiay the Nationa Institute of Chid Heath and Human Deveopment of the Nationa Institutes of Heath and the Division of Materna and Chid Heath of the Heath Resources and Services Administration, incude actation and breastfeeding as priority areas for competitive grant support. In addition, the United States Department of Agricuture supports a significant number of research efforts reated to human actation. The various studies -underway, panned, or recenty competed-seem to focus on the foowing areas: the coection of data on incidence and duration of breastfeeding; determinants and factors reated to breastfeeding behavior, practices, and attitudes; physioogica, nutritiona, and other aspects of human actation; and the deveopment and evautation of interventions and strategies to promote breastfeeding. Exampes of research studies in each of these areas are provided beow. Trend Data Many Materna and Chid Heath programs and Women, Infants, and Chidren programs in state and oca heath agencies are coecting data to determine the incidence and duration of breastfeeding. For exampe, the Montana State Department of Heath and Environmenta Sciences is invoved in an ongoing pediatric nutrition survey that provides for statewide monitoring of breastfeeding. A survey of infant feeding practices, using a sampe drawn from birth certificates, is underway in the Section of Famiy Heath of the Aaska Department of Heath and Socia Services. The Nebraska and Tennessee Nutrition and Women, Infants, and Chidren programs are coecting simiar data through their surveiance systems. 27

34 Numerous community heath centers in different geographic areas are gathering baseine data to use in panning intervention strategies. The Maine Newborn Breastfeeding Surveiance Program monitors the rate of breastfeeding of newborns in a hospitas in Maine using data from the mandatory newborn screening program for metaboic disorders. Significant nationa studies are either continuing to coect or update data, and earier data are being anayzed, pubished, and disseminated. Such efforts incuded the Ross Laboratories Nationa Mothers Survey and the Department of Heath and Human Services/Nationa Center for Heath Statistics Nationa Survey of Famiy Growth, Nationa Heath Interview. Survey-Chid Heath Suppement, Nationa Nataity Survey, and Heath and Nutrition Examination Survey. Determinants/Behaviors/Practices/Attitudes Behaviora and attitudina determinants of breastfeeding are the focus of many current research projects. Some of these research projects are mentioned beow: Factors Affecting Breastfeeding Duration, a study at the Department of Human Nutrition and Food Service Management, University of. Nebraska, conducted by Nancy Lewis and H.M. Fox, focused on the deveopment of a method to identify women who pan to breastfeed but either do not initiate it or stop breastfeeding within two months postpartum. Subjects incuded 45 WIC program participants who were surveyed by teephone within one year after their babies were born. The survey questionnaire used was designed to identify factors reated to breastfeeding success. At the University of Caifornia at Berkeey, Barbara Vandenberg is investigating the effects of breastfeeding on the heath and deveopment of infants. This epidemioogica study, Breastfeeding: Evauation of Antecedents and Effects, is supported by a Nationa Institute of Chid Heath and Human Deveopment grant. Infant Feeding Beiefs and Practices of First-time, Inner City Mothers was the tite of a study conducted by Eizabeth Burki and Janet Reis at Northwestern University (IL) and reported in WIG CURRENTS (Ross Laboratories). Using a sampe of 19 cients from an inner-city cinic that provides heath care services primariy to medicay indigent Back and Hispanic famiies, interviews were conducted in prenata and postpartum cinics. Specific aspects of concern were the accuracy of mothers knowedge of feeding tasks and understanding of an infant s feeding needs, sources of information or infuence for tasks and probems reated to infant feeding, and attitudes and infuences that affected the decision to breastfeed or botte-feed the baby. Determinants of Infant Feeding: Breast vs. Botte is the subject of a study being conducted by Ruth Faden at Johns Hopkins University Schoo of Pubic Heath (MD). It is jointy supported by the Division of Materna and Chid Heath and the Nationa Institute of Chid Heath and Human Deveopment. The study seeks to identify major determinants of infant feeding behavior in new mothers, and, for mothers eecting breastfeeding, the major determinants of duration of breastfeeding. Both urban and rura subjects are incuded in the study. 28

35 Materna Empoyment and Breast-Feeding: A Study of 567 Women s Experiences, conducted by K.G. Auerbach and others at the University of Nebraska Medica Center, was pubished in the American Journa of Dike&es of Chidren in The Decision to Breastfeed: A Study of Low-Income MIC Patients in New York was carried out by Donna O Hare and others, and presented at the 1984 annua meeting of the American Pubic Heath Association. The study surveyed the choice of infant feeding method of 909 women enroed at eight Maternity and infant Care-Famiy Panning Project Cinics during Spring and Summer The findings substantiated those of other investigators and found that the majority of women make the decision to breastfeed prior to pregnancy. Economic and Demographic Determinants of Infant Feeding is one component of the Rand Corporation s (Santa Monica, CA) ongoing popuation studies funded by the Nationa Institute of Chid Heath and Human Deveopment. Infant Feeding Practices Among Primiparae is a prospective study of the frequency and duration of infant feeding practices, being conducted by Survey Research Associates, Inc. of Batimore, MD, with support of the Nationa Institute of Chid Heath and Human Deveopment. Sharron Humenick at the Schoo of Nursing of the University of Wyoming in Laramie is conducting A Study of Eary Management of Breastfeeding. Infant Feeding Practices Tracking Study is supported by the Department of Heath and Human Services/Food and Drug Administration. It is intended to provide information about the prenata and postnata infuences upon infant feeding pans and behaviors, and to provide detaied rea-time (i.e., not retrospective) information about actua feeding practices. Mother-Infant Socia Interaction During Breastfeeding is a study being conducted by Lawrence Hoder at the Cinica Nutrition Research Center at Yae University with support from the Nationa Institutes of Heath. Determinants of Mothers Infant Feeding Practices was the subject of a study by Steven Wirtz at Brigham and Women s Hospita in Boston, MA. Attitudes of Migrants toward Breastfeeding is a survey being conducted by David Myers at Pan de Saud de1 Vae, Inc. in Fort Lupton, CO. Physioogy/Nutrition/Other Aspects A wide variety of studies on the physioogica, nutritiona, and reated aspects of human actation and breastfeeding are in process. Mentioned beow are some of these studies: In foowup of the Surgeon Genera s Workshop, the Nationa Institute of Chid Heath and Human Deveopment announced a Request for Appications for investigator-initated research grant appications for studies on the physioogy of actation and the bioogy of human coostrum and mik. It was recognized that a concerted effort was needed to expore the physioogica processes occurring in the breast, from the time of conception through actation and weaning, in order to understand the deveopment and function of actating tissue. Concomitanty, the functiona 29

36 properties of coostrum and human mik need to be evauated in the context of the roes they pay in infant deveopment. The recommendation of the Surgeon Genera% Workshop for intensified research to provide data on the benefits and contraindications of breastfeeding ed the Nationa Institute of Chid Heath and Human Deveopment to sponsor the Workshop on Methods of Anaysis of Human Mik and Coostrum. Foowing this workshop a Request for Proposa was announced on this topic for research to deveop highy accurate microtechniques to determine the composition of human mik and to vaidate the techniques on human mik. It is anticipated that mutipe awards wi be made in The Department of Heath and Human Services/Nationa Institutes of Heath, primariy through the Nationa Institute of Chid Heath and Human Deveopment, supports numerous other research projects reated to physioogica, nutritiona, and other aspects of human actation and breastfeeding. A ist of these projects is provided in Appendix B under the foowing categories: physioogy of actation, materna nutrition aspects, infant physioogy, infant nutrition aspects, composition of human mik, immunoogica aspects, and human mik banks. The Nationa Institute of Chid Heath and Human Deveopment wi sponsor an internationa conference on the Effects of Materna and Environmenta Factors of Human Lactation to be hed January 15-19,1986, in Mexico. It is expected that new research initiatives ivi emanate from this meeting. Drugs in breast mik continued to be studied by John T. Wison and other staff of the Departments of Pharmacoogy and Therapeutics and Pediatrics at Lousiana State University. A recent paper, Pharmacokinetic Pitfas in Estimation of the Breast Mik/Pasma (M/P) Ratio for Drugs was submitted for pubication in ate In cooperation with Purdue University, a foowup study, entited Nutritiona Intake of Breastfed Infants Especiay Reated to Vitamin B6, Foic Acid, and Ascorbic Acid is underway at Ba State University in Indiana. A variety of research reated to human actation and breastfeeding is supported by the United States Department of Agricuture, principay through its Human Nutrition Research Centers and Agricutura Experiment Stations. A ist of research studies reated to human subjects is provided in Appendix C. Interventions/Strategies Other research activity centers around the vaue of different interventions and strategies in promoting breastfeeding. A coupe of exampes are isted beow: Breastfeeding Promotion in a Low-Income Popuation is a Tite V Materna and Chid Heath Improvement Project conducted by Lindsey Grossman at Ohio State University. This project wi identify factors associated with the decision by poor women to breastfeed; identify and test interventions designed to increase breastfeeding in ow-income women, such as postpartum actation support provided by a peer-mentor and education aimed at the mother s key support person; and test the 30

37 generaizabiity of those interventions in a wider but demographicay simiar cinica setting. A Randomized Tria to Promote the Duration of Breastfeeding is the subject of a study at Boston University Schoo of Pubic Heath and Boston City Heath and Hospitas by James Sorenson and Deborah Frank with support from the Nationa Institute of Chid Heath and Human Deveopment. 31

38 NATIONAL AWARENESS The positive impact of the Surgeon Genera s Workshop on Breastfeeding and Human Lactation continues to be observed and experienced throughout our nation. This is argey due to the diverse group of individuas, agencies, and organizations in the private and pubic sectors who are responding to the chaenge of the workshop s recommendations. Participants in the workshop, as we as others who have earned about it through the widey disseminated Workshop Report, have extended the workshop messages to a much broader audience. The Heathy Mothers, Heathy Babies Coaition s Breastfeeding Subcommittee serves as the ongoing foca point for coecting and disseminating information about breastfeeding promotion activities and faciitating new efforts. One of its future efforts wi be a po to determine pubic attitudes about breastfeeding. Foowing are seected exampes of the variety of efforts made to increase awareness of the nationa breastfeeding objective and to stimuate foowup in communities across the nation: Since January 1984, the journas of severa professiona organizations incuded artices on breastfeeding and reports of the Workshop. These incude The American Dietetic Association (18 artices), American Academy of Pediatrics (19 artices), Nationa Association of Pediatric Nurse Associates and Practioners (1 artice), Nurses Association of the American Coege of Obstetricians and Gynecoogists (3 artices), American Coege of Obstetricians and Gynecoogists (2 artices), American Pubic Heath Association (1 artice), American Academy of Famiy Physicians (1 artice), and Nationa Perinata Association (1 artice). Reports of the Workshop aso appeared in such journas and newsetters as the foowing: Perinata Section News, American Academy of Pediatrics, Vo. 10, No. 1, January, 1985 (Vince L. Hutchins). Morbidity and Mortaity Weeky Report, Centers for Disease Contro, December, 1984 (James S. Marks). Pubic Heath Reports, Vo. 99, No. 6, November-December, 1984 (Joyce Arango, C. Everett Koop, and Eizabeth Brannon). Occupationa Heath Nursing, February, 1985 (Marybeth Petschek and Rosemary Barber-Madden). The popuar press aso provided information about breastfeeding. Exampes incude: 32

39 Good Housekeeping, Apri, 1985 (David Zimmerman). Cothed with the Sun, Vo. 4, No. 3, Autumn, Other awareness events incuded: emphasis on breastfeeding at meetings of nationa and state professiona organizations, such as the Second Annua Conference of the Nationa Association of Women, Infants, and Chidren Directors (with a presentation at the penary session and two workshops on promotion of breastfeeding); the 1984 annua meetings of the American Pubic Heath Association (where 25 papers were presented in five sessions); the American Dietetic Association (where four presentations were made on breastfeeding); the American Medica Women s Association (where three speakers presented a two-hour pane on Breastfeeding: Who Does, Who Doesn t and Why? ), and the Nationa Perinata Association (which incuded a session on this topic). La Leche League Internationa sponsored a three-day nationa conference on breastfeeding. 33

40 CONTRIBUTORS The information abstracted in this report was received from many different individuas, organizations, and agencies in the pubic and private sectors. Names and addresses of individuas and agencies who forwarded materias and information directy to the Surgeon Genera s Office, or to the Division of Materna and Chid Heath in Rockvie, MD are isted beow. In addition, the name of a contact person and address of each Department of Heath and Human Services Regiona Office is provided, since staff in these offices coected and summarized considerabe materia and information submitted by the states they serve. If additiona information is desired, inquiries shoud be directed to the state heath agency or the Department of Heath and Human Services Regiona Office which serves the state in which the activity occurred, or to the specific individua or agency, identified beow. Diane Anderson, M.S., R.D. Rainbow Babies and Chidren s Hospita Case Western Reserve University 2101 Adebert Ceveand, OH George Braey Specia Nutrition Programs Food and Nutrition Service, USDA 3101 Park Center Drive Aexandria, VA Katheen G. Auerbach, Ph.D. Department of Obstetrics and Gynecoogy 42nd and Dewey Avenue Omaha, NE Marta I. Baez, R.D., MS. SPRANS Project Coordinator Abert Einstein Coege of Medicine of Yeshiva University 1300 Morris Park Avenue Bronx, NY Lee Baxanda Naturist Society P.O. Box 132 Oshkosh, WI Caro Bryant, Ph.D. Lexington-Fayette County Heath Department 650 Newtown Pike Lexington, KY Saie Eisser, R.N., M.S.N., C.P.N.P. Materna/Chid Heath Greater Southeast Community Hospita 1310 Southern Avenue, SE Washington, DC Ruth R. Faden, Ph.D., M.P.H. The Johns Hopkins University Schoo of Hygiene and Pubic Heath 615 North Wofe Street Batimore, MD

41 Mariyn Grams, M.D. c/o Achievement Press Box 608 Sheridan, WY Eena Grant V.P. Natura Technoogies, Inc. p.0. Box 1704 Beaverton, OR Therese Hadey Wisconsin Nutrition Project, Inc Dayton Street, Room 204 Madison, WI Doris Haire American Foundation for Materna and Chid Heath, Inc. 30 Beekman Pace New York, NY Chandice C. Harris, R.N., M.S.N. Parent-Chid Coordinator The University of Michigan Medica Schoo Ann Arbor, M Jaye Heferd, MS., R.D. Corne University Cooperative Extension Bronx Nutrition Education Program Suite 602, 2021 Grand Concourse Bronx, NY Marci Kramish, R.D., M.P.H. Famiy Medicine Center Durham Heath Care, Inc. 407 Crutchfied Street Durham, NC Minda Lazarov, MS., R.D. Breast Feeding Task Force Tennessee Department of Heath & Environment Bureau of Heath Services 100 9th Avenue North Nashvie, TN MCH News PAC PBMCHRC University of Guam UOG Substation Mangiao, GU Mavis McGuire, R.N., M.A., C.P.N.P. Nationa Association of Pediatric Nurse Associates & Practitioners 1000 Mapewood Drive, Suite 104 Mape Shade; NJ Sobritt Murphy, M.D. Bureau of Materna and Chid Heath New York State Heath Department Abany, NY Deborah Myers, M.S. The Popuation Counci One Dag Hammarskjod Paza New York, NY A.W. Myres Senior Program Officer Chid and Famiy Heath Unit Heath and Wefare Ottawa, Ontario, Canada KA Christine M. Oson, Ph.D., R.D. Division of Nutritiona Sciences 376 MVR Ha Corne University Ithaca, NY B4 Joan Peto, R.D., M.S. Chief Nutritionist Department of Heath and Socia Services Juneau, AK Lynn Perton, M.A., R.D. Chief Nutritionist Pediatric Ambuatory Care St. Luke s Roosevet Hospita Center 428 West 59th Street New York, NY ene S. Rice Heartstart Pubications 2392 Nancy Pace St. Pau, MN Diane Revitte Heath Education Consutant State of Michigan Department of Pubic Heath 3500 North Logan P.O. Box Lansing, MI

42 Jeanne Rose Internationa Chidbirth Education, Inc. P.O. Box Minneapois, MN Ross Laboratories 625 Ceveand Avenue Coumbus, OH Sandra Sherman Nationa Chid Nutrition Project, Inc. 101 North 33rd Street Phiadephia, PA Robert Siverthorne Motion, Inc Highand Pace, NW. Washington, DC Eizabeth Spencer, R.D., M.S. Pubic Heath Nutritionist City-County Heath Department 720 Second Avenue Eau Caire, WI Jo-Ann Thorpe The New York City Breastfeeding Campaign The New York State Department of Heath 8 East 40th Street New York, NY Edith Tibbetts Heath Education Associates, Inc. 211 Sputh Easton Road Genside, PA Jennifer Vickery Heath Education Catawba Pubic Heath District Chester-Lancaster-York Counties South Caroina Department of Heath and Environmenta Contro Box 817 Lancaster, SC Janet Washington Department of Dietetics and Nutrition Brigham-Women s Hospita 75 Francis Street Boston, MA John T. Wison, M.D. Louisiana State University Medica Center P.O. Box Kings Highway Shreveport, LA Bevery Winikoff, M.D., M.P.H. Senior Medica Associate The Popuation Counci One Dag Hammarskjod Paza New York, NY REGIONAL NUTRITION STAFF Department of Heath and Human Services Pubic Heath Service Division of Heath Services Deivery Region I: Connecticut, Maine, Mas- Region II: New Jersey, New York, sachusetts, New Hampshire, Rhode Puerto Rico, Virgin Isands Isand, Vermont Marie1 Cadwe Jean Coins (Sanford) Norris Regiona Nutrition Consutant Regiona Nutrition Consutant HHS/PHS/Division of Heath HHS/PHS/Division of Heath Services Services Deivery Deivery-Cinica Affairs Famiy and Chid Services Unit JFK Federa Buiding, Room 1401 Federa Buiding, Room 3302 Boston, MA Federa Paza Commercia Phone: ~6668-or 9 New York, NY F-I-S: or 9 Commercia Phone: Frs:

43 Region III: Deaware, District of Coumbia, Maryand, Pennsyvania, Virginia, West Virginia Connie Lotz Regiona Nutrition Consutant HHS/PHS/Materna and Chid Heath P.O. Box 13716, Room 4484 Gateway Buiding Phiadephia, PA Commercia Phone: Frs: Region V: Iinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin Coette Zyrkowski Regiona Nutrition Consutant Materna and Chid Heath/Famiy Panning HHS/PHS/Division of Community Heath Services Deivery 300 Wacker Drive, 34th Foor Chicago, IL Commercia Phone: FTS: I 700 Region VII: Nebraska Iowa, Kansas, Missouri, Frank LoGiudice Regiona Nutrition Consutant Nationa Heath Service Corps 601 East 12th Street 5th Foor West Kansas City, MO Commercia Phone: FTS: Region IX: American Samoa, Arizona, Caifornia, Guam, Hawaii, Marsha Isands, Federated States of Micronesia, Nevada, Northern Mariana Isands, Paau Gadys Matthewson Regiona Nutrition Consutant HHS/PHS Division of Heath Services 50 United Nations Paza, Room 341 San Francisco, CA Commercia Phone: FE: Region IV: Aabama, Forida, Georgia, Kentucky, Mississippi, North Caroina, South Caroina, Tennessee Beth Duncan/Kathy Wengen Regiona Nutrition Consutants HHS/PHS/Division of Heath Services Famiy Heath and Services Branch 101 Marietta Towers, Room 1202 Atanta, GA Commercia Phone: I-5254 FTS: Region VI: Arkansas, Louisiana, New Mexico, Okahoma, Texas Frances Vines Regiona Nutrition Consutant HHS/PHS/Division of Heath Services Deivery 1200 Main Tower Buiding, Room 1835 Daas, TX Commercia Phone: FTS: Region VIII: Coorado, Montana, North Dakota, South Dakota, Utah, Wyoming Cynthia Chung Regiona Nutrition Consutant HHS/PHS/DHSD-Program Operations Branch I%1 Stout Street, Room 1194 Federa Buiding Denver, CO Commercia Phone: Frs: Region X: Aaska, Idaho, Oregon, Washington Jean Kajikawa Regiona Program Consutant, MCH HHS/PHS Famiy and Chid Heath Program 2901 Third Avenue, MS 404 Seatte, WA Commercia Phone: FTS:

44 APPENDIX A TASK FORCE ON PROFESSIONAL TRAINING LACTATION IN MODEL POLICY STATEMENT* Promotion of Breastfeeding in the Context of Heath Care: Professiona Training Priorities Heath care professionas, as the source of comprehensive heath services for women and infants, shoud provide eadership in education regarding the benefits of breastfeeding as the optimum nourishment of infants, in order to faciitate an informed choice of infant feeding. Their professiona training shoud incude: emphasis on actation as a physioogic component of the reproductive cyce, on human mik as an idea natura and economic food during infancy, on breastfeeding as a centra part of famiy ife, and on coordination of other community resources avaiabe to the famiy. This training shoud enabe heath professionas to provide skied services to assist in the preparation, initiation, and continuation of breastfeeding. Such training shoud be integrated into the continuum of heath care. It is imperative for heath care professionas to receive adequate basic and ongoing theoretica and practica training in actation and breastfeeding, and to deveop skis which have cross-cutura appication in patient education and the management of breastfeeding. GOAL OF THE TASK FORCE To identify and reduce barriers which keep women from beginning or continuing to breastfeed their infants. (Based on the Surgeon Genera s charge to the Surgeon Genera s Workshop on Breastfeeding and Human Lactation.) * This statement was prepared by the Task Force on Professiona Training in Lactation, June The foowing organizations and agencies are members of the Task Force: American Academy of Famiy Physicians, American Academy of Pediatrics, American Coege of Nurse-Midwives, American Coege of Obstetricians and Gynecoogists, American Dietetic Association, American Home Economics Association, American Hospita Association, American Medica Association, American Nurses Association, American Pubic Heath Association, American Society of Cinica Nutrition, Association for Materna and Chid Heath and Cripped Chidren s Programs, Association of Teachers of Materna and Chid Heath, La Leche League Internationa, March of Dimes Birth Defects Foundation, Nationa Association of Community Heath Centers, Nationa Association of Pediatric Nurse Associates and Practitioners, Nationa Perinata Association, Nationa Rura Heath Care Association, Nurses Association of the American Coege of Obstetricians and Gynecoogists, U.S. Department of Agricuture/Food and Nutrition Service, and U.S. Department of Heath and Human Services/Heath Resources and Services Administration. 38

45 OBJECTIVES OF THE TASK FORCE 1) By 1990, didactic and cinica training in actation and breastfeeding wi be integrated within existing required curricua of heath professiona schoos, particuary in medicine, nursing, and dietetics. 2) By 1990, a advanced training programs (e.g., graduate education and residencies) of heath professionas providing services for women and chidren sha incude appropriate content on management of breastfeeding and actation. 3) By 1990, continuing education programs and pubications offered by appropriate professiona organizations at the nationa, state, and oca eves wi incude actation and breastfeeding as part of a reguar educationa cyce for heath professionas in practice. 4) By 1990, heath care faciities and professiona organizations invoved in the training of heath care professionas wi deveop and impement guideines for updating current practices within the heath care system in order to support optima breastfeeding and actation management, and serve as an effective training fied. 5) By 1990, professiona organizations sha provide a means for sefassessment of their membership to identify gaps in knowedge, skis, and practice of the management of breastfeeding and actation. 39

46 APPENDIX B RESEARCH ON HUMAN LACTATION AND BREASTFEEDING SUPPORTED BY THE NATIONAL INSTITUTES OF HEALTH, DEPARTMENT OF HEALTH AND HUMAN SERVICES* Physioogy of Lactation Symposium on Nutrition and Lactation, Margaret C. Nevie, University of Coorado Heath Sciences Center, Denver, CO. Physioogica Factors Affecting Human Lactation, Margaret C. Nevie, University of Coorado Heath Sciences Center, Denver, CO. Mechanisms in Nutrient Transport into Ces, Margaret C. Nevie, University of Coorado Heath Sciences Center, Denver, CO. Fiamentous Proteins in Mik Synthesis and Secretion, Robert F. Loizzi, University of Iinois, Chicago, IL. *- Hormona Contro of Metaboism in the Mammary Gand, James A. Riema, Wayne State University, Detroit, M. - Neura and Hormona Reguation of Lactation, Cark E. Grosvenor University of Tennessee, Memphis, TN. Neurochemica Contro of Oxytocin Reease, Cark E. Grosvenor University of Tennessee, Memphis, TN. Contro of Gonadotropin Secretion During Lactation, Susan M. Smith, University of Pittsburgh, Pittsburgh, PA. The Physioogic Contro of Proactin Secretion, Jimmy D. Nei& University of Aabama, Birmingham, AL. Bioactive Forms of Proactin: Reguation of Secretion, David M. Lawson, Wayne State University, Detroit, MI. Reguatory Ce Bioogy of Proactin Targets, Janet M. Noin, University of Richmond, Richmond, VA. The Effect of Hyperproactinemia on Cycic LH Reease, Phyis M. Wise, University of Maryand, Batimore, MD. Centra Reguation of Oxytocin Secretion, Edwin W. Haer, University of Minnesota, Duuth, MN. Immunochemica Anaysis of Estrophiin in Mammary Gand, Thomas C. Aen, University of Louisvie, Louisvie, KY. * Improving Estimate of Length of Postpartum Amenorrhea, Katheen Ford, Johns Hopkins University, Batimore, MD. Predictors of Ovuation in Lactating Women, Ronad H. Gray, Johns Hopkins University, Batimore, MD. Source: Federa Human Nutrition Research and Information Management System, 1984.

47 Postpartum Effects of Adoescent Pregnancy, Mark E. Wison, Emory University, Atanta, GA. Sex Hormones in the Reguation of Cacium Homeostasis, Mary L. Thomas, University of Texas Medica Branch-Gaveston, Gaveston, TX. Vitamin D and Cacium in Lactating and Sucking Rats, Svein U. Toverud, University of North Caroina, Chape Hi, NC. Vitamin A Transport during Lactation, Ata C. Ross, Medica Coege of Pennsyvania, Phiadephia, PA. Vitamin D Metaboism during Reproduction, Susan K. Pauson, Northwestern University, Chicago, IL. Nutritiona Roe of Manganese Binding Moecues in Mik, Wai-Yee Chan, University of Okahoma, Okahoma City, OK. Materna Nutrition Aspects Mechanisms by which Manutrition Affects Lactation, Katheen M. Rasmussen, Corne University, Ithaca, NY. Suppementa Fuids and Breast Mik Production, Lois B. Dusdeiker, University of Iowa, Iowa City, IA. Lactation: Diet, Drinking, Smoking, and Infant Growth, Ruth E. Litte, University of Washington, Seatte, WA. Transfer of Persistent Chemicas to Offspring, John J. Lech, Medica Coege of Wisconsin, Miwaukee, WI. Longitudina Study of Zinc Nutrition in Pregnancy and Lactation, Michae K. Hambidge, University of Coorado Heath Sciences Center, Denver, CO. Mothers and Newborns Admitted for Choestero Homeostasis on Breast and Formua, Lisa C. Hudgins, Rockefeer University, New York, NY. Infant Physioogy Mik and Amniotic Fuid Surfactants in Gastrointestina Deveopment, L.M. Lichtenburger, University of Texas Heath Science Center, Houston, TX. Roe of Nutrient in Gastrointestina Maturation and Motiity, Frank H. Morriss, University of Texas Heath Science Center, Houston, TX. Deveopment of the Gastrointestina Mucosa Barrier, Kam-Yee Pang, Massachusetts Genera Hospita, Boston, MA. Postnata Deveopment of Bie Sat Transport, James E. Heubi, Chidren s Hospita Medica Center, Cincinnati, OH. Metaboism of 13C Compounds in Digestive Diseases, Peter D. Kein, Bayor Coege of Medicine, Houston, TX. Maturation of Neonata Carbohydrate Homeostatis, Richard M. Cowette, Women and Infants Hospita-Rhode Isand, Providence, RI. Infant Nutrition Aspects * Body Composition in Neonates, Wiiam J. Kish, University of RO- Chester, Rochester, NY. 41

48 Ceuar Growth of Skeeta Musces: Infuences of Diet, Donad K. Layman, University of Iinois at Urbana-Champaign, Urbana, IL. Measurement of Mik Intake in Newborns, Wiiam W. Hay, Jr., University of Coorado Heath Sciences Center, Denver, CO. Infant Nutrition and Adipocyte Number, Edward J. Masoro, University of Texas Heath Science Center, San Antonio, TX. Genetic and Gestationa Infuences on Chidhood Obesity, Fredda V. Ginsberg-Fener, Mount Sinai Schoo of Medicine, New York, NY. Conservative Nutritiona Energy Substrate in Neonate Nursed Under Radiant Warmer, Stephen Baumgart, Chidren s Hospita of Phiadephia, Phiadephia, PA. Entera Feeding Comparison of Whey Based Formua and Human Mik, John A. Kerner, Stanford University, Stanford, CA. Cinica Studies on Human Mik, Buford L. Nichos, Bayor Coege of Medicine, Houston, TX. Protein Requirements of Norma Infants, Samue J. Fomon, University of Iowa, Iowa City, IA.. Carbohydrate Energy Absorption in Premature Infants, Craig L. Kien, West Virginia University, Morgantown, WV. Physica-Chemica Studies of Fat Absorption in Newborns, Oe C.E. Herne, Brigham and Women s Hospita, Boston, MA. 5. Infant Mik Feeding and Serum Choestero: U.S. Chidren, Maradee A. Davis, University of Caifornia, San Francisco, CA. Infant Foate Nutrition: Effects of Factors in Mik, Nevie Coman, Mount Sinai Schoo of Medicine, New York, NY. Dietary Minera Bioavaiabiity in Premature Infants, Richard A. Ehrenkranz, Yae University, New Haven, CT. Cacium and Phosphorous Nutrition in High-Risk Infants, Reginad C. Tsang, University of Cincinnati, Cincinnati, OH. Rickets in Low Birth Weight Infant: Using Human Mik, Winston W.K. Koo, Chidren s Hospita Medica Center, Cincinnati, OH. Vitamin D. Requirement for Low Birth Weight Infants, Bruce W. Hois, Case Western Reserve University, Ceveand, OH. Studies of Human Zinc Deficiency, Michae K. Hambidge, University of Coorado Heath Sciences Center, Denver, CO. Pathogenesis of Neonata Jaundice and Kernicterus, Lawrence M. Gartner, University of Chicago, Chicago, IL. Composition of Human Mik Conference on Methods for the Anaysis of Human Mik, Robert G. Jensen, University of Connecticut, Stoors, CT. Identification of Components of Coostrum and Human Mik, Robert G. Jensen, University of Connecticut, Stoors, CT. Identification of Components of Coostrum and Human Mik, Margit Hamosh, Georgetown University, Washington, DC. Research in Perinata Medicine, Ian Gross, Yae University, New Haven, CT. 42

49 Evauation of the Nutritiona Quaity of Preterm Human Mik, Richard Ehrenkranz, Yae University, New Haven, CT. Purification, Characterization of Mik Growth Factors, Michae Kagsbrun, Chidren s Hospita Medica Center, Boston, MA. Reguation of Trigyceride Composition of Mik, Stuart Smith, Chidren s Hospita Medica Center of Northern Caifornia, Oakand, CA. The Choine Content of Mik, Steven H. Zeise, Boston University, Boston, MA. Characterization of Membrane Materia in Human Mik, Stuart Patton, University of Caifornia-San Diego, La Joa, CA. Taurine, Carnitine, and Amino Acids in Human Mik, Peggy R. Borum, Vanderbit University, Nashvie, TN. Bioavaiabiity of Trace Metas in Human Mik, Rodney R. Howe, University of Texas Heath Science Center, Houston, TX. Human Mik Seenium Content and Distribution, Mary F. Picciano, University of Iinois at Urbana-Champaign, Urbana, IL. Thyroid Hormone in Preterm Breast Mik, Gibert0 R. Pereira, Chidren s Hospita of Phiadephia, Phiadephia, PA. Immunoogica Aspects Immune Reguation of Human Mik, Larry K. Pickering, University of Texas Heath Science Center, Houston, TX. Immunoogic Defenses Agains Infection in Human Mik, Margaret A. Keer, Los Angees County Harbor-UCLA Medica Center, Torrance, CA. Identification of Components of Coastrum in Human Mik, Margaret A. Keer, Los Angees County Harbor-UCLA Medica Center, Torrance, CA. Immune Responses of Newborns to Ingested Antigens, Richard M. Rothberg, University of Chicago, Chicago, IL Human Mik and Immune Deveopment in Premature Infants, Mark Baow, University of Connecticut, Farmington, CT. Immunocompetence of Coostrum during Vira Infections, Pearay L. Ogra, Chidren s Hospita, Buffao, NY. Coostra Ce Markers, Function and Reguation, Een Richie, University of Texas Heath Science Center, Houston, TX. The Effect of Coostrum on Gut Maturation and Host Defense, Aan W. Waker, Massachusetts Genera Hospita, Boston, MA. Immunoogica Characterization of Human Coostra Ces, Syvia Crago, University of New Mexico, Abuquerque, NM. Effects of Coostrum on Immune Responsiveness, John F. Hasey, University of Kansas, Kansas City, KS. Dynamics of Lymphocyte Transfer to the Newborn, Leonard L. Seeig, Jr., University of Texas Heath Science Center, Daas, TX. Intestina Macromoecuar Transport and Neonata Liver, John N. Uda, Jr., Harvard University, Boston, MA. 43

50 Perinata III~ wii~,,,~, Immunity, and Madeveopment, Chares A- Aford, Jr., 1 Jtivc.1 taiv of Aabama in Birmingham, Birmingham, AL. Antibody SCWCI I( 111, 'Cytotoxicity and Immune Reaction, Steve Koh, University (11 'I'CXib I Icath Science Center, Houston, TX. Epidemiobty 01 I ;mt Botuism, James Chin, Caifornia State Department ( 1 1 IU 11 Y&vices, Berkeey,.. CA. Nutrmona Risk I c(ors and Penaty of Meningitis, Bettyou Sherry, Chidren s ( )r ho~ci,~ Hospita and Medica Center, Seatte, WA. Human Mik hkh OPtimizah 01 I ~t~,,~,n Mik Heat Treatment, Ronad R. Eitenmier, University 01 ( km ML,\, Athens, GA. Human Mik hb *- Wiiam C. Heird, Coumbia University, New York, NY. Human Mik I;.,ig Studies, Richard A. Ehrenkranz, Yae University, New H;IVW, I 1 Human MII\ Ihr~~i~ Studies, Margaret C. Nevie, University of Coorado -{c;hi~ St Ia*IIces Center, Denver, CO.

51 APPENDIX C RESEARCH ON HUMAN LACTATION AND BREASTFEEDING SUPPORTED BY THE U.S. DEPARTMENT OF AGRICULTURE* Physioogy of Lactation Effect of Materna Dietary Lipid on Prostagandin Content of Human Mik and Infant Pasma, M.C. Craig-Schmidt, Auburn University, Auburn, AL. Faiure to Thrive at the Breast, C.A. Johnson, Bayor Coege of Medicine, Houston, TX. Contro of Sodium in Breast Mik, B.S. Keenan, Bayor Coege of Medicine, Houston, TX. Materna Nutrition Aspects socia Factors Infuencing Rapid, Radica Dietary Change in American Aduts, L.E. Grivetti, Agricutura Experiment Station, University of Caifornia, Davis, CA. Human Cacium Requirements and Metaboism During Lactation, J.L. Kirkand, Bayor Coege of Medicine, Houston, TX. Nutrient Leves and Metaboism in Pregnancy, A. Kirksey, Agricutura Experiment Station, Purdue University, West Lafayette, IN. The Effect of Dietary Zinc Suppementation on the Zinc Status of Lactating Women, P.B. Moser, Agricutura Experiment Station, University of Maryand, Coege Park, MD. Nutritiona Requirements for Women During Pregnancy and Lactation, B.L. Nichos, Bayor Coege of Medicine, Houston, TX. Eary Deveopmenta Effects of Margina Vitamin B-6 Nutrition, R.D. Reynods, Betsvie Human Nutrition Research Center, Agricutura Research Service, Betsvie, MD. Infant Physioogy Proteoytic Degradation of Human Mik Lactoferrin in Infants, B.L. Lonnerda, Agricutura Experiment Station, University of Caifornia, Davis, CA. Infant Nutrition Aspects Meta Absorption by Infants, P. Johnson, Grand Forks Human Nutrition Research Center, Agricutura Research Service, Grand Forks, ND. *Source: Federa Human Nutrition Research and Information Management System,

52 Factors Infuencing the Nutrient Intake and Growth of Breast-Fed Infants, A. Kirksey, Agricutura Experiment Station, Purdue University, West Lafayette, IN. Factors Infuencing Foate Status During Infancy, M.F. Picciano, Agricutura Experiment Station, University of Iinois, Urbana, IL. Composition of Human Mik Lipids in Breast Mik and Their Digestion, R.M. Cark, Agricutura Experiment Station, University of Connecticut, Stoors, CT. Dietary Fat and Prostagandin Content of Human Mik, M.C. Craig- Schmidt, Agricutura Experiment Station, Auburn University, Auburn, AL. Micronutrients and Protective Agents in Human Mik, R.R. Eitenmier, Agricutura Experiment Station, University of Georgia, Athens, GA. Trace Eements in Human and Other Miks in Reation to Neonata Nutrition, L.S. Hurey, Agricutura Experiment Station, University of Caifornia, Davis, CA. Trace Eements in Human Mik, C.W. Weber, Agricutura Experiment Station, University of Arizona, Tucson, AZ. Human Mik and Coostntm Components: Effects of Storage and Processing, R. Greenberg, Eastern Regiona Research-Center, Wyndmoor, PA. Dietary Practices Dietary Practices and Nutritiona Status of Materna and Infant Popuations, L. Vaughan, Agricutura Experiment Station, University of Nebraska, Lincon, NE. Infant Feeding Behavior Appying Socia Learning and Diffusion Theories to the Study of Infant-Feeding Behavior, L.S. Sims, Agricutura Experiment Station, Pennsyvania State University, University Park, PA. 46

53 Ei ALUATION QUESTIOtiNAIRE Dear Reader: Pease take a few minutes to answer some questions about this new pubication. Your response wi hep us evauate recent efforts to diiseminate information and stim&te~activities to promote breastfeedmg. Once you have competed the questionnaire pease fod it, sea with tape, and mai. No postage is necessary. Thank you for your. assistan& Are you a physician - Nurse - Nutritionist ~ Other (specify) Do you work in a pubic heath agency e private practice I vountary _ organizaton - other (specify) In which state do you work? From whom did you receive this pubication? Were you aware that a surgeon Genera s Workshop on Breastfeeding and Human Lactation has been hed? Yes No- Do you have a copy of the Report of the Surgeon Generaps Workshop on Bmzs~feeding and Human Lactation? Yes No- If so, did it stimuate you to initiate any breastfeeding activities?, YeS- No-, If so, what kind of activities? Did you have an opportunity to submit information to be incuded in this Foo~p Report? Yes< No- If so: through whom? Did you submit information for thii report? Yes: No- If so, is the information you submitted incuded in thii report? Yes - NO - We are interested in any comments you may have about the reevance and usefuness of this Foowup Report. - How are you niost ikey to read this pubication?. (Check one) : - cover-toxover - sections of interest ony -,introduction on$ - not ikey to rez+d, Pease it resources and references on breastfeeding which you have deveoped or found particuary usefu. Send us a copy, if possibe., - Thank you! c