Starting Obesity Prevention in Infancy: The FitWIC Baby Behavior Project M. Jane Heinig Jennifer...
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Transcript of Starting Obesity Prevention in Infancy: The FitWIC Baby Behavior Project M. Jane Heinig Jennifer...
Starting Obesity Starting Obesity Prevention in Infancy: Prevention in Infancy: The FitWIC Baby The FitWIC Baby Behavior ProjectBehavior Project
M. Jane Heinig Jennifer BañuelosJackie Kampp Jennifer GoldbronnLuz Vera Becerra Kerri Moore
This project has been funded at least in part with Federal funds from the U.S. Department of Agriculture, Food and Nutrition Service. The contents of this publication do not necessarily reflect the view or policies of the U.S. Department of Agriculture, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government.
Results – Focus Groups (2003) “Breast is best.” Health messages regarding breastfeeding
were loud and clear “Helps them protect against viruses better, breastfeeding.
It’s also very important for development of the brain and eyes.”
“My mom breastfed my brothers and so that was something I wanted to do with my son because, you know, that special bond, and I feel there’s a bond and it’s healthier.”
Heinig et al. J Hum Lact. 2006;22:27-38.
UCD Focus Groups (2003)
Many mothers reported that Many mothers reported that their infants were not their infants were not satisfied when they followed satisfied when they followed guidelinesguidelines We asked how could they tell?We asked how could they tell? Many of the mothers told us Many of the mothers told us
about their baby’s behaviorabout their baby’s behavior
Heinig et al. J Hum Lact. 2006; 22: 27-38.
UC Davis Focus Groups (2003) Many mothers believe babies cry
because of hunger (formula and cereal prevent hunger) “When I gave formula, the baby no
longer cried and that is when I decided not to give him breast milk.”
They think their babies will stay full longer if they are overfed “My baby used to wake up, but now I
am giving him formula if he is already full and he no longer wakes up.”
Heinig et al. J Hum Lact. 2006; 22: 27-38.
Results – Focus Groups (2003)
Mothers understand what is best, but many believe that their circumstances force them to make other choices Full, quiet, sleeping child is norm
Mothers believe that health care providers/ support staff do not understand what they are experiencing “They don’t see what you’re going through. They are not
there to see that you can’t do it and you keep trying. It’s like, ‘You try it.’ ”
Heinig et al. J Hum Lact. 2006; 22: 27-38.
Feeding in Response to Baby Behavior We found that mothers feel overwhelmed by
crying and waking If breastfeeding, they start adding formula Add more formula, and more formula Start solid foods (cereal in the bottle) Add other foods and fluids Feed every time the baby makes noise
The Project
Study Design
3-year quasi-randomized educational intervention project (8 sites, 4 each in No. and So. Cal.) Year 1: Material development, staff training, and baseline
data collection Year 2: Intervention period Year 3: Post-intervention data collection, write-up, and
dissemination Concept: Create a clinic environment supporting
positive caregiver-infant interactions Social marketing materials, staff training, handouts, classes,
activities, incentives
Our Study Approach
Train staff to understand why babies behave the way they do
Provide staff with tools (messages, methods, and materials) to help them feel safe and comfortable sharing baby behavior information with parents
Use social marketing materials to tell parents that WIC is a place to learn about baby behavior
Handouts
Social Marketing Materials
Posters were created to advertise that new information was available
Activities and games were available in the waiting areas to promote messages
All Sites Combined: WIC Food Package Selection Increase in Excl BF Food
Package Intervention = 6.3% (43%
higher than baseline) Control = 2.3%
Decreased formula use Reduction in cans of formula
used while caseload increased
Change in EBF Food Package (0-6 mo)
0
5
10
15
20
25
Intervention Control
Per
cen
t
Baseline
Post
Exclusive BF Food Package by Age
0%
5%
10%
15%
20%
25%
30%
1 2 3 4 5 6
Infant Age (mo)
Intervention
Control
Postpartum Participant Survey BF with No Formula at 1 mo
0
5
10
15
20
25
30
35
English Spanish
Pe
rce
nt
Intervention
Control
*
*
Excluding those with self-reported initial medical or latch problems*p<0.05
Postpartum Participant Survey
*p<0.05
*
Asks WIC for Advice
50%
55%
60%
65%
70%
75%
80%
85%
English Spanish
Pe
rce
nt
"Alw
ay
s"
Intervention
Control
**
Postpartum Participant Survey
*p<0.05
*
Likes going to WIC classes
0%
10%
20%
30%
40%
50%
60%
70%
80%
English Spanish
Pe
rce
nt
"Alw
ay
s"
Intervention
Control
*
*
Infants >95th percentile wt/age Attained weight for
age > 95th percentile 5-7 mo
10.7
14.4
4.9
12.6
0
2
4
6
8
10
12
14
16
18
20
Baseline Post
IntControl
According to WHO growth standards *P<.01
N=411N=339
*
NS
Baby Behavior at WIC and Beyond California State WIC will use
messages statewide Oregon State WIC staff has
received training – looking to expand effort
Presentations in AZ later this month
Efforts ongoing to modify/ translate messages for Russian, Hmong, and Vietnamese populations
Opportunities for Collaboration Efforts underway in Alameda County, Solano
County, and Butte County to coordinate agencies to deliver baby behavior messages (as part of continuum of care) Hospitals Child Health and Disability Prevention Program Comprehensive Perinatal Services Program Black Infant Health Early Head Start Home Visitors Teen Parenting Programs
Supporting Informed Infant Feeding Decisions in the First 30 Days
Copyright 2009 UC Regents. All rights reserved.
“Just in Case” A Qualitative Study of Maternal Request for Hospital Formula
14 focus groups in English and Spanish (N=97)
Study focused on maternal request for hospital formula for healthy breastfed infants
Moms use formula in the hospital for many of the same reasons they use it at home
Reasons for Supplementation of Healthy Breastfed Newborns Unrealistic expectations about newborns Lack of preparation for breastfeeding Formula seen as the only solution for
breastfeeding problems Formula seen as the solution for baby
behavior problems
Parents’ Unrealistic Expectations “The imagined baby”1
Parents’ prenatal construct of the baby
Includes both hopes and fears
Will be in conflict with the real baby
Cultural norms have idealized the “quiet, full, sleeping” baby2
1. Stern, Pediatrics 1998; 2. Heinig, JHL 2006
Support Strategies
Prenatally Ask moms about their expectations and address
questions and concerns Gently break the bad news – parenting is tough
Help moms build a support group for the first few weeks
Share information about normal newborn behavior
Lack of Preparation for Breastfeeding
“She had a bottle because the milk wasn’t coming in right away.”
“She was a big baby. She would wake up and need to be fed every 3 hours!”
“I pumped and I got nothing.”
The Facts
Milk doesn’t come in right away 85% of mothers - milk comes in at 24-72 hours pp First time moms’ milk comes in later (avg. 70 hrs
pp) than moms who have BF before (avg. 56 hrs pp)
Colostrum is important too Early milk transfer to the baby varies
Early Milk Transfer to Infants Varies
0
100
200
300
400
500
600
700
800
900
1 2 3 4 5 6 7 8
Days Postpartum
Mil
k tr
ansf
er (
g/d
)
Neville MC et al. Am J Clin Nutr 1988
The Facts
Newborns need to be fed very frequently Frequent feeds can help moms avoid engorgement May feed every 1-2 hours at first, varies widely Days 4 and 5 usually have the most feeds
Several mothers thought that the amount pumped was equal to their production Pumps are not as effective as babies in extracting milk
Colostrum can be difficult to obtain Too much early pumping can cause engorgement
Support Strategies
Make sure that moms know that their milk will come in after they leave the hospital and that it can take several days (must follow-up) Reassure them that colostrum is all newborns need
Help moms to understand that babies need to eat frequently because they are so small
Make sure that any mom who is pumping is properly trained and supported Limit pumping to those who need it
Breastfeeding Problems
Formula perceived as a “solution” to breastfeeding problems – few believed that initial difficulties could be fixed “He didn’t suck well, he rejected it right away.” “I was wondering why he didn’t want to take it.
They told me as a first time mom that it was difficult to put him to breast.”
Percentage of Infants with Poor Suck
49
22
14
0
10
20
30
40
50
Day 1 Day 3 Day 7
% o
f Inf
ants
Dewey et al. Pediatrics 2003; 112: 607-619.
Support Strategies
Make sure that moms know half of all babies will not latch well on the first day but most babies get better quickly with practice (if not, they should call WIC)
Make sure moms have resources if they have problems or questions
Behavioral Problems
Parents believed that formula would stop infant crying and promote sleep “Every time that I tried to breastfeed, he would
have a tantrum, become really angry. So then I thought ‘Why? Why should I make him suffer?’”
“We started the formula on the 2nd day…since he never stopped crying.”
“He wasn’t sleeping and was constantly crying and when I would get him to latch, there was nothing.”
The Facts
Newborn abilities vary widely Ability to control their bodies Range and regulation of states Social interaction skills
Cues may be unreadable or conflicting When adults respond to baby cues, babies get
better at using cues Sleep is erratic and light (lots of dreaming)
Brazelton and many others; Poblano Int J Biol Sci 2008
Support Strategies
Help mothers understand why babies cry and wake
Help them see the baby’s signs of dreaming and cues
But, very important not to dismiss mothers’ concerns too quickly Some babies will be in trouble,
sometimes it’s the “good” ones
Getting Back to Breastfeeding What happens if a baby
is supplemented in the hospital?
How can parents be supported to go back to exclusive breastfeeding?
After Supplementation
Once babies were fed formula, some mothers believed their babies would not go back to breastfeeding “They gave him a bottle at the hospital anyway, so what
did you expect?” “My thing is to continue to give him formula because
that’s what he was used to and he’d take it…I kinda had to give in ‘cause I didn’t have another option.”
Heinig et al. J Hum Lact 2006;22:27-38. Heinig et al. J Hum Lact 2009
Support Strategies
Don’t overemphasize “just one bottle” or “nipple confusion”
Reassure moms that all babies can go back to exclusive breastfeeding with support
Reassure moms that babies don’t “get used” to bottles when they are so young Half of all babies need a few days to learn to latch
even if they’ve never had a bottle
After Supplementation
Many mothers perceived that in-hospital supplementation represented a change in the feeding recommendation “They gave us huge bottles, but I really wanted to
breastfeed.” “If the hospital uses it [formula], it must be better because
they are up to par with research and everything.” Supplementation was often reported to be open
ended No specific amount, no end date, no clear follow-up
Heinig et al. J Hum Lact 2006;22:27-38. Heinig et al. J Hum Lact 2009.
Support Strategies
Ask moms to clarify with the doctor Not a change in feeding recommendation? How much and how long should supplements be
given? Let doctors know what you are hearing
Ask them to consider “prescribing” supplementation
Clear instructions of amounts, times, duration, follow-up
Parents’ Fears
Exclusive BF may seem overwhelming after supplementation Parents may fear removal of the supplement
especially if there was a medical reason for the supplementation
Some parents may fear removal of a supplement even if another child was the one with a medical problem
Thomasgard M, Metz WP. J Dev Behav Pediatr. 1995;16(1):47-53. Boyce WT. Adv Pediatr. 1992;39:1-33.
Support Strategies
Parents need a “safety net” just in case things go wrong Indicators that things are ok or not ok
How will the baby look? How will the baby behave? Will there be obvious signs?
Phone numbers – who can they call and when are they available
Action they can take until they reach you
Summary
Many moms use formula in the first 30 days because they are not prepared or informed
WIC can help support mothers’ infant feeding decisions by helping them see “the door” and not feel forced to abandon their goals
The Big Picture
Baby Behavior at WIC is taught through: Social marketing materials –
posters, games Counseling by trained staff Handouts Classes
WIC has limited contact with a large diverse population
Messages must be modified for other venues