WIC (The Special Supplemental Nutrition Program for Women, Infants, and Children): policy versus practice regarding breastfeeding

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides foods, education, and referrals to participants who are considered to be at nutritional risk. The outreach of the program is impressive, and nearly 9.17 million people participated in the program in 2010. WIC participation is associated with many positive outcomes, including improved birthweights and childhood dietary practices. Despite these benefits, WIC mothers experience lower breastfeeding rates when compared with demographically similar women who do not participate in the WIC program. According to WIC, "A breastfeeding mother and her infant shall be placed in the highest priority level." Despite this statement and others that support breastfeeding, WIC allocates only 0.6% of its budget toward breastfeeding initiatives. Formula expenses accounted for 11.6% ($850 million) of WIC's 2009 expenses. The inconsistency between WIC's policies that encourage breastfeeding vs. practices that favor formula begs further examination. Research shows consistent success with peer counseling programs among WIC participants; however, little money is budgeted for these programs. Rebates included, WIC spends 25 times more on formula than on breastfeeding initiatives. The American Academy of Nursing Expert Panel on Breastfeeding is calling for a re-evaluation of how these taxpayer dollars are spent. Additionally, the American Academy of Nursing recommends a shift from formula bargaining to an investment in structured peer counseling programs. All WIC programs should offer peer counseling support services that encourage breastfeeding and meet the needs of the families they serve.

Report of a Staff Program to Promote and Support Breastfeeding in the Care of Vulnerable Infants at a Children's Hospital

Ill or premature infants do not have the opportunity to begin breastfeeding in an optimal manner; yet, these infants may benefit most from human milk. Health-care providers' knowledge of breastfeeding in both healthy and ill infants is frequently limited due to deficits in training. This article outlines a multifaceted approach to develop a comprehensive, hospital-wide system to support and promote breastfeeding for vulnerable infants. This approach was designed for the staff of the Children's Hospital of Philadelphia.

Blood flow characteristics of the human lactating breast

BACKGROUND

Despite the increased metabolic activity of the lactating breast, no studies have been carried out to determine mammary blood flow (MBF) parameters or the relationship between MBF and milk production in women. The aim of this study was to measure the MBF in the internal mammary artery (IMA) and lateral thoracic artery (LTA) of lactating women and determine if these were related to milk production.

METHODS

Blood flow in the IMA and LTA was measured with color Doppler ultrasound in 55 lactating women. Twenty-four-hour milk production was determined with the test-weigh method.

RESULTS

IMA contributed the greater proportion of blood flow to the lactating breast (70%). MBF was highly variable between women but consistent between the left (126 L/24 h; interquartile range, 76-169) and right (110 L/24 h) breasts. No relationship between MBF and milk production was demonstrated. For 3 women, MBF was markedly reduced in 1 breast that was synthesizing almost no milk compared to the other that was producing a normal volume of milk.

DISCUSSION

Although no relationship between MBF and milk production was found, the substantial reduction in blood flow in the breasts of lactating women producing almost no milk suggests a threshold below which milk production is compromised.

CONCLUSION

Doppler ultrasound did not demonstrate a relationship between MBF and milk production in lactating women. Further investigation is required to fully understand the role of blood flow in milk synthesis.

The relationship of brain development and breastfeeding in the late-preterm infant

Late-preterm infants (34 0/7-36 6/7 weeks gestation) are physiologically and developmentally immature at birth. The relationship between brain development and feeding is important since adequate oral intake is imperative to prevent feeding-related morbidity and mortality associated with being late preterm. One third of brain growth occurs in the last 6-8 weeks of gestation. The ontogeny of coordinated oral feeding appears to follow a chronological, predictable pattern in preterm neonates. This suggests that neurodevelopmental maturation, rather than experience or learned behavior, is largely responsible for feeding behaviors. The aim of this article is to provide a review of the literature that establishes the relationship between brain development and feeding in the late-preterm infant.

Innovations in the provision of human milk and breastfeeding for infants requiring intensive care

Infant admission to the Neonatal Intensive Care Unit requires that the family receives the scientific rationale for the importance of providing human milk for their child. The initiation and maintenance of maternal milk supply must be a priority. Understanding variation in milk composition is crucial so that the infant receives the most appropriate milk throughout the hospital stay. For mothers who wish to breastfeed, a detailed and planned process is essential to ensure success.

A mother with glandular hypoplasia and a late preterm infant

This case study presents a maternal-infant dyad, both of whom bring risk factors to the breastfeeding relationship. The mother had true glandular hypoplasia that was not detected in the antenatal period or during her hospital stay. In addition, the infant was a late preterm infant, bringing the risks of poor feeding behavior and ineffective removal of milk from the breast as well as limited body reserves. Through the use of breastfeeding technology, including test weights, use of a hospital grade double electric breast pump and use of a nipple shield, in addition to a pharmacologic intervention, in which Domperidone was administered, this mother was able to maximize her milk yield and the infant was able to receive human milk for 6 months. This case report highlights the need for a thorough assessment of the breasts as well as the breastfeeding process in all breastfeeding dyads.

A randomized controlled community-based trial to improve breastfeeding rates among urban low-income mothers

OBJECTIVE

The purpose of this study was to assess whether providing a breastfeeding support team results in higher breastfeeding rates at 6, 12, and 24 weeks postpartum among urban low-income mothers.

DESIGN

A randomized controlled trial with mother-infant dyads recruited from 2 urban hospitals.

PARTICIPANTS

Breastfeeding mothers of full-term infants who were eligible for Special Supplemental Nutrition Program for Women, Infants, and Children (n=328) were randomized to intervention (n=168) or usual-care group (n=160).

INTERVENTION

The 24-week intervention included hospital visits by a breastfeeding support team, home visits, telephone support, and 24-hour pager access. The usual-care group received standard care.

OUTCOME MEASURE

Breastfeeding status was assessed by self-report at 6, 12, and 24 weeks postpartum.

RESULTS

There were no differences in the sociodemographic characteristics between the groups: 87% were African American, 80% single, and 51% primiparous. Compared with the usual-care group, more women reported breastfeeding in the intervention at 6 weeks postpartum, 66.7% vs 56.9% (odds ratio, 1.71; 95% confidence interval, 1.07-2.76). The difference in rates at 12 weeks postpartum, 49.4% vs 40.6%, and 24 weeks postpartum, 29.2% vs 28.1%, were not statistically significant.

CONCLUSIONS

The intervention group was more likely to be breastfeeding at 6 weeks postpartum compared with the usual-care group, a time that coincided with the most intensive part of the intervention.

Using milk flow rate to investigate milk ejection in the left and right breasts during simultaneous breast expression in women

Background

Milk ejection is essential for a successful lactation, however techniques to measure milk ejection in women are often complex and invasive. Recent research has demonstrated that at milk ejection, milk duct diameter increased in the breast (measured by ultrasound) at the same time as milk flow rate increased (measured using a weigh balance). This study aimed to evaluate a purpose-built continuous weigh balance (Showmilk, Medela AG) to measure changes in milk flow rate from the breast to identify milk ejections during milk expression. In addition, the Showmilk was used to determine if milk ejection occurred simultaneously in both breasts during double pumping.

Methods

Increased milk flow rates during single pumping were compared to simultaneous ultrasound measurements of increased milk duct diameters in 14 mothers. In addition, increases in milk flow rate were compared between the left and right breasts of 28 mothers during double pumping for 15 minutes with two separate electric breast pumps attached to two Showmilks to record milk flow rate.

Results

Increased milk flow rates were associated with increased milk duct diameters during single pumping. The mean number of milk ejections was not different between the Showmilk (4.2 ± 2.0) and ultrasound (4.5 ± 1.5) techniques. Overall, 67 milk ejections were measured and of these, 48 (72%) were identified by both techniques. The left and right breasts responded synchronously with 95.5% of the flow rate increases corresponding between the breasts. The mean number of milk ejections identified by an increase in milk flow rate during double pumping was 5.1 ± 1.7 and 5.0 ± 1.7 for the left and right breasts, respectively. In addition, mothers chose the same expression vacuum for the left (-198 ± 31 mmHg) and right (193 ± 33 mmHg) breasts.

Conclusion

The Showmilk can simply and non-invasively record milk ejections by measuring increases in milk flow rate that correspond with increases in milk duct diameter. For the first time measurement of milk flow rate has been used to confirm that milk ejections occur simultaneously in the left and right breasts during double pumping. The use of the Showmilk will facilitate further research into the relationship of milk ejection and milk removal.

Parent-infant co-sleeping and its relationship to breastfeeding

Co-sleeping can provide numerous benefits for both the parent(s) and the infant. Perhaps the greatest advantage lies in its promotion of breastfeeding, an act widely recognized for its benefits to both the mother and infant. However, risks also are associated with co-sleeping, prompting many researchers to examine the safety of its practice. Pediatric nurse practitioners need to be informed on issues related to co-sleeping in order to educate parents regarding its risks and benefits, to assess the safety of an established sleeping environment, and to be aware of its prevalence in their patient populations. A review of the literature is presented to inform pediatric nurse practitioners about varied definitions of co-sleeping, the reasons why some parents engage in the practice, cultural preferences for co-sleeping, associated risks and benefits, and its relationship to breastfeeding.

Special considerations for breastfeeding the infant with spina bifida

At present, no research has examined the unique breastfeeding needs of a mother and her infant with spina bifida (SB). This mother-infant dyad will face many unique challenges during the prenatal period, postdelivery, and postsurgical repair of the myelomeningocele (MMC). Each of these periods presents an opportunity for effective evidence-based nursing interventions to promote successful provision of human milk (HM). Beyond the need for nursing care during these crucial events, parents need education about the potential benefits of HM for the long-term complications of SB. Although there is no published evidence specifically related to the benefits of HM for mothers and their infants with SB, studies related to the general benefits of HM suggest that the mothers may enjoy enhanced maternal psychological adjustment while infants with SB may experience improved pain management, reduced infection rates, decreased incidence of allergy, improved cognitive development, and decreased incidence of obesity. Further research is needed to better understand the unique relationship between HM and SB.

The Family & Breastfeeding Laws

Many states have recently enacted breastfeeding legislation that clarifies existing laws to protect the rights of breastfeeding mothers. Families can benefit from learning about the current breastfeeding laws in their states, as this knowledge may empower them if discriminatory situations arise. Knowledge of breastfeeding laws can create a more supportive breastfeeding environment and alleviate fears and anxiety about breastfeeding in public. Nurses are instrumental in educating families about existing laws and possible courses of action should discrimination occur and can direct families to advocacy groups and resources. Additionally, nurses can play a pivotal role in passing breastfeeding legislation through political activism.

State of the science: use of human milk and breast-feeding for vulnerable infants

Human milk is the preferred form of nutrition for all infants including those born preterm or otherwise ill. However, without the commitment of knowledgeable healthcare providers to ensure success during mother-infant separation, many infants fail to receive their mother's own milk. Care of the mother-infant dyad during infant illness requires vigilant monitoring of the lactation experience and the commitment of healthcare providers to take a family through the step-by-step process needed to ensure positive outcomes related to the use of human milk and breast-feeding for vulnerable infants. The science tells us that human milk is the best form of nutrition for all infants. As practitioners we must be doing everything in our power to make sure the infants we care for are able to receive their mother's own milk.

Preserving Breastfeeding for the Rehospitalized Infant

The benefits of feeding newborns with human milk are well established. Unfortunately some hospital practices do not support successful breastfeeding; practices such as early hospital discharge after birth, lack of appropriate follow-up primary care providers, and lack of access to breastfeeding support services can contribute to breastfeeding failure, as well as morbidity and mortality in the infant. Infants experiencing breastfeeding difficulties are sometimes admitted to the hospital with diagnoses such as hyperbilirubinemia/jaundice, dehydration/hypernatremia, rule out sepsis, and weight loss/failure to thrive. This article describes a clinical pathway developed with the express purpose of maintaining and enhancing lactation in mother-infant dyads experiencing breastfeeding difficulties. The goal of the pathway is to maintain lactation and breastfeeding while returning the infant to a state of health. A key focus of the pathway is milk transfer, a concept that is missing from much of the research on lactation difficulties. The pathway considers breastfeeding from both a maternal and an infant perspective, with a goal of preserving breastfeeding. It uses technology to support the breastfeeding process and could be useful for all practitioners working with mother-infant dyads experiencing breastfeeding difficulties.

The Breastfeeding Case Study: A Model for Educating Nursing Students

Due to several national initiatives and recommendations from professional organizations, more women may be encouraged to breastfeed. However, they will not achieve improvement in breastfeeding duration if their health care providers lack knowledge about breastfeeding or are not easily accessible in some areas. Nurses who work with families with children are responsible for a great deal of patient education and can affect women's decisions to initiate and continue breastfeeding. Therefore, it is critical that nurse educators find a way to address this knowledge gap, especially in already overburdened curricula. This article describes a successful model for doing so.

Advocacy for breastfeeding: making a difference one community at a time

In response to the need for health care professionals skilled in lactation management, a breastfeeding course was developed and taught at the University of Pennsylvania. Since 1995, Nursing 361 has been offered to undergraduate junior and senior students. The aim of this article is to discuss how through coursework, nursing students can provide breastfeeding advocacy and change the breastfeeding culture one community at a time. This article provides guidelines for others to conduct such projects, as well as exemplars to demonstrate how advocacy can change communities. Through development of an advocacy project during the course of a semester, a student learns about his or her identified community and is able to make an impact that often lasts years after his or her project is completed.

Ten steps for promoting and protecting breastfeeding for vulnerable infants

Human milk is the preferred food for infants, including ill and preterm infants. Ensuring skilled and comprehensive breastfeeding support for these vulnerable infants requires a specialized approach. The author outlines 10 steps for promoting and protecting breastfeeding in vulnerable infants. The steps include providing the parents with information necessary to make an informed decision to breastfeed; assisting the mother with the establishment and maintenance of a milk supply; ensuring correct breast milk management (storage and handling) techniques; developing procedures and approaches to feeding the infant breast milk; providing skin-to-skin care (kangaroo care) and opportunities for non-nutritive sucking at the breast; managing the transition to the breast; measuring milk transfer; preparing the infant and the family for infant hospital discharge; and providing appropriate follow-up care. Material and examples are drawn from the author's research and clinical work at the Children's Hospital of Philadelphia. Current research is utilized, and the role of the nurse is emphasized throughout.

Medications and lactation: what PNPs need to know

The current rise in breastfeeding rates coincides with a continuously expanding prescription medication market. Now more than ever, pediatric nurse practitioners (PNP) are responsible for ordering and consulting on maternal medications during lactation. PNPs are obligated to determine the safety of medications by critically reviewing recommendations that are based on recent clinical research. However, sources vary widely in the relevance of their information. Ideally, comprehensive research-based recommendations about medications and lactation should be based on the pharmacokinetics of drugs in the maternal system, the oral bioavailability of the medication to the infant, and the infant evaluation. Review of the data enables PNPs to effectively evaluate drugs and their actual risks to a breastfeeding infant, thereby supporting integration of sound evidence-based care into clinical practice.

Nipple shields for preterm infants: effect on milk transfer and duration of breastfeeding

This study reports breastfeeding outcomes for 34 preterm infants whose mothers used ultrathin silicone nipple shields to increase milk transfer. Mean milk transfer was compared for 2 consecutive breastfeedings without and with the nipple shield. Total duration of breastfeeding was calculated for a maximum of 365 days. Mean milk transfer was significantly greater for feedings with the nipple shield (18.4 ml vs. 3.9 ml), with all 34 infants consuming more milk with the nipple shield in place. Mean duration of nipple shield use was 32.5 days, and mean duration of breastfeeding was 169.4 days; no association between these variables was noted. The nipple shield was used for 24.3% of the total breastfeeding experience, with no significant association between the percentage of time the shield was used and total duration of breastfeeding. These findings are the first to indicate that nipple shield use increases milk intake without decreasing total duration of breastfeeding for preterm infants.

Breastfeeding duration among low income women

Breastfeeding has been identified as a possible deterrent to the development of osteoporosis and breast cancer in women. In addition, infants who are breastfed exclusively for at least 4 months reportedly have fewer incidence of SIDS, ear infection, diarrhea, and allergies. Further, low income women who breastfeed may be empowered by the experience. Increasing the frequency and duration of breastfeeding is recognized as a national priority, particularly for low income, minority women. Yet, recent national data indicate that in 1997, only 16.5% of low income mothers breastfed for at least 6 months. Short breastfeeding duration in low income women may be due to problems unique to them; thus, consistent and comprehensive breastfeeding support should be provided by midwives, nurses, lactation consultants, and peer counselors who are skilled in culturally sensitive management of lactation within the context of limited financial and social resources. This article focuses on the benefits of breastfeeding, and factors that may influence its duration. It also explores culturally relevant strategies as well as suggested interventions to increase breastfeeding duration among low-income women.

Taking a bite out of CRISP. Strategies on using and conducting searches in the Computer Retrieval of Information on Scientific Projects database

A vast array of information useful to the scientific community is readily available on the internet. Currently, the National Institutes of Health (NIH) offers user access to several large databases, some of which are pertinent to nurses interested in research, health policy formation, and identifying funded research projects. One such database, the Computer Retrieval of Information on Scientific Projects (CRISP), provides information on research grants funded by the NIH from 1972 to the present. Retrieval of scientific information for each project in CRISP is made available by project title, grant number, abstract, principal investigator, eight-digit CRISP Thesaurus terms, and key words. This article introduces the reader to CRISP and provides a set of succinct strategies for conducting comprehensive searches in the database.

Women's health. The role of advanced practice nurses in the 21st century

Advanced practice nurses have the capability of providing a variety of services in women's health care. The role and functions of certified nurse midwives, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists are discussed. Current issues and barriers to advanced practice nursing are presented and include role definitions and regulations, second licensure, educational level, prescriptive authority, third party reimbursement, admitting privileges, and malpractice reform. Future directions and recommendations are provided.