Reasons for in-hospital formula supplementation of breastfed infants from low-income families

Non-medical formula use in newborn infants still common at two Swedish hospitals after a breastfeeding support program

AIM

To evaluate the effectiveness of a breastfeeding support programme on reducing infant formula use and to investigate indications for formula in newborn infants in Sweden.

METHODS

A quasi-experimental study design was carried out. It included 255 mother-infant pairs in a control group, who received standard care and 254 pairs in an intervention group, who took part in a breastfeeding support programme. Data were collected by reviewing patient records from two regional hospitals in Uppsala and Gotland and recruitment took place between 2017 and 2019.

RESULTS

Median age of mothers were 31 years (range 20-49) and median gestational age of infants were 39 + 6 weeks/days (range 37 + 0 to 42 + 4). The intervention did not reduce infant formula use. In total, 87/507 (17%) of the infants received formula. Among children receiving formula 30/87 (34%) had a medical indication, whereas 57/87 (66%) had no medical indication. Main reasons for medically indicated formula use were hypoglycaemia, 13/30 (43%), and weight loss, 13/30 (43%). Main reasons for non-medical use were mothers'/parents' wishes, 25/57 (44%) and infants' dissatisfaction, 11/57 (19%).

CONCLUSION

Continued efforts are needed to develop effective breastfeeding interventions with increased focus on infant formula reduction.

A nation‐wide study on the common reasons for infant formula supplementation among healthy, term, breastfed infants in US hospitals

In‐hospital infant formula supplementation of breastfed infants reduces breastfeeding duration, yet little is known about common reasons for infant formula supplementation. We examined the three most common reasons for in‐hospital infant formula supplementation of healthy, term, breastfed infants in the US reported by hospital staff. Hospital data were obtained from the 2018 Maternity Practices in Infant Nutrition and Care survey (n = 2045), which is completed by hospital staff. An open‐ended question on the top three reasons for in‐hospital infant formula supplementation was analyzed using thematic qualitative analysis and the frequencies for each reason were reported. The top three most common reasons for in‐hospital infant formula supplementation reported by hospital staff included medical indications (70.0%); maternal request/preference/feelings (55.9%); lactation management‐related issues (51.3%); physical but non‐medically indicated reasons (36.1%); social influences (18.8%); perceived cultural/societal/demographic factors (8.2%) and medical staff/institutional practices (4.7%). These findings suggest that a variety of factors should be considered to address unnecessary infant formula supplementation. Lactation management support delivered in a timely and culturally sensitive manner and targeted to mother‐infant dyads with potential medical and physical indications may reduce unnecessary in‐hospital infant formula supplementation.

The three most commonly reported reasons by hospital staff for infant formula supplementation were found to be related to medical indications (70.0%); maternal request/preference/feelings about breastfeeding such as frustration or lack of confidence (55.9%); lactation management‐related issues (51.3%); physical but non‐medically indicated reasons (36.1%); social influences (18.8%); perceived cultural/societal/demographic factors (8.2%); and medical staff/institutional practices (4.7%).

Underlying many of the reported three most common reasons for infant formula supplementation is potentially lack of lactation management support that considers the social influences (e.g. from family and friends) and that is culturally relevant.

These findings suggest that a variety of factors should be considered to address unnecessary infant formula supplementation.

Evaluating Birth Outcomes From a Community-Based Pregnancy Support Program for Refugee Women in Georgia

Refugee women face numerous and unique barriers to sexual and reproductive healthcare and can experience worse pregnancy-related outcomes compared with U.S.-born and other immigrant women. Community-based, culturally tailored programs like Embrace Refugee Birth Support may improve refugee access to healthcare and health outcomes, but empirical study is needed to evaluate programmatic benefits. This community-engaged research study is led by the Georgia Doula Access Working Group, including a partnership between academic researchers, Emory Decatur Hospital nurses, and Embrace. We analyzed hospital clinical records (N = 9,136) from 2016 to 2018 to assess pregnancy-related outcomes of Embrace participants (n = 113) and a comparison group of women from the same community and racial/ethnic backgrounds (n = 9,023). We controlled for race, language, maternal age, parity, insurance status, preeclampsia, and diabetes. Embrace participation was significantly associated with 48% lower odds of labor induction (OR = 0.52, p = 0.025) and 65% higher odds of exclusive breastfeeding intentions (OR = 1.65, p = 0.028). Embrace showed positive but non-significant trends for reduced cesarean delivery (OR = 0.83, p = 0.411), higher full-term gestational age (OR = 1.49, p = 0.329), and reduced low birthweight (OR = 0.77, p = 0.55). We conclude that community-based, culturally tailored pregnancy support programs like Embrace can meet the complex needs of refugee women. Additionally, community-engaged, cross-sector research approaches could ensure the inclusion of both community and clinical perspectives in research design, implementation, and dissemination.

In-Hospital Formula Feeding and Breastfeeding Duration

BACKGROUND

In-hospital formula feeding (IHFF) of breastfed infants is associated with shorter duration of breastfeeding. Despite evidence-based guidelines on when IHFF is appropriate, many infants are given formula unnecessarily during the postpartum hospital stay. To account for selection bias inherent in observational data, in this study, we estimate liberal and conservative bounds for the association between hospital formula feeding and duration of breastfeeding.

METHODS

Infants enrolled in the Minnesota Special Supplemental Nutrition Program for Women, Infants, and Children were selected. Breastfed infants given formula were matched with infants exclusively breastfed (n = 5310) by using propensity scoring methods to adjust for potential confounders. Cox regression of the matched sample was stratified on feeding status. A second, more conservative analysis (n = 4836) was adjusted for medical indications for supplementation.

RESULTS

Hazard ratios (HR) for weaning increased across time. In the first analysis, the HR across the first year was 6.1 (95% confidence interval [CI] 4.9-7.5), with HRs increasing with age (first month: HR = 4.1 [95% CI 3.5-4.7]; 1-6 months: HR = 8.2 [95% CI 5.6-12.1]; >6 months: HR = 14.6 [95% CI 8.9-24.0]). The second, more conservative analysis revealed that infants exposed to IHFF had 2.5 times the hazard of weaning compared with infants who were exclusively breastfed (HR = 2.5; 95% CI 1.9-3.4).

CONCLUSIONS

IHFF was associated with earlier weaning, with infants exposed to IHFF at 2.5 to 6 times higher risk in the first year than infants exclusively breastfed. Strategies to reduce IHFF include prenatal education, peer counseling, hospital staff and physician education, and skin-to-skin contact.

Women's Perceptions about Breastfeeding: A Preliminary Study

Background: Breastfeeding rates are low in many communities in the United States and require attention to come up with ideas that will help increase breastfeeding. This study investigated the effects of income, age, race and education on mothers’ perceptions about breastfeeding and whose needs and views should be considered in a women’s breastfeeding journey. Methods: A survey was distributed via email and Facebook to 525 participants; 453 participants (86.3%) responded to the survey. Results: Younger adults were more likely to agree that fathers should have some say about breastfeeding. Those earning USD 0–USD 50,000 were more likely to agree relative to those with higher incomes on children being entitled to mother’s milk, and children’s needs over-riding those of others. There was a statistically significant difference by education about women's wishes about breastfeeding being considered more important than those of their spouses. However, there was no statistically significant difference for any demographic group for breastfeeding decisions coming from women only. On women’s breasts being primarily for infant's nutrition, people who earned USD 0–USD 50,000 were more likely to agree relative to those who earned more than USD 50,000; younger adults were significantly more likely to agree. Those who earned USD 0–USD 50,000 were more likely to agree relative to those in other income brackets that extended family members should have input regarding babies being breastfed; minority participants were significantly more likely to agree relative to white participants; those with less than 4-year college education were more likely to agree relative to those with a minimum of four-year college education. Younger adults were more likely to agree that employers must provide extended maternity leave to make it easier for mothers to breastfeed. On women having the right to breastfeed in public places, younger adults were significantly more likely to agree compared to older adults. Conclusion: Women have favorable views about breastfeeding and prefer being in charge about decisions to breastfeed.

International Board Certified Lactation Consultants' Practices Regarding Supplemental Feeding Methods for Breastfed Infants

BACKGROUND

According to the Baby Friendly Hospital Initiative, when supplementary feeding occurs, mothers should be counseled on the use and risks of feeding bottles and teats. To help support this initiative it is important to understand the supplementation practices of Internationally Board Certified Lactation Consultants (IBCLC)®.

RESEARCH AIMS

To determine (1) if the location of an IBCLC's practice has any impact on supplemental feeding methods; (2) the preferred methods of and the main reasons for supplementation; (3) the level of an IBCLC's confidence with supplemental feeding methods; (4) who is making supplemental feeding decisions; and (5) if there are geographical differences among supplementation choices and reasons for supplementation.

METHODS

An exploratory, descriptive, cross sectional survey of IBCLCs was conducted to generate data about their use of supplemental feeding methods. The survey was sent via email invitation through the International Board of Lactation Consultant's Board of Examiners, with a response rate of 11.5% (N = 2,308).

RESULTS

There was no standard method of supplementation among participants. Participants indicated that they were confident advising mothers on alternative feeding methods. Only 17.6% (n = 406) of participants reported that the IBCLC was the caregiver who recommended the method of supplementation used. The majority of participants believed the Supplemental Feeding Tube Device SFTD) best preserves the breastfeeding relationship, and this was their preferred method of supplementation. However, the bottle was ranked as the number one method used in the United States, Australia, and Canada. The use of alternative feeding methods may be overwhelming to the mother.

CONCLUSION

Supplementation by alternative feeding methods might help preserve the breastfeeding relationship and help reach the World Health Organization's goal of increasing exclusive breastfeeding rates.

Factors in the Hospital Experience Associated with Postpartum Breastfeeding Success

Introduction: Hospitals are in a unique position to promote, protect, and support breastfeeding. However, the association between in-hospital events and breastfeeding success within population-based samples has not been well studied. Materials and Methods: A stratified (by education and birth weight) systematic sample of 5,770 mothers taking part in the Utah Pregnancy Risk Assessment Monitoring System, 2012-2015, were included. Mothers, 2-4 months postpartum, completed the 82-item questionnaire, including if they had ever breastfed their new baby, and if so, current breastfeeding status. Relationships between in-hospital experiences and breastfeeding termination and duration were evaluated via Poisson and Cox proportional hazard regression models, respectively, adjusting for other in-hospital experiences, maternal age, race/ethnicity, maternal education, marital status, smoking, physical activity, delivery method, pregnancy complications, and length of hospital stay. Results: Of all, 94.4% of mothers self-reported breastfeeding initiation, of whom 18.8% had breastfed <2 months, having breastfed on average 3.2 weeks (standard error: 0.07). In fully adjusted models, mothers who reported receiving a pacifier, receiving formula, or had staff help them learn how to breastfeed had a higher prevalence of terminating breastfeeding before 2 months (adjusted prevalence ratio [aPR] = 1.13, 95% confidence interval [CI]: 0.97-1.32; aPR = 1.20, 95% CI: 1.07-1.36; and aPR = 1.25, 95% CI: 1.08-1.34). Conversely, mothers who reported starting and feeding only breast milk in the hospital and receiving a phone number to call for help with breastfeeding had a lower prevalence of breastfeeding termination before 2 months (aPR = 0.72, 95% CI: 0.61-0.86; aPR = 0.57, 95% CI: 0.51-0.64; and aPR = 0.91, 95% CI: 0.80-1.03). Adjusted Cox models showed similar direction of associations. Conclusions: Encouraging mothers to exclusively breastfeed in the hospital, and reducing gift packs containing pacifiers and formula, may be key areas United States hospitals can focus on to increase breastfeeding success. Prospective assessment in other geographical regions is needed to corroborate these findings.

Breastfeeding Intention Versus Outcomes at Two to Three Weeks Postpartum

Breastfeeding is the optimal nutrition for infants, offering protection from many illnesses for both infant and mother. While breastfeeding initiation rates approach or exceed Healthy People 2020 goals, increasing duration remains a national public health priority. Hospital practices play an important role. An urban, academic hospital in the northeast United States with Baby-Friendly designation initiated a quality improvement (QI) project to learn how infant feeding outcomes at 2–3 weeks postpartum compare to initial breastfeeding intention. A lactation student made telephone calls to a convenience sample of breastfeeding mothers, questioning them about their current infant feeding practices and the breastfeeding support they received. The women participating in this QI project were those deemed most likely to meet their infant feeding goals. All the women gave birth in a Baby-Friendly facility, thus all their nurses had at least 20 hours of breastfeeding education, all medical providers had had at least 3 hours of breastfeeding education, and IBCLCs were available to inpatients 7 days a week. All were encouraged to call the hospital's Breastfeeding Warmline and were provided with a list of outpatient resources. However, just2–3 weeks postpartum, one-third were not exclusively breastfeeding despite their initial intention.

Formula Milk Supplementation on the Postnatal Ward: A Cross-Sectional Analytical Study

Breastfeeding rates are low in the UK, where approximately one quarter of infants receive a breastmilk substitute (BMS) in the first week of life. We investigated the reasons for early BMS use in two large maternity units in the UK, in order to understand the reasons for the high rate of early BMS use in this setting. Data were collected through infant feeding records, as well as maternal and midwife surveys in 2016. During 2016, 28% of infants received a BMS supplement prior to discharge from the hospital maternity units with only 10% supplementation being clinically indicated. There was wide variation in BMS initiation rates between different midwives, which was associated with ward environment and midwife educational level. Specific management factors associated with non-clinically indicated initiation of BMS were the absence of skin-to-skin contact within an hour of delivery (p = 0.01), and no attendance at an antenatal breastfeeding discussion (p = 0.01). These findings suggest that risk of initiating a BMS during postnatal hospital stay is largely modifiable. Concordance with UNICEF Baby Friendly 10 steps, attention to specific features of the postnatal ward working environment, and the targeting of midwives and mothers with poor educational status may all lead to improved exclusive breastfeeding rates at hospital discharge.

Formula supplementation in hospital and subsequent feeding at discharge among women who intended to exclusively breastfeed: An administrative data retrospective cohort study

BACKGROUND

Among women who intend to exclusively breastfeed, it is important to identify mothers and their infants who have a greater risk of formula supplementation in hospital, and are unlikely to recover exclusive breastfeeding at discharge. We investigated factors associated with in-hospital formula feeding among healthy term infants born to women who intended to exclusively breastfeed, and among this group, predictors of infant feeding at discharge.

METHODS

Retrospective cohort study utilizing routinely collected clinical data for women who intended to exclusively breastfeed and gave birth to healthy term infants in five hospitals in New South Wales, Australia, 2010-2013. Robust Poisson regression was used to obtain adjusted relative risks (aRR) for the associations between formula feeding in hospital, feeding at discharge, and associated factors.

RESULTS

Of 24 713 mother-infant dyads in the study population, 16.5% received formula in hospital. After adjustment, the strongest predictors of formula supplementation were breastfeeding difficulties (aRR 2.90 [95% confidence interval {CI} 2.74-3.07]), Asian born mother (aRR 2.07 [95% CI 1.92-2.23]), and neonatal conditions (aRR 2.00 [95% CI 1.89-2.13]). Among infants who received formula (n=3998), 49.3% were fully breastfeeding at discharge, 33.1% partially breastfeeding, and 17.5% formula-only feeding. Compared with formula-only feeding, special care nursery admission (aRR 1.23 [95% CI 1.17-1.30]) and ≥1 neonatal conditions (compared with none) were most strongly associated with fully breastfeeding at discharge (aRR 1.21 [95% CI 1.16-2.16]).

CONCLUSION

Women and their infants who receive formula in hospital need additional support to attain exclusive breastfeeding by hospital discharge. Such support is especially needed for younger women, smokers, and women with breastfeeding difficulties.

Breastfeeding initiation: An in-depth qualitative analysis of the perspectives of women and midwives using Social Cognitive Theory

OBJECTIVE

to explore women's and midwives' expectations, knowledge and experiences of breastfeeding initiation using Social Cognitive Theory.

DESIGN

a qualitative study using focus group discussions and individual interviews. Breastfeeding initiation was defined for this study as a process within the first 48hours after birth. Data were analysed using qualitative inductive analysis then further deductive analysis using Social Cognitive Theory (SCT).

SETTING AND PARTICIPANTS

a purposefully selected sample of primigravid antenatal and postnatal women (n=18) and practising midwives (n=18) from one Health Board area in Scotland.

FINDINGS

attachment of the baby to the breast at birth was hindered by sleepy babies and the busy unfamiliar hospital environment. These resulted in mothers struggling to maintain their motivation to breastfeed and to develop low self-efficacy. Instinctive attachment was rare. Midwives who considered it was normal for babies to be sleepy and unable to attach or feed at birth did not facilitate instinctive baby behaviour. Midwives sometimes experienced lack of autonomy and environmental circumstances that made women centred care difficult. Furthermore caring for high numbers of women, dependent on their help, resulted in reduced self-efficacy for providing effective breastfeeding support.

KEY CONCLUSIONS

interviewing both women and midwives specifically about initiation of breastfeeding has allowed for deeper insights into this critical period and enabled a comparison between the data obtained from mothers and midwives. The findings suggest that instinctive attachment is not an expectation of either mothers or midwives and results in a loss of breastfeeding confidence in both.

IMPLICATIONS FOR PRACTICE

to facilitate initiation there is a need for more research to develop appropriate maternal and midwifery skills, and make changes to the cultural environment in hospitals. Social Cognitive Theory could be used as a framework in both the antenatal and immediate postnatal period to develop strategies and materials to increase women's and midwives' self-efficacy specifically in initiation.

Predictors of supplementation for breastfed babies in a Baby-Friendly hospital

PROBLEM

Supplementation of breastfed babies is common during the hospital stay.

BACKGROUND

The Baby Friendly Hospital Initiative (BFHI) optimises practices to support exclusive breastfeeding, yet supplementation is still prevalent.

OBJECTIVE

To determine predictors for supplementation in a cohort of breastfed babies in a Baby-Friendly hospital.

METHODS

Electronic hospital records of 1530 healthy term or near term singleton infants and their mothers were examined retrospectively and analysed to identify factors associated with in-hospital supplementation using Poisson regression (unadjusted and adjusted).

FINDINGS

Fifteen percent of breastfed infants were supplemented during their hospital stay. Analysis by multivariable Poisson regression found that supplementation was independently associated with overweight (reference normal weight) (aRR [adjusted relative risk]=1.46; 95% CI: 1.11-1.93); primiparity (aRR=1.40; 95% CI: 1.09-1.80); early term gestation (37-37⁶ weeks, aRR=2.79; 95% CI: 1.88-4.15; 38-38⁶ weeks, aRR=2.03, 95%CI: 1.46-2.82); birthweight less than 2500 grams (reference 3000-3499 grams) (aRR=3.60; 95% CI: 2.32-5.60) and use of postpartum uterotonic (aRR=2.47; 95% CI: 1.09-5.55). Greater than 65 minutes of skin-to-skin contact at birth reduced the risk of supplementation (aRR=0.66; 95% CI; 0.48-0.92).

CONCLUSION

These identified predictors for supplementation, can inform the development of interventions for mother-infant pairs antenatally or in the early postpartum period around increased breastfeeding education and support to reduce supplementation. It may also be possible to reduce supplementation through judicious use of postpartum uterotonics and facilitation of mother-infant skin-to-skin contact at birth for greater than one hour duration.

Variation in Formula Supplementation of Breastfed Newborn Infants in New York Hospitals

OBJECTIVES

We examined the variation between 126 New York hospitals in formula supplementation among breastfed infants after adjusting for socioeconomic, maternal, and infant factors and stratifying by level of perinatal care.

METHODS

We used 2014 birth certificate data for 160 911 breastfed infants to calculate hospital-specific formula supplementation percentages by using multivariable hierarchical logistic regression models.

RESULTS

Formula supplementation percentages varied widely among hospitals, from 2.3% to 98.3%, and was lower among level 1 hospitals (18.2%) than higher-level hospitals (50.6%-57.0%). Significant disparities in supplementation were noted for race and ethnicity (adjusted odds ratios [aORs] were 1.54-2.05 for African Americans, 1.85-2.74 for Asian Americans, and 1.25-2.16 for Hispanics, compared with whites), maternal education (aORs were 2.01-2.95 for ≤12th grade, 1.74-1.85 for high school or general education development, and 1.18-1.28 for some college or a college degree, compared with a Master's degree), and insurance coverage (aOR was 1.27-1.60 for Medicaid insurance versus other). Formula supplementation was higher among mothers who smoked, had a cesarean delivery, or diabetes. At all 4 levels of perinatal care, there were exemplar hospitals that met the HealthyPeople 2020 supplementation goal of ≤14.2%. After adjusting for individual risk factors, the hospital-specific, risk-adjusted supplemental formula percentages still revealed a wide variation.

CONCLUSIONS

A better understanding of the exemplar hospitals could inform future efforts to improve maternity care practices and breastfeeding support to reduce unnecessary formula supplementation, reduce disparities, increase exclusive breastfeeding and breastfeeding duration, and improve maternal and child health outcomes.

Health Professionals' Perspectives on Breastfeeding Support Practices

Background:

The decrease in rates of exclusive breastfeeding has resulted in increased rates of infant mixed feeding. The WHO Baby-Friendly Hospital Initiative (BFHI) has been associated with significant increases in breastfeeding initiation and duration in maternity hospitals. However, little is known about whether or not the teaching hospital of the University of Dammam, Saudi Arabia, followed the ten steps recommended in the BFHI.

Objectives:

This study was carried out to assess healthcare professionals' perspectives and opinions about the breastfeeding support practices at the teaching hospital.

Materials and Methods:

This research is a mixed methodology cross-sectional study carried out in the King Fahd Hospital of the University, Al-Khobar, Saudi Arabia. The first phase used a self-administered questionnaire to assess professionals' awareness and opinions about actual breastfeeding practices. The first phase results led to a qualitative interview design for the second phase. Descriptive statistics were used to describe and summarize the data. The chi-square test was used to examine the difference between the observed and expected frequencies of normal data.

Results:

There were no breastfeeding supporting policies followed at the hospital as per those recommended by BFHI. Mothers with breastfeeding problems were not referred for help and follow-up phone calls were not made to postpartum women after discharge. Healthcare professionals indicated that there were no hospital-based breastfeeding support groups, lactation consultants/specialists or lactation management unit available.

Conclusions:

There is a need for breastfeeding support policies, practices and staff education to facilitate care consistent with the ten steps of the BFHI. Further study is needed to assess mothers' perspectives on breastfeeding approaches at the King Fahd Hospital of the University.

Likelihood of Breastfeeding Within the USDA's Food and Nutrition Service Special Supplemental Nutrition Program for Women, Infants, and Children Population

BACKGROUND

Breastfeeding is an important public health initiative. Low-income women benefiting from the U.S. Department of Agriculture's Food and Nutrition Service Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are a prime population for breastfeeding promotion efforts. Research aim: This study aims to determine factors associated with increased likelihood of breastfeeding for WIC participants.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement guided the systematic review of literature. Database searches occurred in September and October 2014 and included studies limited to the previous 10 years. The following search terms were used: low-income; WIC; women, infants, and children; breastfeeding; breast milk; and maternal and child health. The criterion for inclusion was a study sample of women and children enrolled in the WIC program, thereby excluding non-United States-based research.

RESULTS

Factors that increased the likelihood of breastfeeding for WIC participants included sociodemographic and health characteristics ( n = 17); environmental and media support ( n = 4); government policy ( n = 2); intention to breastfeed, breastfeeding in hospital, or previous breastfeeding experience ( n = 9); attitudes toward and knowledge of breastfeeding benefits ( n = 6); health care provider or social support; and time exposure to WIC services ( n = 5).

CONCLUSION

The complexity of breastfeeding behaviors within this population is clear. Results provide multisectored insight for future research, policies, and practices in support of increasing breastfeeding rates among WIC participants.

The Impact of Hospital Resources and Availability of Professional Lactation Support on Maternity Care: Results of Breastfeeding Surveys 2009-2014

BACKGROUND

Breastfeeding provides maternal and infant health benefits. Maternity care practices encompassed in the 10 Steps to Successful Breastfeeding are positively associated with improved breastfeeding outcomes. This study assessed changes in maternity care practices and lactation support.

MATERIALS AND METHODS

In 2009, 2011, and 2014, New York (NY) hospitals providing maternity care services were surveyed to assess the implementation of 9 of the 10 Steps to Successful Breastfeeding, professional lactation support, distribution of formula and discharge packs, and patient and hospital barriers to breastfeeding success. Generalized estimating equations were used to evaluate changes over time.

RESULTS

Surveys were completed by 138/138 (2009), 128/129 (2011), and 125/125 (2014) NY hospitals. During this time period, the percent of hospitals reporting implementation of Steps 2, 4, 6, or 9 increased, and the mean number of 9 steps implemented increased from 4.3 to 5.3. Hospitals distributing formula samples at discharge to breastfeeding mothers decreased significantly from 39 (32%) to 3 (2%). Professional lactation staffing ratios (N/1,000 births) of both International Board Certified Lactation Consultants and Certified Lactation Counselors increased between 2009 and 2011, but then decreased between 2011 and 2014. Reported barriers to breastfeeding support changed, with reductions in mixed messages from staff, but increases in lack of financial resources for breastfeeding support, inadequate prenatal education, mothers not being prepared, and family not being receptive to breastfeeding.

CONCLUSIONS

Between 2009 and 2014, NY hospitals reported increased barriers and a reduction in professional lactation support, which may have contributed to the limited improvements in breastfeeding support.

Reasons for Infant Feeding Decisions in Low-Income Families in Washington, DC

BACKGROUND

Breastfeeding rates for low-income, African American infants remain low.

OBJECTIVE

This study aimed to determine the barriers, support, and influences for infant feeding decisions among women enrolled in the Washington, DC, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) after revisions in the WIC package to include more food vouchers for breastfeeding mothers and their infants and improvement of in-hospital breastfeeding support.

METHODS

We surveyed 100 women, using a 42-item verbally administered survey that asked about demographics, infant feeding method, and influences and support for feeding decisions.

RESULTS

The majority of participants (76%) initiated breastfeeding; 31% exclusively breastfed in the hospital. Participants were more likely to breastfeed if they had some college education, were unemployed or employed full-time, had only one child, and had been breastfed themselves as infants. Barriers to prolonged breastfeeding included limited support after hospital discharge, pain, and perceived insufficient milk supply. Participants in this study had higher breastfeeding initiation and in-hospital exclusivity rates after improvement of in-hospital breastfeeding support.

CONCLUSION

Clients of WIC initiated breastfeeding at a high rate but either supplemented with formula or stopped breastfeeding for reasons that could be remedied by improved prenatal education, encouragement of exclusive breastfeeding in the hospital, and more outpatient support.

Infant Formula Feeding at Birth Is Common and Inversely Associated with Subsequent Breastfeeding Behavior in Vietnam

BACKGROUND

The association between infant formula feeding at birth and subsequent feeding patterns in a low- or middle-income context is not clear.

OBJECTIVE

We examined the association of infant formula feeding during the first 3 d after birth with subsequent infant formula feeding and early breastfeeding cessation in Vietnam.

METHODS

In a cross-sectional survey, we interviewed 10,681 mothers with children aged 0-23 mo (mean age: 8.2 mo; 52% boys) about their feeding practices during the first 3 d after birth and on the previous day. We used stratified analysis, multiple logistic regression, propensity score-matching analysis, and structural equation modeling to minimize the limitation of the cross-sectional design and to ensure the consistency of the findings.

RESULTS

Infant formula feeding during the first 3 d after birth (50%) was associated with a higher prevalence of subsequent infant formula feeding [stratified analysis: 7-28% higher (nonoverlapping 95% CIs for most comparisons); propensity score-matching analysis: 13% higher (P < 0.001); multiple logistic regression: OR: 1.47 (95% CI: 1.30, 1.67)]. This practice was also associated with a higher prevalence of early breastfeeding cessation (e.g., <24 mo) [propensity score-matching analysis: 2% (P = 0.08); OR: 1.33 (95% CI: 1.12, 1.59)]. Structural equation modeling showed that infant formula feeding during the first 3 d after birth was associated with a higher prevalence of subsequent infant formula feeding (β: 0.244; P < 0.001), which in turn was linked to early breastfeeding cessation (β: 0.285; P < 0.001).

CONCLUSIONS

Infant formula feeding during the first 3 d after birth was associated with increased subsequent infant formula feeding and the early cessation of breastfeeding, which underscores the need to make early, exclusive breastfeeding normative and to create environments that support it.

Effect on Baby-Friendly Hospital Steps When Hospitals Implement a Policy to Pay for Infant Formula

BACKGROUND

The Baby-Friendly Hospital Initiative requires hospitals to pay market price for infant formula. No studies have specifically examined the effect of hospitals paying for infant formula on breastfeeding mothers' exposure to Baby-Friendly steps.

OBJECTIVES

To investigate the effect of hospitals implementing a policy of paying for infant formula on new mothers' exposure to Baby-Friendly steps and examine the effect of exposure to Baby-Friendly steps on breastfeeding rates.

METHODS

We used a repeated prospective cohort study design. We recruited 2 cohorts of breastfeeding mother-infant pairs (n = 2470) in the immediate postnatal period from 4 Hong Kong public hospitals and followed them by telephone up to 12 months postpartum. We assessed participants' exposure to 6 Baby-Friendly steps by extracting data from the medical record and by maternal self-report.

RESULTS

After hospitals began paying for infant formula, new mothers were more likely to experience 4 out of 6 Baby-Friendly steps. Breastfeeding initiation within the first hour increased from 28.7% to 45%, and in-hospital exclusive breastfeeding rates increased from 17.9% to 41.4%. The proportion of mothers who experienced all 6 Baby-Friendly steps increased from 4.8% to 20.5%. The risk of weaning was progressively higher among participants experiencing fewer Baby-Friendly steps. Each additional step experienced by new mothers decreased the risk of breastfeeding cessation by 8% (hazard ratio = 0.92; 95% CI, 0.89-0.95).

CONCLUSION

After implementing a policy of paying for infant formula, breastfeeding mothers were exposed to more Baby-Friendly steps, and exposure to more steps was significantly associated with a lower risk of breastfeeding cessation.

Evaluation of the impact of breast milk expression in early postpartum period on breastfeeding duration: a prospective cohort study

Background

Breast milk expression (breast pumping) has become prevalent as an important dimension of breastfeeding behavior. It is, however, not clear whether increasing breast milk expression contributes to extend the duration of breastfeeding. The objective of the present study was to evaluate the impact of breast milk expression in early postpartum period on breastfeeding duration amongst mothers of healthy term infants.

Methods

A prospective cohort study had been conducted from March to June 2010. Mothers who gave birth to healthy, full-term and singleton babies were enrolled at discharge. These women were interviewed at 6 weeks postpartum about their breastfeeding behaviors. According to expressing patterns at 6 week postpartum, women were divided into three groups: direct breastfeeding (group 1), combining direct breastfeeding with expressing (group 2), exclusive expressing (group 3). The investigators followed up the women by telephone thereafter at a bimonthly basis and documented breastfeeding duration. Survival analysis was conducted to explore the association between expressing patterns at 6 weeks postpartum and breastfeeding duration. Associated factors of exclusive expressing at 6 weeks postpartum were characterized by logistic regression analysis.

Results

Four hundred one eligible women were enrolled at discharge. Among the 389 women who attended the face-to-face interview at 6 weeks postpartum, 345 women continued breastfeeding. They were divided into 3 groups by their expressing patterns. According to survival analysis, women who exclusively expressed breast milk at 6 months postpartum (group 3) were 1.77 times as likely to stop breastfeeding as those who did not (group 1 and 2) (95 % confidence interval: 1.25–2.48; P <0.001). There is, however, no significant difference of breastfeeding duration between group 1 and group 2. Subgroup analysis showed that exclusive expressing women who were exclusively breastfeeding at 6 weeks postpartum had the shortest breastfeeding duration. Mother’s high education level, short maternity leave, breast milk expression in hospital and bottle-feeding in hospital were associated factors to exclusive expressing at 6 weeks postpartum.

Conclusions

Exclusive expressing in the early postpartum period may not help women to achieve long-term breastfeeding duration, especially in women who were exclusively breastfeeding.

Effect of a hospital policy of not accepting free infant formula on in-hospital formula supplementation rates and breast-feeding duration

Objective

To investigate the effect of public hospitals in Hong Kong not accepting free infant formula from manufacturers on in-hospital formula supplementation rates and breast-feeding duration.

Design

Prospective cohort study.

Setting

In-patient postnatal units of four public hospitals in Hong Kong.

Subjects

Two cohorts of breast-feeding mother–infant pairs (n 2560). Cohort 1 (n 1320) was recruited before implementation of the policy to stop accepting free infant formula and cohort 2 (n 1240) was recruited after policy implementation. Participants were followed prospectively for 12 months or until they stopped breast-feeding.

Results

The mean number of formula supplements given to infants in the first 24 h was 2·70 (sd 3·11) in cohort 1 and 1·17 (sd 1·94) in cohort 2 (P<0·001). The proportion of infants who were exclusively breast-fed during the hospital stay increased from 17·7 % in cohort 1 to 41·3 % in cohort 2 (P<0·001) and the risk of breast-feeding cessation was significantly lower in cohort 2 (hazard ratio=0·81; 95 % CI 0·73, 0·90). Participants who non-exclusively breast-fed during the hospital stay had a significantly higher risk of stopping any or exclusive breast-feeding. Higher levels of formula supplementation also increased the risk of breast-feeding cessation in a dose–response pattern.

Conclusions

After implementation of a hospital policy to pay market price for infant formula, rates of in-hospital formula supplementation were reduced and the rates of in-hospital exclusive breast-feeding and breast-feeding duration increased.

The healthy newborn hydration model: a new model for understanding newborn hydration immediately after birth

The normal small volume of breast milk produced in the first 2 days following birth may raise concerns about adequate hydration in breast-fed newborns. These concerns are further magnified when breast-fed infants lose ≥7% of their birth weight within 2 days postnatally. Weight loss following birth is presumably mostly water loss that could result in hypohydration and subsequent hypernatremic dehydration. However, excess fluid loss immediately following birth is a normal and necessary process. Furthermore, newborns exposed to excess fluid intake during labor may need to lose ≥7% of birth weight in the first 2 days following birth in order to achieve euhydration. Normal newborn fluid loss following birth confounds the use of weight loss as the sole measure of newborn hydration. We thus propose the healthy newborn hydration model that highlights the normalcy of newborn weight loss immediately following birth and the healthy newborn's compensatory mechanisms for preserving adequate hydration. We also recommend the use of serum sodium to measure intravascular osmolarity in addition to monitoring weight loss to obtain a more comprehensive newborn hydration assessment. Research is necessary in healthy newborns to identify relationships among fluids received in utero, newborn weight loss, and hydration, as evaluated with laboratory measures, in the first 2 days following birth. This information will guide clinicians in correctly identifying newborns with inadequate hydration who are in need of supplementary fluids versus newborns with adequate hydration for whom exclusive breast-feeding can be supported and encouraged.

Midwives’ Time and Presence: A Key Factor in Facilitating Breastfeeding Support for New Mothers

BACKGROUND: There is now a plethora of work that has examined new mothers’ experiences of receiving breastfeeding support. However, there remains limited literature describing women’s experiences of receiving this support from midwives in the early postnatal period.

AIM: The study aimed to explore and describe women’s experiences of receiving breastfeeding support from midwives in the early postnatal period.

METHOD: A qualitative descriptive approach was used. Six first-time mothers who initiated breastfeeding after birth consented to be involved and participated in an in-depth interview. The techniques associated with dimensional analysis and constant comparison were used to analyze the data set.

FINDINGS: Two categories were identified that described women’s experiences of midwifery breastfeeding support. These were related to the midwives’ ability to spend and give the gift of time to women. Alternatively, the midwife’s busyness and inability to be present for the woman was considered a barrier to receiving positive breastfeeding support and the woman’s ability to problem solve any breastfeeding issues.

CONCLUSION: The findings of this study confirm both the importance of midwives spending time providing breastfeeding support and the negative consequences of a lack of time given for the provision of this support. Mothers have asked for midwives to be present; investing time in them, listening to them, and helping them solve problems. Current care models present barriers contributing to both the perceptions and realities of midwives’ lack of time, presenting a need to reconsider the design of maternity care environments and to adopt a caseload approach where women receive relationship-based care.

Predictors and consequences of in-hospital formula supplementation for healthy breastfeeding newborns

BACKGROUND

Although exclusive breastfeeding is recommended for the first 6 months, the use of breast milk substitutes is widespread around the world.

OBJECTIVES

To describe the patterns of infant formula supplementation among healthy breastfeeding newborns, to identify factors contributing to in-hospital formula supplementation, and to assess the dose-response relationship between the amount of in-hospital formula supplementation and the duration of any breastfeeding.

METHODS

A sample of 1246 breastfeeding mother-infant pairs was recruited from 4 public hospitals in Hong Kong and followed prospectively for 12 months or until weaned. Multiple logistic regression analysis was used to examine factors associated with in-hospital supplementation. Cox regression analysis was used to explore the impact of in-hospital supplementation on breastfeeding duration.

RESULTS

Of the total, 82.5% of newborns were supplemented in the hospital; one-half received formula within 5 hours of birth. Assisted vaginal delivery (odds ratio [OR] = 2.06, 95% confidence interval [CI] 1.03, 4.15), cesarean section (OR = 3.45, 95% CI 1.75, 6.80), and higher birth weight (OR = 1.56, 95% CI 1.12, 2.18) were positively associated with in-hospital formula supplementation, whereas initiating breastfeeding in the delivery room (OR = 0.55, 95% CI 0.33, 0.89) was associated with decreased likelihood of in-hospital supplementation. Any infant formula in the first 48 hours was associated with a shorter duration of breastfeeding (hazard ratio [HR] = 1.51, 95% CI 1.27, 1.80), but there was no dose-response effect.

CONCLUSION

In-hospital formula supplementation is common in Hong Kong hospitals and appears to be detrimental to breastfeeding duration. Continued efforts should be made to avoid the provision of infant formula to breastfeeding babies while in the hospital unless medically indicated.

Maternal accounts of their breast-feeding intent and early challenges after caesarean childbirth

BACKGROUND

breast-feeding outcomes are often worse after caesarean section compared to vaginal childbirth.

OBJECTIVES

this study characterises mothers' breast-feeding intentions and their infant feeding experiences after caesarean childbirth.

METHODS

data are from 115 mothers on a postnatal unit in Northeast England during February 2006-March 2009. Interviews were conducted an average of 1.5 days (range 1-6 days) after the women underwent unscheduled or scheduled caesarean.

RESULTS

thematic analysis of the data suggested was mostly considered the 'right thing to do,' preferable, natural, and 'supposedly healthier,' but tiring and painful. Advantages of supplementation involved more satiated infants, feeding ease, and longer sleep bouts. The need for 'thinking about yourself' was part of caesarean recovery. Infrequent feeding was concerning but also enabled maternal rest. Other breast-feeding obstacles were maternal mobility limitations, positioning difficulties, and frustration at the need for assistance. Participants were confused about nocturnal infant wakings, leading many to determine that they had insufficient milk. Mothers were surprised that sub-clinically poor infant condition was common following caesarean section. Some breast-feeding difficulty stemmed from 'mucus' expulsion that had to occur before the infants could be 'interested' in feeding. Women who cited motivations for breast feeding that included benefit to themselves were more likely to exclusively breast feed on the postnatal unit after their caesareans than those who reported infant-only motivations.

CONCLUSIONS

for the majority of mothers, breast feeding after a caesarean is affected by interrelated and compounding difficulties. Provision of more relational breast-feeding information may enable families to better anticipate early feeding experiences after caesarean section childbirth.

Overcoming clinical barriers to exclusive breastfeeding

Although a large majority of US mothers now begin breastfeeding, exclusive breastfeeding rates fall far below national health objectives, with vulnerable populations being least likely to breastfeed exclusively. This article explores common personal and societal barriers to exclusive breastfeeding and offers evidence-based strategies to support mothers to breastfeed exclusively, such as ensuring prenatal education, supportive maternity practices, timely follow-up, and management of lactation challenges. The article also addresses common reasons nursing mothers discontinue exclusive breastfeeding, including the perception of insufficient milk, misinterpretation of infant crying, returning to work or school, early introduction of solid foods, and lack of support.

[Factors associated with the use of supplements among newborns in communal wards in Rio de Janeiro, 2009]

The scope of this study was to estimate the prevalence of the use of supplements among newborns and analyze the factors associated with their use. A cross-sectional study was conducted in 2009 with a representative sample of 687 mothers interviewed in 15 communal wards in hospitals of the Unified Health System in the city of Rio de Janeiro. Prevalence ratios (PR) of supplement use were obtained by Poisson Regression with robust variance, using a hierarchical model. The prevalence of supplement use was 49.8%. Factors associated with supplement use were: being submitted to the rapid HIV test (PR = 1.37; CI95%:1.18-1.58); cesarean delivery (PR = 1.57; CI95%:1.38-1.79); not being helped to breastfeed in the delivery room (PR = 1.60; CI95%:1.29-1.99); mother-child separation (PR = 1.24; CI95%:1.05-1.46); pacifier use (PR = 1.31; CI95%:1.08-1.58); maternal or neonatal interventions (PR = 1.56; CI95%:1.34-1.82); BFH certification (PR = 0.52; CI95%:0.44-0.61); and not receiving help to breastfeed in the communal ward (PR = 0.78; CI95%:0.66-0.92). Supplements to breast milk are being widely used. Hospital routines should be reviewed, so that exclusive breastfeeding becomes the norm.

Maternal request for in-hospital supplementation of healthy breastfed infants among low-income women

BACKGROUND

While hospital policies and medical issues are important factors in determining exclusive breastfeeding rates, medically unnecessary supplementation of infants is likely to be due, in part, to maternal request for formula.

OBJECTIVES

The goal of this project was to gain an understanding of the facilitating factors and decision-making processes surrounding maternal request for formula in the early postpartum period.

METHODS

A series of 12 focus groups were conducted among 97 English- and Spanish-speaking low-income participants in California's Supplementary Nutrition Program for Women, Infants, and Children (WIC). Mothers were asked to share their in-hospital infant-feeding experiences.

RESULTS

The overarching theme that emerged was "lack of preparation" for what the early postpartum period would be like. Specifically, the decisions to formula feed fell into the following categories: inadequate preparation for newborn care (the need for rest and unrealistic expectations about infant behavior), lack of preparation for the process of breastfeeding, and formula as a solution to breastfeeding problems. Cultural factors were not mentioned as reasons for supplementation.

CONCLUSION

Interventions to promote in-hospital exclusive breastfeeding must address mothers' real and perceived barriers, specifically mothers' expectations related to breastfeeding and infant behavior.

[Use of supplementation for breast-fed neonates in the maternity ward]

OBJECTIVES

The aim of this study was to evaluate our practices regarding the use of supplementation for breast-fed neonates.

METHODS

A descriptive and prospective study conducted between 22/05/2010 and 23/03/2010 comprising breast-fed, healthy, singleton infants at the Maternity University Hospital of Tours. Indications for supplementation were collected prospectively by paramedics.

RESULTS

The study included 281 breast-fed neonates, of whom 99 (35 %) received supplementation. Supplemented neonates were more often children of primiparae (61.6 % versus 44%; P=0.005), or born to mothers without experience of breast-feeding (69.7% versus 48.9%; P=0.001), born by cesarean section (21.2% versus 10.4%; P=0.01), or were small for gestational age (10.1 % versus 6.6%; P=0.003). The main indications were: to prevent additional weight loss, hunger of the newborn, hypoglycemia, and difficulty to breast-feed. Twenty-nine percent of the neonates were given supplements without medical indication.

CONCLUSION

One third of breast-fed infants receive supplementation, not always medically justified. A better understanding of medical indications would avoid supplementation being given to breast-fed infants.

In-hospital formula supplementation of breastfed babies: a population-based survey

BACKGROUND

  In-hospital formula supplementation of breastfed newborns is commonplace despite its negative association with breastfeeding duration. Although several studies have described the use of formula supplementation, few have explored the factors that may be associated with its use. The aim of this study was to explore factors associated with in-hospital formula supplementation using data from a large Australian population-based survey.

METHODS

  All women who gave birth in September and October 2007 in two Australian states were mailed questionnaires 6 months after the birth. Women were asked how they fed their baby while in hospital after the birth. Multivariable logistic regression was used to explore specified a priori factors associated with in-hospital formula supplementation.

RESULTS

  Of 4,085 women who initiated breastfeeding, 23 percent reported their babies receiving formula supplementation. Breastfed babies had greater odds of receiving formula supplementation if their mother was primiparous (adj. OR=2.16; 95% CI: 1.76-2.66); born overseas and of non-English-speaking background (adj. OR=2.03; 95% CI: 1.56-2.64); had a body mass index more than 30 (adj. OR=2.27; 95% CI: 1.76-2.95); had an emergency cesarean section (adj. OR=1.72; 95% CI: 1.3-2.28); or the baby was admitted to a special care nursery (adj. OR=2.72; 95% CI: 2.19-3.4); had a birthweight less than 2,500 g (adj. OR=2.02; 95% CI: 1.3-3.15) or was born in a hospital not accredited with Baby-Friendly Hospital Initiative (BFHI) (adj. OR=1.53; 95% CI: 1.2-1.94).

CONCLUSIONS

  The number of factors associated with in-hospital formula supplementation suggests that this practice is complex. Some results, however, point to an opportunity for intervention, with the BFHI appearing to be an effective strategy for supporting exclusive breastfeeding.

Predictors of breastfeeding exclusivity in a WIC sample

OBJECTIVE

To examine predictors of breastfeeding exclusivity in low-income women who received services from a Chicago area clinic of the Special Supplemental Nutrition Program for Women, Infants and Children Program (WIC).

DESIGN

A secondary data analysis of existing clinical and administrative data.

SETTING

An urban community health center serving low-income families.

PARTICIPANTS

Two hundred and thirty-five (235) low-income women who initiated breastfeeding and received WIC services.

METHODS

Logistic regression models were fit to existing prenatal and postpartum data to determine predictors of breastfeeding exclusivity during the immediate postpartum period.

RESULTS

Only 23% of the sample breastfed exclusively. Women who received first-trimester prenatal care were more likely to exclusively breastfeed than women who entered prenatal care in later trimesters (OR = 2.02, p ≤ 0.05). Women who declared intentions prenatally to exclusively breastfeed were more likely to exclusively breastfeed than women who did not intend to breastfeed (OR = 3.85, p ≤ 0.001). Overweight/obese women were less likely to exclusively breastfeed than normal/underweight women (OR = 0.50, p ≤ 0.05).

CONCLUSION

Findings from this study can be used to develop tailored interventions to promote breastfeeding exclusivity among low-income WIC recipients.

Maternal hospital experiences associated with breastfeeding at 6 months in a northern California county

A retrospective cohort study of infant-feeding practices at 6 months of age was conducted for 382 breastfed infants in a semirural northern California county. The authors hypothesized that almost exclusive breastfeeding at 6 months would be related to maternal experiences in the hospital. Multiple logistic regression analysis, controlling for maternal age and education, found that almost exclusive breastfeeding at 6 months was positively associated with receiving a telephone number for breastfeeding help from the hospital (odds ratio, 6.45; 95% confidence interval, 1.23-33.9), use of a breast pump in the first 6 months (odds ratio, 2.19; 95% confidence interval, 1.01-4.76), and gestational age (odds ratio, 2.26; 95% confidence interval, 1.08-4.71 for a 4-week age difference), whereas formula supplementation at the hospital had a negative association (odds ratio, 0.27; 95% confidence interval, 0.13-0.56). Making postpartum breastfeeding support easily accessible and offering breast pumps at low or no cost may help to increase exclusive breastfeeding rates in this county.

First- and second-trimester WIC participation is associated with lower rates of breastfeeding and early introduction of cow's milk during infancy

BACKGROUND

Existing literature suggests prenatal participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) may reduce breastfeeding among low-income mothers. However, little is known about whether the timing of WIC entrance during pregnancy influences infant feeding decisions.

OBJECTIVE

This study assesses the association between the timing of prenatal participation in WIC and various infant feeding practices, including breastfeeding initiation, breastfeeding for at least 4 months, exclusive breastfeeding, formula feeding, and early introduction of cow's milk and solid food.

DESIGN

Cross-sectional survey matching of birth certificate data to mothers' interviews 9 months after the child's birth. Mothers provided information on participation in the WIC program, infant feeding practices, and sociodemographic characteristics.

SUBJECTS

A nationally representative sample of 4,450 births in 2001 from the Early Childhood Longitudinal Survey-Birth Cohort.

ANALYSES

Multivariate logistic regression techniques (using STATA 9.0 SE, Stata Company, College Station, TX) estimated the relationship between the timing of prenatal WIC participation and infant feeding practices.

RESULTS

Entry into the WIC program during the first or second trimester of pregnancy is associated with reduced likelihood of initiation of breastfeeding and early cow's milk introduction; and entry during the first trimester is associated with reduced duration of breastfeeding. WIC participation at any trimester is positively related to formula feeding.

CONCLUSIONS

Prenatal WIC participation is associated with a greater likelihood of providing babies infant formula rather than breastmilk after birth. Findings also indicate that there are critical prenatal periods for educating women about the health risks of early cow's milk introduction. Given the health implications of feeding infants cow's milk too early, WIC may be successful in educating women on the health risks of introducing complementary foods early, even if direct counseling on cow's milk is not provided.