Susan M. Gross

WIC-Based Interventions to Promote Breastfeeding Among African-American Women in Baltimore: Effects on Breastfeeding Initiation and Continuation

We evaluated the single and combined effects of introducing a motivational video and peer counseling into four matched WIC clinics on breastfeeding initiation and continuation at 7-10 days among African-American WIC participants. Of the 242 women with complete data, 48% initiated breastfeeding, but only 31% were still breastfeeding at 7-10 days. Initiation was associated with cesarean delivery, infant feeding instruction, no artificial milk discharge pack, attending the peer counselor only-intervention site, and intention to breastfeed. Continuation was influenced by infant feeding instruction, no artificial milk discharge pack, and intention to breastfeed. Overall, trends toward a positive impact of the breastfeeding promotion activities were evident but weak, and largely gone by 7-10 days postpartum.

Counseling and motivational videotapes increase duration of breast-feeding in African-American WIC participants who initiate breast-feeding.

OBJECTIVE To evaluate the relative effects introducing motivational videotapes and/or peer counseling in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics serving African-American women have on breast-feeding duration. DESIGN Experimental intervention study. Pregnant women were enrolled at or before 24 weeks gestation and were followed up until postpartum week 16. Women were interviewed at enrollment, 7 to 10 days, 8 weeks, and 16 weeks postpartum. SUNJECTS/SETTING: One hundred fifteen African-American WIC participants who initiated breast-feeding and who had been enrolled in 1 of 4 clinics. INTERVENTION Two-by-two factorial design, in which 4 clinics were randomly assigned to receive either no intervention, a motivational video package intervention, a peer-counseling intervention, or both interventions. MAIN OUTCOME MEASURES Breast-feeding duration in weeks and relative risk ratios for breast-feeding cessation before 16 weeks postpartum. STATISTICAL ANALYSIS PERFORMED Contingency table analysis, including chi2 tests and log-rank tests; multivariate analysis using Cox proportional hazards regression analysis. RESULTS A higher proportion of women were breast-feeding at 8 and 16 weeks postpartum in the intervention clinics than in the control clinic. The proportion of women reporting breast-feeding declined at 8 and 16 weeks postpartum, but the rate of decline was slower in the 3 intervention clinics than in the control clinic. Being younger than 19 years of age or older than 25 years of age, having a male infant, and returning to work or school all negatively affected breastfeeding duration, whereas previous breast-feeding experience positively influenced breast-feeding duration. APPLICATIONS/CONCLUSIONS WIC-based peer counselor support and motivational videos can positively affect the duration of breast-feeding among African-American women. WIC nutritionists and other health professionals in contact with this population should expand their efforts toward promoting increased duration of breast-feeding.

The Differential Impact of WIC Peer Counseling Programs on Breastfeeding Initiation across the State of Maryland

This cross-sectional study examines Maryland’s women, infants, and children (WIC) breastfeeding initiation rates by program participation. The authors report on data regarding demographic and health characteristics and infant feeding practices for infants (n = 18 789) newly WIC-certified from January 1, 2007 to June 30, 2007. The authors compared self-reported, breastfeeding initiation rates for 3 groups: peer counselor (PC-treatment group) and two comparison groups, lactation consultant (LC), and standard care group (SCG). Reported breastfeeding initiation at certification was 55.4%. Multiple logistic regression analysis, controlling for relevant maternal and infant characteristics, showed that the odds of breastfeeding initiation were significantly greater among PC-exposed infants (OR [95% CI] 1.27 [1.18, 1.37]) compared to the reference group of SCG infants, but not significantly different between LC infants (1.04 [0.96, 1.14]) and the SCG. LC and SCG infants had similar odds of breastfeeding initiation. In the Maryland WIC program, breastfeeding initiation rates were positively associated with peer counseling. J Hum Lact. 25(4):435-443.

Early Postpartum: A Critical Period in Setting the Path for Breastfeeding Success

BACKGROUND In the United States, most mothers who initiate breastfeeding will either stop or begin supplementing with formula before their infants are 3 months old. Routine breastfeeding education and support following hospital discharge are critical to breastfeeding success. The purpose of this article is to identify this critical period for supporting and reinforcing breastfeeding. METHODS We will use data from participants enrolled in the Maryland State Program of the U.S. Department of Agricultures Supplemental Nutrition Program for Women, Infants, and Children (WIC). This cross-sectional study will explore whether breastfeeding patterns during the period between birth and postnatal WIC certification differ by participation in a local WIC agency that provides breastfeeding peer counselor support (PC) versus two comparison groups, the lactation consultant (LC) and standard care (SC) groups. RESULTS During 2007, 33,582 infants were enrolled in the Maryland State WIC program. Infant breastfeeding status was categorized as exclusively breastfeeding, partially breastfeeding, or not breastfeeding. At certification, 30.4% of infants were breastfeeding, 25.3% had been breastfed but had stopped before certification in WIC, and 44.3% never breastfed. The breastfeeding initiation rate was higher for the PC group compared with the LC and SC groups (61.6% vs. 54.4% and 47.6%, respectively; p < 0.001). Participants in the PC group were more likely to certify as exclusively and partially breastfeeding compared with the LC and SC groups (36.0% vs. 24.8% and 25.3%, respectively; p < 0.001). CONCLUSION Our analysis identifies a window of opportunity during which targeted contact with breastfeeding mothers could enhance longer-term breastfeeding rates.

Are Unmet Breastfeeding Expectations Associated With Maternal Depressive Symptoms

OBJECTIVE Most US women intend and initiate breastfeeding, yet many do not breastfeed as long as desired. Not meeting ones own prenatal expectations is a plausible mechanism for the previously observed association between lack of breastfeeding and postpartum depression (PPD). This study explored whether meeting prenatal expectations for exclusive breastfeeding was associated with PPD symptoms. METHODS The 2005 Infant Feeding Practices Study II (IFPSII) followed US mothers, primarily white women with higher education and income, from midpregnancy to 1 year postpartum. Depressive symptoms were defined as Edinburgh Postnatal Depression Scale (EPDS) of 10 or higher, measured at 2 months postpartum. Logistic regression analysis evaluated the odds of maternal depressive symptoms as a function of meeting prenatal expectations for exclusive breastfeeding, accounting for breastfeeding behavior, demographics, and postnatal experiences. RESULTS Among IFPSII participants, 1501 intended exclusive breastfeeding and completed the EPDS. At 2 months, 589 (39.2%) had met prenatal expectations for exclusive breastfeeding. EPDS was 10 or higher for 346 participants (23.1%). Adjusted odds of depressive symptoms were lower among women meeting prenatal exclusive breastfeeding expectations versus those who were not (odds ratio 0.71, 95% confidence interval 0.52-0.96). In subgroup analysis, there was no association between met expectations and depressive symptoms among women with lower incomes (<200% federal poverty level) or those intending mixed breast and formula feeding. CONCLUSIONS Among middle- and higher-income women who intended exclusive breastfeeding, those meeting prenatal breastfeeding expectations reported fewer PPD symptoms at 2 months postpartum. Clinician understanding and support of maternal expectations may improve maternal mental health.

Young women with physical disabilities: risk factors for symptoms of eating disorders.

&NA; Women with disabilities are at risk for poor psychological adjustment and unhealthy weightcontrol practices. This study was conducted to determine the prevalence of symptoms of eating disorders in a clinic‐based sample of women who had two disabling conditions and to identify condition‐related risk factors that were linked to these symptoms. A cross‐sectional survey of 71 women (mean age = 23 yr) with spina bifida or rheumatologically related illnesses was conducted to assess the symptoms of eating disorders, condition‐related characteristics, and weight‐control practices. Symptoms of eating disorders were measured by the Eating Disorders Inventory (EDI). Eight percent of the respondents reported a sufficient number of symptoms of eating disorders to indicate a possible clinical disorder. More than 20% of the respondents scored at or above the clinical cut‐point on at least one of the eight EDI subscales. Selected conditionrelated characteristics (multiple conditions, condition‐affected driving, and uncertainty of illness course) were associated with EDI scores after adjusting for demographic variables, family factors, and weight‐control practices.

Met Expectations and Satisfaction with Duration A Patient-Centered Evaluation of Breastfeeding Outcomes in the Infant Feeding Practices Study II

Background: Breastfeeding expectations predict breastfeeding duration. The extent to which expectations for duration are met remains unknown. Objectives: To evaluate prospective measures of expected breastfeeding duration, changes in expectations over time, and factors associated with meeting expectations. Methods: The Infant Feeding Practices Study II followed women from late pregnancy to 1 year postpartum. Expected breastfeeding duration was assessed 5 times. Logistic regression identified factors associated with met prenatal expectations. Subgroup analysis compared met prenatal expectations to satisfaction with breastfeeding duration. Results: One-year postpartum, 34.7% of 1802 participants had met prenatal expected breastfeeding duration, and 23.9% were still breastfeeding. Fifty-eight percent of women met expectations stated at 7 months postpartum. Modifiable risk factors associated with meeting prenatal expectations included early regular breast pump use (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.18-2.07). Return to work was negatively associated with met expectations (return by 6 weeks postpartum: OR, 0.48; 95% CI, 0.33-0.71; later return: OR, 0.73; 95% CI, 0.56-0.95). Among those who reported on satisfaction with duration (n = 1226), 40.4% were satisfied. Satisfaction was associated with meeting expectations (OR, 10.56; 95% CI, 7.67-14.55), but expectation and satisfaction measures were not equivalent. Elevated body mass index and depressive symptoms at 2 months postpartum were negatively associated with both measures. Conclusion: Most participants did not meet prenatal or postnatal expectations for breastfeeding duration and were unsatisfied with duration. However, at 12 months, more participants felt they had met their expectations and were satisfied with their breastfeeding duration than were actually breastfeeding. Therefore, women may perceive greater breastfeeding progress than suggested by Healthy People 2020 benchmarks.

Role of the Elementary School Cafeteria Environment in Fruit, Vegetable, and Whole-Grain Consumption by 6- to 8-Year-Old Students

Objective Examine how the physical cafeteria environment contributes to 6‐ to 8‐year‐olds’ school food consumption. Design Cross‐sectional observational study. Before‐and‐after lunch tray photos taken with iPads to capture food selection and consumption. Setting 10 New York City public elementary school cafeterias. Participants A total of 382 students aged 6–8 years who ate lunch in the cafeteria on observation days. Main Outcome Measures Fruit, vegetable, or whole‐grain consumption. Analysis Pearsons chi‐square and multivariate logistic regression assessed associations between cafeteria environmental factors (time to eat lunch, noise, and crowding) and vegetable, fruit, and/or whole‐grain consumption with 95% confidence, adjusted for school‐level demographics and clustered by school. Results Approximately 70% of students selected fruits, vegetables, and/or whole grains. When selected, consumption was 25%, 43%, and 57%, respectively. Longer time to eat lunch was associated with higher consumption of fruits (odds ratio [OR] = 2.0; 95% confidence interval [CI], 1.1–3.8; P = .02) and whole grains (OR = 2.1; 95% CI, 1.003–4.2; P < .05). Quieter cafeterias were associated with eating more vegetables (OR = 3.9; 95% CI, 1.8–8.4; P < .001) and whole grains (OR = 2.7; 95% CI, 2.6–4.7; P < .001). Less crowding was associated with eating more fruit (OR = 2.3; 95% CI, 1.03–5.3; P = .04) and whole grains (OR = 3.3; 95% CI, 1.9–5.6; P < .001). Conclusions and Implications Healthy food consumption by 6‐ to 8‐year‐old students is associated with cafeteria crowding, noise, and time to eat lunch. Implementing and enforcing changes to the cafeteria environment mandated by wellness policies may reduce plate waste.