Promoting, Protecting and Supporting Breastfeeding: a North Carolina Blueprint for Action

Home , La Leche League, Mary Rose Tully, Weaning

Promoting, Protecting and Supporting Breastfeeding Promoting, Protecting and Supporting Breastfeeding

A North Carolina Blueprint for Action 2006

A North Carolina Blueprint for Action / 2006 A North

State of North Carolina Department of Health and Human Services Division of Public Health www.ncdhhs.gov

N.C. DHHS is an equal opportunity employer and provider. ____ copies of this public document were printed at a cost of $____ or $____ per copy. 08/06 Promoting, Protecting and Supporting Breastfeeding

A North Carolina Blueprint for Action 2006

North Carolina Department of Health and Human Services Division of Public Health Women’s and Children’s Health Section Nutrition Services Branch

Gladys Mason, MS, RD, RLC-IBCLC Sarah Roholt, MS, RD Editors

This publication is in the public domain and may be reprinted without permission. Citation of the source is appreciated. Suggested citation: Mason G, Roholt S. 2006. Promoting, Protecting and Supporting Breastfeeding: A North Carolina Blueprint for Action. North Carolina Division of Public Health, Raleigh, NC. Blueprint Authorship, Photo and Graphic Credits

A special thank you for contributing to the writing of the blueprint is extended to:

Corrine Giannini, RD, LDN, Nutrition Program Consultant, Women’s Health Branch, Division of Public Health, N.C. Department of Health and Human Services

Gladys Mason, MS, RD, RLC-IBCLC State Breastfeeding Coordinator, Nutrition Services Branch, Division of Public Health, N.C. Department of Health and Human Services

Sarah Roholt, MS, RD, Clinical Services Unit Supervisor, Nutrition Services Branch, Division of Public Health, N.C. Department of Health and Human Services

Marcia Roth, MPH, Director of Planning and Development, Center for Infant and Young Child Feeding and Care, Department of Maternal and Child Health, School of Public Health, University of North Carolina at Chapel Hill

Sherée Thaxton Vodicka, MA, RD, LDN, Healthy Weight Communications Coordinator, Physical Activity and Nutrition Branch, Division of Public Health, N.C. Department of Health and Human Services

A special thank you for the graphics and layout of the blueprint is extended to:

Christie Adams in the Graphic Arts Unit with the N.C. Department of Health and Human Services. Table of Contents Foreword 7 North Carolina Breastfeeding Blueprint 9 Breastfeeding: A Public and Personal Health Issue 11 Introduction 11 Benefits of Breastfeeding 12 Barriers to Breastfeeding in North Carolina – 14 Why Women Are Not Breastfeeding Status of Breastfeeding in North Carolina – Why We Need to Improve 15 Key Recommendations For Promoting, Protecting and Supporting 19 Breastfeeding in North Carolina From Recommendations to Action 23 Communities 24 Health Care System 28 Workplaces 35 Child Care Facilities 37 Insurance Coverage 39 Media, Social Marketing, and Public Education 43 Laws, Policies, and Regulations 45 Research and Evaluation 48 Appendices Appendix 1. References A1-1 Appendix 2. WHO/UNICEF International Code of Marketing A2-1 of Breast-Milk Substitutes Appendix 3. A Community Continuum of Breastfeeding Support: A3-1 Breastfeeding Peer Counselors, Breastfeeding Educators, and Board Certified Lactation Consultants Appendix 4. A Breastfeeding-Friendly Child Care Checklist A4-1 Appendix 5. United States Breastfeeding Committee Position Statements A5-1 • Benefits of Breastfeeding • Economic Benefits of Breastfeeding • Breastfeeding and Child Care • Workplace Breastfeeding Support • State Breastfeeding Legislation Appendix 6. Public Forum: Promoting, Protecting, A6-1 and Supporting Breastfeeding in North Carolina (September 2004) • NC DHHS Media Release for the Breastfeeding Forum • Agenda for the Breastfeeding Forum • Organizers of the Breastfeeding Forum • Forum Participants Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

Message from the Secretary North Carolina Department of Health and Human Services

It is with great pleasure that I present this Blueprint for Action for promoting, protecting and supporting breastfeeding in North Carolina. The Blueprint for Action has been developed by the N.C. Division of Public Health in collaboration with a work group of representatives from state and community agencies and organizations.

Breastfeeding is one of the most effective ways to promote the health of our children during their early years of life. Moreover, the evidence shows that breastfeeding conveys important benefits to both the child and the mother that extend throughout the life cycle.

Promoting breastfeeding is one important way that the N.C. Department of Health and Human Services carries out its mission of protecting the public health, fostering self-reliance, and eliminating health disparities. I invite you to join with us in using this blueprint and responding to its call to action.

Community-driven, ethical, compassionate and evidence-based health and regulatory practices that promote, protect and support breastfeeding in North Carolina require that a wide range of public health programs and state and local organizations work in partnership. Our collective commitment to this process will foster the achievement of our goal of improving the health of all who live and work in North Carolina – beginning with our babies and our mothers.

Sincerely,

Carmen Hooker Odom Secretary

6 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

Foreword

North Carolina’s children are our number-one priority, and our commitment to giving them a healthy start begins with promoting, protecting and supporting breastfeeding. Breastfeeding is the best possible foundation for infant and young child feeding. Many groups, including the American Academy of Pediatrics, American Association of Family Physicians, American College of Obstetricians and Gynecologists, and Academy of Breastfeeding Medicine, recommend that infants receive their mother’s milk for at least the first year of life.

North Carolina has taken many important steps forward, and effective interventions have been implemented at the state and community level to increase the initiation of breastfeeding, to make it an exclusive practice (rather than being combined with infant formula), and to increase its duration. Despite measurable progress, however, much remains to be done. North Carolina has yet to attain the Healthy People 2010 performance goals of having at least 75 percent of new mothers initiate breastfeeding, with at least 50 percent of the infants continuing to be breastfed until at least six months of age and 25 percent continuing until at least one year of age.

This blueprint incorporates input from a broad spectrum of community, state and national stakeholders and experts in the field. The document is intended to serve as a guide for North Carolina communities, health care systems, professional societies, academic and training programs, workplaces, and child care facilities to support, promote, and protect breastfeeding.

For breastfeeding to be successful, all mothers must have the broad support of their family, friends, communities, health care providers, insurers, workplaces, and policy makers. This supportive environment can empower mothers in North Carolina to breastfeed their infants.

7 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

We hope that the charge set forth through this blueprint will resonate with all North Carolinians committed to improving the health of women, infants, and children.

Leah Devlin, DDS, MPH State Health Director N.C. Division of Public Health

Kevin Ryan, MD, MPH Chief, Women’s and Children’s Health Section N.C. Division of Public Health

Alice Lenihan, RD, MPH, LDN Head, Nutrition Services Branch N.C. Division of Public Health

Peter J. Morris, MD, MPH Past President North Carolina Pediatric Society

8 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

A North Carolina Breastfeeding Blueprint

The Nutrition Services Branch (NSB) in the NC Division of Public Health spearheaded the development of this document, Promoting, Protecting and Supporting Breastfeeding: A North Carolina Blueprint for Action. To ensure that the blueprint would reflect the experiences and perspectives of a wide range of stakeholders and supporters of breastfeeding, the NSB invited representatives from diverse disciplines and communities across the state to participate in a public forum on September 9, 2004, entitled “Promoting, Protecting and Supporting Breastfeeding in North Carolina.” The forum resulted in the specific recommendations contained in this blueprint. Appendix 6 includes information about the public forum.

The ultimate goal for North Carolina, formally adopted through the public forum, is to “increase breastfeeding initiation and duration rates by positively influencing the breastfeeding climate.” To move successfully towards this goal, changes are needed in communities, the health care system, the workplace, child care facilities, the insurance industry and legislation. Ideally, these changes will come through public and private organizations working individually and collectively to seek new policies and legislation, develop programs, use the media and conduct research. Working together, we can promote and assure the opportunity for early, exclusive and continued breastfeeding for all North Carolina mothers and infants.

Refer to Appendix 1 and Appendix 5 for references used to support the discussions in this blueprint.

9 Vision:

North Carolina mothers will be enabled to begin their children’s lives by breastfeeding - the best possible foundation for infant and young child feeding. Breastfeeding: A Public and Personal Health Issue

11 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

Introduction immunities against acute and chronic illness. A mother’s milk Breastfeeding is not simply a provides protection and growth lifestyle choice. It is universally factors unique to her infant and endorsed by the world’s health changes over time (even over and scientific organizations as the the course of a day) to meet the best way of feeding infants. The changing nutritional needs of her best infant and young child infant. Human milk, unique and feeding practices are defined specific to humans, cannot be internationally as early and duplicated by any artificial means. exclusive breastfeeding for 6 months, then continuation of Strong evidence exists that breastfeeding while adding age- infants fed human milk experience appropriate complementary foods decreases in the incidence and/or for two years or more. The severity of childhood infectious evidence is clear that breastfeeding illnesses including bacterial provides immediate and lifelong meningitis, bacteremia, diarrhea, nutrition and health benefits for respiratory tract infections, both mother and child, as well as necrotizing enterocolitis (NEC), larger economic, environmental otitis media, and urinary tract and social benefits to families and infections. Some studies suggest communities. Breastfeeding must that breastfeeding decreases rates be considered the standard for of sudden infant death syndrome infant feeding in the first year of (SIDS). life or longer. Evidence is growing that breastfeeding may reduce the Benefits of Breastfeeding incidence of a variety of chronic For infants and children health issues including diabetes mellitus (type 1 and type 2), For infants and children, human certain cancers, overweight/ mother’s milk supports optimal obesity, hypercholesterolemia, and development and provides

12 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

asthma in older children For family and community and adults. Breastfeeding also Breastfeeding offers benefits has been associated with slightly to the family and community-at- enhanced cognitive development. large beyond those related to the For mothers improved health of mothers and children. Breastfeeding has the The benefits of breastfeeding potential to decrease health care are not confined to infants and costs, some estimating by as much children. Mothers who breastfeed as $3.6 billion annually, although within the first 30-60 minutes some small portion of these after the birth of their infants savings would be offset by the and who continue breastfeeding cost of health services to at least through the baby’s first support breastfeeding (i.e., year, will gain both immediate lactation consultants). With the and lifelong health benefits. decrease in infant illness associated The longer a woman spends with breastfeeding, there could be breastfeeding, the greater the reduced parental absenteeism from beneficial effect. Mothers who work and/or more time for parents breastfeed experience decreased to spend with family and friends. post-partum bleeding, more rapid Families that breastfeed may uterine involution, and a faster experience lower food costs, return to prepregnancy weight since infant formula costs upwards than women who do not of $1,200 -$1,500 annually. breastfeed. Additional benefits Benefits of breastfeeding for the of continued breastfeeding include environment include reduced increased child spacing, a energy demands to manufacture, decreased risk of ovarian cancer transport, and prepare infant and premenopausal breast cancer, formula, along with a reduced and possibly a decreased risk of burden of disposing of infant hip fractures and osteoporosis formula packaging (i.e., bottles after menopause. and cans).

13 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

Barriers to Breastfeeding them from initiating or in North Carolina continuing with breastfeeding. Why Women Are Not Other concerns for the new Breastfeeding mother which may lead to early discontinuation of Some groups of women in breastfeeding include fear of pain, North Carolina appear less likely fear of inadequacy of milk supply, than others to breastfeed. lack of support and care for her Demographic characteristics such own needs, and a perception of as race, age, ethnicity, education, not having enough time to marital status and income have nurse. Hospital practices can been found to be associated with interfere with early establishment the decision to breastfeed. Data of breastfeeding. Separating suggest that women are less likely mother and infant diminishes a to breastfeed if they have lower mother’s chance of learning to income and less education, are recognize early feeding cues and unmarried, obese, depressed or of emptying her breasts frequently smoke. (Source: North Carolina enough to foster optimal milk Pregnancy Risk Assessment and production. A hospital’s casual use Monitoring Survey [PRAMS] of infant formula to “supplement” data). breastfeeding without medical A common barrier for women indication, giving pacifiers to to initiate or to continue infants, and providing samples exclusively breastfeeding is a of infant formula (which implies lack of knowledge among the endorsement of them) are general population and health practices associated with shorter breastfeeding duration. care professionals about the risks of not breastfeeding. Inconsistent Limited family or community and inaccurate information about support for breastfeeding during how to breastfeed confuses the critical postpartum period can mothers and often discourages be another barrier to breastfeed-

14 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

ing, especially when there are “International Code of Marketing limited role models and support of Breast-milk Substitutes.” Refer systems for new mothers. New to Appendix 2 for information on mothers need adequate food, the International Code. drink, rest, and help to manage their stress. In our society, where Status of Breastfeeding breasts are depicted primarily as in North Carolina sexual rather than as the Why We Need to Improve essential way of feeding and Among the 115,000 -119,000 nurturing infants, there also may births each year in North be psychosocial barriers associated Carolina, there has been an with meeting an infant’s nutritional increase in the number of needs through breastfeeding. infants who begin their lives The extensive commercial breastfeeding: 69.9% in 2003, promotion of infant formulas and compared to 64.2% in 1999. their easy accessibility have Of the 69.9% of women who created widespread acceptance initiated breastfeeding in 2003, that these products are equal approximately 47% continued to human milk and merely a to breastfeed eight weeks or lifestyle choice for the mother. beyond, compared to 40.3% The perceptions that these in 1999 (source: NC PRAMS). products are more up-to-date, While North Carolina has convenient, or improved are false experienced an increase in impressions created through breastfeeding initiation, the state marketing. To further exacerbate remains below the Healthy People the problem, these products 2010 goal of having at least 75% are frequently distributed as free of mothers initiate breastfeeding. samples to healthcare professionals With only about 47% of women and through direct distribution to still breastfeeding at eight weeks, families of young children; both North Carolina also falls short of practices conflict with the the goal of having at least 50%

15 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

of the infants continuing to be percent of infants who initiated breastfed until at least six months breastfeeding has slowly improved, of age. from about 26% in 1993 to 54.3% in 2005. However, the extent of A twelve-year study (1993-2005) changes in the percent of infants of infants enrolled in the N.C. initiating breastfeeding varies with Supplemental Nutrition Program race and ethnicity. (Figure 1). for Women, Infants, and Children (WIC) shows the

Figure 1: Breastfeeding Initiation among Infants Participating in N.C. WIC Program* by Race and Ethnicity (1993-2005)

Percentage 30

20 10 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year

White Black Hispanic American Indian Total

16 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

The number of infants breastfeed- relatively slowly over these 11 ing for six months and for one year years (Figure 2). has also steadily improved, though

Figure 2: Duration of Breastfeeding among Infants Participating in the N.C. WIC Program* (1993-2005)

Ever Breastfed 60 At Least 6 months 50 At Least 12 months 40

Percentage 20 10

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year

*Among infants born during the reporting period (Source: N.C. Pediatric Nutrition Surveillance System). Healthy People 2010 Objective: Increase the proportion of mothers who breastfeed their babies in the early postpartum period to 75%, with at least 50% of the infants continuing to be breastfed until at least 6 months of age, and 25% continuing to at least one year of age.

17 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

A map of North Carolina by while others are not. The data county illustrates that some suggests also that there are areas of the state are close to the significant geographic disparities Healthy People 2010 objective in the state regarding breastfeed- for breastfeeding initiation ing initiation. (Figure 3).

Figure 3: Breastfeeding Initiation Rates among Women Participating in the N.C. WIC Program, 2005

<-25% 26%-50% 51%-74% >=75%

Breastfeeding Initiation Rates in Percent Healthy People 2010 Objective: Increase the proportion of mothers who breastfeed their babies in the early postpartum period to 75%.

18 Key Recommendations for Promoting, Protecting and Supporting Breastfeeding in North Carolina

19 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

Participants at the 2004 Breastfeeding Forum recommended a variety of actions to improve breastfeeding by promoting, protecting and supporting breastfeeding for all North Carolina mothers and babies. Following the forum, these recommendations were assessed using relevant criteria adapted from the North Carolina Healthy Weight Initiative state plan, Moving Our Children Toward A Healthy Weight. The four criteria selected and systematically applied to the recommendations included in this blueprint follow:

Criterion 1. Does the recommendation have a basis in science and/or best practice –– that is, has the implementation of the recommendation been shown to have a positive effect or association with breastfeeding?

Criterion 2. Does the recommendation provide the degree of specificity necessary to guide the development of effective strategies and to evaluate their impact?

Criterion 3. When considered in their entirety, do the recommendations address the most relevant variables that are associated with promoting, protecting and supporting initiation and duration of breastfeeding?

Criterion 4. When considered in their entirety, do the recommendations support (directly or indirectly) North Carolina’s commitment to eliminate health disparities?

20 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

This review process resulted in the following eight key recommendations for breastfeeding:

I. Encourage the adoption of activities that create breastfeeding- friendly communities.

II. Create a breastfeeding-friendly health care system.

III. Encourage the adoption of breastfeeding-friendly workplaces.

IV. Assist child care facilities in promoting, protecting and supporting breastfeeding.

V. Advocate for insurance coverage by all third-party payers for breastfeeding care, services, and equipment when necessary.

VI. Involve media and use social marketing and public education to promote breastfeeding.

VII. Promote and enforce new and existing laws, policies and regulations that support and protect breastfeeding.

VIII. Encourage research and evaluation on breastfeeding outcomes, trends, quality of care, and best practices.

These eight key recommendations provide a framework for action to increase the number of North Carolina mothers who will be enabled to choose and succeed in breastfeeding their children. The next section of the blueprint, “From Recommendations to Action.” outlines actions for each of the eight key recommendations.

21 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

In deciding which key recommendations and actions to include, given the array of possibilities and available resources, we tried to select the most appropriate and sustainable interventions for North Carolina. It was also important to incorporate actions for which effectiveness has been determined by evidence-based research. This last effort was facilitated by the fact that the Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), and the US Breastfeeding Committee (USBC) have synthesized available research to identify activities determined to be effective.

22 From Recommendations to Action

23 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

The purpose of this section of the blueprint is to offer recommended actions that will interest and engage a broad spectrum of stakeholders and supporters of breastfeeding for each of the eight key recommendations.

Due to the natural overlapping of issues across the eight key recommendations, the reader is encouraged to review all eight areas to identify actions relevant to their interests, regardless of how the actions are categorized.

A cumulative effort by many, regardless of the magnitude of any single effort, will contribute towards making breastfeeding the norm for infant feeding in North Carolina. It is hoped, therefore, that leaders within communities, government, health care, business, academia, and public and private organizations will use one or more sets of recommended actions relevant to their settings to guide them in their efforts to promote, protect and support breastfeeding. It is only through a well-orchestrated combination of individual efforts, policies, environmental support and research that we will achieve the vision for North Carolina’s mothers and children so clearly articulated at the breastfeeding public forum.

Communities

I. Encourage the adoption of activities that create breastfeeding-friendly communities.

Women usually understand the benefits of breastfeeding for their children, but may lack information on the benefits of breastfeeding for themselves and their families. They also may not have access to support on how to breastfeed or how to manage the problems sometimes associated with breastfeeding. Some women who would like to consider breastfeeding may hesitate to do so

24 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

when the father of their baby, their family, or the community in which they live are not supportive. Educating and supporting the whole family and the community at-large, therefore, will result in increasing breastfeeding rates. Assuring support before, during and after delivery with social networks and breastfeeding peer counselor services can positively affect a woman’s decision to initiate and to continue breastfeeding.

Breastfeeding peer support is a social network that is a cost-effective approach for women of every socioeconomic background. Women tend to be influenced by other women, and new mothers are more likely to talk to other mothers about breastfeeding. Peer counselors have been effective in settings where contact with professional breastfeeding support is limited and where social networks are scarce.

Breastfeeding peer counselors are usually women with breastfeeding experience and are of similar socioeconomic status as the women to whom they offer support. Breastfeeding peer counselors are trained to help other women overcome challenges that might otherwise lead the women to not breastfeed or to wean early although breastfeeding was initiated.

Integrating peer support within the community service system and through community partnerships helps to maintain ongoing peer counseling program success. In some communities, mother-to-mother groups are already in place. Groups, such as La Leche League International, offer free and enthusiastic peer support.

Board Certified Lactation Consultants are another group that may be called upon in the community to visit homes and support new mothers. Additional information about breastfeeding peer counselors, breastfeeding educators and board certified lactation consultants can be found in Appendix 3.

25 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

Public acceptance of breastfeeding as the normal infant feeding method is not found in all parts of the society and diverse communities of North Carolina, yet public acceptance is essential to increasing the numbers of women who initiate and continue breastfeeding their infants. For some pregnant women, the social barriers are too great to even consider breastfeeding. Mothers who breastfeed often report feeling embarrassed to nurse their hungry babies when they are away from home. In North Carolina, even though it is legal to breastfeed in public, women have been asked to leave restaurants, shopping malls, and other public places because they were breastfeeding their infants.

Recommendations for Action – Communities

1. Use consistent and culturally appropriate breastfeeding promotion and support messages. Encourage and support collaboration in the development and provision of such messages among state and community agencies and organizations that provide services to young families. Such agencies and organizations include, but are not limited to, private and public health care systems (i.e., hospitals, public health departments, physicians’ offices, birthing centers), educational systems, and breastfeeding support groups.

2. Develop ways to acknowledge the important role that the father of the infant and the woman’s family members (e.g., parents, siblings, grandparents, other relatives) and friends play in influencing a woman’s decision to breastfeed. Provide targeted and culturally appropriate support and education to each of these groups of individuals. Include ways to provide this information through community organizations.

26 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

3. Acknowledge the important role of age when influencing adolescents regarding infant feeding choices, and develop and provide appropriate and relevant messages, critical support and education targeted to their needs.

4. Provide easy access to breastfeeding resources and breastfeeding toll-free assistance by phone, in English, Spanish and TTY, with referral to 24 hour - 7 days a week support.

5. Promote interagency collaboration among private and public health care systems, educational systems and community organizations currently offering breastfeeding support. This effort could include state and local WIC programs, public health departments, school systems, hospitals, community breastfeeding support groups (such as La Leche League and Nursing Mothers), physicians’ offices, Head Start, and the North Carolina Smart Start Program.

6. Assess the availability and accessibility of community breastfeeding support networks. Develop ways to increase and to integrate community breastfeeding peer counselors, educators, and experts into easily accessible community services. Establish a universal goal of providing peer-to-peer and lactation support to all new mothers, without regard to income, program eligibility or other demographic characteristics.

7. Establish links between maternity facilities and community breastfeeding support networks to establish continuous care and support to breastfeeding mothers and babies.

8. Develop ways to create a welcoming and comfortable atmosphere for breastfeeding mothers and babies for

27 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

community events and public spaces such as local shopping centers, government offices and parks.

9. Offer technical assistance to faith-based and other community organizations to encourage the development of breastfeeding-friendly practices.

10. Identify and recruit community leaders to further the progress in establishing breastfeeding as a community norm.

11. Incorporate breastfeeding information in all state and local sponsored school health education curricula, from kindergarten through higher education, to increase understanding of breastfeeding as the standard for infant feeding.

Health Care System

II. Create a breastfeeding-friendly health care system.

Attitudes toward and success with breastfeeding are greatly influenced by events during pregnancy, labor and birthing, the time immediately after birth, and during later visits with health care providers.

Education and counseling during pregnancy regarding maternal readiness, breast health and breastfeeding initiation can affect a woman’s decision to breastfeed. Birthing practices can play a pivotal role in the initiation and length of time breastfeeding continues. The presence of a supportive, non-judgmental individual throughout labor and delivery both eases labor and enhances breastfeeding. Because of its relationship with the birth experience, breastfeeding must be supported throughout the maternity

28 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

hospital stay and then extended to the community after the infant and mother return home.

Breastfeeding must also be supported in all medical services that serve mothers of young children, whether surgical, infectious disease or other. Unnecessary disruption of breastfeeding is often the result of medical interventions outside the maternity or newborn setting. Board certified lactation consultants are available in many areas and can provide lactation management services and adjunct support to health care providers within the health care facility itself and/or in the home of the breastfeeding mother.

Facilities such as birthing centers, hospitals and pediatric practices that are breastfeeding-friendly typically experience an increase in breastfeeding rates. Actions taken to become a breastfeeding-friendly health facility can be part of a comprehensive set of practices such as those implemented in pursuit of World Health Organization/UNICEF Baby-Friendly Hospital Initiative (BFHI) designation. They can also be discrete, less comprehensive interventions which, over time, create a more breastfeeding-friendly environment.

North Carolina currently has no certified breastfeeding-friendly hospitals or birthing centers. Yet in 2004, North Carolina hospitals provided birthing assistance to more than 119,000 mothers. In the United States, as of April 2006, just 53 hospitals and birthing centers carry the BFHI designation, despite evidence of the improved health outcomes for infants and mothers and improved patient and staff satisfaction in BFHI facilities. It is important to note that facilities implementing fewer than the full ten steps have achieved improved maternity care and breastfeeding outcomes. Although challenging, maternity care facilities should be encouraged to strive to implement all ten steps and receive BFHI status.

29 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

Educating hospital staff and other health care professionals through training and ongoing continuing education can enhance compliance with optimal maternity and pediatric care practices, including those associated with breastfeeding support. Many clinicians indicate that they lack the skills and/or confidence to help mothers initiate normal breastfeeding or manage breastfeeding challenges. Some still have the misconception that the overall benefit of breastfeeding is small and that use of infant formulas does not create any risks.

Education to increase the knowledge, attitudes and skills of health care providers is needed regarding breastfeeding. At a minimum, this education should address the importance of exclusive breastfeeding as a health behavior with multiple benefits for both mother and child; the differences between human milk and infant formulas; and the importance of accessing a referral network to appropriately manage breastfeeding challenges.

The health care system must pay attention also to the widespread practice of advertising and distributing samples of infant formula to new mothers before, during and after the hospital stay. This practice has a negative impact on breastfeeding, with a disproportionately negative impact on mothers who are particularly vulnerable, including first-time, less educated, or nonwhite mothers, or mothers (and/or their infants) who experience illness during the postpartum period. The most common reason women give for stopping breastfeeding in the early postpartum period is a perceived lack of a sufficient milk supply. This false perception of insufficiency of breast milk can be further exacerbated when the health care system readily provides free samples of infant formula, implying product endorsement.

30 WHO/UNICEF Ten Steps to Successful Breastfeeding

1. Have a written breastfeeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within one half-hour of birth. 5. Show mothers how to breastfeed and maintain lactation even if they may be separated from their infants. 6. Give newborn infants no food or drink other than breastmilk, unless medically indicated. 7. Practice rooming in - allow mothers & infants to remain together - 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

The World Health Organization (WHO) and United Nations International Children’s Emergency Fund.(UNICEF)

31 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

Recommendations for Action – Health Care Systems

1. Engage the North Carolina Hospital Association and other health professional organizations in championing the implementation of the Baby-Friendly Hospital Initiative (BFHI) in North Carolina. Develop ways to provide technical assistance and support to community-based health care facilities (i.e., community and primary health centers, local health departments, physician practices) to adopt the policies and practices defined in the Baby-Friendly Hospital Initiative (BFHI). Pursue funding to assist maternity care facilities in implementing the evidence-based practices encompassed in the BFHI Ten Steps to Successful Breastfeeding.

2. Develop and implement a North Carolina-specific method and a tool for assessing a facility’s progress toward breastfeeding support and compliance with breastfeeding best practices.

3. Disseminate evidence-based information on the cost-effectiveness of breastfeeding and on effective breastfeeding-friendly practices to key decision-makers for health care institutions.

4. Develop policies, protocols and standards of practice that integrate clinical best practices throughout local health care systems and institutions, with reliance on breastfeeding authorities such as the Academy of Breastfeeding Medicine (ABM), American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists, American Academy of Family Physicians (AAFP), and the International Lactation Consultant Association (ILCA).

32 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

5. Establish a system for publicly recognizing hospitals and other maternity care facilities that have made improvements in maternity care practices related to breastfeeding.

6. Establish breastfeeding education courses that target clinical staff of hospitals and maternity care facilities and assure financial support for staff to attend.

7. Develop and enhance the curricula of graduate and professional education programs of medicine, nursing, midwifery, public health, nutrition, and allied health to address at a minimum: the basics of human lactation, the significance of exclusive breastfeeding for the first six months of life, lactation management, and how to access and collaborate with a lactation referral network for mothers.

8. Provide breastfeeding support skills training and continuing education to community-based providers in obstetrics, family medicine, pediatrics, nursing, midwifery, nutrition, health education, and social services.

9. Develop ways to require professional licensing and board recertification to include breastfeeding education for health care providers working with pregnant or new mothers and their infants.

10. Provide up-to-date, evidence-based information to health care providers regarding the risks and benefits of different medications (including contraception) as they affect women and their infants during lactation.

33 Benefits of Breastfeeding to Employers

Breastfeeding makes healthier babies, and healthier babies result in mothers missing less time from work and fewer health care dollars spent.

Breastfeeding positively impacts a company’s bottom line through:

• Lower health care costs • Enhanced employee productivity • Improved employee satisfaction • Reduced turnover rate • Improved company image as family friendly

34 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

Workplaces

III. Encourage the adoption of breastfeeding-friendly workplaces.

North Carolina is a national leader in the number of women in the work force, with mothers being the fastest-growing segment of the state labor force. Returning to work or school, however, is a commonly perceived barrier to breastfeeding.

It is often difficult for most mothers – and especially those who are breastfeeding – to see how they can return to work (or school) after the birth of a child. One in every three new mothers returns to work within three months of her child’s birth; two of three return within six months. Approximately seven of ten working moms with very young children work full-time. Adolescent mothers are the least likely to breastfeed and are likely to return to school as early as ten days after giving birth, as is required in many school districts.

New mothers who work outside the home or return to school are less likely to breastfeed. Of those who do initiate breastfeeding, those who work or go back to school continue for fewer months than women who do not work outside of the home. Women living in the lower socio-economic groups tend to return to work earlier and to jobs where the work environments are not necessarily conducive to continued breastfeeding.

Workplaces can support breastfeeding by providing flexibility in the work schedule, work locations and break times, and job-sharing to accommodate breastfeeding or milk expression. Employers can utilize many different strategies to support breastfeeding,

35 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

depending upon the size and needs of the agency or organization. One of most effective ways to support breastfeeding at the workplace is having support for breastfeeding from supervisors and colleagues.

Ideally, all workplaces would offer a Nursing Mothers Room (NMR). The NMR should be centrally located with adequate lighting, ventilation, privacy, seating, a sink, an electrical outlet, a refrigerator, and a changing table. Overall, this area should be a clean, comfortable and secure space for breastfeeding or expressing milk and a safe space for storing expressed milk. Refer to Appendix 5 for additional information on workplace breastfeeding support and to www.nutritionnc.com for the resource packet “How to Become a Mother-Friendly Workplace that Supports Breastfeeding.”

Recommendations for Action – Workplaces

1. Educate business and industry about the benefits of instituting breastfeeding-friendly workplace policies and practices for both employers and employees.

2. Provide technical assistance to businesses and schools about becoming breastfeeding-friendly. The technical assistance should address assuring support of employees for breastfeeding; establishing a private and safe space for on-site expression and storage of breastmilk; including breastfeeding services and equipment as a component of company benefits; and protecting breastfeeding women from harassment.

3. Disseminate information on effective breastfeeding-friendly workplace models for diverse settings including: small, medium and large businesses; businesses that are professional, technical, or

36 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

agricultural in nature; and businesses that have salaried and/or hourly employees.

4. Create a workplace recognition program to honor employers and schools who support breastfeeding employees and students.

5. Require implementation of breastfeeding-friendly policies and practices in all agencies that receive public funds.

6. Establish a model workplace lactation support program within state and local government agencies.

Child Care Facilities

IV. Assist child care facilities in promoting, protecting and supporting breastfeeding.

With increasing numbers of women returning to work or school, child care facilities are an essential setting for promoting and facilitating continuation of breastfeeding. Child care facilities can play a key role in establishing breastfeeding as the community norm for infant feeding.

Child care homes and centers are a major source of emotional and tangible support for new mothers, many of whom may have a strong desire to continue breastfeeding when they are separated from their babies. Child care providers can demonstrate support for a woman’s decision to breastfeed in a variety of ways. Of greatest importance, though, is creating a breastfeeding-friendly child care environment and developing a knowledgeable and supportive staff.

37 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

Targeted information, education and training for child care providers are essential steps towards successful adoption of a child care breastfeeding protection and support policy. Such a policy should include support for the following practices: providing a place for breastfeeding mothers to nurse their babies or express milk; training staff on the importance of breastfeeding and in the proper storage and handling of human milk; providing flexible breaks to breastfeeding employees to accommodate breastfeeding or milk expression; and providing positive breastfeeding promotion messages in the home or center.

To indicate their support of breastfeeding, some child care facilities use breastfeeding-friendly symbols such as the “Breastfeeding Welcome Here” materials that were developed through USDA. The knowledge that a child care facility supports a mother’s decision to breastfeed can translate into positive community recognition for the facility both as an employer and as a child care service provider. Additional information on breastfeeding and child care is available in Appendix 4 and Appendix 5.

Recommendations for Action – Child Care Facilities

1. Encourage state child care licensing and accreditation agencies and boards to reinforce the importance of breastfeeding-friendly practices by distributing evidence-based guidelines, providing technical assistance, and monitoring performance for supporting breastfeeding in child care settings.

2. Provide ongoing training opportunities for child care providers on how to support breastfeeding and to assure safe and consistent storing, handling and feeding of pumped human milk at child care facilities.

38 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

3. Provide technical assistance to community child care facilities on how to develop policy, space, incentives and programs that support breastfeeding.

4. Disseminate information and provide ongoing training opportunities for child care providers on effective child care models that support breastfeeding, while recognizing the diversity of child care settings (i.e., small, medium and large settings; center-based, at a workplace, or home-based; and provision of infant and/or toddler care).

5. Incorporate breastfeeding education and promotion into early childhood programs such as Head Start and North Carolina’s More at Four and Smart Start.

Insurance Coverage

IV. Advocate for insurance coverage by all third-party payers for breastfeeding care, services, and equipment when necessary.

Increasing evidence of the cost-effectiveness of breastfeeding, including lower medical expenditures for breastfed infants as compared with never-breastfed infants, has resulted in greater attention to the role that health insurance can play in improving access to breastfeeding support and lactation services. Some states have worked in partnership with health care insurance plans to review coverage policies and to recommend provider reimbursement for prenatal, perinatal, and postpartum breastfeeding education and lactation services.

Provider reimbursement for breastfeeding and lactation support is an essential component of increasing breastfeeding initiation and

39 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

duration. Ideally, reimbursement should include community office-based visits with physicians and board certified lactation consultants, breastfeeding classes, breast pumps and pumping kits when needed, and vitamin D supplements.

Insurance coverage of breastfeeding support services requires clarification of a number of issues such as: who is the “beneficiary” (the mother or the infant); what determines medical need (i.e., universally available or only per defined medical criteria); and what constitutes the definition of a “qualified provider.” Public insurance programs like Medicaid can establish the standard for best practices while ensuring that breastfeeding mothers and their infants will experience the myriad of benefits associated with having healthier babies.

Recommendations for Action – Insurance Coverage

1. Assess the availability and quality of lactation services across the state with regard to provider qualifications, service definitions and financing.

2. Conduct a survey to determine the extent to which public and private insurance companies provide coverage for breastfeeding services.

3. Compile existing data regarding costs and benefits to insurance companies that cover breastfeeding services (such as lactation services, breast pumps, Vitamin D supplements, and donor human milk for high-risk infants) and disseminate this information to health plan managers and industry leaders.

40 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

4. Work with the major health care reimbursement systems such as Medicaid, the State Employee Health Plan, and other insurance companies to develop model policies that promote adequate reimbursements for breastfeeding services.

5. Provide training and information to maternity care facilities and community providers regarding coverage policies and billing procedures for breastfeeding-related services through different plans.

6. Develop and disseminate a consumer’s guide to insurance coverage of breastfeeding services.

41 Social Marketing Principles

The major principles of both social marketing and commercial marketing are generally known as “the four P’s” of product, price, place, and promotion. The “product” is the behavior change being promoted.

In using social marketing to promote breastfeeding, marketers must find the unique appeal that makes their product, breastfeeding, more desirable than the competition, using infant formula. The price includes the emotional, psychological, physical, and social costs of breastfeeding as perceived by a target audience. The place refers to the optimal venues or locations to deliver the message to the target audience, realizing that this might differ widely from one demographic group to another. Promotion strategies must resonate with the target audience to encourage behavior change and be delivered in a well-coordinated fashion to be effective.

42 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

Media, Social Marketing, and Public Education

VI. Involve media and use social marketing and public education to promote breastfeeding.

Positive breastfeeding images, combined with factual media campaigns and social marketing, can help mothers and families make informed decisions about infant feeding. Media, social marketing, and public education initiatives can play an important role in strengthening the perception of breastfeeding as the accepted behavior for all mothers.

A media campaign typically is directed toward a wide audience and uses public channels such as television, radio, print materials and outdoor advertising. There is evidence showing that media campaigns, particularly television commercials, improve attitudes toward breastfeeding and increase initiation rates.

Social marketing goes beyond media and utilizes established commercial marketing principles to study influences on behavior and then to use the findings to encourage healthy behaviors and/or support behavior change. A social marketing campaign may encompass multifaceted approaches and will use carefully designed messages targeting specific audiences such as consumers, their support systems, health care providers, the community, and the general public. Professional endorsements, direct mail, incentive items, and sponsoring events are social marketing strategies used to address specific barriers to behavior changes such as initiation and continuation of breastfeeding. Established as an effective model for addressing a wide variety of public health issues, social marketing is being used to increase public awareness and community support for breastfeeding.

43 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

Media and social marketing approaches are used effectively in commercial infant formula advertising. The commercial marketing of infant formulas has been shown to negatively impact breastfeeding. To counteract the commercial marketing of these products, media and social marketing strategies must be used to focus on breastfeeding.

Recommendations for Action – Media, Social Marketing, and Public Education

1. Develop and implement a social marketing campaign for target audiences (and which complements actions recommended in this blueprint) to promote breastfeeding among North Carolina’s diverse populations, with emphasis on increasing breastfeeding initiation and duration.

2. Partner with local media outlets (television, radio, print) and request that they broadcast existing research-based media campaigns, such as “Babies are Born to be Breastfed” (developed through US DHHS) or “Loving Support Makes Breastfeeding Work” (developed through USDA) to improve acceptance and knowledge of the importance of breastfeeding.

3. Provide promotional and educational materials/posters on breastfeeding, to be used in place of educational materials provided by commercial infant formula manufacturers, in public and private health care offices, schools and child care settings.

4. Use culturally appropriate toys, picture books, textbooks, visual aids, and room decorations that depict breastfeeding in health care offices, schools, child care settings, and workplaces.

44 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

5. Incorporate breastfeeding content into the science and health curricula of schools for preschool, primary, secondary, and postsecondary education.

6. Develop public/private partnerships at the local and state levels to promote the use of media advocacy to stimulate public discussion of breastfeeding.

7. Encourage the media to highlight advocacy efforts and activism that promotes, protects and supports breastfeeding as the community norm for feeding infants.

8. Continue support for the N.C. Family Health Resource Line (1-800-367-2229) as a primary statewide source for information and referral for breastfeeding questions and concerns.

Laws, Policies, and Regulations

VII. Promote and enforce new and existing laws, policies and regulations that support and protect breastfeeding.

Increasingly, attention is being focused on the role of federal and state legislation and regulatory action in the support and protection of breastfeeding. North Carolina was among the first states in the nation to review and amend state statutes for this purpose. In 1993, the N.C. General Assembly exempted breastfeeding from the criminal statutes, and at the same time, clarified that women have the right to breastfeed in public, even if there is exposure of the breast.

45 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

N.C. Gen. Stat. sec. 14-190.9 1993 N.C. ALS 301; 1993 N.C. Sess. Laws 301; 1993 N.C. Ch. 301; 1993 N.C. HB 1143§ 14-190.9. Indecent exposure. (b) Notwithstanding any other provision of law, a woman may breast feed in any public or private location where she is otherwise authorized to be, irrespective of whether the nipple of the mother’s breast is uncovered during or incidental to the breast feeding.

More than half of the States (39) have enacted legislation in support of breastfeeding. State laws currently in place or under review related to breastfeeding include: breastfeeding in public, enhanced maternity and lactation benefits through insurance plans, and voluntary or regulatory compliance with components of the Baby-Friendly Hospital Initiative and breastfeeding-friendly workplaces. Some states, viewing government as a major employer and a critical player in providing leadership for breastfeeding promotion and support, are considering incentives for state employers and contractors that demonstrate breastfeeding-friendly workplaces.

In 1981, the World Health Assembly adopted the World Health Organization’s (WHO) International Code of Marketing of Breast-Milk Substitutes, a comprehensive set of guidelines that suggest standards for the appropriate marketing and distribution of commercial infant formulas. Generally referred to as the International Code, it addresses issues related to advertising of these products to the public, the distribution of free samples and gifts to mothers and health care workers, the promotion of infant formula products in health care facilities, and information used in the labeling and marketing of infant formulas. While challenging to fully implement, the International Code offers the opportunity for developing new and/or revising existing state policies and standards. Refer to Appendix 2 for additional information on the International Code.

46 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

It is widely recognized that breastfeeding-friendly laws, policies and regulations can be an effective way to increase societal awareness and understanding that breastfeeding is an essential health behavior that needs to be encouraged and supported. Refer to Appendix 5 for additional information on state breastfeeding legislation.

Recommendations for Action – Laws, Policies, and Regulations

1. Assess state legislation and identify ways that it could be strengthened to further promote, protect, and support breastfeeding in North Carolina.

2. Identify legislative champions and advocates most likely to sponsor improved breastfeeding policy.

3. Expand to all health clinics providing maternal and child services, the policy of the N.C. Women, Infants and Children Special Supplemental Nutrition Program (WIC) that prohibits displaying or distributing materials provided by or bearing the advertising logos of companies that manufacture infant formulas.

4. Engage state and local associations of health professionals (pediatricians, obstetrician-gynecologists, family practitioners, nutritionists, and nurses) to discourage the use of informational and educational materials provided by or bearing the advertising logos from companies that manufacture products replacing human milk and to avoid tacit endorsement by allowing sponsorship for meetings or trainings.

47 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

5. Establish public policy mandating that advertising and labels of products substituting for human milk and marketed in North Carolina be in accordance with the International Code of Marketing of Breast-milk Substitutes (ICMBS). Product labels should be easily understood by the consumer and list potential side effects and contraindications similar to those required of all pharmaceutical products.

6. Review the feasibility of North Carolina legislation to regulate advertising of products that are manufactured to replace human milk (i.e., infant formulas).

7. Monitor legislation and enactment of new laws, policies and regulations that may potentially impact policies that encourage a breastfeeding-friendly environment.

Research and Evaluation

VII. Encourage research and evaluation on breastfeeding outcomes, trends, quality of care, and best practices.

The scientific evidence for both the benefits of breastfeeding as the optimal infant feeding for human beings and for the efficacy of interventions that promote breastfeeding continues to grow more robust. Policy makers, practitioners, patients and consumers all depend on the findings of research and evaluation studies to guide individual care, collective decision making including public health decisions, and the allocation of resources. Formal evaluation studies of interventions implemented in North Carolina to increase breastfeeding initiation and duration will allow experts and the lay public alike to assess effects of the interventions and their relative contribution in achieving the state’s breastfeeding goals.

48 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

Ongoing monitoring of breastfeeding initiation and duration rates can identify trends in decreasing disparities in breastfeeding and facilitate the achievement of targeted goals across all population groups. Research can identify the extent to which recommended actions are being implemented, providing baseline information for determining the effectiveness of this blueprint. Continuous data gathering, monitoring and analysis of breastfeeding trends, best practices, quality of care, and innovative state and community programs assures that the investment that North Carolina makes in breastfeeding will serve as the catalyst for future action to increase breastfeeding among North Carolina infants.

Recommendations for Action – Research and Evaluation

1. Maintain current statewide systems that collect and analyze state and population breastfeeding trend data: Pregnancy Risk Assessment Monitoring System (PRAMS), Behavioral Risk Factor Surveillance System (BRFSS), Child Health Assessment and Monitoring Program (CHAMP), Pediatric Nutrition Surveillance System (PedNSS), and Pregnancy Nutrition Surveillance System (PNSS).

2. Continue to develop trend data from statewide data studies regarding the incidence and duration of exclusive and partial breastfeeding, especially among minority and ethnic groups experiencing lower breastfeeding rates.

3. Support research studies such as:

a. Reviewing statewide data, controlling for known variables, to gain insight on what additional factors influence breastfeeding rates.

49 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

b. Analyzing influences (social, cultural, economic, environmental, knowledge-related, attitudinal, psycho-social) on infant feeding choices, especially among minority and ethnic population groups experiencing low breastfeeding rates.

c. Assessing the array of postpartum services to the breastfeeding mother and infant and their relevance to breastfeeding initiation and duration rates.

d. Analyzing effectiveness of breastfeeding-friendly practices in maternity clinics, hospitals, workplaces, and child care facilities.

e. Determining if more cost-effective mechanisms may be developed to increase the number of baby-friendly hospitals statewide.

f. Assessing costs to the N.C. Medicaid Program for infants who are not breastfed as compared to those who are exclusively breastfed.

g. Assessing the feasibility and effectiveness of combining breastfeeding promotion with other important healthy lifestyle behavior change programs such as maternal smoking cessation, returning to pre-pregnancy weight, and family planning.

50 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

h. Assessing the impact that medications and birth control choices have on breastfeeding initiation and duration.

i. Analyzing the impact of breastfeeding on the incidence of chronic childhood diseases, including obesity.

Appendices

A-1 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

Appendices

1. References

2. WHO/UNICEF International Code of Marketing of Breast-Milk Substitutes

3. A Community Continuum of Breastfeeding Support: Breastfeeding Peer Counselors, Breastfeeding Educators, and Board Certified Lactation Consultants

4. A Breastfeeding-Friendly Child Care Checklist

5. United States Breastfeeding Committee Position Statements

• Benefits of Breastfeeding • Economic Benefits of Breastfeeding • Breastfeeding and Child Care • Workplace Breastfeeding Support • State Breastfeeding Legislation

6. Public Forum: Promoting, Protecting, and Supporting Breastfeeding in North Carolina (September 2004)

• N.C. DHHS Media Release for the Breastfeeding Forum • Agenda for the Breastfeeding Forum • Organizers of the Breastfeeding Forum • Forum Participants Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

1 x i d n e p p A References

Key references used to support the discussions and development of this blueprint.

1. Breastfeeding (Position Paper). American Academy of Family Physicians. 2001. (available at www.aafp.org)

2. Breastfeeding and the Use of Human Milk. American Academy of Pediatrics Policy Statement; Section on Breastfeeding. Pediatrics, Vol. 115 No.2 February 2005. (available at http:www.aap.org)

3. Breastfeeding Handbook for Physicians. American Academy of Pediatrics and The American College of Obstetricians and Gynecologists. 2006.

4. The Economic Benefits of Breastfeeding: A Review and Analysis. By Jon P. Weimer. Food and Rural Economics Division, Economic Research Service, U.S. Department of Agriculture, Food Assistance and Nutrition Research Report No. 13. 2001. (available at www.ers.usda.gov)

5. Shealy KR, Benton-Davis S, Grummer-Strawn LM. The CDC Guide to Breastfeeding Interventions. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2005. (available at www.cdc.gov/breastfeeding)

6. Smith PH, Avery M, Gizlice Z. Trends and Correlates of Breastfeeding in North Carolina: Results from the North Carolina Pregnancy Risk Assessment Monitoring System (PRAMS) 1997-2001. State Center for Health Statistics. Raleigh, N.C. (available at www.schs.state.nc.us)

7. United States Breastfeeding Committee. Benefits of breastfeeding [issue paper], Economic benefits of breastfeeding [issue paper], Breastfeeding and child care [issue paper], Workplace breastfeeding support [issue paper]. Raleigh, N.C: United States Breastfeeding Committee; 2002 and State breastfeeding legislation [issue paper]. Raleigh, N.C: United States

A1-1 N.C. Division of Public Health /2006 DivisionofPublicHealth N.C. Promoting, Protecting andSupportingBreastfeeding this blueprint.this Additional sourcesofinformation development the usedto of support

13. 12. 9. 11. 10. 14. 8.

American CollegeofObstetriciansandGynecologists(ACOG) • American Academy ofPediatrics (AAP) U.S. Department of Health and Human Services. HHSBlueprintfor U.S. DepartmentofHealthandHumanServices. mothers andinfants http://www.bfmed.or http://www.acog.or http://www.aafp.or 2000.(availableat Health andHumanServices, (conference edition,2volumes).Washington, D.C:U.S.Departmentof womenshealth.gov/breastfeedin Officeon and HumanServices, Women’s Health,2000.(availableat Action onBreastfeeding.Washington, D.C.U.S.DepartmentofHealth Maternal andChildHealthBureau.(availableat Administration, HealthResources andServices Health andHumanServices, United States:Anationalagenda.Rockville, Md.U.S.Departmentof www.usbreastfeeding.or American Academy ofFamily Physicians(AAFP) Breastfeeding Committee;2003.(allissuepapersavailableat U.S. Department of Health and Human Services. HealthyPeopleU.S. DepartmentofHealthandHumanServices. 2010 Academy ofBreastfeedingMedicine(ABM) United StatesBreastfeedingCommittee(2001).inthe • resources andinitiatives Breastfeeding SectionandadditionalinformationonAAPbreastfeeding http://www.aap.org/breastfeeding http:www.aap.or g g forbreastfeedingpositionpaper forbreastfeedinginformation g g forclinicalprotocolsthecare ofbreastfeeding forbreastfeedingresourcesandpositionpapers g andincludedalsoinAppendix5ofthisblueprint) g

) / A North Carolina Blueprint for Action / ANorth A1-2 / forinformationontheAAP www.usbreastfeeding.or www.healthypeople.gov www. g / ) )

A p p e n d i x 1 for a summary l N.C.Public Health Division of / 2006 / A North Action for Blueprint Carolina

for information and resources on for information on the La Leche League / g for information about breastfeeding and for information about for information on worldwide projects g g A1-3 for information on social marketing and breastfeeding, for information on social g for information on Board Certified Lactation g for information on finding a IBCLC in your community for information on finding a IBCLC in your g and mother-to-mother breastfeeding support and mother-to-mother of breastfeeding legislation in the U.S. http://www.lalecheleague.or http://www.lalecheleague.org/Law/summary.htm Consultants International Lactation Consultants Association (ILCA) • Linkages and Young Child Feeding. Linkages is managed by the Academy for Linkages is managed by the Academy Child Feeding. and Young Educational Development with funding provided by the Bureau of Global Health of the United States Agency for International Development. La Leche League International (LLLI) • http://www.linkagesproject.or related to infant feeding, including the Innocenti Declaration 2005 on Infant breastfeeding-related activities International Board of Lactation (IBLCE) Consultation Examiners http:www.iblce.or www.ilca.or http://www.cdc.gov/breastfeeding initiatives and activities http://www.babyfriendlyusa.or efforts in the United States Baby-Friendly Best Start Social Marketing www.beststartinc.or “Loving Support Makes Breastfeeding Work” including the campaign (CDC) and Prevention Centers for Disease Control Baby-Friendly USA Baby-Friendly breastfeeding, surveillance data, research, and new breastfeeding-related and information about the association, World Breastfeeding Week and other Breastfeeding Week and information about the association, World Promoting, Protecting and Supporting Breastfeeding and Supporting Protecting Promoting, 19.

21.

20. 18.

16. 17. 15.

A p p e n d i x 1 N.C. Division of Public Health /2006 DivisionofPublicHealth N.C. Promoting, Protecting andSupportingBreastfeeding

27.

26. 25. 24. 23. 22.

• • U. S.DepartmentofAgriculture(USDA) papers http://www.usbreastfeeding.or United StatesBreastfeedingCommittee(USBC) foods andfeeding International CodeofMarketingBreast-MilkSubstitutes,complementary about theBaby-Friendly HospitalInitiative,theWHO/UNICEF http://www.unicef.org/programme/breastfeeding/baby.ht United NationsInternationalChildren’sEmergency Fund (UNICEF) Become aMother-Friendly Workplace thatSupportsBreastfeeding” data,andtheresourcepacket:“Howto educational materials,surveillance www.nutritionnc.co Branch North CarolinaNutritionServices Assessment MonitoringSystem(PRAMS) http://www.schs.state.nc.u North CarolinaStateCenterforHealthStatistics(N.C.SCHS) laws bystate www.ncsl.org/programs/health/breast50.ht National ConferenceofStateLegislatures • breastfeeding the country resources andeducationalmaterialsfromWICPrograms throughout www.fns.usda.gov/wicwork http://www.fns.usda.gov/wic www.ers.usda.go breastfeeding activities (Note: Five USBCpositionpapersareincludedinAppendix5ofthisblueprint.) m forinformationandlinksbreastfeedingresources, v forEconomicResearchreports/studieson Services s forbreastfeedingdatafromthePregnancy Risk g forbreastfeedinginformationandissue s

forawidevarietyofbreastfeeding / / A North Carolina Blueprint for Action / ANorth A1-4 forinformationonFNSWICProgram m forasummaryofbreastfeeding m forinformation

A p p e n d i x 1 / www.4woman.gov N.C.Public Health Division of / 2006 or g / A North Action for Blueprint Carolina

for information on “The Healthy for information on “The / A1-5 for information about research and information for information about v for information on breastfeeding education for health for information on breastfeeding education g on breastfeeding www.dhhs.go www.womenshealth.gov/breastfeedin http://www.healthypeople.gov Breastfeeding/ for materials and resources on breastfeeding, Breastfeeding/ for materials Breastfeeding Campaign including the National People 2010” objectives for the nation 2010” People • www.wellstart.or and links with other professionals, other breastfeeding resources, breastfeeding activities U. S. Department of Health and Human ServicesU. S. Department of Health DHHS) (U.S. • • Wellstart International Wellstart Promoting, Protecting and Supporting Breastfeeding and Supporting Protecting Promoting,

28.

29.

A p p e n d i x 1 N.C. Division of Public Health /2006 DivisionofPublicHealth N.C. Promoting, Protecting andSupportingBreastfeeding maternity wards andhospitals. SUPPLIES: HEALTH CARE WORKERS: company-paid nursesorsimilar personnel. displays, posters,ordistributionofpromotionalmaterials. Nouseof HEALTH CARE FACILITIES: SAMPLES: ADVERTISING: These humanmilksubstitutescanincludefoodandbeveragessuchas: representedasapartial ortotalreplacementforhumanmilk. otherwise SCOPE: marketing anddistributionofhumanmilksubstitutes. AIM: Thecodeprotectsandpromotesbreastfeedingbyensuringappropriate WHO/UNICEF International CodeofMarketing This appendixisanabbreviatedversionoftheInternationalCodeMarketing Follow-up milks Vegetable mixes Other milkproducts Infant formula Thecodeappliestohumanmilksubstitutes,whenmarketedor Nofreesamplestomothers,theirfamilies,orhealthcare workers. Nofreeorlow-costsupplies ofhumanmilksubstitutesto of Breast-MilkSubstitutes.Thefull-lengthversioncanbefoundat http://www.unicef.org/programme/breastfeeding/code.htm. Noadvertisingoftheaboveproductstopublic. of Breast-Milk Substitutes (adopted in1981) Nogiftsorsamplestohealth careworkers. No promotionofproducts,i.e.noproduct

/ A North Carolina Blueprint for Action / ANorth A2-1 Feeding bottles,nipples Juices andbabyteas Cereals

A p p e n d i x 2 N.C.Public Health Division of / 2006 / A North Action for Blueprint Carolina

A2-2 Product information must be factual and scientific. information must be factual Product Products should be of a high quality and need to consider the Products Product labels must clearly state the benefits of breastfeeding, the must clearly state the benefits of labels Product Promoting, Protecting and Supporting Breastfeeding and Supporting Protecting Promoting, climatic and storage conditions of the country where they are used. climatic and storage conditions of the need for the advice of a health care worker, and a warning about health and a of a health care worker, need for the advice the use of infants, other pictures or text idealizing hazards. No pictures of infant formula are allowed. PRODUCTS: Informational and educational materials must explain the benefits of materials must explain the Informational and educational and the hazards associated with bottle feeding, breastfeeding, the health formula. costs of using infant LABELS: INFORMATION:

A p p e n d i x 2 N.C. Division of Public Health /2006 DivisionofPublicHealth N.C. Promoting, Protecting andSupportingBreastfeeding depending on the natureoftrainingprogram and/ortheindividual’s training iscompletedduring undergraduate orpost-graduateeducation, andevaluate routinelactationmanagementsupport.This plan, intervene educationpreparesonetoassess, of timetolactationmanagement. Lactation the healthcaretheyprovide, butwhodonotspecializeordevotethemajority intended forindividualswhoprovidelactationmanagement asoneaspectof performing avarietyofotherclinicalresponsibilities.This leveloftrainingis care providerswhoassistfamilieswithbreastfeeding,inaddition to Breastfeeding Educators: community agency. activities. Peer counselorsmaybevolunteersorpaid employeesofa counsel womenintheclinic,athome,hospital,and atcommunity asarolemodelandtobeavailable aspects ofpeersupportaretoserve the womentowhomsheisgoingofferhersupport.Themostimportant comparable lifeexperience,socioeconomicstatus,andculturalbackgroundas for aslongtheychose.Thebreastfeedingpeercounselorshouldhave women. Theirpurposeistoencouragewomencontinuebreastfeeding provide information,assistanceandsupporttoprenatalbreastfeeding in thecommunitywithbreastfeedingexperiencewhohavebeentrainedto Breastfeeding Peer Counselors: –– wouldbeavailablethroughoutNorthCarolina. the fullspectrumofsupport––frompeer-to-peer, togeneralist,expert breastfeeding educators,andboardcertifiedlactationconsultants.Inthisway support throughtheexistenceofpeercounselors,healthprofessional A goalofallcommunitiesshouldbetocreateacontinuumbreastfeeding Breastfeeding Peer Breastfeeding Counselors, Educators, A CommunityContinuumofBreastfeeding Support: and Board Certified Lactation Consultants Lactation Certified and Board Breastfeedingeducatorsareprofessionalhealth Breastfeedingpeercounselorsarewomen

/ A North Carolina Blueprint for Action / ANorth A3-1 ,

A p p e n d i x 3

N.C.Public Health Division of / 2006 / A North Action for Blueprint Carolina

A3-2 Promoting, Protecting and Supporting Breastfeeding and Supporting Protecting Promoting, health professionals within the community, or to run lactation support services or to run lactation health professionals within the community, pump loaner programs. such as peer counselor programs or breast persistent sore nipples, premature infants, twins or triplets, infants with persistent sore nipples, premature infants, with complications. Lactationcongenital anomalies, or infants or mothers separate fees for services and sometimes receive consultants often charge lactation consultants are third-party reimbursement. Board certified provide lactation training for staff and sometimes hired by health agencies to breastfeeding assistance. They have obtained advanced lactation management They have obtained advanced lactation breastfeeding assistance. met the requirements experiences and have successfully education and clinical typically referred to as “IBCLC.“ for International Board Certification, Lactation individual consultation for common consultants provide in-depth, as difficulty with latch-on, and complex breastfeeding problems such training. Educators are aware of community resources and can refer families are aware of community resources and training. Educators for additional breastfeeding assistance. to lactation consultants Board CertifiedInternational Lactation Consultants (IBCLC): Lactation clinical focus is are clinical specialists whose primary consultants situation. Peer counselors sometimes complete these courses for advanced sometimes complete these courses counselors situation. Peer

A p p e n d i x 3 N.C. Division of Public Health /2006 DivisionofPublicHealth N.C. Promoting, Protecting andSupportingBreastfeeding U s e t h i D A s t a c a e t b a p b v “ o f m b D A A D D A H A D W o o i e e a r n n b n r r r r o c A A s e i o r r r r o o a h l d e e e d e n e c r e v o i e e e e e k s e p b s e e t e t o a a a d u s c c c l s t a o o r l e p r t u n s s s t k i H b a a c m f f c y p o n r r e l h e o t r r t t t t e B i o B o a u t o r r r o p s C s e g C a d h a b a s ? s f f f s w e h e e t r r o m t u n b t o t s e e e g e r i r h t r g g c e b r a r t y p r f h t e e t e o h u e e e e e t e o h i i e b t y o s o f r c r v v h r ” e h a S s d d e d c n c b r u f e l o r e i i c e s e i e u s e i h i i i i t e a s a r a a i n p u M c l n n n e e l p a r r n a t n i d i p l n e a n n b a d i t i r g g g d s s l d a s s f s t a o i f e d t s d d d s n i o n r s ? e e s r i n o e i e s t t , u b s n p m a a a d d c a e r e d s r t h s r c B t v v g t a o n n n l b i i n p d m s o p C r u C t a h i i e p l d d b d p p o e e t s p p f s h m a i i f o i d p r i a a i c r n o i s u i w w r e e S c m a s a c e e e o a t s t o i s s i g n e t t e t o e c n t e a v o e l s d b i f t t t v p a i t s o u i n t r f e e r c r e s ? r t n a c a o i d y f h e l e e p e h n r d a ? e o s D i t i f f i a d o i l e e n e e t e a c ? e b n e s e n e e v s i f f d u d n p h p c t s s n p n t t i r t r g a r f d

s a t r t c - u a l e e k s ‛ w / A North Carolina Blueprint for Action / ANorth r e i i A4-1 a i s t i i o o i i o n c o e r m e C r f t a C n n s c v n i n y f d u k p c s a a e l n e o c c e s e i l b i e n g e e o a d e n n C n t i t g h u l e w h g n t b n r g u d h h m f t e t n d e f o p s d t i g e r o d f s a o l - r f - e v s e a - e e d w i f H e l r a t a r ? e u ‛ n n o i e y e d r r o i s e C o h a h s e n t g d t t c F l a e c d F ‛ a o r n p n o t s s e d l e - h ? r t t e d n t i o h u f e s t t p i k r n i k e f l e r a n t r r r y n i W m f h e e C m e g e n l r s v b a e l e e I l e d y l i i C p f p e c i n a t l b o i e r d t i i e r e e e p t a o o d h u n P d s c e o o o s d a e i ( r a n n r n l i f r e n e o h u e n i n n i n n s s c r t v c c g o t t g n r t m i x p o y g h r e - o e y l r a a g ? e d d i d p u a u n m l e f n m v d f o i r r c r t t e i n m n a e l a l r e c c e c e a h s t e f i y r a y o a t e n s l g ? a a d r a i m a c r s f s e e o t n i b ) e o e n n d n s t c l r d ? g e e - n t e r i s .

A p p e n d i x 4 N.C.Public Health Division of / 2006 / A North Action for Blueprint Carolina

. g A5-1 www.usbreastfeeding.or • Benefits of Breastfeeding • Economic Benefits of Breastfeeding • and Child Care Breastfeeding • Support Breastfeeding Workplace • Legislation Breastfeeding State Promoting, Protecting and Supporting Breastfeeding and Supporting Protecting Promoting, Committee (USBC) Issue Papers, which are in the public domain and which Issue Papers, Committee (USBC) downloadable at This Appendix includes the following United States Breastfeeding the following United States Breastfeeding This Appendix includes

A p p e n d i x 5 N.C. Division of Public Health /2006 DivisionofPublicHealth N.C. Promoting, Protecting andSupportingBreastfeeding B best way of feeding infants. feeding of way best the as organizations scientific and Benefits of Breastfeeding of Benefits ends. breastfeeding after years many for last and childbirth after moments first the from begin breastfeeding of fits bene- The feeding. of form other any by duplicated be cannot that children for advantages offers Breastfeeding Children for Benefits rewards. environmental and economic of range a society,provides For breastfeeding advantages. health lifelong provides and birth child- and pregnancy from recovery with helps breastfeeding mothers, For illness. chronic and acute against protects and development optimal supports breastfeeding children, For society. and mothers for also but children for only not benefits of array vast the on light shed have research of endorsed by the world’sthe health by endorsed universally is reastfeeding 1–3 Y ears Breastfeeding of Benefits • • • children: Breastfed sick. get do they when illnesses shorter and symptoms fewer have and healthier are breastfed are who those children, formula-fed with Compared • • • (e.g., diarrhea, (e.g., symptoms their and illnesses tious infec- from suffer to likely less are (SIDS) syndrome death infant sudden of incidence lower a have acuity visual of tests on also and age, school at tests IQ and cognitive on higher score months 4 least at for exclusively fed breast- are and disease the of tory his- family a have they if diabetes, onset juvenile of risk lower a have disease, Hodgkin’s(e.g., cancer of forms some from often less suffer colitis) (Crohn’sulcerative eases disease, dis- bowel inflammatory common most two the of risk lower a have gitis menin- infections, tract respiratory 7 ) 9 9 10 childhood leukemia) childhood 7 ear infections, ear

/ A North Carolina Blueprint for Action / ANorth A5-2 4–6 7,8 • • • • milk: human infants, premature For lower.points 8–15 are that IQs future have formula receive who those milk, human receive who infants premature with Compared infants. birthweight low and premature for also but infants full-term for just not benefits provides Breastfeeding • • • tem and other infectious diseases infectious other and tem sys- gastrointestinal the of disease life-threatening of risk the reduces maturation brainstem hastens costs hospital reduces stay hospital of length shortens significantly braces require to likely less are and cavities fewer have cence adoles- in and childhood in obesity of risk lower a have may months 4 least at for breastfed exclusively and disorders allergic for risk at if eczema, and asthma against protected significantly are 13,14 1 1,12 1

A p p e n d i x 5 Benefits of Breastfeeding the preparation of infant formula. Breastfeeding requires no packaging, and its production does not harm the environment. Benefits for Society Breastfeeding offers society not only improved health of children and mothers but also economic and environmental benefits. Breastfeeding reduces the need for costly health services that must be paid for by insurers, government agencies, or families. Breastfeeding reduces the number of sick days that families must use to care for their sick children. The estimated cost of artificial feeding (up to $1,200 per year for powdered formula) is four times that of breastfeeding (approximately $300 per year for increased food for a lac- tating woman). Concentrated and ready-to-feed formulas are even more expensive than powdered formula. The cost of artificial feeding has increased steadily over the last 10 years. Electricity or fuel are consumed in N.C.Public Health Division of / 2006 / A North Action for Blueprint Carolina 9

18 17 A5-3 Exclusive breastfeeding for the first 6 months postpartum, in the absence of menses, is 98 percent effective in pre- venting pregnancy. Breastfeeding mothers are reported to be more confident and less anxious than bottle-feeding mothers. Breastfeeding contributes to feelings of attachment between a mother and her child. The 16,17 Breast Milk Facts Unique in its composition and function, breast 7,15 17 Promoting, Protecting and Supporting Breastfeeding and Supporting Protecting Promoting, Breastfeeding reduces the risk 16 supplies growth factors that combine to mature the infant gut provides the infant with immune factors manufactured to fight allergens and illnesses specific to the mother’s envi- and infant’s ronment changing needs of the growing child contains substances essential for optimal development of the brain, with infant’s effects on both cognitive and visual function contains an ideal balance of nutrients that the infant can easily digest changes over time, and even over the course of to a meet day, the 16 omen who have breastfed are less • • Breast milk is an amazing substance that cannot be duplicated by any artificial means. • milk: • • cial effect. Breastfeeding reduces osteoporosis. Breastfeeding mothers enjoy a quick- er recovery after childbirth, with reduced risk of postpartum bleeding. more months a woman has spent breastfeeding, the greater the benefi- 2 weight than mothers who formula feed. Mothers who breastfeed are more likely to return to their prepregnancy Benefits for Mothers Breastfeeding offers a range of benefits for mothers as well as their children. W likely to develop ovarian and premenopausal breast cancers. for long-term obesity. for long-term obesity. Exclusive breastfeeding may reduce the risk of anemia by delaying the return of the menstrual cycle for 20 to 30 weeks.

A p p e n d i x 5 N.C. Division of Public Health /2006 DivisionofPublicHealth N.C. Promoting, Protecting andSupportingBreastfeeding Benefits of Breastfeeding of Benefits • • W • • Breastfeedingrates can be increased by: persist. disparities social and ethnic but breastfeeding, initiate to choosing are women of numbers Greater child. the for exist may that vantages disad- economic or social any despite nutrition ideal provides Breastfeeding feeding. infant of method preferred the as recognized is months, 6 after foods solid of tion introduc- gradual with life, of months 6 first the for breastfeeding Exclusive best. is life of weeks few first the beyond lasts that breastfeeding exclusive beneficial, is breastfeeding of amount any Though What’sNeeded • • • • • include: States United the in breastfeeding to related facts Economic Appropriate legislation Appropriate settings care child in feeding milk human for Accommodation mothers support lactation skilled and appropriate Culturally and diseases that are preventable by breastfeeding by preventable are that diseases and conditions on year every spent are dollars excess billion 7 to $3.6 infants. breastfed versus infants formula-fed for life of year first the diarrhea—in and infections), (ear media otitis infections, illnesses—respiratory common most three the treat to prescriptions and visits office sick-child cover to Medicaid, including insurers, by spent is more billion $1.3 year per $750,000 WIC save would recipients WIC among rate breastfeeding the in increase percent 10 Every breastfeeding not are who babies for formula buy to (WIC) Women,Children for and Program Infants of Nutrition Department Agriculture’sSupplemental Special U.S. the by spent is funds federal in year per million $578 formula infant as such substitutes milk breast on families by spent is year per billion $2 orksite support for breastfeeding for support orksite Economic Facts Economic 19 6. Lykke Mortensen E, Fleischer LykkeE, Mortensen 6. criticaleval- DraneLogemannDL, JA. A 5. JW,Remley Anderson BM, Johnstone 4. Worldoptimal Organization.The Health 3. Medicine. of Institute 2. Pediatrics. American of Academy 1. References usbreastfeeding.org Committee’sWebwww. at site Breastfeeding States United the visit promotion, and benefits feeding breast- on information more For The association between duration of duration between association The JM. Reinisch SA, Sanders K, Michaelsen 2000;349–356.14: tivedevelopment. betweeninfanttypeoffeeding cogni-and evidenceuationtheassociationtheof on 525–535. 70: 1999; meta-analysis. a opment: devel- cognitive DT.and Breastfeeding inf-pr-2001/en/note2001-07.html A Review.Systematic WHO a of results breastfeeding: exclusive of duration 1991. Press, Academy lactation milk. human of use the and Breastfeeding vailable at: http://www.who.int/at: vailable Pediatrics . Washington,. National DC: 1997; 100: 1035–1039. 100: 1997; 20 PediatrEpidemiol .

Nutrition during Nutrition / A North Carolina Blueprint for Action / ANorth A5-4 Am J Clin Nutr Clin J Am 6 HeinigMJ, Dewey KG. Health advan- 16. MF.of Picciano composition Nutrient 15. 20. Ball TM, Wright AL. Health care costs of costs WrightTM, Ball care Health AL. 20. WeimerJ. 19. RM. Lawrence RA, Lawrence 18. on breastfeeding of Effects MH. Labbok 17. .HeinigMJ, Dewey KG. Health advan- 9. M. Niemela A K, Matysaari M, Uhari 8. 14. Gillman MW, Gillman SL, Rifas-Shiman 14. in breastfeeding NF.of Butte role The 13. M. Mimouni D, Mimouni M, Gdalevich 12. 11 for evidence the of Review MK. Davis 10. .HeinigMJ. Host defense benefits of breast- 7. . GdalevichM, Mimouni D, David M, Pediatrics life. of year first the in feeding formula 13. No. Report Research Nutrition Food and Assistance W analysis. reviewand breastfeeding:a 1999. profession. medical the for guide Breastfeeding:a 143–158. 48: 2001; mother.the calreview. tagesofbreastfeeding for mothers: criti-a 53–67. 48: 2001; milk. human 2461–2467. 285: meta-analytic review of the risk factors risk the of review meta-analytic were breastfed as infants. as breastfed were who adolescents among overweight of Risk GA. Field Colditz HR, AE, Rockett Frazier CS, AL, Jr,Berkey CA Camargo America obesity. ies. stud- prospective of meta-analysis with review systematic a childhood: in asthma bronchial of risk the and Breast-feeding 2001;45:520–527. prospectivestudies. tematicreview and meta-analysis of ofatopic dermatitis in childhood: asys- MimouniM. Breast-feeding and the onset 11:29–33. 1998; cancer.childhood and feeding infant between association an calreview. tagesofbreastfeeding for infants: criti-a 1079–1083. 22: 1996; media. otitis acute for North Am ingduration and exclusivity. feedingfor the infant: effect of breastfeed- JAMA intelligence. adult and breastfeeding ashington, DC: USDA; 2001 Mar.2001 ERS USDA; DC: ashington, J Pediatr J 2002; 287: 2365–2371. 287: 2002; Pediatric Clinics of North of Clinics Pediatric 2001; 48: 189–198. 48: 2001; ,2001; 48: 105–123. The economic benefits of benefits economic The 1999; 103 (4 pt 2): 870–876. 2): pt (4 103 1999; NutrRes Rev NutrRes Rev 5th edition. Mosby,Louis, edition. St. 5th Pediatr Clin North America North Clin Pediatr Pediatr Clin North Am North Clin Pediatr 2001; 139: 261–266. 139: 2001; J Am AcadDermatol Clin Infect Dis Infect Clin In J Cancer J In 1997;10: 35–56. 1996;9:89–110. JAMA PediatrClin 2001; Suppl 3

A p p e n d i x 5 Benefits of Benefits of Breastfeeding N.C.Public Health Division of / 2006 / A North Action for Blueprint Carolina

A5-5 isit us at www.usbreastfeeding.org. protecting protecting | promoting | supporting V Goals of the United States Breastfeeding Committee [issue paper]. Raleigh, NC: United States Breastfeeding Committee; 2002. Promoting, Protecting and Supporting Breastfeeding and Supporting Protecting Promoting, Goal IV Increase protection, promotion, and support for breastfeeding mothers in the work force. Ensure access to comprehensive, current, and culturally appropriate lactation care and services for all women, children, and families. Goal II Ensure that breastfeeding is recognized as the normal and preferred method of feeding infants and young children. Goal III Ensure that all federal, state, and local laws relating to child welfare and family law recognize and support the importance and practice of breastfeeding. The mission of the United States Breastfeeding Committee (USBC) is to protect, promote, and support breastfeeding in the United States. The USBC exists to ensure the rightful place of breastfeeding in society. The USBC works to achieve the following goals: Goal I 4 © 2002 by the United States Breastfeeding Committee. Cite as: United States Breastfeeding Committee. breastfeeding This paper was funded in part Maternal by and the Child Health and Health Resources Services Bureau Administration’s and the Centers for Disease and Control U.S. Prevention, Department of Health and Human Services. For Further Information For further information, contact: U.S. Department of Health and Human Services, Maternal and Child Health Bureau (MCHB) www.mchb.hrsa.gov United States Breastfeeding Committee www.usbreastfeeding.org

A p p e n d i x 5 N.C. Division of Public Health /2006 DivisionofPublicHealth N.C. Promoting, Protecting andSupportingBreastfeeding Y • financialtoll on the U.S. economy. termhealth outcomes but also exacts a ever,not only affects short- and long- ty. The ofinfants, children, mothers, and socie- andbreast milk for the optimal health Economic Benefits of Breastfeeding of Benefits Economic economy.its and citizens its both of health improved States United the thereafter,promises foods appropriate with conjunction in and months, 6 first the for exclusively milk breast of provision the and Breastfeeding • • ble by breastfeeding. by ble preventa- conditions and diseases treat to year each paid be must billion $3.6 of minimum a ers, insur- government and private For work to care for sick children. sick for care to work from missed days tivity,more and produc- decreased claims, health increased in results feeding mula nation’sfor-the employers, For baby’syear.first the for more or $1,200–$1,500 to amount can formula infant of purchase the families, For theimportance of breastfeeding earsof research have confirmed absence ofbreastfeeding, how- 2 1 of Breastfeeding of Benefits Economic • • • • • substantial: are ing breastfeed- not of costs medical The Breastfeeding Not of Costs Medical million. breastfeedingnot $225are respiratorysyncytial virustodue Additionalhealthcarecostsfor babies. breastfed in rate percent 1.2 a and babies la-fed formu- in occurrence percent 10.1 $30,750 more than for 1,000 for than more $30,750 to $26,585 from range babies never-breastfed 1,000 among infections lower-respiratory from hospitalization for Costs media,gastrointestinaland illness. lower-respiratoryillness, otitis never-breastfed$475per infantfor betweenHMOcostsan$331and attributableformulatofeeding healthExcessofcareservicesuse insulin-dependent diabetes melli- diabetes insulin-dependent for costs care health Additional enterocolitis, necrotizing of case each for spent is $200,000 breastfed. exclusively infants 5

/ A North Carolina Blueprint for Action / ANorth A5-6 4 with a with 3 3 • • • • well: as substantial are feeding breast- not of costs nonmedical The Feeding Artificial of Costs Nonmedical $750,000 per year.per $750,000 WIC save would recipients WIC among rates breastfeeding in increase percent 10 Every breastfeeding. be could who families for mula for- buy to WIC by spent is funds federal in year per million $578 thoseforformula-feeding a mother. (WIC)are about 55percent of W mentalNutrition Program for motherinthe Special Supple- Coststosupport breastfeedinga formula. as such substitutes milk breast on families by spent is year per billion $2 mate of $1,301,100,000. of mate esti- high a and $1,185,900,000 of estimate low a breastfeeding: not to attributable rate IDDM percent 2–28 a assuming dren, chil- formula-fed in (IDDM) tus omen,Infants and Children 5 1

A p p e n d i x 5 in children who 14 fewer cavities in 12 and less malocclusion 13 Economic Benefits of Breastfeeding rth the Investment National Agenda requiring braces 86,000 tons of metal and 800,000 pounds of paper packaging, added to U.S. landfills each year have been breastfed 550 million formula cans, with worksite breastfeeding protection breastfeeding worksite employers for incentives support and insurance coverage for lactation care and services Healthy People 2010 HHS Blueprint for Action on Breastfeeding in Breastfeeding the United States: A continued full authorization of the WIC program with improved breastfeeding support services inclusion of breastfeeding care and services in government health strategic plans pro- of breastfeeding coordination agencies government among grams Better vision, teeth, • • • Supporting Optimal Breastfeeding Is Wo As a preventive measure, breastfeeding promotes improved health outcomes and is cost-effective. The U.S. government has recognized the importance of breastfeeding with three recent major policy statements on breastfeeding. These take into account the relationship between improved breastfeeding practices and our national health. • • • Needed What’s Achieving our national goals for increasing the incidence and duration of breastfeeding will require: • • • • N.C.Public Health Division of / 2006 9 and / A North Action for Blueprint Carolina 10

7 11 6 and throughout adulthood A5-7 8 ture infants who do not receive human milk IQs 8–15 points lower in prema- Illness and death from bacteria associated with feeding powdered infant formulas, which is not sterile 3- to IQ 11-point deficit in formula-fed babies Less educational achievement noted with both formula-fed children Longer hospital stays in premature infants who do not receive human milk Slower brainstem maturation • • • • • Breastfeeding’s Health Breastfeeding’s Benefits Promoting, Protecting and Supporting Breastfeeding and Supporting Protecting Promoting, childhood overweight and obesity premenopausal breast cancer ovarian cancer thyroid cancer osteoporosis lupus allergies lymphomas and leukemia autoimmune thyroid disease type I and type II diabetes ulcerative colitis disease and Crohn’s multiple sclerosis poorer school performance lower developmental and cognitive scores respiratory syncytial virus sudden infant death syndrome (SIDS) asthma 10 billion BTUs of energy ($2 BTUs of 10 energy billion If a parent misses 2 hours of work for the excess illness attributable to formula feeding, greater than 2,000 hours—the equivalent of 1 year of employment—are lost per 1,000 never-breastfed infants. used each year in the million) pack- for processing, States United formula. and transporting aging, • For mothers • • • • • • • • • • • • • Breastfeeding is universally endorsed by health the and world’s scientific organizations as the best way of feeding infants. Studies have found that not breastfeeding increases the risk for and incidence of the illnesses and conditions listed below. For children • • • 2 Other Costs of Not Breastfeeding Not breastfeeding also carries intangi- ble costs—those not associated with specific dollar amounts in research findings. Such costs include: • • 1

A p p e n d i x 5 N.C. Division of Public Health /2006 DivisionofPublicHealth N.C. Promoting, Protecting andSupportingBreastfeeding Economic Benefits of Breastfeeding of Benefits Economic Drug and Administration, Food U.S. 6. breast- not of cost The JM. Riordan 5. BisqueraCooperJA, Berseth TR, CL. 4. WrightTM, Ball care Health AL. 3. cost Potential KG. Dewey TuttleCR, 2. WeimerJ. 1. References • • • • • education for health professionals health for education families for support and education Substitutes Milk Breast of Marketing of Code International the of provisions the of implementation acts health child in guage lan- breastfeeding of inclusion months 6 after foods solids of introduction gradual with life, of months 6 first the for breastfeeding exclusive supports that legislation of development Accessed November 20, 2002. 20, November Accessed cfsan.fda.gov/%7Edms/inf-ltr3.html. 11.Apr Availablehttp://www.at: careunits intensive neonatal in formulas infant powdered(dry) of use with associated infections on letter Supplements. Dietary and Labeling Products, Nutritional of Office Nutrition, and Safety Applied Food for Center 93–97. 13: 1997; commentary.a feeding: Pediatrics birthverylowweightinfants. hospitallengthstayandof charges in Impactnecrotizingof enterocolitis on 870–876. 2): pt life. of year first the in feeding formula of costs 885–890. 96: California. in WomenHmong Low-Income Among Breast-feeding Increasing with Programs WIC Associated Stamps, Medi-Cal, Food for AFDC, savings 13. No. Report Research Nutrition Food and ERS Assistance W analysis. reviewand breastfeeding:a ashington, DC: USDA; 2001 Mar.2001 USDA; DC: ashington, Enterobacter sakazakii Enterobacter The economic benefits of benefits economic The 2002;109:423–428. Pediatrics J Am Diet Assoc Diet Am J Health professionalsHealth 1999; 103(4 1999; J Hum Lact Hum J 2002 1996; 13. Erickson PR et al. Estimation of the of Estimation al. et PR Erickson 13. PM, Emmett EE, Birch WilliamsC, 12. 11 Brainstem (2000) al. et SB Amin 10. WadsworthRM, Long- Hardy ME. 9. Breast- BC. Gladen WJ, Rogan 8. DM. Fergusson LJ, Horwood 7. 14. Palmer B. The influence of breast- of influence The B. Palmer 14. . Lucas A et al. Breast milk and subse- and milk Breast al. et Lucas A infant formula. infant with associated risk caries-related Nutr Clin study.cohort population-based a from report a factors: dietary tal postna- and prenatal with associated is full-term born children in y 3.5 age at Stereoacuity K. Northstone 261–264. 339: preterm. born dren chil- in quotient intelligence quent 318–322. 1): Pt (2 106 2000; type. feeding of function a as infants premature in maturation 631–635. 5: function. cognitive midlife and attainment educational cohort: birth national a in breastfeeding of effects term Dev Hum Early development. cognitive and feeding 2002. 20, e9. November Accessed pediatrics.org/cgi/content/full/101/1/ 101(1):e9. Availablewww.at: outcomes. academic and cognitive later and Breastfeeding Lact commentary.a cavity: oral the of development the on feeding 395–403. 20: 1998; 14: 93–98. 14: 1998; Public Health Nutr Health Public 2001; 73: 316–322. 73: 2001; Pediatr Dent Pediatr 1993; 31: 181–193. 31: 1993; Lancet

/ A North Carolina Blueprint for Action / ANorth Pediatrics A5-8 Pediatrics 2002; J Hum J 1998; 2002; Am J Am 1998; 3

A p p e n d i x 5 Economic Economic Benefits of Breastfeeding N.C.Public Health Division of / 2006 / A North Action for Blueprint Carolina

A5-9 isit us at www.usbreastfeeding.org. protecting protecting | promoting | supporting V [issue paper]. Raleigh, NC: United States Breastfeeding Committee; 2002. Goals of the United States Breastfeeding Committee Promoting, Protecting and Supporting Breastfeeding and Supporting Protecting Promoting, dren, and families. Goal II Ensure that breastfeeding is recognized as the normal and preferred method of feeding infants and young children. Goal III Ensure that all federal, state, and local laws relating to child welfare and family law recognize and support the importance and practice of breastfeeding. Goal IV Increase protection, promotion, and support for breastfeeding mothers in the work force. The mission of the United States Breastfeeding Committee (USBC) is to protect, promote, and support breastfeeding in the United States. The USBC exists to ensure the rightful place of breastfeeding in society. The USBC works to achieve the following goals: Goal I Ensure access to comprehensive, current, and culturally appropriate lactation care and services for all women, chil- 4 benefits of breastfeeding This paper was funded in part Maternal by and the Child Health and Health Resources Services Bureau Administration’s and the Centers for Disease and Control U.S. Prevention, Department of Health and Human Services. © 2002 by the United States Breastfeeding Committee. Cite as: United States Breastfeeding Committee.

A p p e n d i x 5 N.C. Division of Public Health /2006 DivisionofPublicHealth N.C. Promoting, Protecting andSupportingBreastfeeding R percent (1993). percent 70 to (1970) percent 30 from soared has care child in enrolled children of percentage the years, 20 just In employed. are 3 age under dren chil- with women of percent 75 that Breastfeeding and Child Care Child and Breastfeeding months. The introductionof solid foods after 6 thefirst 6months of life, with gradual childrenbe breastfed exclusively for (November2000) recommends that Blueprintfor Actionon Breastfeeding HumanServices’ fits,the U.S. Department of Health and Becauseof breastfeeding’s many bene- society.of well-being economic the enhances and mothers of health the to contributes also Breastfeeding advantages. health lifelong offers and infants, for development and child care settings. care child of variety a in day each of most or part spend children young of millions States United the in time, same the At leastthe first year of life. continuationof breastfeeding for at feeding supports optimal growth optimal supports feeding breast- that shown has esearch Blueprint America’sChildren: Breastfeeding:HHS 2 It is estimated is It recommendsthe 1 and Child Care Child and Breastfeeding benefitsto families are enormous. And mothersto continue to breastfeed, the partnersand advocates in encouraging Whenchild care settings become strong breastfeeding. of continuation mother’s a porting sup- in role vital a play can providers care child care, child in enrolled W day.each time some for parents their than other one some- by for cared are 2 age through birth from toddlers and infants childrenin their care. fromthe improved health status of the childcare settings themselves benefit public and the private sectors. private the and public the both with lies support this viding pro- for Responsibility services. care child of use make and school or work to return they as breastfeeding ue contin- and establish mothers helping for essential is support knowledgeable that demonstrated has Research What’sNeeded Being Well-of Indicators National Key ith so many young children young many so ith 3 found that 51 percent of percent 51 that found

A5-10 / A North Carolina Blueprint for Action / ANorth • • • by: settings care child in breastfeeding support can zations organi- care child state and National • • • by: breastfeeding support can sectors, regulatory and licensing including agencies, Governmental breastfeeding of benefits the about mation infor- disseminate that campaigns promotion health in participating importance its and breastfeeding about knowledge providers’ care child improve to programs training new initiating breastfeeding supporting and promoting, protecting, for need the of awareness current increasing Program Food Care and Child Adult the under milk human expressed feeding for ment reimburse- provide to continuing milk human of handling and storage the about information accurate providing employees own their to encouragement and support breastfeeding providing 1

A p p e n d i x 5 Breastfeeding and Child Care N.C.Public Health Division of / 2006 / A North Action for Blueprint Carolina

Benefits of Breastfeeding A5-11 diseases (Crohn’s disease, diseases ulcerative (Crohn’s colitis) suffer less often from some forms of cancer dis- (e.g., Hodgkin’s ease, childhood leukemia) have a lower risk of juvenile onset diabetes, when there is a family history of the disease and the children are breastfed exclusively for at least 4 months are significantly protected against asthma and eczema, when at risk for allergic disorders and breastfed exclusively for at least 4 months may have a lower risk of obesity in childhood and in adolescence have fewer cavities and are less likely to require braces score higher on cognitive and IQ tests and also on tests of visual acuity have a lower incidence of sudden infant death syndrome (SIDS) are less likely to suffer from infectious illnesses and their symptoms (e.g., diarrhea, ear infections, respiratory tract infections, meningitis) have a lower risk of the two most common inflammatory bowel caring for a breastfed child and handling expressed human milk sharing knowledge of community resources that may be unfamiliar to the child care provider providing space for mothers to breastfeed their children on-site creating an environment that fos- ters the formation of parent support groups and the ability to share information empowering families to advocate at their workplaces for policies that support breastfeeding establishing clear communication with the child care provider about shared responsibilities related to • • • • • Breastfeeding is universally endorsed by health the and world’s scientific organizations as the best way of feeding infants. Breastfed children: • • • • • • • • Families themselves must be responsible for: • Promoting, Protecting and Supporting Breastfeeding and Supporting Protecting Promoting, fering children breast milk in f containers other than bottles (e.g., cups or spoons) when parents request it designating a space for the safe ex- safe the for a space designating milk human of storage and pression ings, and the training and scheduling of its staff providing a welcoming atmosphere that encourages mothers to initiate and continue breastfeeding after returning to work or school training staff to provide accurate basic breastfeeding information and referrals for skilled breastfeeding support when necessary purchase of electric breast pumps for expression of human milk when such devices are needed integrating breastfeeding into plans for the design of a child care its equipment facility, and furnish- developing health campaigns for employees that include breastfeeding promotion and protection considering child care settings when developing consumer education materials, breastfeeding promotion campaigns, and quality improvement initiatives supporting cost-effective rentals or to store, handle, and feed mother’s milk (e.g., informing child care providers that mother’s milk is not a biohazard and does not require gloves for handling) teaching child care providers how 2 • • o • • Child care settings are the natural and logical place for supporting breastfeeding mothers by: • • • • The private sector—including employers, insurance companies, and other organizations and agencies— can support breastfeeding by: •

A p p e n d i x 5 N.C. Division of Public Health /2006 DivisionofPublicHealth N.C. Promoting, Protecting andSupportingBreastfeeding Breastfeeding and Child Care Child and Breastfeeding Child on Forum Interagency Federal 3. and Health of Department U.S. 2. and Health of Department U.S. 1. References everyone. affects that issue health public important an mately ulti- but issue, nutrition and health a or issue, care child a issue, parent a just not community.is a It of being well- overall the to contributes and money,mother,saves and baby the for health good promotes settings care child into breastfeeding Integrating Conclusion Government Printing Office; 2002. Office; Printing Government well-being. of indicators national children:key Statistics. Family and 2001. Pediatrics; of Academy Village,Grove IL: American action for blueprint Bureau. Health Child and Maternal and Bureau Care Child Services, Human gov/Breastfeeding/bluprntbk2.pdf. 2000. Availablewww.4woman.at: Women’son Office Services, Health; Human and Health of Department breastfeeding. Health. Women’son Office Services, Human HHS blueprint for action on action for blueprint HHS Healthy child carechild America: Healthy W ashington, DC: U.S. DC: ashington, W ashington, DC: U.S. DC: ashington, [fact sheet]. Elk sheet]. [fact America’s www.usbreastfeeding.org Committee Breastfeeding States United www.mchb.hrsa.gov (MCHB) Bureau Health Child and Maternal Services, Human and Health of Department U.S. www.usda.gov of (USDA) Department Agriculture U.S. contact: information, further For Information Further For

A5-12 / A North Carolina Blueprint for Action / ANorth 3

A p p e n d i x 5 Breastfeeding Breastfeeding and Child Care N.C.Public Health Division of / 2006 / A North Action for Blueprint Carolina

A5-13 isit us at www.usbreastfeeding.org. protecting protecting | promoting | supporting V Goals of the United States Breastfeeding Committee [issue paper]. Raleigh, NC: United States Breastfeeding Committee; 2002. Promoting, Protecting and Supporting Breastfeeding and Supporting Protecting Promoting, dren, and families. Goal II Ensure that breastfeeding is recognized as the normal and preferred method of feeding infants and young children. Goal III Ensure that all federal, state, and local laws relating to child welfare and family law recognize and support the importance and practice of breastfeeding. Goal IV Increase protection, promotion, and support for breastfeeding mothers in the work force. The mission of the United States Breastfeeding Committee (USBC) is to protect, promote, and support breastfeeding in the United States. The USBC exists to ensure the rightful place of breastfeeding in society. The USBC works to achieve the following goals: Goal I Ensure access to comprehensive, current, and culturally appropriate lactation care and services for all women, chil- 4 and child care This paper was funded in part Maternal by and the Child Health and Health Resources Services Bureau Administration’s and the Centers for Disease and Control U.S. Prevention, Department of Health and Human Services. © 2002 by the United States Breastfeeding Committee. Cite as: United States Breastfeeding Committee.

A p p e n d i x 5 N.C. Division of Public Health /2006 DivisionofPublicHealth N.C. Promoting, Protecting andSupportingBreastfeeding W W retention. employee and morale, employee absenteeism, reduced care, health for savings cost employer,in the for rewards tremendous offers feeding breast- for accommodations Providing money,flexibility.time, and of ment invest- small a with reduced be can challenges workplace these of Many milk. human storing and pumping for facilities inadequate and time break of lack include Challenges workplace. the to return they once breastfeeding tinue con- to difficult it find often women but mothers, and babies for benefits health proven offers Breastfeeding months. 6 within return thirds two- and birth, giving after months 3 within work to return mothers of One-third time. full work percent 70 approximately 3, age under dren chil- with women employed Among force. labor U.S. the of orkplace Breastfeeding Support Breastfeeding orkplace are the fastest growing segment growing fastest the are children and infants with omen 1,2 Breastfeeding Support Breastfeeding W ble, safe, and relatively easy to imple- to easy relatively and safe, ble, feasi- are strategies The support. ing breastfeed- workplace of benefits the experience to employers and mothers, infants, allow can strategies Simple What’sNeeded • • • • • • • • noted: have programs support feeding breast- adopted have that Companies Employers for Benefits munity com- the in image family-friendly employees valuable retain and attract to ability improved loyalty greater and morale higher productivity employee improved year) first the over baby per $400 of age aver- (an costs care health lower children ill for care to absenteeism reduced employees of children breastfed the among illness less support breastfeeding in invested $1 per $3 of savings cost orkplace

A5-14 / A North Carolina Blueprint for Action / ANorth components of a workplace breast- workplace a of components Possible resources. and needs its to tailored program support feeding breast- a develop should agency or organization, company, Each company.the to tailored program support breastfeeding a Develop organizations. tribal and organizations, sales and ing manufactur- offices, government local institutions, educational corporations, including settings, of range wide a in effective proven have strategies These budget. modest a only require they and ment, short-term basis. short-term a on hired consultant lactation a and mother,breastfeeding a was recently or is who employee an mothers, tant expec- nurses, company specialists, resource human include members force task women’sPotential needs. assess to force task a convene to companies larger in useful be may It T in appear program support feeding able 1. 1. able 1

A p p e n d i x 5 orkplace Breastfeeding Support Comprehensive W Breastfeeding Mothers’ Break Employer hires a skilled lactation care provider to coordinate a breastfeeding support program. A Room (or rooms) close to women’s worksites. Employer provides collection kits. Additional multi-user electric pumps are provided if needed. Room large enough to accommodate several users comfortably. Items listed in “Adequate” column are available in the BMBR. Employer provides a small refrigerator in the BMBR for storage of human milk. Employer offers a 6- to 14-week paid maternity leave (ILO). In addition, mother can bring child to work, caregiver can bring child to workplace, or on-site day care is available. Nursing breaks are paid and are counted as working time. Breastfeeding education is offered to the partners of employees who are expectant fathers. N.C.Public Health Division of / 2006 / A North Action for Blueprint Carolina

Facilities Expanded orkplace Education A5-15 ritten Company Policy W W Breastfeeding Mothers’ Break Employer allows expanded unpaid breaks during the workday for expressing milk or breastfeeding the child. New employees, supervisors, and coworkers all receive training on the breastfeeding support policy. Employer contracts with skilled lactation care provider on an “as needed” basis. Improved aesthetics to promote relax- ation. Items listed in “Adequate” column are available near the BMBR. Employer makes available refrigerator space designated for food near BMBR. Employer grants 12-week unpaid maternity leave (FMLA). part-time allows employer In addition, individualized job work, sharing, compressed of work hours, scheduling or work week, telecommuting. A Room (BMBR) for use only by breastfeeding women. Employer provides one multi-user electric breast pump, and employees provide their own collection kits. Adequate Promoting, Protecting and Supporting Breastfeeding and Supporting Protecting Promoting, clean, private, comfortable multi- comfortable private, clean, able and comfortable chair. able 1: Components of a Workplace Breastfeeding Support Program Company breastfeeding support policy is communicated to all pregnant employees. communi- of list a provides Employer support. breastfeeding for resources ty Employer allows creative use of accrued vacation days, personal time, sick days, and holiday pay after childbirth. Employer allows two breaks and a lunch period during an 8-hour work day for expressing milk or breastfeeding the child. extra time is allowed for cleaning hands and equipment. Employee supplies cold packs for storage of milk. Employer grants a 6-week unpaid maternity leave. Employee provides her own breast pump. T Sink, soap, and water, paper towels. If these are very far from BMBR, A a bath- not is (that space purpose in outlet electrical an with room) breastfeed. to or milk pump to order 2 T The table below outlines components of several levels of workplace breastfeeding support. The choice of components depends on the number of women who need support and the resources and realities of the workplace.

A p p e n d i x 5 N.C. Division of Public Health /2006 DivisionofPublicHealth N.C. Promoting, Protecting andSupportingBreastfeeding est with a designated lead person, lead designated a with est easi- is program support breastfeeding the of operation safe and Smooth process. planning the facilitate can port sup- breastfeeding of levels two least at for costs specific on information with decision-makers key Providing Room. Break Mothers’ Breastfeeding a in placement for pumps multi-user chase pur- or rent also can They pumps. use personal- purchased on rates counted dis- arrange to manufacturers pump breast with contract can Employers group. support mother’s a or department, health a sultant, con- lactation a hospital, local a from acquired be can them obtain to how and pumps of types about Information models. as used be can programs support breastfeeding successful Other users. program tial poten- of priorities and needs the and space, available potential the gram, pro- the use to likely are who women of number the include factors Key W for protection job include should It employees. breastfeeding against discrimination and of harassment prohibit also should policy The breaks. for allotted time and provided facilities as such program, support workplace the of details out spell should policy The employees. all to communicated policy written a by governed be should program A policy.support company’sbreastfeeding the about employees all Inform month. each work of hours few a only ate gener- programs minimal though even orkplace Breastfeeding Support Breastfeeding orkplace workplace breastfeeding support breastfeeding workplace • • • • include: employers and mothers both benefit can that options scheduling of Examples ment. adjust- of period a be ity,will there flexibil- of Regardless childbirth. ing follow- work to return mothers’ new ease can arrangements work Flexible options. scheduling flexible Consider jobs. desirable less to employees feeding breast- assigning on ban a and leave, maternity after and during employees months or weeks several over load work full-time their to leave from return phase-back, job one of benefits and responsibilities the share and time part work each job-sharing, discretion own their at time take can ers work- which from work, off days paid of set one into grouped are days personal and time, vacation time, earned part-time work in which workers which in in which two workers two which in in which sick time, sick which in 3

A5-16 / A North Carolina Blueprint for Action / ANorth Breastfeeding or expressing milk dur- milk expressing or Breastfeeding bathroom). a (not place clean private, a in space provide and job, the on milk express or breastfeed to time break sufficient women Allow • • • cold storage capability is essential is capability storage cold secure addition, In important. is sink a of Proximity use. after equipment clean must and hands clean have must mothers reasons, safety milk For decreases. ually grad- younger,then is child the when greatest is milk express or breastfeed to needed breaks of number The child. her for milk of supply good a up keep to mother a enables hours working ing home from jobs their of part or all work telecommuting, days fewer on hours more work employees week, compressedwork ules sched- home their accommodate to hours unusual work to arrange flex-time, in which workers which in where employees where in which in 3

A p p e n d i x 5 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

5 x i d n e p p A (this could include coolers with cold incentives, mandates, honoring packs, provided by employees). model practices) Conclusion The majority of new parents work Women who work in a variety of sites • establish worksite support pro- hard to be both dedicated, quality throughout the week or the workday grams for government employees workers and dedicated, devoted par- have special challenges and need • replicate existing model legislation ents. Many industries, companies, authorization from their employer to and policies in new locations departments, and divisions work cre- atively to make their work environ- use creative solutions. Solutions may • reconsider aspects of welfare-to- ments family-friendly. include expressing milk in a vehicle work legislation that have made or in a nursing mothers’ room in a breastfeeding more difficult Increased initiation and duration of shopping mall. • develop systems to assist business- breastfeeding are important national and global public health goals. By Provide education. es wanting to improve breastfeeding support falling short of these goals, we put Many parents get information and babies and mothers at increased support for family issues from friends These laws should apply to all sectors health risk. Breastfeeding support in and coworkers. The worksite can be a of the work force, including part-time the workplace is an essential compo- significant source of support for workers and welfare-to-work participants. Particular attention is needed nent of meeting these goals and is breastfeeding. truly a win-win-win for mothers, for disadvantaged families, who suf- babies, and employers. Information collected by the breast- fer the most illness, have the lowest feeding support program can be pro- breastfeeding rates, and often work in vided to pregnant and breastfeeding jobs lacking workplace breastfeeding References employees, as well as to new or support. 1. Fein SB, Roe B. The effect of work expectant fathers, so that each family status on initiation and duration of does not have to go through the same Several states have passed or are con- breast-feeding. Am J Public Health information-gathering process. sidering legislation mandating that 1998; 88(7): 1042–1046. employers make available appropriate 2. Roe B, Whittington LA, Fein SB, Useful information includes a list of space and sufficient time for mothers Teisl MF. Is there competition child care facilities near the worksite to breastfeed or express milk in the between breastfeeding and maternal and a list of resources for obtaining workplace. employment? Demography 1999; breast pumps. 36(2): 157–171. Other states’ legislation does not Support and be aware of leg- include mandates but offers tax incen- islation and policies promot- tives to companies with strong breast- ing workplace support for feeding support.4 breastfeeding women. Legislators, government agencies, and Legislators and policymakers have business leaders are responsible for played an important role in promoting providing the vision and leadership workplace support for breastfeeding on a national level that will support women. breastfeeding mothers, reward pro- More state and federal laws are need- gressive and forward-thinking compa- ed to: nies, and encourage others to join the effort. • protect breastfeeding women from discrimination Tax incentives for breastfeeding support, paid maternity leave, and model • promote adequate maternity leave family support programs in govern- • encourage employers to accommo- ment agencies are all part of this date the needs of breastfeeding vision and leadership. employees (e.g., through tax

4 Workplace Breastfeeding Support

A5-17 N.C. Division of Public Health /2006 DivisionofPublicHealth N.C. Promoting, Protecting andSupportingBreastfeeding feeding. (AAFP). Physicians Family American of Academy Resources Additional cur- KA. Friedman A EN, Baldwin 4. Bar-YamWorkplaceNB. lactation 3. W porations. cor- two in women formula-feeding and breast-feeding among rates illness infant and absenteeism maternal of Comparison RG. Mrtek MB, Mrtek R, Cohen, Promotion mothers. employed by breast-feeding of duration and dence inci- the on programs lactation corporate two of impact The MB. Mrtek R, Cohen ?pg=875-4810-7250. http://www.awhonn.org/awhonn/ workplace. the in lactation breastfeedingand statement: Position (AWHONN).Nurses Neonatal and Women’sof Association Obstetric Health http://www.aap.org/policy/re9729.html. Pediatrics Breastfeedingand the use ofhuman milk. American AcademyofPediatrics (AAP). cy/x1641.xml. Services, Office on Women’son Office Services, Health. Human and Health of Department U.S. ilo.ch:1567/cgi-lex/convde.pl?R191. (R191). 2000 Availablehttp://ilolex. at: Recommendation, Protection Maternity Organization Labor International ch:1567/cgi-lex/convde.pl?C183. (C183). Availablehttp://ilolex.ilo. at: 2000 Convention, Protection Maternity Organization Labor International 148–153. 10: orkplace Breastfeeding Support Breastfeeding orkplace on November 22, 2002. 22, November on league.org/LawBills.html#. Accessed A International. League Leche La IL: Schaumburg, U.S. the in lation legis- breastfeeding of summary rent 249–254. 14: workplace. the with working II: part support, vailable at: http://www.laleche-at: vailable A Position statement on breast-on statement Position vailable at: http://aafp.org/poli- at: vailable Am J Health PromotionHealth J Am 1997Dec; 100(6). Availableat: 1994; 8: 6. 8: 1994; J Hum Lactation Hum J Am J Health J Am A vailable at: vailable 1998; 1995; Mar; Issue 2. Issue Mar; ductivity. pro- and health promote to practices best workplace: the at support Breastfeeding W html. http://www.usbreastfeeding.org/StratPlan. national agenda. national a States: United the Breastfeedingin Committee. Breastfeeding States United f A (UNICEF). Children’sNations Fund United dol/wb/public/jobs6497.html. 1999. Availablehttp://www2.dol.gov/ at: Labor,of Women’s Department Bureau; 1964–1999. Labor.of Department U.S. bk2.pdf. www.4woman.gov/Breastfeeding/bluprnt- W on Office Services, Human and Health ing. breastfeed-on action for blueprint HHS fl/04/key_messages.htm. vailable at: http://www.unicef.org/at: vailable ashington Business Group on Health. on Group Business ashington omen’s2000. Health; Available at: W ashington, DC: U.S. Department of Department U.S. DC: ashington, Family Health in Brief in Health Family Facts for life: breastfeeding.life: for Facts W ashington, DC: U.S. DC: ashington, A vailable at: vailable

A5-18 / A North Carolina Blueprint for Action / ANorth W omen’sjobs: 2000 5

A p p e n d i x 5 orkplace W orkplace Breastfeeding Support W N.C.Public Health Division of / 2006 / A North Action for Blueprint Carolina

A5-19 isit us at www.usbreastfeeding.org. protecting protecting | promoting | supporting V [issue paper]. Raleigh, NC: United States Breastfeeding Committee; 2002. Goals of the United States Breastfeeding Committee Promoting, Protecting and Supporting Breastfeeding and Supporting Protecting Promoting, Goal II Ensure that breastfeeding is recognized as the normal and preferred method of feeding infants and young children. Goal III Ensure that all federal, state, and local laws relating to child welfare and family law recognize and support the importance and practice of breastfeeding. Goal IV Increase protection, promotion, and support for breastfeeding mothers in the work force. The mission of the United States Breastfeeding Committee (USBC) is to protect, promote, and support breastfeeding in the United States. The USBC exists to ensure the rightful place of breastfeeding in society. The USBC works to achieve the following goals: Goal I Ensure access to comprehensive, current, and culturally appropriate lactation care and services for all women, children, and families. 6 This paper was funded in part Maternal by and the Child Health and Health Resources Services Bureau Administration’s and the Centers for Disease and Control U.S. Prevention, Department of Health and Human Services. © 2002 by the United States Breastfeeding Committee. Cite as: United States Breastfeeding Committee. support breastfeeding

A p p e n d i x 5 N.C. Division of Public Health /2006 DivisionofPublicHealth N.C. Promoting, Protecting andSupportingBreastfeeding 2003 F Suppor us a a L r ppl i a e e s t f ci c e ul y ons d l U t i w t o be t ni i . i e he e de l t ve s ow e n d r i r c ng S y a ons t r w ______o o o o o o F o o o B o o o o o P o o o o L o o o o S a e w t ur um pa oc r or e i s e a de s e ni a O C C C C C P S P E E E E M O I W W O R F D c kpl a ys ve ps n s B e t ur ubs r l m m m m ha ha ha ha ha e r s t t e t t i oa ul ovi i i e he he he r hi on s a di r t t t pum a e pl pl pl pl c d t o hi hi not a i i i i i t r c t a ngs ha r r r r r r i i r r c l i oom de oye oye oye oye i e , , , di - s s n n of ng, a n a c ( ( ( us uppor t t t t s he t pl pl pl s f nd om z a a a a a p e d e c e i f e e bl bl bl ( d, t d e r r r e e e onj e 10 5 a r c pe ua m d by r a a a di c t s s p e e e pone he pr bu by a m pum s s s pr ubs ubs i u by , , r r t bl l e e ng e a unc t m ovi i s l e ovi s s i c i i on. nd i t t br ona nut i i m e e l s e k e va i i i A nk nk di e pur i i pe e nut xpl l m C nt di di p de e a m p t a de s s t ng i a bor c e om l l T pl e c l on s i pr z z a a l pl oye s s nk pos e a i s he s e e w c nd nd t pum o oye f t i uppl f ov oye pum s s ha y) ow w n) f m a w e a o y t r pum pum e l br e a us us e i t i i k m e di ______de a _____ l t t n ) r r pi a k t h e r i p e e o oo e ppl ng e e a pum d ng/ e f o t m p p s of of s r he of f m e t e on f pur r y) a nt m e e e b f o r a s ______U m ( p e e e nt r a ______pl s s de a r f e d d l S c pa i pl e r

a a t i oye A5-20 ha he / A North Carolina Blueprint for Action / ANorth i B d e ng a l di s ge oye t c t C a h f s a e c t r e s e e l s a i a a i t e e o uppor e t s a h t w va di e or s w d n gui ue be o ng W i r o l r s s k a ha e r pa pa de bl k f t r s o r oom vi f i c t i e pe s n a o ge t e t rk ) or o t a t i r r t he ons r e . i a W p on m T Br t o w or l hi pl s r a or k s oye e c pl kp c a he e ac r l s s a c e c kl a t e B nd f . i e r s N e t e e as m ot P m d a t a pl f a ge y e i l oye e l n be di 1 of g ng e m t s he i os w n m t ho

A p p e n d i x 5 l xua e s ng 2 di ny s e ge ) i e a s e pa f 183) t P s m ba i s a om t on s e e d i c i e k c nt br n i de i or e s oye n e w t pol e ne pl ng - onve s m di he C a om om oda t e e r s e n f n w s m e f o a t a on i d s t l e s ng a l a om t N.C.Public Health Division of / 2006 oye r on s e e z c y di r e r c pl w e b ke ni a duc ve da e a ngs s s m r de t f a or r g a s e t e oye o e de di r / A North Action for Blueprint Carolina r s f l w

ha s e o a pl - t ovi r O t e k r e he o hou oye f r m r r on c s not p c ne e i i e ot b e t pl t s r e e r or c bo nt r r m f ng 8 m a t nt nd e a a de nd pa e r a c on/ c L oda n di a i our ng a e s t o o l e s ks he m t t gna ovi e r a e a nt di on n e f or a c r ng i i ot t e e uppor s pr t c s ona k om on on e s pr y a ) ni i m va i i a br f e t c t vi i t gna d e t t l l t ( od r e or r l l A c c a e i e o a a s a d r a r t t a r r a a na a c w L t t hi b c l k uni r p i e ng ks ue d c o h e r e A5-21 upe ni o pe l r t t d M a m duc duc e i t m s i o pi br c e nd l e on e e or F nt h l hi y , i c f a w c d by ( I w l t k s c c l r ks ( a br l om i or a om e i y k e a e t ki c ng ng f hi r ks c unc d on pum e nd s C c i l i of f i m c ks a or e ks di di a ne a t pol ngs k a e w o c l e e e e oye ng a i e c r w or ks e i ve h t e e ons ng e e f e h pol o ng w d t e d t i ks a s f f pl on t br i l d i us t w ngs i t t 12 ut e i e a w i e e di unpa s nd ot i l w e t l s s l r m c e e nt w ks l s d hi a s ng w a m w a a cy > 12 6 e e a d e i e e a e s i c pr br t 12 e e w r l t oda f ve ki s l e e of c ne r r t m r l m s e c uni r m ks d, d, d, ve i o > 12 6 a s i t b b om i i i m gi s de s a duc a t a ha br t i pr r bi a xpr nde a a c r s m e he p e s - r r e s he ude e e e e n t e a x d, d, d, c - l d l e e e r i l r r i i i e r i ot om ovi f f e r ot br y n npa npa npa om a ont om a e a l a a a c ont om xpa y c B ob or nc r t n a f hi c pr of of i ha t c P J F C M C O C m 2 pa e P P P U U U T C c our s a s a ni e r t r r ks kpl p e a o o o o o o o o o o o o o o o o o o o o o o o o o o o a t t he e he or a m S t t r o B W O O M d c e t n ni Promoting, Protecting and Supporting Breastfeeding and Supporting Protecting Promoting, e U t t i r 2003 W

A p p e n d i x 5 N.C. Division of Public Health /2006 DivisionofPublicHealth N.C. Promoting, Protecting andSupportingBreastfeeding B the past decade: past the over legislation breastfeeding of form some enacted have states Thirty-four harassment. prevent to and feeding breast- choose to women more age encour- to is legislation breastfeeding all of goal The so. do to continue to or breastfeed to begin to decision woman’sa affect can that barriers the of some remove to legislation enacted have breastfeeding, of importance the recognize which legislatures, U.S. duration. and incidence its increase to set been have objectives state and national breastfeeding, of benefits many the of Because gains. environmental and economic through large at society to contributes also but bonding, and health improved State Breastfeeding Legislation Breastfeeding State • uations. sit- various in child her breastfeed to right mother’s a enforce and/or clarify,protect, that laws new creating by legislation feeding breast- enacted have states Many babies and mothers through mothers and babies benefits only not reastfeeding 1 Legislation Breastfeeding State law rather than only in the bill, so that so bill, the in only than rather law actual the in directly information this anyone looking at the law.the at looking anyone by seen be easily can information the United States today relates to a moth- a to relates today States United the in legislation breastfeeding Most Public in Breastfeeding feeding. breast- promoting in role effective especially an play can below lined out- areas the on focused Legislation breastfeeding. nonexclusive and exclusive of tion dura- the regarding recommendations current and children and women for breastfeeding of importance the about information provides that preamble a contain bills breastfeeding Many A • • feeding in general. in feeding breast- of support the encouraging Legislature, the of Resolutions lawsthat pertain to breastfeeding. lawsby adding language to existing Otherstates have amended various few states have passed have states few 2 Some states include states Some

A5-22 / A North Carolina Blueprint for Action / ANorth 3 women have the right to breastfeed to right the have women that clarify not do laws these because example, For mothers. feeding breast- to protection sufficientafford not may be, to right the have they wherever breastfeed to right the have women that specify clearly not do during or incidental to breastfeeding. to incidental or during breast the of exposure is there if even apply laws their that provided have ing from criminal statutes, criminal from ing breastfeed- exempt merely that Laws be, to right the have they where place any in breastfeed to right the women give expressly to laws their amended or created have states Eighteen breast. the of exposure is there if even be, to right the have they where place private or public any in breastfeed to right the have women that specifies clearly it when effective most is Legislation public. in breastfeed woman’sto a right enforce or ify clar- to attempting legislation of form some enacted have states 30 date, Topublic. in breastfeed to right er’s 5 4 and eight states eight and 7 and that and 1 6

A p p e n d i x 5 or 23 26 On the federal 25 if they set up lac- 24 Breastfeeding Legislation 21 State Encouragements included 22 Providing mothers with a remedy for violation of from the civil law, penalties and fines to an award of attorneys’ fees. solve the problem of discrimina-

tation support that conformed to state guidelines. To tion against breastfeeding mothers, 10 states have enacted legislation that either encourages employers to support breastfeeding mothers when they return to work, or requires the employers to take specific actions to provide this support. Recognizing that encouragement alone may not be enough to provide employees with adequate support, six states have enacted laws that Employment Issues Experience has shown that legislation is still necessary to protect breastfeeding mothers from discrimination in the workplace. Because working environments or conditions may discourage mothers from continuing to breastfeed once they return to work, many women see no alternative to weaning their children or quitting can their have jobs. difficulty Women in obtaining relief from the courts because of several federal court opin- ions that do not find discrimination against breastfeeding mothers to be actionable. Initial employment legislation only encouraged employers to provide breastfeeding support, rather requiring support, as is the more recent trend. • level, a bill has been submitted but not yet enacted into law that would provide tax incentives for expending funds on lactation support. “infant-friendly” allowing businesses to advertise themselves as “mother-friendly” N.C.Public Health Division of / 2006 / A North Action for Blueprint Carolina

and one state 18 The strongest law in the New York placed its nursing- York New A5-23 19 20 where they have the right to be, public or private, even if there is exposure of the breast. Eliminating any restrictions on the right to breastfeed, such as requiring the breastfeeding mother to be discreet or modest, excepting the right to breastfeed from a private home or residence of another, limiting the right to only those places where both a mother and her child have a right to be, or defining the age of the breastfed baby or child. Specifying that it is a discrimina- tory practice to stop a woman from breastfeeding in public, and that it is segregation to tell her to go to some other location to nurse her baby. Clarifying that women have a right to breastfeed in any place with its approach. New York’s law, with its approach. York’s New which contains no restrictions, applies to mothers wherever they may go, in public or private settings. It applies even if there is exposure of the breast during or incidental to breastfeeding. Breastfeeding legislation can help provide mothers with a remedy for date, three violations. To states provide for civil fines or penalties for violation of their laws, provides for an award of reasonable attorneys’ fees if a mother is forced to seek legal redress through the courts. • in-public law into its civil rights statutes, thus providing breastfeeding with the mothers same in York New rights and remedies as any other people whose civil rights are violated. The trend in nursing-in-public legislation seems to be evolving, with these various approaches combined: • • nation was enacted by New York nation in was enacted by York New 1994. One 13 Apparently or defining limiting the 17 Most Most of the 10 9 excepting the 14 One city ordi- 8 12 15 16 Promoting, Protecting and Supporting Breastfeeding and Supporting Protecting Promoting, 11 right to breastfeed in a private home or residence of another, right to breastfeed to only those places where both a mother and her child have a right to be, 2 New York was one of York the New first states to exempt breastfeeding from its criminal statutes (1984). Four states have enacted laws that not only clarify the right to breastfeed in public but clearly state that it is a dis- criminatory practice to stop a mother from breastfeeding. Note that restrictions may be unlawful Note that restrictions if they contradict or unconstitutional law the existing laws (e.g., existing on to women breastfeed that allows property). any federal restric- putting that considered states did not laws ultimately into their tions do so, did and that the include states are in the minority. restrictions requiring the breastfeeding mother to be discreet or modest, when they frequent private businesses open to the public, they may not ade- quately prevent businesses from engaging in practices that hinder breastfeeding. Restrictions or limitations on the right to breastfeed are not favored, as they defeat the purpose of legislation and can discourage women from breastfeeding. Restrictions may include the age of the breastfed baby or child. New York recognized that more York was New needed to protect breastfeeding mothers, and as a result it enacted a very strong law that created an enforceable right to breastfeed, leading the nation its law amended the its law law a amended to year later the restriction. remove nance clarifies that it is segregation to tell a woman to breastfeed in a particular place. state that initially put a restriction into put a restriction that initially state

A p p e n d i x 5 N.C. Division of Public Health /2006 DivisionofPublicHealth N.C. Promoting, Protecting andSupportingBreastfeeding place to express her milk on the job. the on milk her express to place sanitary private, a with mothers vide pro- to employers requires also and breaks, regular her on breastfeed or milk express to mother breastfeeding a allow not to discrimination is it that so. do to stall bathroom a not is that place private a provide also to employers require five all employees. breastfeeding accommodating in actions specific take to employers is breastfeeding or wants to express to wants or breastfeeding is she because employee other any from differently her treat to or breaks, her on breastfeed or express to mother a allow not to discrimination is it that law its in clarifying by employees breastfeeding supporting to approach different a taken has state sixth The employee. other any from differently mother breastfeeding a treat to crimination dis- is it that clear it make states six the of two only but work, to return they when mothers breastfeeding accommodate to employers require State Breastfeeding Legislation Breastfeeding State breaks. her on milk express breast milk on the job, the on milk breast express to time break sufficient with ers moth- provide to employers require of its laws. its of violation for penalty civil a of form the in remedy a for provides also states those of one of law current hensive protection. hensive compre- most the with mothers vides pro- approaches of combination a that found has (Connecticut) state One actionable. be to not mothers breastfeeding against discrimination found that sions deci- court federal negative the rides over- also It mothers. breastfeeding against discriminating or against action taking from them prevents it action, specific any take to employers require necessarily not does approach 27 31 31 28 Five states require states Five Four of those states those of Four 33 32 Its law clarifies law Its Though this Though 30 The most The 29 and expressmilkregularly. breastfeedabletonot toisshe or if ill alsocausemotherbecomecantheto motherinfantrisk.andSeparationat breastfeedingthe relationship between effectsuddenseparationa of putcan breastfeedingthelemsfor mother. The presentJurydutycansignificant prob- Duty Jury • • • combined: approaches ous vari- these with evolving, be to seems legislation employment in trend The tony’fees. attorneys’ of award an to fines and penalties law,civil the from of violation for remedy a with mothers Providing so. do to place sanitary private, a and milk, express to time break sufficient provide to employers Requiring breastfeeding. is she because ees employ- other from differently her treat to or breaks, her on feeding breast- or milk expressing from woman a stop to practice tory discrimina- a is it that Specifying

A5-24 / A North Carolina Blueprint for Action / ANorth age. certain a under child a with home at are who parents excusing as such infant, and mother breastfeeding the protecting for avenues other provide laws their as mothers, breastfeeding exempt to legislation specific enact to need the seen not have states Other state. each in existing already laws duty jury general the with in fit to crafted were they as guage, lan- their of terms in similar all at from jury duty.jury from mothers breastfeeding exempting laws enacted have states Several laws. duty jury state’sexisting the own with consistent most be would approach which see to and legislation, feeding breast- specific enacted already have that states of language the at look to be would step second problem. the A solve would that exist already tions exemp- other if see to be would step duty,first jury a from mothers feeding breast- exempt would that legislation enacting contemplating were state a If 35 34 These laws are not are laws These 3

A p p e n d i x 5 . Code Code, Such laws International 49 only one state has Breastfeeding Legislation Code, . While the United States State Additionally, states may Additionally, 48 N.C.Public Health Division of / 2006 require the education of health professionals to include specific breastfeeding content. would prohibit a manufacturer of infant formula from engaging in marketing activities that violate the While there are no state laws at the present time pertaining to the have a Massachusetts and York New provision in their perinatal guidelines that require a physician prescription or a request by the mother before a formula discharge bag can be distributed. feeding is to enact legislation that provides for the payment or reimbursement of breastfeeding equipment Milk Banks There is currently no legislation regu- lating the use of donor human milk. Medicaid and insurance third-party payers can and do cover processing fees for circumstances in which donor human milk is prescribed. International Code of Marketing of Breast- milk Substitutes Another issue that has arisen in the United States is the enactment of legislation to enforce the Code of Marketing of Breast-milk Substitutes joined numerous other countries in signing the attempted to enact legislation designed to enforce it. Breastfeeding Equipment and Supplies Another method of supporting breast- for qualifications, as one state has done. 46 / A North Action for Blueprint Carolina

44 Also, breastfeed- 43 Several state laws that 47 45 A5-25 42 ing can be considered as a factor in federal sentencing proceedings. and mother. Also, some public service and education campaigns produced by health departments include the promotion of breastfeeding. The role of states may include licensing or registering lactation consultants, and setting forth requirements Other methods of encouraging breastfeeding could be looked at in regards to state legislation that comes from federal For case instance, law. mothers in federal prison have the right to breastfeed their babies during regular visitation periods. Education, Training, and Licensure In order to promote breastfeeding, some states require hospitals and providers of care to women and families to offer the services of a lactation consultant and/or information on breastfeeding and its benefits to infant Thus, the trend in family law legislation seems to be evolving, with breastfeeding a factor to be considered in determining parenting time in divorce or separation cases. Mothers in Prison Mothers who are sent to prison can still be encouraged to breastfeed. law Legislation, such as York’s New that allows mothers under certain circumstances to have their children with them for the first year of life, helps to ensure that their babies still receive the benefits of being breastfed. administer maternal and child health programs require promotion of breastfeeding as well as availability of breastfeeding services and support. One of 38 The third state wo of these cases Another provides that T 40 37 39 36 Promoting, Protecting and Supporting Breastfeeding and Supporting Protecting Promoting, 41 date, only three states have

lines is consideration of the lack of reasonable alternatives to the needs of a nursing child. these matters. an exception to its visitation guide- rule that it is not discrimination to consider breastfeeding in deciding 4 To addressed breastfeeding and family law by enacting legislation. they make custody and visitation decisions. There are many court decisions from around the United States that clarify the importance of breastfeeding and require courts to consider it as a factor in deciding custody and visitation issues in family law cases. contribute greatly to level a family’s of health. Inappropriate, abrupt, and lengthy separations from the breastfeeding mother can result in a child prematurely weaning, becoming ill, and suffering from a variety of psychological disorders. These difficulties can be avoided if courts consider breastfeeding when In situations where parents separate or divorce, decisions on custody and visitation can negatively affect or even destroy the breastfeeding relationship, as well as the bond that the child has with Because the mother. breastfeeding is such an important health choice for both the baby and the courts mother, that support breastfeeding in family law situations can Family Law Situations requires courts to consider breastfeeding in deciding parental responsibility issues in divorce and separation cases. those states requires that whether a child is nursing be considered as a factor in determining the frequency, duration, and type of parenting time to be granted.

A p p e n d i x 5 N.C. Division of Public Health /2006 DivisionofPublicHealth N.C. Promoting, Protecting andSupportingBreastfeeding incidence and duration, and for the for and duration, and incidence breastfeeding for goals its attaining in States United the assist will efforts all situation, specific its consider to need will state paper.each Though this in suggested as laws amending or enacting recommends Committee Breastfeeding States United the breastfeeding, of support possible est great- the offer to wishing states For Conclusion state. one in done been has as tax, sales from exempt made be thus and supplies medical as treated be can supplies and equipment Breastfeeding services. and care breastfeeding for reimbursement third-party tate facili- to modified be can codes ance insur- health State consultant. tation lac- a of services the as well as items, such cover to payers third-party for requirements through and grams) pro- WIC as (such programs health child and maternal through done be could This shields. and pumps breast as such lactation, maintaining successfully for essential supplies and State Breastfeeding Legislation Breastfeeding State mothers. and children, infants, of health optimal 50 11 VT.MN, GA, CA, 10. CA. 9. MO. 8. VA,SD, RI, MI, IL, AK, WA, WI. 7. MT,MN, NV,MI, FL, NY, UT.NC, 6. MO, MN, ME, LA, IA, HI, FL, CA, 5. IA, IL, HI, GA, CT,FL, CA, DE, AK, 4. NV. LA, 3. NY.MT,NJ, FL, NH, DE, AK, 2. State by “State entitled chart See 1. Endnotes 20. 1994 NY ALS 98, NY CLS Civ R § R Civ CLS NY 98, ALS NY 1994 20. HI. 19. CT,NJ. HI, 18. 245.02. 245.012 § CLS NY 17. Ordinance City Philadelphia of City PA 16. NH. CT,HI, LA, 15. GA. 14. VT.MO, MN, GA, CA, 13. 1848). Breastfeed (H.R. to Act Right 12. 25. CA, CT, FL, HI, GA, IL, MN, TN, TX, TN, MN, IL, GA, CT,HI, CA, FL, 25. WA. 24. TX. 23. WA.TX, FL, GA, 22. 21. . Fortier v.Group,Fortier Steel legis- such pass to attempted Colorado UT,VT. MT,NV, NY,NM, NJ, TX, OR, NC, UT,VT, VA, WA, WI. NY,TX, NM, SD, NJ, RI, OR, NC, MT,MO, NV,MN, MI, ME, LA, NH, lalecheleague.org/LawBills.html. www.at U.S.” the in Legislation Breastfeeding of Summary Current “A also see 1/29/03”; Legislation of As Breastfeeding Enacted of Listing 49 F. Supp. 2d 305 (1999); F.305 49 2d Supp. WA. Bowen, (1993); Ark. 218 App. Department, Security Employment (1990); 867 W Sterling, 11788;LEXIS 79-e. 9-1105. 4401. H.B. TrackingBill MA 2001 restriction, this with bill pending a has Massachusetts failed; it but lation allace v.allace PyroMining, 846 F.2d846 (1988). 927 997 F.(1998); 997 306 Supp. Pendrix-Wangv. Director, Martinez v.Inc., Martinez N.B.C.

A5-26 / A North Carolina Blueprint for Action / ANorth Barrash v.Barrash 2002 U.S. Dist. U.S. 2002 789 F.789 Supp. Bond v.Bond 42 29. CA, IL, MN, TN. MN, IL, CA, 29. CT,TN. MN, CA, IL, 28. CT,HI. 27. and Promotion Breastfeeding 26. 0 MD. 50. AB CA 2001 2447, Cal Bill Assembly 49. LA. 48. MN. IL, CA, 47. MT.IL, FL, 46. MO. FL, CA, 45. see example, For 36. exempt states several example, For 35. ID. IA, OR, CA, 34. CT. 33. HI. 32. CA. 31. CT,TN. MN, CA, IL, 30. 44. 43. 611,2001. § Correc CLS NY 42. ME. 41. UT. 40. MI. 39. UT.MI, ME, 38. 37. U.S. v.U.S. Dyce, v.Barrios et RichardThornberg,etc., Lester, 1 TaxIncentive (H.R. Act Employers’ 2447. F 2002. Code 14-7-860, SC Ann 2002; 1, § 234 ch. Mass Laws 2002; Ann 305/10.2, ILCS 705 2002; §40.013, Stat Fla 2002; 15-12-1, § OCGA age. certain a under children with home at parents P Norton, and Norton of Marriage Ford, 3987; Ohio LEXIS 1990 App. (1990); 676 A.D.2d al., P Norton, and Norton of Marriage (Minn.). Dist); West(Ohio 1993 4 98040 App. Law Ct. 2000); App. v. .2d 254. .2d Ct. 1981); (Col. App. 254 .2d 163). .3d 1462 (1996). 1462 .3d

Lennane, 716 F.(1989). 716 987 Supp. 108 Idaho 443 (1985); 443 Idaho 108 Goose v.Goose Goose, 84 Cal. App. 4th 536; Cal. 4th 84 App. 84 Cal. App. 4th 536 (Ca 536 Cal. 4th 84 App. 320 U.S. App. D.C. 1; 91 1; U.S. D.C. 320 App. Kerstetter v.Kerstetter Kerstetter, Faber v.Faber Faber, Presuttiv. Presutti, 406 NW 2d 4 2d NW 406 In re:The In In re:The In Fordv. Lester 640 640 159 5

A p p e n d i x 5 Breastfeeding Legislation State §191.918 (Health Program, Nursing in Public) cations) Maine Me SP 888, ALS 1999 702, Me 1999 Me Laws 702, 1999 Me Ch 702, 19-A MRS §1653, 2001 (Family Law) Me HP 1039, ALS 2001 206, Me 2001 Me Laws 206, 2001 Me Ch. 206, 5 MRS §4634, 2001 (Nursing in Public) Maryland Md SB 252, ALS 2001 137, Md. 2001 Md. Chap 137, Ann Md §11- Code exemption) (Tax 211,2002 Michigan Mi SB 107-109, ALS 1994 313-315, Mi 313-315, MCLS 1994 §41.181, Mi P.A. §67.1, (Nursing 17.4i,§117.5h in Public) Michigan Complied Laws § 25.312(7a) Ch 722, Children, Act Child of Custody 1970 MCLS §722.27a (Family Law) Minnesota Minn SF ALS 2621,1990 568, Minn 1990 Minn Ch Law 568, Minn Stat §145.894,2002 (Information Campaign) Minn SF 2751, ALS 1998 369, Minn 1998 Minn Ch Law 369, Minn Stat.§181.939, 617.23 (Employment) Minn SF 3346, ALS 1998 407, Minn 1998 Minn Ch Law 407, Minn Stat. §145.905 (Nursing in Public) Missouri Mo SB 8, 1999, R.S.Mo §191.915, Louisiana La HB 377, ALS 2001 576, La. 2001 La. ACT 576. 777, La RS 51:2247.1, 2002 (Nursing in Public) La RS 40:2213, 2002 (Consultant qualifi- N.C.Public Health Division of / 2006 / A North Action for Blueprint Carolina

HRS 378- , 1990 Hi ALS 326 (WIC) (WIC) 326 ALS Hi 1990 , , 2001 Ill ALS 2001 68, Ill 2001 Ill 1995 Ill ALS 1995 59, Ill 1995 Ill ALS 1997 244,1997 Ill Ill , , , A5-27 Laws 290 (WIC) Ill SB 542 Laws 68 (Employment) Iowa Ia HF 2350, ALS 1994 1994 1196, Ia Ia Ia Ch 1196, 1994 Code 1196, Ia LAWS §607A.5, 2002 (Jury Duty) Ia SF 2302, ALS 2000 2000 1140, Ia. Ia. Iowa Ch 1140, 2000 1140, Ia. LAWS Code §135.30A, 2002 (Nursing in Public) Idaho Ida SB 1468, 1996ALS 189, Ida. 1996 Ida Ch189, Ida Code §2-212, 2002 (Jury Duty) Illinois Ill SB 190 Laws 59, 720 ILCS 2002 5/11-9, (Nursing in Public) Ill SB 404 Laws 244, 20 ILCS 2310/2310-442, 2002 (Information Campaigns) Ill SB 619, ALS 1997 290, Ill 1997 Ill Fl SB 1668, ALS 1994 217, Fl 1994 Fla Laws Ch 217, Stat §363.318, §383.015, §383.016, §383.318 §383.311, (Employment, Health Program) Georgia Ga SB 29, ALS 1999 304, Ga 1999 Ga Laws 304, (Nursing in Public) (Later amended by Ga SB 221, 2001, OCGA §31-1-9) OCGA §34-1-6 (Employment) Hawaii 2280 HB Hi 489-22, 2002 (Nursing in Public) Public) in (Nursing 2002 489-22, Hi HB 266, ALS 1999 172 Hi Hi HB 2774, 1999, HRS §489-21, HRS §489-21, HRS 1999, 2774, HB Hi 10.2, 2002, HRS §378-2, 2002 (Employment) ; 2001 Ct ALS 2001 182 Ct , 1993 Fl ALS 1993 4, Fl 1993 Fla 1997 Ct ALS 1997 210, Ct Conn Gen , , Promoting, Protecting and Supporting Breastfeeding and Supporting Protecting Promoting, 6 Laws 10, 31 Del C. §310 (Nursing in Public) Florida Fl HB 231 Laws ch. 4, Stat. §383.015, §800.02–800.04, §847.001 (later 827.071) (Nursing in Public) Connecticut Ct SB 260 Stat §46a-64, and §53-34b (Nursing in Public) Ct HB 5656 (Employment) Delaware Del HB 31, ALS 1997 10, Del 71 Del Cal Assembly Concurrent Cal Resolution 155, 1998 (Employment) AB 1814, Cal ALS 2000 266, Cal Stats 2000 Ch 266, Cal Code Civ Proc §210.5 (Jury Duty) AB 1025, Cal ALS 2001 821, Cal Stats 2001 Ch 821, Cal Lab. Code §1030, 1031, 1032, 1033, 2001 (Employment) Public) California AB 977, Cal ALS 1995 463, Cal Cal Health & Saf Code §123360 and §123365 (Information Campaign, Health Program) AB 157, Cal ALS 1997 59, Cal Stats 1997 Ch 59,Cal Civ Code §43.3 (Nursing in Public) Listing of Enacted Breastfeeding Legislation as of 1/29/03 Alaska Ak Ak ALS SB Stat 78, AK 297, 1998 §01.10.060, §29.25.080 (Nursing in State by State

A p p e n d i x 5 N.C. Division of Public Health /2006 DivisionofPublicHealth N.C. Promoting, Protecting andSupportingBreastfeeding 1 Ch NM 117,1999 Laws NM 1999 NM 117,1999 ALS 545, SB NM Mexico New Public) in (Nursing §26:4B-4 Stat. NJ 101, Ch NJ 1997 101, Laws NJ 1997 NJ 101, 1997 ALS 1212, SN NJ Jersey New Public) in (Nursing 132:10-d RSA 10 1999, 441, HB NH Hampshire New Nev Stat 443 (Nursing in Public) Nev SB 416, 1995 Nev ALS 443, 1995 Public) in (Nursing §201.232 201.220, § Stat §201.210, Rev Ann. Nev 105, Ch Nev 1995 105, Stat Nev 1995 Nev 105, 1995 ALS 317, SB Nev Nevada (WIC) 1991 3, HJR Mt Public) in §50-19-501(Nursing Anno. Code Mont 299, Ch. Mt 1999 299, Laws Mt 1999 Mt 299, 1999 ALS 398, SB Mt Montana State Breastfeeding Legislation Breastfeeding State Public) in (Nursing 1993 14-190.9, Sec. Stat. Gen. 301, Ch. NC 1993 301, Laws Sess. NC 1993 NC 301, 1143,1993 ALS HB NC Carolina North Law(Nursing in Prison) CLSCorrec §611 NY 2001, Correction Public) in (Nursing 1984 245.02, §245.01, CLS NY Public) in (Nursing §79-e R Civ CLS LAWSNY 98, NY 1994 98, ALS NY 1994 3999, SN NY YorkNew Public) in 17, NM Stat Ann §28-20-1 (Nursing Stat §28-20-1 NM Ann 17, Code Ann §30-3-34 (Family Law) (Family Code §30-3-34 Ann Utah 80, Ch. Ut 1997 80, Laws Utah 1997 Ut 80, 1997 ALS 33, SB Ut Public) in (Nursing §76-10-1229.5 §76-9-702, §17-15-25, §10-8-50, Code §10-8-41, Ut Ann 262, HB Ut Utah Employment) Public, in (Nursing 165.034 – 165.031 165.005, – §165.001 Code Tex1995 599-600, 600, Ch 599- Tex1995 Laws 599-600, Gen T T §50-1-305(Employment) PubTn Acts161,Tenn Code Ann 1856,1999SBTn Tn 161,1999ALS T Public) in (Nursing 2002 24.1, §22-22- Laws Cod SD 109, Ch SD 2002 SD 109, 2002 ALS 184, SB SD Dakota South Public) in (Nursing 45-1 §11-Laws Gen RI 1997, 2319, SB RI Island Rhode 9-1105,1997 Ordinance City Philadelphia of City Pennsylvania: Only Philadelphia of City Pennsylvania: Duty) (Jury §10.050 ORS 1085, Laws Ore 1999 Ore 1085, 1999 ALS 1304, SB Ore Public) in (Nursing §109.001 ORS 306, Laws Ore 1999 Ore 306, 1999, ALS 744, SB Ore Oregon ex HB 359 & 340, 1995 Tex1995 340, & 359 ALS HB ex exas ennessee

A5-28 / A North Carolina Blueprint for Action / ANorth V Public) in (Nursing 2002 §4502, VSA 117,Vt 117,2002 9 Laws Act Vt Vt 117,2002 2002 ALS 156, SB Vt V §948.10 (Nursing in Public) in (Nursing §948.10 944.20, § Wis165, Stat.§944.17, Wis1995 Wis1995 Laws 165, Act W W Employment) Public, in (Nursing 9A.88.010 Wa Wa W Medicaid) Va Public) in (Nursing Code §18.2-387 Ann Va Va ermont irginia is AB 154,1995 Wisis 154,1995 AB 165, ALS

ashington isconsin Acts 398, 1994 Va1994 398, VaActs 398, Ch.

H J R 248, 1994 (Supplies for (Supplies 1994 248, R J H 1188,Va1994 HB 1994 398, ALS h 8 C 43.70.640, RCW 88, Ch. Wa2001 1590, HB 2001 88, ALS 7

A p p e n d i x 5 State Breastfeeding Legislation State N.C.Public Health Division of / 2006 / A North Action for Blueprint Carolina

A5-29 isit us at www.usbreastfeeding.org. protecting protecting | promoting | supporting V [issue paper]. Raleigh, NC: United States Breastfeeding Committee; 2003. Goals of the United States Breastfeeding Committee Promoting, Protecting and Supporting Breastfeeding and Supporting Protecting Promoting, dren, and families. Goal II Ensure that breastfeeding is recognized as the normal and preferred method of feeding infants and young children. Goal III Ensure that all federal, state, and local laws relating to child welfare and family law recognize and support the importance and practice of breastfeeding. Goal IV Increase protection, promotion, and support for breastfeeding mothers in the work force. Goal I Ensure access to comprehensive, current, and culturally appropriate lactation care and services for all women, chil- The mission of the United States Breastfeeding Committee (USBC) is to protect, promote, and support breastfeeding in the United States. The USBC exists to ensure the rightful place of breastfeeding in society. The USBC works to achieve the following goals: 8 © 2003 by the United States Breastfeeding Committee. Cite as: United States Breastfeeding Committee. legislation breastfeeding

A p p e n d i x 6 N.C. Division of Public Health /2006 DivisionofPublicHealth N.C. Promoting, Protecting andSupportingBreastfeeding (September 2004)” Promoting, Protecting, andSupportingBreastfeedinginNorthCarolina This Appendixincludesthefollowinginformationabout“PublicForum: • Forum Organizers • Agendafor Breastfeeding the Forum • NC DHHSMediaRelease for Breastfeeding the Forum • Forum Participants

/ A North Carolina Blueprint for Action / ANorth A6-1

A p p e n d i x 6 e n m ary a and o r t fr C bers 50 onths, . Odom s m

m K e r infant

o v e t i Infant

Secre ti c b ation, of

e a b r t for

i e m n oting, r

D D e 4

s m Hooker 0 nal Healthy

le 2010 dvisor, 0 re o s, insurance, ilies and identify p a 2 p

e m , m

breastfeeding, r e a 7

t . h

s t

e Nati it on “Pro p

h senior e w Carmen

foundation S nt Public Info n

eastfeeding. initiate : Carolina initiated e el Hill, N.C. r o

e ny of those that receive its p t B MD, a sh.; Alice Lenihan, head, m percent breastfed at 12 a ati

a ices r C. Pediatric Society; Molly m best

D o v

W 14 r b N.

N.C.Public Health Division of / 2006 e

lla the others to

public forum S and o

in health care sy m c lk, and

Labbock, udies, Cha as i eattle, t ns, individuals and f n

S Supporting i m S / A North Action for Blueprint Carolina

ate plan and meet t i Public Health; Ginger Sall, La Leche League h, t onths,

s r 25 percent to breastfeed for one year. mothers in North lt d and

m a e state needs a blueprint to turn those nu

rolina e ee .

a m f

ting m d breast tfeeding ICEF and the Depart C

organizatio opportunities N il h as

t U eeding in North Carolina.” h develop re c and or Continuing ### f e for 75 percent of onths, and fo b Nor rinatal Education, m to the ce . to 4:30 p. r Morris, MD, president of n continued at six m of te A6-2 a community Health and Human young e Carolina barriers f P o 1 ess t 0 r Dr. and 0 State d group of specialists. Th group of specialists. y adv North 2 l MEDIA ADVISORY MEDIA ADVISORY - a 9 9 ntal and public agencies, will hold a ntal and public agencies, 6 e ant help 7 CDC’s Pediatric Nutrition Surveillance. The Healthy Peo institutions, m 2 o ic include will ad to f i C m and Ida Friday Center N ing t , m gn h d i Departmen g i e illia l e d s a t l a R Presenters People 2010 Goals: Promoting, Protec Thursday, Sept. 9, 8:00 a. In 2002, about 51 percent of lower inco breastfeeding, 18 percent accor Objectives for breastfeeding ar percent to breastfeed for six The North Carolina Division of Public Hea non-govern Protecting and Supporting Breastf Pessl, director, Evergreen Pe Nutrition Services Branch, N.C. Division of International representative the United Nations, New York, NY; Dr. Miriam New York, NY. Young Child Feeding and Care, UNICEF, United Nations, educational strategies W The foru Gladys Mason, 919-715-0645 i u , d r e o e c e t i f ey w n f m l e 7 O C m 4 al I Carol Schriber n 4 e o c Eas i i -7 t 0 v : 3 a r e 3 e F. r m 19 s 7 r S 9 a ) o l E: f e i 9 Promoting, Protecting and Supporting Breastfeeding and Supporting Protecting Promoting, 3- l a n 1 : ups’ go R 3 I e 7 M (9 c R i l 1 9) X r HE b overno 0 o Gro A u 0 91 P 2 ( F BACKGROUND: CONTACT: WHY: WHEN: W WHAT: WHO RALEIGH – Not enough North Carolina infants are being fe RALEIGH – Not enough North Carolina infants are being benefits are weaned far too early, says around. Michael G F Contact:

A p p e n d i x 6 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

Agenda September 9, 2004 Promoting, Protecting and Supporting Breastfeeding In North Carolina: A Public Forum

8:00 am Registration and Poster Sessions 8:45 Welcome and Introduction in the Grumman Auditorium Recognizing the Challenge Peter Morris, MD, MPH President of North Carolina Pediatric Society, and Medical Director

Focusing on the Issues Molly Pessl, BSN, IBCLC Director of Evergreen Perinatal Education, Seattle, WA A Look at Breastfeeding in North Carolina Alice Lenihan, MPH, RD, LDN Branch Head of Nutrition Services Branch, North Carolina Division of Public Health, Raleigh, NC 10:00 Break and Poster Sessions 10:30 Panel Discussion to Explore the Issues: Public Policy, Public Awareness, Community Organizations and Families Moderator – Mary Rose Tully, MPH, IBCLC, Director of Lactation Services, University of North Carolina, Women’s and Children’s Hospital, Chapel Hill, NC Panel Members

• Ruth Sheehan, Columnist, Raleigh News and Observer, Raleigh, NC • Janice Payne, Breastfeeding Counselor, Forsyth County Health Department, Winston-Salem, NC • Elizabeth Julye, BS, Nutritionist and Breastfeeding

Coordinator, Granville-Vance Health Department, A p p e n d i x 6 Granville, NC

A6-3 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006 6 x i d n e p p A • Nancy Register, FNP, IBCLC, Family Nurse Practitioner, SAS Institute, Cary, NC • Jean Holliday, Supervisor, NC Department of Insurance, Raleigh, NC • David Weismiller, MD, ScM, Associate Professor, The Brody School of Medicine at ECU, Greenville, NC • Miriam Labbock, MD, MPH, Senior Advisor, Infant and Young Child Feeding and Care, UNICEF, New York, NY 12:15pm Networking Lunch and Poster sessions (lunch is provided ) 1:30 Facilitated Discussion Groups (choose one) Room – Bellflower AB (A-1) Public Awareness: Health Care Systems, Insurance, Educational Institutions Room – Windflower AB (A-2) Public Awareness: Community Organizations and Families Room – Dogwood A (B-1) Public Policy: Health Care Systems, Insurance, Educational Institutions Room – Dogwood B (B-2) Public Policy: Community Organizations and Families Room – Mountain Laurel AB

(C-1) Community Organizations and Families: Individuals and Families Room – Azalea AB

(C-2) Community Organizations and Families: Organizations and Work-sites 3:00 Break and Poster Sessions

A6-4 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C.Promoting, Division Protectingof Public Health and /Supporting 2006 Breastfeeding / A North Carolina Blueprint for Action

3:30 Going for the Gold Findings and Recommendations from the Discussion Groups Closing Remarks Miriam Labbock, MD, MPH, and Ginger Sall, BA La Leche League International Representative to the UNICEF and Department of Public Information of the United Nations 4:30 Adjourn A p p e n d i x 6

A6-5 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

Forum Organizers

A special thank you is extended to the members of the Breastfeeding Work

6 x i d n e p p A Group in collaboration with the North Carolina Division of Public Health who worked tirelessly to organize the breastfeeding public forum. Their vision for the children of North Carolina is that they start life breastfeeding, the best possible foundation for optimal infant and young child feeding. The forum members are listed below.

From Within the From Outside the Division of Public Health Division of Public Health

Gladys Mason, MS, RD, RLC-IBCLC Ginger Sall State Breastfeeding Program Coordinator Former Chairman, Current Representative to the Nutrition Services Branch United Nations La Leche League International Josephine Boyington, PhD, MPH, LD Jam Gourley, RLC- IBCLC Breastfeeding Forum Coordinator Nutritionist/Breastfeeding Coordinator Nutrition Services Branch Wake County Human Services Alice Lenihan, MPH, RD, LDN Diane Yelverton, RNC, MS Branch Head, Nutrition Services Branch Perinatal Outreach Coordinator Wake Area Health Education Center Corrine Giannini, RD (AHEC) Nutrition Program Consultant Women’s Health Branch Nutrition Laurie Dunn, MD Faculty Physician and Neonatalogist Elizabeth Julye, BS Wake Medical Center Child Nutrition Program Assistant Nutrition Services Branch Marcia Roth, MPH Director of Planning and Development Kathy Griffin, MS, RD Center for Infant and Young Child Feeding Nutrition Program Consultant Department of Maternal & Child Health Nutrition Services Branch School of Public Health Sarah Roholt, MS, RD University of North Carolina at Chapel Hill Clinical Unit Supervisor Nutrition Services Branch Mary Rose Tully, MPH, RLC-IBCLC Director of Lactation Services Sherée Thaxton Vodicka, MA, RD, LDN University of North Carolina - Chapel Hill Healthy Weight Communications Women’s & Children’s Hospital Coordinator Physical Activity and Nutrition Branch Janice Sommers, MPH Senior Research Administrator Center for Health Promotion and Disease Prevention University of North Carolina at Chapel Hill

A6-6 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

Forum Participants Jessica Altemara Toni Andrews Regina Asriel La Leche League of NC NC DPH Nutrition NC DPH Nutrition Fayetteville, NC 28303 Services Branch Services Branch (910) 822-4012 Angier, NC 27501 Skyland, NC 28776 (919) 639-4582 (828) 654-9930 Matt Avery NC State Center Linda Aycock Sheila Bazemore for Health Statistics Onslow County NC DPH Children Raleigh, NC 27699 Health Department & Youth Branch (919) 715-4572 Jacksonville, NC 28540 Raleigh, NC 27699 (910) 347-2154 (919) 715-3422 Katina Beasley NC Division Margaret Blandford Susan Boyd of Child Development New Bern CDSA Duplin County Raleigh, NC 27699 New Bern, NC 28562 Health Department (919) 662-4499 (252) 514-4770 Kenansville, NC 28349 (910) 296-2130 Josephine Boyington Dorine Bradley NC DPH Nutrition Coalition to Improve Sheila Britt-Smith Services Branch Quality of Life Forsyth County Raleigh, NC 27699 Sanford, NC 27331 Health Department (919) 715-1934 (919) 774-8144 Winston-Salem, NC 27101 (336) 703-3334 Janet Bryan Dee Buckley NC DPH Nutrition WakeMed Medical Center Karen Bullock Services Branch Raleigh, NC 27610 Coalition to Improve New Bern, NC 28561 (919) 350-8599 Quality of Life (252) 638-5744 Sanford, NC 27331 Mary Ann Burghardt (919) 774-8144 Tavondia Burdett NC DPH Nutrition Pitt County Services Branch Mary Burkett Health Department Raleigh, NC 27699 Duke University Medical Center Greenville, NC 27834 (919) 715-8602 Durham, NC 27704 (252) 902-2365 (919) 684-5190 Bonnie Carlton Sheila Byrd Appalachian State University Melissa Caminiti Northampton County Boone, NC 28607 UNC Hospital Health Department Chapel Hill, NC 27599 Ellen Chetwynd Jackson, NC 27845 UNC Family Practice Center Najmul Chowdhury (252) 534-5841 Chapel Hill, NC 27599 NC DPH Nutrition Joanne Carl (919) 966-2109 Services Branch Coastal AHEC Raleigh, NC 27699 Wilmington, NC 28402 (919) 715-0644 (910) 343-0161 A p p e n d i x 6

A6-7 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

Heidi Churchill Nola Claiborne Ann Conlon-Smith Duke University Medical Center Goldsboro Pediatrics La Leche League of NC Durham, NC 27710 Goldsboro, NC 27534 Raleigh, NC 27615 (919) 688-2693 (919) 734-4736 (919) 845-8826

6 x i d n e p p A Tonia Connaughton- Laurie Cox Sheila Cromer Espino Forsyth Medical Center Perinatal & Family Support Unit Carrboro Community Winston-Salem, NC 27106 Cary, NC 27513 (919) 715-3407 Health Center Margaret Davis Carrboro, NC 27510 Mecklenburg County Deborah Dee (919) 942-8741 Health Department UNC Department of Phyllis D’Agostino Charlotte, NC 28216 Maternal & Child Health Forsyth County (704) 333-4154 Chapel Hill, NC 27516 (919) 929-8781 Health Department Cathy Doyle Winston-Salem, NC 27106 Dare County Sandra Duvall Beverly Denton Health Department Prospect Hill Community Wilson County Manteo, NC 27954 Health Center Health Department (252) 475-5022 Prospect Hill, NC 27314 (336) 562-3311 Wilson, NC 27893 Lisa Ferrari, MD (252) 237-3141 Durham Pediatrics Theresa Flynn, MD Norma Escobar Durham, NC 27704 Wake County Human Services La Leche League (919) 220-4000 Raleigh, NC 27610 (919) 250-3957 Wilmington, NC 28412 Debbie Foreman (910) 392-1335 Twin County Lucy Freeman Wanda Fogg Health Department La Leche League of NC Coor-Franklin County Hollister, NC 27823 Greenville, NC 27834 Adolescent Parenting Program (252) 586-5154 (252) 758-3874 Henderson, NC 27536 Corrine Giannini Ziya Gizlice (252) 433-9110 NC DPH Women’s NC DPH Office Anthony Garcia Health Branch of State Statistics UNC-School of Public Health Raleigh, NC 27699 Raleigh, NC 27699 Raleigh, NC 27604 (919) 715-3406 (919) 715-4481 (919) 807-3008 Jam Gourley Sheryl Grant Debbie Gordon Wake County Human Services Carolina Parent Magazine WFUSM Department Clayton, NC 27520 Durham, NC 27516 of Pediatrics (919) 212-9200 (919) 956-2430 Winston-Salem, NC 27157 Paige Hall-Smith Joseph Halloran (336) 716-2530 UNC-Greensboro NC DPH Nutrition Kathy Griffin Greensboro, NC 27402 Services Branch NC DPH Nutrition (336) 334-4735 Raleigh, NC 27699 Services Branch (919) 715-2623 Jamesville, NC 27846 (252) 792-6171

A6-8 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

Barbi Harvey Beth Herring Jennifer Herrmann Eagle’s Nest Durham County Onslow County Christian Fellowship Health Department Health Department Raleigh, NC 27617 Durham, NC 27701 Jacksonville, NC 28540 (919) 846-0470 (919) 560-7839 (910) 347-2159 Eslie Holliday Jean Holliday Patricia Huegerich Women’s Hospital NC Department of Insurance Community Member Greensboro, NC 27402 Raleigh, NC 27699-1201 Chapel Hill, NC 27516 (919) 733-5060 (919) 929-7691 Julie Hurt NC DPH Nutrition Sheila Jones Catherine Jorgensen Services Branch Family First Mother Charlotte, NC 28211 of Granville County Raleigh, NC 27615 (704) 367-5051 Creedmoor, NC 27522 Kathryn Kolasa (919) 528-1581 Elizabeth Julye ECU University Health Systems Granville-Vance District Mary Ellen Kelley Greenville, NC 27834 Health Department Twin County (252) 744-1358 Henderson, NC 27536 Health Department Kathy Lamb (252) 492-3147 Roanoke Rapids, NC 27870 NC DPH Nutrition (252) 535-4845 Jonathan Kotch Services Branch UNC- Chapel Hill Miriam Labbok, MD Raleigh, NC 27699 Department of Maternal MPH (919) 715-0641 & Child Health Infant and Young Child Alice Lenihan Chapel Hill, NC 27599 Feeding and Care Section NC DPH Nutrition (919) 966-5976 of UNICEF Services Branch New York, NY 10001 Jessica LaMontagne Raleigh, NC 27699 Piedmont Health Services Elaina Lee, MD (919) 715-0636 Carrboro, NC 27510 Imperial Center Family Medicine Gladys Mason (919) 942-8741 Durham, NC 27703 NC DPH Nutrition (919) 941-0158 Lynda Loveland Services Branch WRAL-TV Kim Lovenduski Raleigh, NC 27699 Raleigh, NC 27606 NC DPH Nutrition (919) 715-0645 (919) 821-8834 Services Branch Paris Mock Raleigh, NC 27699 Michelle McClafferty NC Division (919) 733-1171 Better Birth Partners of Medical Assistance Cary, NC 27511 Monica McVicker Raleigh, NC 27699 (919) 233-4718 Robeson County (919) 857-4020 Health Department Bonnie Moore Peter Morris, MD MPH Lumberton, NC 28360 WakeMed Medical Center NC Pediatric Society (910) 671-3274 Raleigh, NC 27615 Raleigh, NC 27620 Merry K. Moos UNC-Chapel Hill Department of Ob/Gyn Chapel Hill, NC 27599 A p p e n d i x 6 (919) 966-1601

A6-9 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

Margie Mould Joanne Moylan Beth Murnane WakeMed Medical Center Pitt County Health Department Sunrise Pediatric Associates PA Raleigh, NC 27610 Greenville, NC 27834 Raleigh, NC 27607 (919) 350-8599 (252) 902-2388 (919) 788-0505

6 x i d n e p p A Savithri Nageswaran, MD Sheila Nichols Susan O’Hara-Brill UNC-Chapel Hill NC DENR Children’s Chatham Lactation Services Department of Pediatrics Environmental Health Branch Chapel Hill, NC 27516 Carrboro, NC 27510 Wilkesboro, NC 28697 Mary Overfield Vivien Omile Ysaura Ortega Rodriguez Nursing Mothers of Raleigh Wake County Human Services Tri-Co Community Raleigh, NC 27614 Raleigh, NC 27604 Health Center (919) 847-4903 (919) 250-4748 Newton Grove, NC 28366 Janice Payne (910) 567-6194 Heather Owens Forsyth County Coalition To Improve Nan Pardington Health Department The Quality of Life Orange County Winston-Salem, NC 27102 Sanford, NC 27331 Health Department (336) 703-3359 (919) 774-8144 Hillsborough, NC 27278 Molly Pessl (919) 245-2381 Annie Perry Evergreen Perinatal Education Vance County Adolescent Wendalyn Perry Seattle, WA Parenting Program NC DPH Nutrition Gail Proper Henderson, NC 27536 Services Branch Nursing Mothers of Raleigh (252) 433-9110 Raleigh, NC 27699 Raleigh, NC 27603 (919) 715-2619 Alice Pettit (919) 779-9982 NC Cooperative Kelly Pippin Jeaninne Raeford Extension Program Vance County Adolescent Wilson County Hillsborough, NC 27278 Parenting Program Health Department (919) 245-2054 Henderson, NC 27536 Wilson, NC 27893 (252) 433-9110 Gail Pruett (252) 291-3144 NC Nurses Association Jackie Quirk Elizabeth Ricci Raleigh, NC 27605 NC Child Care Health Duplin County Health Services (919) 821-4250 & Safety Resource Center Kenansville, NC 28349 Raleigh, NC 27604 Valeria Rainey (910) 296-2130 (919) 807-3003 Piedmont Health Services Sarah Roholt Carrboro, NC 27510 Nancy Register NC DPH Nutrition (919) 245-2060 SAS Health Care Center Services Branch Cary, NC 27513 Michael Roberts Raleigh, NC 27699 (919) 531-2435 UNC-Ch School of Dentistry (919) 715-0646 Chapel Hill, NC 27599 Pam Rock (919) 966-2739 Tri-Co Community Health Center Newton Grove, NC 28366 (910) 567-6194

A6-10 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

Marcia Roth Kevin Ryan, MD MPH Ginger Sall UNC- School of Public Health, NC DPH - WCHS La Leche League Dept of Maternal Raleigh, NC 27605 Cary, NC 27513 & Child Health (919) 715-7932 (919) 469-3609 Chapel Hill, NC 27599 Satsuki Scoville Carolyn Sexton (919) 966-7735 Mother NC DPH Children Susanne Schmal Durham, NC 27705 & Youth Branch Duke University Medical Center (919) 416-9448 Raleigh, NC 27699 Durham, NC 27710 (919) 783-6519 Ruth Sheehan (919) 681-5724 News & Observer Reggie Singleton Ida Shaw Raleigh, NC 27609 The Males Place Guilford County (919) 829-4828 Charlotte, NC 28216 Health Department (704) 336-6423 Sara Smith Greensboro, NC 27405 Kate B. Reynolds Carolyn Sparks (336) 641-3214 Charitable Trust NC DPH Nutrition Marla Smith Winston-Salem, NC 27106 Services Branch NC Partnership for Children (336) 721-2271 Raleigh, NC 27699 Raleigh, NC 27609 (919) 715-8793 Vivien Stearns Lauri Starling United Child Development David Stone NC Assoc for the Education Greensboro, NC 27262 Surry County of Young Children (336) 378-7700 Health Department Raleigh, NC 27609 Dobson, NC 27017 Catherine Sullivan (910) 510-5034 (336) 401-8411 The Brody School Tammy Suggs of Medicine at ECU Stephanie Tatum Guilford County Health Dept Greenville, NC 27834 EFNEP NC State University High Point, NC 27260 (252) 744-5463 Raleigh, NC 27695 (336) 601-2033 (919) 515-9137 Joyce Taylor Sheri Taylor Coalition To Improve Sheree Thaxton Vodicka Rex Healthcare Medical Center The Quality of Life NC DPH Physical Activity Raleigh, NC 27607 Sanford, NC 27331 and Nutrition Branch (919) 784-3224 (919) 774-8144 Raleigh, NC 27699 (919) 715-1928 Cathy Thomas Teresa Tollison NC DPH Physical Activity Guilford County Mary Rose Tully and Nutrition Branch Health Department UNC Healthcare Women’s Raleigh, NC 27699 Greensboro, NC 27214 & Children Hospital (919) 715-3830 (336) 641-3085 Chapel Hill, NC 27514 (919) 966-3428 Amy Veatch Sarah Verbiest Nursing Mothers of Raleigh March of Dimes Meredith Wansley Raleigh, NC 27607 Raleigh, NC 27612 Guilford County (919) 821-4424 (919) 781-2481 Health Department High Point, NC 27265 (336) 845-7571 A p p e n d i x 6

A6-11 Promoting, Protecting and Supporting Breastfeeding / A North Carolina Blueprint for Action N.C. Division of Public Health / 2006

Sharon Ware Valerie Watford David Weismiller. MD ScM NC DPH Children NC DPH Nutrition The Brody School and Youth Branch Services Branch of Medicine at ECU Raleigh, NC 27699 Raleigh, NC 27699 Greenville, NC 27834 (919) 715-1653 (919) 715-0640 (252) 744-2608 6 x i d n e p p A Sue Williams Leila Willis Cathy Wooton NC DPH Nutrition Urban Ministries Durham Pediatrics Services Branch of Wake County Durham, NC 27704 Fayetteville, NC 28301 Raleigh, NC 27604 (919) 220-4000 (910) 486-1703 (919) 256-2187 Suzanna Young Anne Wrenn Diane Yelverton NC DPH Physical Activity Brunswick County Wake AHEC and Nutrition Branch Health Department Raleigh, NC 27610 Raleigh, NC 27605 Bolivia, NC 28422 (919) 350-5911 (919) 715-3119 (910) 253-2278 Elizabeth Zimmerman Steven Zeisel, MD PhD NC Prevention Partners UNC-Chapel Hill Carrboro, NC 27510 School of Public Health (919) 843-3414 Chapel Hill, NC 27599 (919) 966-7218

A6-12

Promoting, Protecting and Supporting Breastfeeding Promoting, Protecting and Supporting Breastfeeding

A North Carolina Blueprint for Action 2006

A North Carolina Blueprint for Action / 2006 A North

State of North Carolina Department of Health and Human Services Division of Public Health www.ncdhhs.gov

N.C. DHHS is an equal opportunity employer and provider. 09/06