Creating an Office Setting That Promotes and Supports Breastfeeding

Email: [email protected] August 2009 Creating an Office Setting that

Objectives Promotes and Supports Breastfeeding In an effort to maximize Esther K. Chung, MD, MPH, FAAP breastfeeding initiation and duration, at the end of this training participants will be able to: ll health care providers, In the early 19th century, breastfeeding • Apply the basic principles of breastfeeding to provide whether providing general was the norm in the United States. anticipatory guidance, or specialty care, play a very With the introduction of cow’s support, and resources A to facilitate breastfeeding important role in a family’s decision to milk, scientific advances in formula exclusively for the first six initiate and continue breastfeeding. manufacturing and widespread months, and thereafter with the introduction of other Breastfeeding rates in the United formula marketing, formula feeding foods for up to one year and States, though on the rise, are not has replaced breastfeeding as the as long as mutually desired by the mother and baby. as high as they should be. We live cultural norm. Though breastfeeding • Manage common in a culture where breastfeeding is is currently not the norm in the breastfeeding problems and challenges (i.e., milk supply, thought of as a health behavior that United States, it is the norm in other breast soreness, returning is “good for babies,” but one that is developed countries, including Norway to work), bearing in mind the impact of health care not always chosen by families. Our and Australia, where breastfeeding professionals’ attitudes duties as health care professionals initiation rates are nearly 100 percent. and recommendations on a are to actively encourage families to Similarly, in many developing countries, families’ decision to initiate and continue breastfeeding. breastfeed and to reduce the social which are the countries of origin for • Describe the adverse many of our patients, breastfeeding is effects of secondhand smoke on children, provide Our duties as health care the norm. Health care professionals counseling to families to should lead the way by making reduce tobacco exposure professionals are to actively and quit smoking, and use encourage families to breastfeed breastfeeding the cultural norm in their community resources and office settings. the PA Quitline. and to reduce the social disparities • Identify appropriate communication skills or related to breastfeeding. This article provides practical strategies to support and information on how to create an office promote breastfeeding setting that promotes and supports among mothers who smoke disparities related to breastfeeding. breastfeeding, independent of the and provide assistance to The health benefits of breastfeeding quit smoking. specialty in which you practice. Health • Develop a plan for practice to women, including reduced risks care offices should set the example improvement (i.e., related to for breast and ovarian cancers, and office policy and practices) for other businesses by making their that optimizes outcomes for children including reduced risks for office environments a place where families related to breast- acute otitis media, gastroenteritis, feeding and tobacco cessa- breastfeeding is accepted and tion and promote continuing asthma, and obesity are irrefutable. encouraged. It is extremely important education among staff. The environmental and economic • Use the new Women, Infants to be supportive of breastfeeding in benefits to society have been and Children (WIC) Food verbal and nonverbal communication Packages as a resource for demonstrated but are too often breastfeeding promotion and that is used with families. The underestimated. Health professionals support. American Academy of Pediatrics use an active approach to a number calls for the office setting to provide of health behaviors, including tobacco an inviting, encouraging, informative, cessation and alcohol prevention. flexible, and supportive environment Likewise, health professionals should for breastfeeding families. These enthusiastically promote and support Copyright © 2009 Pennsylvania Medical Society breastfeeding. continued on page 2 2

Creating an Office Setting Figure 1: Table 1: that Promotes and Supports General Tips for Making Your Office Breastfeeding-Friendly Breastfeeding continued from page 1 1. Encourage exclusive recommendations apply to all breastfeeding for the first six settings serving families and are not months of the baby’s life. limited to obstetric and pediatric 2. Welcome breastfeeding in all offices. Breastfeeding, after all, is patient areas of the office. a public health issue that impacts 3. Display images of breastfeeding everyone. mothers and their infants and post signs allowing mothers to Many health care professionals breastfeed their children in all argue that, by definition, doctors’ patient areas. offices support breastfeeding. 4. For mothers uncomfortable with Philosophically many practices may breastfeeding in public, provide support the notion of breastfeeding a private space for them to but that does not necessarily mean breastfeed. that they welcome breastfeeding. 5. Avoid marketing and promoting For example, in many office waiting infant formula, do not distribute rooms, advertisements for infant free formula, or display formula can be found. According to advertisements for formula via a recent report from the Government pens, posters, calendars, etc. Accounting Office, a major way 6. Always provide culturally that the formula industry markets competent care. Copy of a breastfeeding poster their product is through the medical 7. Be familiar with local hospital from the Pennsylvania Department community, including physician policies and community of Health. offices. If a woman sitting in your resources, including a phone See http://www.dsf.health.state. waiting room picks up a magazine resource and refer families when and sees a plump baby in a formula necessary. pa.us/health/cwp/view.asp? A=179&Q=247761. advertisement, then in her mind 8. Track breastfeeding initiation and she may retain positive images of duration rates in your practice. Used with permission. continued on page 3 9. Be familiar with current professional policy statements. 10. Develop and maintain a written breastfeeding office policy. 11. Provide patient education Table 2a: materials. Specific Tips for Practices Providing Pediatric Care 12. Train all staff about the health 1. Discourage the use of pacifiers until breastfeeding is well established. benefits and challenges to 2. Avoid supplementation with infant formula unless medically indicated. breastfeeding. 3. Minimize separation of the baby from the mother, particularly in the first 13. Identify a breastfeeding several days of life. champion who serves as 4. Reserve appointments for newborns needing follow-up within 48 to 72 hours a resource person and an following hospital discharge. advocate in the community to work with local resources and to 5. Encourage breastfeeding on demand. work toward legislative change 6. Encourage families to choose a supportive caregiver or child care center. to improve supports for women 7. Allow infants to feed on demand and avoid scheduled feedings when who breastfeed. possible. 14. Be a model employer by 8. Consider hiring a lactation specialist, who has been certified by the providing breastfeeding employees with space, time, International Board of Lactation Consultant Examiners (IBCLCE). education, and privacy to pump 9. Have a telephone support line for questions related to breastfeeding. and store breastmilk. 3

Creating an Office Setting ashamed. In the future, the mother that Promotes and Supports may not feel that she is able to Table 3: Resources for breastfeed in the office and she may Office Brochures, Posters continued from page 2 Breastfeeding eventually switch to infant formula, and Decals babies fed formula. Similarly, if the which is easily accessible and Brochures nurse triaging her is using a pen generally accepted by all. Similarly, An Easy Guide to Breastfeeding if a mother needs to breastfeed her with the name of a formula vendor from the Office on Women’s Health on it, the woman is going to believe child and the office staff tell her that of the Department of Health and that the nurse and practice support there is no suitable place where Human Services. Available in English formula. On the other hand, if there she can do this, then she may targeting the general population, African are images of breastfeeding mothers interpret that to mean breastfeeding American women, and American Indian in the waiting area, and there are is not supported by the office. On and Alaska Native women. Also avail- no advertisements for formula, the other hand, if the registration able in Chinese and Spanish. http:// then the mother is going to take clerk smiles and makes a positive www.4woman.gov/Pub/BF.General.pdf interest in breastfeeding and will comment about breastfeeding, then Download for free, or call 1-800-994- 9662 to order up to 25 free copies. likely feel supported if she decides to continued on page 4 breastfeed. Breastfeeding Your Baby from the Academy of Obstetricians and We cannot assume that families Gynecologists. http://www.acog.org/ know that we are supportive of Figure 2: bookstore/Breastfeeding_Your_Baby_ breastfeeding unless we tell them. P119.cfm. Packs of 50 available for It may be that many staff members $23.10. are educated about the benefits Breastfeeding Your Baby: and challenges to breastfeeding, Answers to Common Questions from while others are not. Alternatively, the American Academy of Pediatrics. it may be that some staff members https://www.nfaap.org/netforum/eweb/ dynamicpage.aspx?site=nf.aap.org do not support all aspects of Copy of the “Breastfeeding Welcome &webcode=aapbks_productdetail&key= breastfeeding. For example, Here” decal, available from Maternity 19a755d0-2fa7-495e-80a7- if a registration clerk, who is Care Coalition. c43b3a1c674e. Packs of uncomfortable with breastfeeding in 50 available to members for $30. http://www.momobile.org/ public, gives a breastfeeding mother Posters a disapproving look, the mother breastfeeding/DecalCampaign.html. Breastfeeding: Baby’s First may feel unsupported and even Used with permission. Immunization poster available from the American Academy of Pediatrics. Table 2b: http://www.aap.org/breastfeeding/PDF/ Specific Tips for Practices Providing Women’s Health Care BFIZPoster.pdf. Download for FREE. Breastfeeding impact posters from 1. Inform all pregnant women about the importance of breastfeeding, but do not the Pennsylvania Department of Health, limit breastfeeding education to pregnant or breastfeeding women. featuring men and women of various 2. Encourage expectant families to attend prenatal breastfeeding classes when ethnic backgrounds. http://www.dsf. available. health.state.pa.us/health/cwp/view. 3. Educate families about the importance of skin-to-skin contact immediately asp?A=179&Q=247761. (Accessed following delivery and within the first hour of birth. February 6, 2009). Order for FREE. 4. Promote rooming-in, where the infant remains in the mother’s room for the Breastfeeding Your Baby poster. postpartum stay, with families From the Academy of Obstetricans and 5. Provide accurate information about peripartum medications and interventions Gynecologists. http://www.acog.org/ on breastfeeding initiation and duration. bookstore/Breastfeeding_Your_Baby_ Poster_P462.cfm. Order for $9 each. 6. Avoid instrumentation and cesarean section deliveries when possible. Decals 7. Minimize separation of the mother from the baby, particularly in the first several days postpartum. Breastfeeding Welcome Here decals. 8. Consider hiring a lactation specialist, who has been certified by the (IBCLCE). http://www.aap.org/breastfeeding/ 9. Have a telephone support line for questions related to breastfeeding. PDF/BFIZPoster.pdf. $1.50 each. 4

Creating an Office Setting Figure 1 (see page 2) is a copy of adhesive decals can be placed on that Promotes and Supports a breastfeeding poster that health surfaces to face in or out. professionals can order online, free For your convenience, we have also Breastfeeding continued from page 3 of charge, from the Pennsylvania provided you with a list of resources the mother may feel welcomed to Department of Health. These multi- (see table 3) where you can access continue breastfeeding and feel extra ethnic, laminated posters can be affordable and free materials to make confident in her decision to do so. placed in waiting rooms and patient your office more breastfeeding- rooms to show your patients that you friendly. The more welcomed patients feel in promote and support breastfeeding. your office, the more likely they are to Figure 2 (see page 3) is a copy of References are available at return, and the more comfortable they the “Breastfeeding Welcome Here” www.pamedsoc.org/ will feel in seeking your professional decal, available from Maternity Care counterdetails or by calling (800) help. The tips in Table 2a (see page 2) Coalition. This removable, self- 228-7823, ext 7806. are a compilation of guidelines.

Faculty and all others who have the ability to control the content of continuing medical education activities sponsored by the Pennsylvania Medical Society are expected to disclose to the audience whether they do or do not have any real or apparent conflict(s) of interest or other relationships related to the content of their presentation(s). Debra L. Bogen, MD, is Assistant Professor of Pediatrics, University of Pittsburgh School of Medicine. Dr. Bogen is a Board Certified Pediatrician. She is a member of the American Academy of Pediatrics (AAP), PA Chapter, AAP, Academy of Breastfeeding Medicine, and PA Breastfeeding Coalition to name a few. Esther K. Chung, MD, MPH, is on the Medical Staff, Department of Pediatrics, A.I. DuPont Hospital for Children and Thomas Jefferson University Hospital. Dr. Chung is a Board Certified Pediatrician. She is a member of the AAP, PA Chapter, AAP, Philadelphia Pediatric Society, and Pennsylvania Public Health Association. She serves on many professional and scientific committees. Judith L. Gutowski, BA, IBCLC, RLC, is Lactation Consultant Coordinator at the Breastfeeding Center of Pittsburgh, a pediatric practice. Ms. Gutowski is a certified International Board Certified Lactation Consultant (IBCLC) and a La Leche League leader. She is a member of the International and United States Lactation Consultant Association, PA Breastfeeding Coalition, Vice Chairman, and La Leche League International to name a few. FACULTY FACULTY Amy L. Holtan, MA, RD, LDN, is a Public Health Nutrition Consultant, Pennsylvania Department of Health, Bureau of Family Health, Division of Women, Infants, and Children (WIC). She is responsible for coordinating various aspects of the WIC Program. Kathleen L. Hoover, M. Ed, IBCLC, RLC, FILCA, is a Lactation Consultant, Riddle Memorial Hospital, Media, PA. Ms. Hoover is certified as a registered lactation consultant and IBCLC. Cynthia A. Lucero, MD, is Medical Epidemiologist, Office of Public Health Surveillance and Research, Veteran’s Affairs, Pala Alto Health Care System. Dr. Lucero is a Board Certified Pediatrician. She is a member of the Society for Healthcare Epidemiology of America, Association for Professionals in Infection Control and Epidemiology, International Society for Disease Surveillance, and Disease Society of America. Cynthia E. Maki, BS, MS, is a Public Health Nutrition Consultant, Pennsylvania Department of Health, Bureau of Family Health Division, Division of Women, Infants, and Children. She is responsible for developing the breastfeeding objectives of the WIC agency and externally. Deborah Moss, MD, MPH, is Assistant Professor, Pediatrics, University of Pittsburgh School of Medicine. Dr. Moss is a Board Certified Pediatrician. She is a member of the AAP, PA Chapter AAP, and Founder-Co-Chair, Pediatric Tobacco Issues, a special interest group. Todd H. Wolynn, MD, MMM, IBCLC, FAAP, is Executive Director of the Breastfeeding Center, Pittsburgh and the Pediatric Alliance, PC, a pediatric multigroup corporation. Dr. Wolynn is a Board Certified Pediatrician and IBCLC. He is a member of the AAP and PA Chapter, AAP. He serves on many professional committees. 5 Providing Breastfeeding Support in the Primary Care Setting is Not Only Good Medicine, it’s Also Good for the Practice Todd L. Wolynn, MD, MMM, IBCLC, FAAP

tandard-of-care practice PCP offices. While follow up It is also strongly recommended necessitates the support of visits back to your office may be to communicate with the mother’s Sexclusive breastfeeding of necessary, the continuity of care for obstetrician/gynecologist (OB/GYN) infants for the first six months of the problem is enhanced. or PCP to enhance the quality of life. Breastfeeding support services care delivered. represent a tremendous unmet Coding For Breastfeeding If the mother is not your primary care medical need, a decisive chance to Support Services patient, medical services rendered to improve health outcomes, and an The types of codes used will her to address a breastfeeding issue enhanced business opportunity for depend on the details of the may be reported using the “office or your practice. Smart use of office visit. The physician may need other outpatient new patient” codes resources and coding knowledge to indicate that on the day an (CPT 99201-99205) and billed to her can improve the health care you “established patient preventative insurance as an encounter separate deliver and give you a competitive medicine” service (CPT 99391-) from the infant’s. If a request for a edge. for the infant was performed, the consultation is received from her patient’s condition also involved a PCP, OB/GYN, or other appropriate An Unmet Need significant, separately identifiable source, an “office or other outpatient Most lactation services occur in “established patient problem- consultation” code (CPT 99241- maternity hospital settings. These oriented” E/M service (CPT 99211- 99245) may be reported. services typically focus on the 99215) above and beyond the inpatients. Once mother and baby work associated with a preventive 3 R’s of a Consultation are discharged, outpatient services visit to address a breastfeeding • Requested service from an are usually conducted by lactation issue. This circumstance may be appropriate source and need for consultants without medical provider reported by adding modifier-25 to consultation support at hospital lactation centers the appropriate level E/M service. or by private practice lactation Modifier-25 is key to reporting • Rendering the service consultants in the community. when your work is “significant” • Report with findings and Without physician/physician and therefore, additionally billable. recommendations must be extender involvement, the service Without the use of modifier-25, provided to the requesting is rarely covered by insurance and breastfeeding support services physician is paid fee-for-service by the family. offered during a preventive visit may The lactation consultant’s scope not be adequately represented or Consultation codes are typically of care, which usually focused on reimbursed. You can increase the reimbursed at higher levels due “feeding/latching” problems and their likelihood that the insurer will pay to the added work and expertise solutions, does not permit medical for both services by organizing your involved. diagnoses and treatment. Maternal note so that the documentation for After the initial use of a consultation or infant medical problems may the problem-oriented E/M service is code, subsequent medical services result in trips back to one or more separate from documentation for the rendered to the mother would be primary care physicians (PCPs). preventive service. reported using the “office or other Whether for a mother, baby, or both, It is imperative if a pediatric office outpatient established patient” lactation support provided by a provides billable breastfeeding codes (CPT 99212-99215). physician and/or physician extender care to the mother that appropriate New and established office codes can be billed and reimbursed. documentation take place. The and new and established preventive Importantly, this type of lactation mother’s insurance may need to be medicine codes will be utilized for support can address both mother investigated to determine if a referral infants you see depending on the and baby’s needs in a single stop is needed because your primary care circumstances. Remember that without the need to go to separate practice is not identified as her PCP. continued on page 6 6

Providing Breastfeeding Support in Their services may be billed reveals that the infant is not the Primary Care Setting “incident to” another licensed breastfeeding well and has lost close continued from page 5 and reimbursable health care to seven percent of birth weight. A professional under established risk for dehydration and other related once you or your practice have seen patient visit codes by following complications is acknowledged due the infant in the hospital on rounds criteria required for “incident to” to feeding difficulties. The physical and billed for that service, the baby billing. The IBCLC/physician “shared indicates adequate hydration and is is not considered “new” when seen visits” can be very effective and overall normal. in your office the baby is considered efficient for clinical care. When the The mother complains about nipple an established patient. physician and IBCLC “share” the irritation and pain with nursing. same patient, on the same day, their A medical history is taken and The appropriate use of coding work is combined and billed under physical exam of the mother is and billing is ESSENTIAL the physician at 100 percent of completed. No significant medical to operating a successful the fee schedule. Visits conducted history issues are present but the breastfeeding support service. with physician involvement, mother’s nipples are indeed red and Please refer to the American including face-to-face time with irritated. A breastfeeding session is Academy of Pediatrics, Supporting the patient, oversight, and decision observed and an improper latch is Breastfeeding and Lactation: making, qualify for evaluation and corrected on the spot with almost The Primary Care Pediatrician’s management service coding. Guide to Getting Paid available instantaneous relief of the mother’s at http://www.aapdistrictii.org/ Having a lactation consultant as pain associated with nursing. You BreastCoding.pdf. This resource is part of your office staff can be very are confident that the corrected condensed yet complete and can effective depending on the volume latch will solve the problem. You be used as a template for groups of breastfeeding support services prescribe a topical treatment to help intending to integrate breastfeeding you offer. They can offer immense the mother’s nipples heal. services into their practice. The expertise and make the service A follow up visit is scheduled for American Academy of Pediatrics, become cost-efficient. Breastfeeding both the mother and the baby within American Medical Association, and support sessions may require up the next few days. other medical organizations also to an hour or more. The amount of have resources for coding. time actually required by a physician As shown below, this interaction or extender is reduced while the would be appropriately coded How to Integrate the Lactation lactation consultant works under with a preventive 9939X code for Consultant into the Physician their supervision. The key is efficient the well care, a 25 modifier and a Practice Visit use of the appropriate personnel to Sick 9921X to reflect the services International Board of Certified provide these services. involved in diagnosing and treating the infant’s feeding problem. Lactation Consultants (IBCLC) are Providing Breastfeeding Support currently not licensed providers Service in your Office Enables: The services utilized to diagnose and in Pennsylvania and generally are treat the mother’s medical problem not recognized by most insurance • Standard of Care Medicine are appropriately coded with a New companies, as such. The United with potential significant Sick 9920X code with diagnosis of States Lactation Consultant Health Benefits Sore Nipples. Association is coordinating efforts • A Revenue Source for throughout the country to establish appropriately provided and Infant Codes licensure for IBCLCs. coded service CPT: 99391 Potentially, some IBCLCs can • Enhanced care with the (Established preventive < l yr) bill commensurate with their integration of a lactation ICD9: V20.2 background within health care consultant (Diagnosis: well care) practices and these services can 25 modifier condition be covered by insurance. Examples Brief Case Example: requiring significant and include: registered nurse, nurse A 4-day old infant, 39-week additional work practitioner, physician assistant, and gestational age with normal birth during the well visit licensed nutritionist. weight, comes in for an established preventive care visit. The history continued on page 7 7 Smoking and Breastfeeding? What is a Doctor to Do? Debra L. Bogen, MD, Deborah R. Moss, MD, MPH, and Cynthia Lucero, MD

Introduction to Smoking Societal benefits of breastfeeding Despite the preponderance of and Breastfeeding include health care savings,2 information about the health risks of vidence to support the diverse fewer missed days at work,3-5 and smoking, women continue to smoke benefits of breastfeeding to environmental effects, such as no at alarmingly high rates. Based Einfants, mothers, and society pollution or waste. on national data from 2006, 18 continues to grow. The Agency percent of all women report current In contrast to breastfeeding, tobacco for Health Care Research and smoking12 and 13 percent of women use continues to be linked to Quality (AHRQ) Evidence Report, reported smoking during the last numerous adverse consequences “Breastfeeding and Maternal and three months of pregnancy.13 for mothers, infants, and society. Infant Health Outcomes in Developed Smoking during pregnancy is Countries,”1 indicated that breastfed Association between smoking associated with adverse pregnancy infants have lower risk of acute and breastfeeding outcomes, including premature otitis media, atopic dermatitis, Women smokers are significantly less birth, low birth weight, and higher non-specific gastroenteritis, likely to intend to breastfeed and to incidence of stillbirth6, 7 After obesity, sudden infant death, and initiate breastfeeding.14-23 Smokers pregnancy, infants whose mother’s hospitalization for lower respiratory also stop breastfeeding sooner than smoke are at increased risk of infections. Mothers who breastfeed non-smokers.24 Horta in a meta sudden infant death syndrome,8, have a lower risk of breast cancer, analysis found that among women 9 asthma, and hospitalizations for ovarian cancer, and type 2 diabetes. pneumonia and bronchitis.10, 11 continued on page 8

Providing Breastfeeding Support in the Primary Care Setting continued from page 6

Mother Codes CPT: 99213 (Establish sick office visit) ICD9: 779.3 (Diagnosis: feeding disturbance) Mother codes CPT: 99204 (New sick office visit) ICD9: 676.34 (Diagnosis: Sore Nipples) As a physician, the goal is to increase the availability and quality of lactation support services in the primary care setting. The medical community actively helped to disassemble thousands of years of the passing on lactation skills from generation to generation, and it is incumbent upon US to make breastfeeding right again! 8

Smoking and Breastfeeding? general population, or may have months, exposure to environmental concerns about adverse health tobacco smoke, and, especially, What is a Doctor to Do? 30 continued from page 7 effects of smoking on their baby. the combination of the two were Whatever the etiology, smokers are significantly associated with who initiated breastfeeding, smokers significantly less likely to initiate or severe bronchiolitis and prolonged had a pooled odds ratio of 1.93 (95 continue to breastfeed. hospitalization. Importantly, passive percent cumulative incidence 1.55, smoking did not increase the risk 2.40) of stopping breastfeeding Smoking and Breastfeeding when infants were breastfed for more before three months compared to Initiation Rates in Pennsylvania than four months.36 Findings from non-smokers. Physiologic factors Between 2004 and 2006, the a birth cohort study demonstrated that impact milk volume have number of Pennsylvania resident live that the triad of recurrent lower been proposed as one reason births to mothers who smoked prior respiratory tract infection in infancy, for the difference in breastfeeding to pregnancy rose from 32,398 to maternal smoking, and breastfeeding rates between smokers and non- 32,960, while the rate of live births for less than three months was smokers.25 Rat models demonstrated to mothers who smoked prior to strongly associated with asthma a decrease in prolactin release with pregnancy but not during pregnancy at ages four and 10 years. The nursing and decreased milk output rose from 24.5 percent to 24.9 investigators also found that and rat pup growth with exposure percent. Based on data reported breastfeeding three months or longer to nicotine or tobacco smoke. on the Pennsylvania certificate of attenuated the effect of prenatal Nicotine increases dopamine, which live birth between 2004 and 2006, smoking on asthma.37 So what of in turn inhibits prolactin release and rates of breastfeeding initiation smoking and breastfeeding? increases adrenaline, which in turn among women who smoked in There is increasing evidence that decreases oxytocin release. Prolactin the third trimester of pregnancy the incidence of acute respiratory is essential for milk production rose from 35.2 percent to 37.8 infections in breastfed infants of while oxytocin is essential for milk percent and varied according to smoking mothers is decreased ejection. In a human study, women age, ethnicity, and race. Among compared to formula-fed infants of who smoked at least 15 cigarettes women in Pennsylvania who smoking mothers.38, 39 per day had significantly lower basal smoked during the third trimester of Colic: Survey based studies, both prolactin levels on days one and 21 pregnancy, there is a trend towards longitudinal and cross-sectional, post partum than non-smokers but increasing breastfeeding initiation have demonstrated that maternal the rise in prolactin measured with rates. Asian American women who smoking during pregnancy40, 41 and nursing was not different between smoked during the third trimester after delivery42 are associated with groups. Oxytocin levels were not of pregnancy reported the highest an increased risk of infantile colic. different between groups in this rate of breastfeeding initiation On the other hand, some studies study.26 Similarly, Hopkinson reported (49.3 percent in 2006) compared have found that breastfeeding is lower milk volumes among smokers with whites (39.2 percent in 2006) associated with a lower risk of expressing milk for their preterm and African-American women infantile colic42, 43 while others have infant than non-smokers.27 (28.6 percent in 2006). (Source: not.44-46 What about studies that look Pennsylvania certificate of live birth) Based on epidemiologic data, at both infant feeding method and Donath suggested the difference smoking with regard to risk of colic? What is known about the effects in breastfeeding rates between One study found that exposure of smoking and breastfeeding on smokers and non-smokers is more to tobacco via breast milk was infant health? likely explained by lower rates of associated with an increased risk of Respiratory Infections: breastfeeding intention among colic but this study did not control for Many studies have reported smokers than by physiologic smoking in pregnancy.47 By contrast, maternal smoking and/or lack of factors.21 Breastfeeding intention Canivet et al found that exclusive breastfeeding as risk factors for is a strong predictor of actual breastfeeding was protective against respiratory infections or acute breastfeeding practice.28 Other colic, even among infants whose respiratory disease hospitalizations possible explanations are that mothers smoked and breastfed.41 in children.31-35 One recent study smokers are more likely to perceive Additional research is needed in this examining risk factors for severe their milk supply as insufficient,29 area. bronchiolitis in infants found are less health conscious than the that breastfeeding less than four continued on page 9 9

Smoking and Breastfeeding? women who cannot or will not In the office-based setting, the What is a Doctor to Do? stop smoking, breastfeeding is clinician can assist all smokers by continued from page 8 still advisable, since the benefits recommending effective treatment of breast milk outweigh the that consists of behavioral Infant Sleep: One study has risks from nicotine exposure.”51 management and pharmacotherapy. examined the impact of smoking Beginning with the 2001 American Behavioral treatment can take and breastfeeding on infant sleep/ Academy of Pediatrics (AAP) policy many forms, from individual to wake patterns.48 In this study, statement, “The Transfer of Drugs group counseling and telephone women and their babies served as and other Chemicals into Human to in-person treatment. Regardless their own controls a week apart. Milk,” nicotine was removed from of treatment type, cessation rates The study was conducted in a the tables of drugs contraindicated increase according to the intensity of controlled environment; infants during breastfeeding.52 In the 2005 treatment. That is, the more intensive were not exposed to second-hand policy statement, “Breastfeeding the treatment (longer sessions, smoke prior to either study time. and the Use of Human Milk,” the greater number of sessions) the Infants spent less time sleeping AAP supported the continuation of higher the quit rate. breastfeeding among mothers who in the three and a half hours after In addition to counseling, smoke by stating definitively that exposure to tobacco via breast milk pharmacotherapy is a proven smoking is not a contraindication to than when not exposed. Although effective component of tobacco breastfeeding.53 Other organizations, this was a small study, its findings dependence treatment. The use of including the American Academy of are consistent with the current risk pharmacotherapy, either nicotine Family Physicians (AAFP) and World reduction strategy to have mothers replacement therapy (NRT), such Health Organization (WHO), have refrain from smoking immediately as nicotine gum, inhaler, lozenge, made similar recommendations.54 before breastfeeding. patch, or nasal spray or non-nicotine While supporting breastfeeding in replacement therapy (Bupropion and Infant Weight Gain: Little found that the context of maternal smoking, the Varenicline) can triple the likelihood infants whose mothers smoked and policies strongly encourage smoking of successful quitting with quit rates breastfed were heavier at one year cessation or reduction.55,56 of age and had a higher body mass of 30-40 percent reported in various pharmacotherapy trials.26-28 While index than infants whose mothers Strategies to Reduce Smoking counseling and pharmacotherapy did not smoke and breastfeed or The Public Health Service Smoking 49 are each effective therapies when smoked and formula fed. In a more Cessation Clinical Practice Guide- used alone, it has been shown recent, large, well -designed study, line57, 58 summarizes evidence to date that the use of counseling with smoking and breastfeeding were on effective cessation interventions pharmacotherapy augments not related to infant growth except by primary care providers. It states the cessation rate. Therefore, that infants who were exposed to that primary care physicians should it is important that physicians tobacco during pregnancy and were address the Five A’s: breastfed showed some “catch-up identify and refer all smokers and growth.”50 • Ask about smoking status of strongly recommend or prescribe every patient. pharmacotherapy. Current Recommendations • Advise smokers to quit. Regarding Smoking and Breastfeeding and Breastfeeding • Assess smokers’ readiness to Pharmacotherapy for Smoking Recommendations about set a quit date. Cessation breastfeeding in mothers who Although the AAP and other • Assistance toward cessation. smoke have evolved as new organizations encourage data on the relative risk-benefit • Arrange additional assistance as discussions with mothers regarding relationship becomes available. needed. breastfeeding, smoking, and In 2000, the U.S. Department of smoking cessation, there have By following these practice Health and Human Services (HHS) been no formal recommendations recommendations, physicians issued the “HHS Blueprint for regarding NRT or other can significantly reduce smoking Action on Breastfeeding.” In the pharmacologic management of rates and the adverse health section addressing tobacco smoking for breastfeeding women. consequences related with consumption, it stated, “for smoking.59 continued on page 10 10

Smoking and Breastfeeding? cessation, recommendations on months (38 percent) than national the use of these products should rates and the Healthy People 2010 What is a Doctor to Do? 21 continued from page 9 be incorporated into breastfeeding objectives. Physicians who work guidelines. with women of child bearing age However, limited evidence supports have an opportunity to both promote Data continue to emerge regarding the use of NRT during pregnancy60 breastfeeding and smoking cessation use of medication and breastfeeding. and lactation61 as a harm reduction and may be called upon to give In one survey, 40 percent of strategy although no formal advice regarding smoking cessation pediatricians report using the guidelines exist. When used as and the safety of breastfeeding for Physicians’ Desk Reference (PDR) directed, the 21-mg nicotine patch smoking mothers. when considering breastfeeding and transfers no more nicotine into breast medication decisions. While the PDR However, survey data of health milk than one pack-a-day smoking is a good general pharmaceutical care providers’ practices suggest while 14- and 7-mg patches and reference, it is considered a poor that there is room for improvement. nicotine gum confer less.61-63 source of information about the Oncken et al. surveyed obstetrical Additionally, NRT (specifically the potential effects of medications on and pediatric providers in the nicotine patch) has no significant a lactating mother or her infant.24 It Boston area and found that only influence on infant milk intake.61 In contains information from package 58 percent of obstetrical providers order to minimize the transfer of inserts produced by pharmaceutical and 34 percent of pediatric nicotine into breast milk, women are manufacturers, based on their providers discussed risks and encouraged to remove their nicotine product studies. Since manufacturers benefits of NRT with pregnant or patch at bedtime and to refrain rarely conduct their own studies lactating mothers. Among women from chewing nicotine gum, using on lactating women, package in a controlled trial of telephone a nicotine nasal spray or smoking inserts generally recommend counseling for smoking cessation cigarettes for two to three hours prior that the medication not be taken that did not include medication, to and during breastfeeding.62 while breastfeeding, even when 29 percent reported discussing Smokers have expressed support for studies have been done by others. a cessation medication with their the use of NRT during pregnancy64; Physicians should be aware of obstetric providers.71 Surveys of however, surveys of mothers and this limitation and utilize resources adult smokers have also reported physicians have found very low that contain more comprehensive low rates of smoking cessation levels of support for NRT use in lactation safety information. For medication recommendations and breastfeeding women. A survey of example, the National Library of prescriptions to parental smokers new mothers found that only two Medicine Drugs and Lactation during child health care visits percent of nonsmoking mothers and Database, (LactMed), http://toxnet. by both pediatricians and family four percent of smoking mothers nlm.gov/cgi-bin/sis//htmlgen?LACT is physicians.72, 73 In one study, 15 agreed that a breastfeeding woman a reliable and free on-line resource.25 percent of smoking parents had could use NRT.30 Physician surveys pharmacotherapy recommended and have found as few as 15 percent of What is the Physician’s Role? eight percent received a prescription pediatricians believe all forms of NRT Improving maternal smoking for a smoking cessation medication to be safe with breastfeeding and cessation rates and breastfeeding by their child’s physician.72 fewer still (five to 11 percent) would rates are important challenges for Parents are receptive to physicians recommend or prescribe NRT for many states, including Pennsylvania. talking to them about smoking lactating smokers.65, 66 Nationwide, eight-35 percent cessation.74, 75 Mothers are equally of breastfeeding mothers are There is also very limited published as likely to ask their own physician smokers.15, 17, 18 Studies by the data on the two non-nicotine as their child’s physician for advice Annie E. Casey Foundation ranked medications available for the on smoking and breastfeeding.30 Pennsylvania cities among the worst treatment of tobacco dependence Other studies have found that most in the nation for maternal smoking (Bupropion/Zyban® and Varenicline/ parents believe it is an important part rates for more than a decade.19, 20 Chantix™) in lactating women.67-70 of a pediatrician’s job to ask about a While Pennsylvania has high rates When more definitive information parent’s smoking status.39 Surveys of smoking during pregnancy, it has is available regarding the safety of smoking parents have found that lower rates of breastfeeding initiation of NRT and the non-nicotine most wanted some kind of smoking (69 percent) and duration at six prescription medications for smoking continued on page 12 11

Resources for Patients What they provide Pennsylvania 24-hour Free Quitline Phone is staffed by clinically trained counselors. Callers are 1-800-QUIT-NOW referred to a counselor and are mailed an appropriate booklet http://1800quitnow.cancer.gov/ based upon their readiness to make a quit attempt. Special materials are also available for spit tobacco users and pregnant women. In Pennsylvania this quitline is supported by the Pennsylvania Department of Health (DOH). Physicians may order free materials from the Quitline. Determine to Quit This DOH website offers support and help with quitting smoking. http://www.determinedtoquit.com/ Individuals can click on the “Community Support and Resources” button to find programs in their own community. Resources for Providers Physician Smoking Cessation Counseling Education The Pennsylvania Area Health Education Center offers this free http://www.paahec.org/ online program. Smoke-Free Homes The website is intended to provide resources, information, ideas, http://www.kidslivesmokefree.org/ and opportunities for collaboration for pediatric clinicians. Smokefree.gov CDC sponsored webpage with quit support materials, links to http://www.smokefree.gov/ on-line chat and telephone counselors, research trials/studies, and print materials. Treatobacco.net Treatobacco.net provides evidence-based data and practical sup- http://www.treatobacco.net port for the treatment of tobacco dependence. It is aimed at phy- sicians, nurses, pharmacists, dentists, psychologists, researchers, and policy makers. Treatobacco.net is produced and maintained by the Society for Research on Nicotine and Tobacco, in associa- tion with the World Bank, Centers for Disease Control and Preven- tion, the World Health Organization, the Cochrane Group, and a panel of international experts. NIDA InfoFacts: Cigarettes and Other Tobacco Products This NIDA InfoFact sheet discusses statistics associated with http://www.drugabuse.gov/Infofax/tobacco.html smoking and tobacco use, health hazards, promising research, and treatments that are available to help smokers quit. It is also available in Spanish. Treating Tobacco Use and Dependence, 2008 Update: A comprehensive document, this guideline contains evidence- Clinical Practice Guideline based strategies and recommendations designed to assist clini- http://www.ahrq.gov/path/tobacco.htm cians, tobacco dependence treatment specialists, and others in delivering and supporting effective treatments for tobacco use and dependence. Help for Smokers and Other Tobacco Users Available in both English and Spanish, this booklet is a companion http://www.ahrq.gov/consumer/tobacco/helpsmokers.htm of the “Treating Tobacco Use and Dependence: 2008 Update” Clinical Practice Guideline. It is written in an easy-to-understand format and includes educational and motivational messages and resources to help patients/consumers quit smoking. HealthCare Provider Reminder Systems, Provider, This CDC guide helps health care delivery systems to improve the and Patient Education: Action Guide delivery of tobacco use treatment to patients. http://www.prevent.org/content/view/159/178/ Guide to Community Preventive Services: This guide, released by the CDC in 2001, provides recommenda- Tobacco Use and Control tions to decision makers about the types of interventions most http://www.cdc.gov/tobacco/tobacco_control_programs/ appropriate for reducing tobacco use and exposure for different stateandcommunity/comguide.htm populations. Recommendations are based upon the strength of the evidence for each intervention type according to a systematic review process and are helpful to decision makers when selecting an intervention for specific groups or individuals. National Tobacco Cessation Collaborative The purpose of the NTCC web site is to provide in one place the http://www.tobacco-cessation.org/ best available information on tobacco cessation. This information comes from the many agencies and organizations working to increase tobacco cessation in the United States and Canada. 12 Integrating Lactation Support Providers into Pennsylvania Health Care Practices Judith L. Gutowski, BA, IBCLC

ost patients seek Breastfeeding has both immediate help with breastfeeding.8 Breastfeed- information and guidance and long-term health benefits.5 Penn- ing challenges can be complex, and Mabout breastfeeding sylvania’s breastfeeding rates for 2005 some mother/baby pairs need more from their health care provider. were 71 percent at birth, 36 percent services than others. Community re- The importance of the provider’s at six months, and 16 percent at 12 sources and comprehensive lactation recommendations should never months.6 These low rates reflect the care are scarce in many geographical be underestimated. Maternity and many physical and social barriers that areas in Pennsylvania. It is the physi- pediatric care providers have a women face in order to continue to cian’s role to know the breastfeeding profound influence on breastfeeding breastfeed. Lack of support services services that are available in the initiation, exclusivity, and duration. for breastfeeding can result in un- community and to refer mothers for Their opinions and advice provide necessary use of formula, premature the appropriate level of service. crucial support that is critical to weaning, or bottle-feeding pumped breastfeeding success. Collaboration milk with far-reaching consequences Health care providers among physicians, other health care to the health of women and children. Research shows that the role of professionals, and lactation specialists Ideally, all pregnant women would the health care provider is critical to achieves coordinated and optimal 2, 3, 7, 9, 10 begin to receive lactation care during breastfeeding success. To in- care for breastfeeding families. the first trimester of pregnancy. After crease breastfeeding duration, health birth, rather than providing episodic care provider practices must be able Background and Need breastfeeding support (the current to identify and solve breastfeeding The provision of timely and appro- “crisis intervention” model), there problems. The American Academy of priate lactation support has been would be a continuous care process Pediatrics (AAP), American College of shown to increase the likelihood aimed at eliminating barriers to Obstetrics and Gynecology (ACOG), of successful breastfeeding and breastfeeding, providing education, American Academy of Family Physi- improve duration.1, 2, 3 Early lacta- preventing problems, and enhancing cians (AAFP) and the Academy of tion difficulties are common, even in maternal confidence.2,3,7 This pro- Breastfeeding Medicine (ABM) have women who are highly motivated to cess would continue until the time of provided guidelines for the optimal breastfeed and who receive lactation weaning.36 level of breastfeeding support in a guidance during the hospital stay.4 health care provider practice. It is estimated that 30 percent of Today, most women find they are breastfeeding women require profes- inundated with lactation support The AAP Policy statement on sional assistance to overcome prob- on postpartum day one, but at one “Breastfeeding and Human Milk” lems and 81 percent have general month they may have to contact as recommends, “a formal, observed breastfeeding concerns.4 many as six providers before finding evaluation of breastfeeding, including continued on page 13

Smoking and Breastfeeding? Improving health care providers’ The table on page 11 provides What is a Doctor to Do? willingness to have these discussions information about available resources continued from page 10 during routine health care visits, to help Pennsylvania practitioners including child health visits, could aid mothers to quit or reduce their cessation help from the pediatrician’s lead to improvements in both smoking and support breastfeeding. breastfeeding and smoking cessation office and the majority feel it would References are available at rates. Efforts are needed to increase be acceptable if their child’s doctor www.pamedsoc.org/ health care providers’ practices of prescribed or recommended it to counterdetails or by calling (800) 23, 39,74 smoking cessation counseling and them. 228-7823, ext 7806. offering proven cessation aids. 13

Integrating Lactation Support Protocol #14 “Optimizing Care for health care team. This practice is 12 Providers into Pennsylvania Infants and Children”) . Providers defined in the “Clinical Competencies can use these tools to analyze Professional Standards for IBCLCs.”7 Health Care Practices current office practices and commit Table 1 on page 14 identifies core continued from page 12 to implementing these quality areas of competency for IBCLCs. position, latch, and milk transfer” at improvement steps. The IBCLC employed within a health- the first pediatric visit, between three Many primary care providers have 5 care practice can receive insurance to five days of age. During this visit not received formal training in lacta- reimbursement for their services the breastfeeding dyad should also tion, although some pursue it on their through “incident to” billing under be assessed for risk factors that own. There is a wealth of evidence the physician or through billing under endanger successful breastfeeding. that many physicians feel uncomfort- other credentials they may have.18 A referral for comprehensive lactation able and are inadequately prepared Those who are in private practice assessment and plan of care is ap- to work hands-on with breastfeeding usually bill their clients directly and propriate for one or more risk factors: problems.13, 14, 15 Additionally, effective provide documentation for the cli- lactation interventions require long • ≤38 weeks gestation ent to seek reimbursement on their term and time-intensive strategies.3 own. However, it is difficult to obtain • Baby not latching-on Primary care providers work under reimbursement for independently bill- or latch difficulty increasing resource and time con- straints making it difficult to provide continued on page 14 • Nipple or breast pain thorough lactation support. • Jaundice Support from an International “Ten Steps to Support • Infant weight loss > seven Board Certified Lactation percent of birth weight Parents’ Choice to Consultant (IBCLC) Breastfeed Their Baby, • Use of any breastfeeding aid: International Board Certified Lacta- Breastfeeding Promotion in nipple shield, supplemental tion Consultants (IBCLCs) have Physicians’ Office Practices,” nutrition system, breast shells demonstrated specialized knowledge AAP 1999, revised 2003 and clinical expertise in breastfeeding • Infant with a medical diagnosis and human lactation and are certified 1. Make a commitment to the likely to affect normal feeding, importance of breastfeeding. by the International Board of Lacta- for instance, a baby with Down tion Consultant Examiners (IBLCE). 2. Train all staff in skills to support syndrome, cleft palate, cardiac They typically deal with breastfeeding breastfeeding. condition, etc. problems and come from a variety 3. Inform women about the benefits • Woman with a medical condition of backgrounds including nurses, and management of breastfeeding. likely to affect lactation, for midwives, family physicians, pe- 4. Assess infants during early instance, a history of breast diatricians, obstetricians, childbirth follow-up visits. surgery, hypothyroidism, educators, dietitians, occupational 5. Encourage mothers to breastfeed polycystic ovarian syndrome, and physical therapists, experienced on demand. profound obesity, etc. mother support counselors, and 6. Show mothers how to breastfeed others. They work in a variety of set- and maintain lactation when they A follow-up visit at two to three tings including hospitals, neonatal will be away from their babies. weeks after birth confirms that the intensive care units, lactation clinics, 7. Provide anticipatory guidance to baby is gaining weight. maternal and child health services, support exclusive breastfeeding Frameworks for creating a WIC, corporations, physicians’ of- for the first six months of life. breastfeeding-friendly physician fices, and private practice.16 8. Provide accurate information office have been written by the on maternal issues to support Several studies have shown an breastfeeding. Academy of Pediatrics, (“Ten Steps increase in breastfeeding duration 9. Communicate support to Support Parents’ Choice to with the employment of IBCLCs. The Breastfeed Their Baby, Breastfeeding of breastfeeding in office clinical practice of the IBCLC con- environment. Promotion in Physicians’ Office sists of systematic problem-solving 11 10. Expand the network of support Practices”) , and the Academy of in collaboration with breastfeeding for breastfeeding. Breastfeeding Medicine (Clinical mothers and other members of the 14

Integrating Lactation Support knowing one’s limits and when to breastfeeding counselors similar to Providers into Pennsylvania refer. The lay support groups and La Leche League Leaders. peer counselors found in many The basic services provided by these Health Care Practices communities also provide ongoing two latter groups are not sufficient for continued from page 13 support and encouragement for solving all of the problems that cause normal breastfeeding and refer ing IBCLCs, either because lactation mothers to wean prematurely. If there women with problems to their support is not considered a medical are no IBCLCs in the area, the surest primary physician or a lactation necessity, or because it is not a way to know that families will find the consultant. covered benefit. A document about care they need is for a physician or insurance coding for lactation support someone in the physician’s office to Community breastfeeding groups services is provided by the AAP and obtain extra training in clinical lactation La Leche League Leaders are moth- can be found at http://www.aap.org/ support skills for breastfeeding 19 ers who are members of La Leche breastfeeding/CODING.pdf. challenges. For example, an online League International, have breastfed course is available at at least one child for at least nine Breastfeeding educators http://www.breastfeedingtraining.org months, and have undergone an A second group of professionals who and provides CME.21 accreditation process that includes can provide breastfeeding support training and education about breast- The American Academy of Pediatrics are breastfeeding educators (or other feeding management, parenting, recommends identifying, utilizing, titles found in Table 2, see page 15). child development, and communica- and referring to all of the available These health workers have received tion skills. La Leche League Leaders types of breastfeeding support training in basic breastfeeding are volunteers.20 They assist breast- described above.5,12 It is in the best support skills. This training is typically feeding women in their community. In interest of health care providers and a 15- to 45-hour course that covers Pennsylvania there are several other their patients to develop working the normal course of breastfeeding, nursing mothers’ organizations with with particular attention given to continued on page 15

Table 1: Core areas of competency for International Board Certified Lactation Consultants

Skills For Normal Course Skills For Maternal Skills For Infant of Breastfeeding Breastfeeding Challenges Breastfeeding Challenges • Assess adequate milk intake • Insufficient milk supply: • Traumatic birth • Normal infant sucking patterns perceived and real • 35-38 weeks gestation • Maintaining milk production • Flat/inverted nipples • Small for gestational age • Normal newborn behavior • Prevention and treatment of sore • Large for gestational age • Sleepy newborn nipples, plugged duct, or nipple pore • Multiple births • Importance of exclusive human • Mastitis • Preterm birth milk feedings • Overproduction of milk • Hypoglycemia • Prevention and treatment • Breast surgery or trauma • Sleepy infant of engorgement • Cultural beliefs that interfere with • Excessive weight loss • Mother/baby separation breastfeeding • Slow/poor weight gain • Milk expression techniques • Medical conditions that • Hyperbilirubinemia • Collection, storage, and impact breastfeeding • Ankyloglossia transportation of milk • Adolescent mother • Colic/fussiness • SIDS prevention behaviors • Postpartum psychological issues • Gastric reflux • Family planning methods • Weaning • Lactose overload and breastfeeding • Induced lactation and relactation • Food intolerances • Planning follow-up care for • Death of an infant • Neurodevelopmental problems breastfeeding • Teething and biting • Community resources for • Infant with dysfunctional suck breastfeeding • Cranial-facial abnormalities, i.e., micrognathia, cleft lip and/or palate • Down syndrome • Cardiac problems • Chronic medical conditions, i.e.. cystic fibrosis, PKU 15 The Impact of the New Women, Infants, and Children (WIC) Food Packages on Breastfeeding Promotion and Support Amy L. Holtan, MA, RD, LDN, Martha Kautz, RNC, BS, IBCLC, RLC, and Cynthia Maki, MS, RD

he Women, Infants, and Americans2 as well as current infant cused on mitigating health problems Children (WIC) food package1 feeding practice guidelines of the associated with overweight and is changing. Supplemental American Academy of Pediatrics obesity and increasing the intake of T 3 foods offered by the WIC program (AAP). They also allow for whole grains and dietary fiber. The have not changed since 1980. participant and cultural preferences. food package is also being changed Beginning in October 2009, foods to decrease the health risks as- Foods originally on the WIC program offered to all women, infants, and sociated with use of supplemental addressed public health needs, such children through the Pennsylvania formula while breastfeeding. as anemia and low protein intake. WIC Program will better align with Today’s public health needs are fo- the current Dietary Guidelines for continued on page 16

Integrating Lactation Support all ILCA members provide Providers into Pennsylvania outpatient services. Pennsylvania Pediatric Office http://www.ilca.org/falc.html Health Care Practices with Breastfeeding-Friendly continued from page 14 • La Leche League Leaders—to Best Practice aid with the normal course of The Breastfeeding Center of Pittsburgh relationships among people and breastfeeding and basics. has developed a model for providing organizations who have the mission http://www.llli.org/Web/ comprehensive lactation support to promote, support, and protect Pennsylvania.html within a pediatric office. Six of the breastfeeding. All health care pro- eight pediatricians and a pediatric vider staff should be familiar with the • WIC Agencies nurse practitioner are (International local resources and know how to http://www.pawic.com/ Board Certified Lactation Consultants refer patients for breastfeeding sup- localagency.html (IBCLCs) and the practice employs five port. In particular, office nurses and additional IBCLCs. A breastfeeding baby’s initial visit usually lasts one to medical assistants who triage phone one and a half hours and consists of a calls and have frequent patient in- history, physical exam of the infant and teraction should understand the risk the mother’s breasts, and observation factors for lactation problems and of a feeding. A physician with IBCLC know how they are managed within Table 2: Titles often used certification or an IBCLC who consults their practice setting. They should by breastfeeding support with a physician does the assessment. also know when and how to provide professionals The team develops a plan with the referrals for resources outside of the parents. • Breastfeeding specialist practice setting. • Lamaze international When there is a problem, the babies Breastfeeding support providers in breastfeeding support specialist are seen for on-going, frequent appointments until the problem your area of Pennsylvania can be • Breastfeeding counselor • Breastfeeding educator resolves. Whether or not early follow-up found at http://www.pawic.com/ • Certified breastfeeding educator visits are needed, all breastfeeding breastfeeding-guide.pdf (CBE) infants have an ambulatory visit at You may also refer to these online • Early breastfeeding care two to three weeks of age to monitor weight gain and provide additional resources for finding breastfeeding specialist/doula breastfeeding training support and encouragement to the support providers: • Certified lactation educator mother during this critical period. • International Board Certified • Certified lactation counselor More information can be found at: Lactation Consultant (IBCLC) (CLC) http://www.pediatricalliance.com/ index.cfm searchable database—not • WIC peer counselor 16

The Impact of the New ning in October 2009, women who months. Additional foods available Women, Infants, and Children exclusively breastfeed will receive ad- on the fully breastfeeding mother and ditional amounts of milk, eggs, fruits, infant package is an additional value (WIC) Food Packages and vegetables and are the only WIC of $65 per month between month six continued from page 15 participant type who automatically and 11. This article focuses on the impact of receive cheese and canned fish. the new food packages on breast- Fully breastfed infants (WIC’s term for New WIC Guidance Related feeding promotion and support. exclusive breastfeeding) will receive to Breastfeeding and Formula The food package changes, which twice the amount of baby fruits Issuance and vegetables and will be the only In order to reduce the risk of breast- pertain to breastfeeding mothers and 1 infants, facilitate WIC and health care infants who will receive baby meats. feeding failure, the new USDA food provider efforts to promote and sup- Additional food for the mother is an package rules stipulate that NO port the establishment of exclusive additional value of $25 per month continued on page 17 and long-term breastfeeding. between birth of the infant and five

Lack of breastfeeding can set chil- Food Packages dren up for risk factors for ill health. The life-long impact can include Fully (exclusively) breastfeeding mother and infant poor school performance, chronic 0-5 months: Mother additional value of $25 of foods per month diseases, impaired intellectual and 6-12 months: Mother and infant additional value of $65 of foods per month social development, and reduced 4 productivity. New United States Department of Agriculture Studies conducted in industrialized Starting October 2009 countries have shown that the risks Infant Foods/Month – associated with not being breastfed No foods issued for infants younger than 6 months of age for at least six months include: Food Category Fully (exclusively) breastfed Formula fed • 3.5 times more likely to be hospi- Infant cereal 24 ounces 24 ounces talized for respiratory infections Fruit/vegetable* 64 jars (256 ounces) 32 jars (128 ounces) • 2 times more suffer from diarrhea Meat* 31 jars (77.5 ounces) None • 1.6 times more ear infections * New food or changed amounts

• 1.5 times more likely to become Mother Foods/Month overweight during childhood.5 Issued birth of infant to Issued birth of Health care providers play a primary 12 months infant to six months role in promoting and supporting ex- Food category Fully (exclusively) No breastfeeding clusive and long-term breastfeeding breastfeeding among their patients.6 It is important Milk* 24 quarts 16 quarts to note that there is an inverse Cereal 36 ounces 36 ounces relationship between the amount of Cheese* 1 pound None formula given and degree of health risk. The more human milk that is Juice* (12 oz. conc.) 3 cans 2 cans substituted with formula, the higher Eggs 2 dozen 1 dozen the sum of health consequences. Peanut butter 18 ounces None The WIC program will assist your pa- Beans* 4 cans 4 cans tients to achieve a successful breast- (1 pound can) feeding experience by providing Canned fish* 30 ounces None counseling and education, issuing breast pumps to women who meet Whole grains* 16 ounces 16 ounces WIC criteria, and providing additional Fruits/vegetables* $10 voucher $8 voucher foods for both mom and infant older * New food or changed amounts than six months. Specifically, begin- 17

The Impact of the New of breastfeeding problems provided according to the num- Women, Infants, and Children and return to exclusive ber of missed breastfeedings. breastfeeding is the goal. (WIC) Food Packages • Amount of formula will be continued from page 16 • Special formula will continue to issued according to the be provided by prescription and nutritional needs of the child. formula will be issued the FIRST specified medical condition. month of life. Health care providers • If the participant wants formula are encouraged to promote exclusive • When formula is needed for life for personal reasons, WIC will breastfeeding with support and refer- situations, such as an unsup- ral during this vulnerable period. portive workplace, formula will be continued on page 18 In order to promote the enhanced food packages and decrease the Difference in Weight Gain Pattern Between WHO and health risks related to formula CDC Growth Charts At 50th Percentile Weight for Age supplementation, Pennsylvania It is normal for the exclusively breastfed infant to be ½ to ¾ pounds heavier WIC guidance regarding formula than the formula fed infant at 3 months of age but ¾ to 1 ½ pounds lighter issuance to breastfed infants is than a formula fed infant by one year of age. undergoing major change. The following guidelines are under consideration: • Before issuing any formula, all WIC mothers will be encouraged to express and provide their own milk, instead of formula. • Health care providers are encouraged to promote and support the same. • Mothers who meet WIC criteria will be issued a breast pump and provided with education on pumping and storing human milk. • Pumps cannot be issued to

participants who do not meet Gungor D. and Bartok C. Center for Childhood Obesity Research, Pennsylvania State University, 2008 WIC criteria and the type of breast pump is also issued by set criteria. What appears to • In cases of medical need, such be faltering growth on the CDC as inadequate weight gain, the chart is actually amount of standard or hydro- normal growth lyzed protein formula shall be is- for the exclusively sued by breastfeeding and infant breastfed infant. growth assessment according to appropriate weight gain patterns for breastfed infants and WIC criteria (definition and discussion to the right). • Adequate formula will be issued to participants with medical need, during the time

of medical need. Resolution Kautz, M., 2008, PA Department of Health 18

The Impact of the New Health care providers play infants exhibit a more rapid weight Women, Infants, and Children gain pattern than formula fed infants. a primary role in promoting However, between four and 12 (WIC) Food Packages and supporting exclusive and months, the breastfed infant weight continued from page 14 long-term breastfeeding gain pattern slows considerably compared to formula fed infants. encourage that she purchase among their patients. Therefore, when exclusively breastfed it on her own, so she and her infants are plotted on current growth infant can receive the enhanced patients and supporting the success charts their growth appears to falter benefits of the fully breastfeed- of these important public health between four and 12 months. It is ing food packages. The cost measures. normal for the exclusively breastfed of small amounts of formula will infant to be three quarters to one and be far below the cost of the ad- Determining Need by Growth a half pounds lighter than a formula ditional foods received. The growth of an infant is strongly fed infant at one year of age. See • Health care providers are linked to how he or she is fed. charts on page 17. encouraged to promote Current growth reference charts7 WIC assessment criteria relies on exclusive, fully breastfeeding. are based on formula fed and combination fed infants. Therefore evidenced-based research, which is • Unless medically needed, partici- the current charts are based on how used to determine adequacy of infant pants who request formula shall children grow. The variable of how growth. WIC determines growth on be informed of the health conse- infants were fed was not controlled patterns, not on a single measure- quences, the potential for early in the development of these charts. ment. According to WIC criteria, weaning, and the potential for Newer evidence-based research infants who fall at or above minimum initiating breastfeeding problems. shows that breastfeeding is the weight gain standards are consid- ered to have an adequate growth • Health care providers are biological norm and the breastfed pattern. The weight gain chart that encouraged to help increase infant is the standard for measuring 8 Pennsylvania WIC will be using as public awareness. healthy growth. Charts developed based on this research demonstrate a minimum to assess growth for As you can see by these guidelines, how infants should grow.4 One of healthy full-term exclusively breastfed health care providers play a primary the major differences between these infants, which is based on USDA role in promoting exclusive and long- two growth charts is that between child growth standards and AAP term breastfeeding among their zero to three months breastfed recommendations is included. Exclusive long-term breastfeeding results in maximum health benefits and maximum amount of supple- Minimum Weight Gain Patterns of Healthy mental foods for mother and baby. Full-term Exclusively Breastfed WIC Infants The Pennsylvania WIC program Age Weight Gain Pattern looks forward to your support. WIC will continue to work with providers 0-2 weeks • Lose and regain birth weight to promote exclusive breastfeeding • Back to birth weight by 2 weeks throughout Pennsylvania. • Three weeks in cases of delayed lactogenesis Contact Cynthia Maki, such as C-section, early latch-on/suck difficulties, Pennsylvania State WIC Breastfeed- maternal/infant complications ing Coordinator at, (717) 783-1289 3-4 weeks > 7 oz/week or [email protected] for questions. 1-3 months 1 ¼ lb or more/month (5 oz/wk) References are available at 4-6 months ¾ lb or more/month (3 oz/wk) www.pamedsoc.org/ 7-12 months ½ lb or more/month (2 oz/wk) counterdetails or by calling Pennsylvania WIC 2008, based on 2001 USDA WIC Nutrition Risk Criteria for Inadequate Growth.9 Adapted (800) 228-7823, ext 7806. from Academy of Pediatrics, Average of Mean Values for Published Gains in Weight for Healthy Exclusively Breastfed Infants, 2006.6 19 Breastfeeding Support in the Primary Care Setting: Post-Test

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Cindy Jones, who is 5 feet, 3 inches tall and weighs 240 pounds, is a 28 year old female who presents during her first trimester. This is her second pregnancy. Her first child, now age 3, was born three weeks early through a vaginal delivery. During your discussion, she tells you he was hospitalized within the first three months of his life for a respiratory infection, but she is not specific about what caused the infection. She bottle-fed him partly because she thought she could not breastfeed because she smokes one to two packs of cigarettes per day. She tells you that her doctors three years ago did not talk to her about breastfeeding. She has chosen to stay at home while her children are young, and due to family income, qualifies for and is enrolled in the WIC program.

1. With regard to smoking, which of the following facts would you share 4. While all lactation care is recommended for all women during the first with Cindy? trimester of pregnancy, Cindy is a candidate for a comprehensive lactation a. Smoking mothers usually produce the same volume of breast milk evaluation due to the following risk factors: (Check all that apply) as nonsmoking mothers so it is OK to breastfeed if you are a smoker. a. Asthma b. Smoking increases incidence of stillborn births, increases number of b. Obesity premature births, and results in lower birth weight of baby. c. GERD c. The infant of a smoker is more irritable than the infant of a d. Low income non-smoker. e. Early delivery 37 ½ weeks d. A and C f. Hiatal hernia e. B and C f. A, B, and C 5. Practices that are successful in promoting a breastfeeding-friendly culture have implemented which of the following strategies? (Check all that apply) 2. With regard to breastfeeding, which facts would you share with Cindy? a. Provide a private space for mother to breastfeed a. Lower incidence of ovarian cancer, breast cancer, and Type 2 b. Encourage exclusive breastfeeding for the first six months of diabetes for a breastfeeding mom. baby’s life b. Non-smoking mothers typically breastfeed three months longer c. Provide patient education materials than smoking mothers. d. Train staff about the health benefits and challenges to breastfeeding c. Infants who are breastfed for at least six months are less likely e. Consider utilization of lactation consultants to suffer from diarrhea and ear infections. f. A, B, and D only d. Infants whose mothers don’t smoke have an increased risk g. A and E only of sudden infant death syndrome, asthma, and hospitalizations for pneumonia and bronchitis. 6. Breastfeeding is not advisable for smoking mothers because the benefits e. A, B, C of breast milk do not outweigh the risks from nicotine exposure. f. B, C, D ❒ True ❒ False g. A, C, D 7. Breastfeeding support services offered during a preventive visit may 3. You advise Cindy that the WIC Program will implement changes in be reimbursed with the use of Modifier 25 and documentation for the October 2009 for women who exclusively breastfeed to better align with problem-oriented E/M service separate from the preventive service. current infant feeding practice guidelines. Which of the following are new ❒ True ❒ False benefits that Cindy can expect if changes are made in October 2009? 8. When the physician and a certified lactation consultant “share” the same a. Additional amounts of milk, eggs, fruits, and vegetables patient, on the same day, their work is combined and billed under the b. Cheese and canned fish physician rate at 100 percent of the fee schedule. c. Twice the amount of baby fruits and vegetables, and infants will ❒ True ❒ False receive baby meats d. Extra formula for the infant in the first month of life 9. The duty of a health care provider is to actively encourage families to e. A, B, C breastfeed and to reduce social disparities of breastfeeding because of f. A, C, D the positive outcomes for the infant. g. A, B, C, D ❒ True ❒ False PRSRT STD U.S. POSTAGE PAID HARRISBURG, PA PERMIT NO. 922

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Evaluation: Breastfeeding Support in the Primary Care Setting - The following evaluation will guide the development of future programs for Pennsylvania clinicians. Please take a few moments to reply and fax your response to (717) 558-7848. 1. Using a rating of 1-5, with 5 meaning very satisfied and 1 not satisfied at all, please 2. Was the information provided in an unbiased, credible identify whether the monograph met the following objectives to enhance the primary manner? care clinicians ability to:  Yes  No If No, why is it biased? Very Not Satisfied Satisfied at All 3. With regard to the strategies, processes, or Apply the basic principles of breastfeeding to provide anticipatory procedures presented in this educational activity guidance, support, and resources to facilitate breastfeeding about breastfeeding in the office setting, what exclusively for the first six month, and thereafter with the introduction 5 4 3 2 1 behavior or practice(s) protocol will you change or of other foods for up to one year as long as mutually desired by what new strategy or procedure will you implement mother and baby. in your practice as a result of your participation in this activity? Manage common breastfeeding problems and challenges, i.e., milk supply, breast soreness, return to work, bearing in mind the impact 5 4 3 2 1 of health care professionals’ attitudes and recommendations on a family’s decision to initiate and continue breastfeeding. 4. Overall, the information in this issue was:

Identify some of the current gaps in the management of Breastfeeding 5 4 3 2 1  Very helpful  Not very helpful Gain skills to identify appropriate communication or strategies to  Helpful  Not helpful of all support and promote breastfeeding among mothers who smoke and 5 4 3 2 1  Somewhat helpful provide assistance to quit.

Describe the adverse effects of secondhand smoking on children, 5. Please indicate your professional license type by provide counseling to families to reduce tobacco exposure and quit 5 4 3 2 1 checking the appropriate box. smoking, and utilize community resources and the PA Quitline.  MD  DO  PA  CRNP  IBCLC  RD Develop a plan for practice improvement, (i.e., related to office  Other, specify policy and practices), that optimizes outcomes for families related to breastfeeding and tobacco cessation and promotes continuing 5 4 3 2 1 education among staff.