WIC PROGRAM AND CSFP
Hospital supplementation, cultural identity
and breastfeeding measures
In a sample of Minnesota WIC participants born in 2015
The importance of breastfeeding exclusivity during the hospital stay
Numerous studies have found that formula supplementation of breastfed infants during the hospital stay is a
risk factor for early cessation of breastfeeding. An analysis of infants enrolled in the Minnesota WIC program
in 2010 found that breastfed infants fed formula in the hospital were 144% more likely to have stopped
breastfeeding by three months than those not receiving formula in the hospital. i
The American Academy of Pediatrics Policy Statement on Breastfeeding states, “Hospital routines to
encourage and support the initiation and sustaining of exclusive breastfeeding should be based on the
American Academy of Pediatrics-endorsed WHO/UNICEF ‘Ten Steps to Successful Breastfeeding’”. They
recommend “Give no supplements (water, glucose water, infant formula or other fluids) to breastfeeding
newborn infants unless medically indicated”. ii
The Baby-friendly Hospital Initiative (BFHI) Step 6 states “Give infants no food or drink other than breast-milk,
unless medically indicated”. iii The BFHI sets an expectation that at least 75% of infants be either exclusively
breastfed or exclusively fed human milk from birth to discharge.
The Healthy People 2020 objective MICH 23 aims to reduce the proportion of breastfed newborns who receive
formula supplementation within the first 2 days of life, from a 2006 baseline of 24.2 to a target of 14.2%. iv
Purpose of this project
In late 2013, due to concerns about health disparities among diverse high risk populations that are aggregated
in the current WIC race and ethnicity categories, some WIC agencies in Minnesota began piloting a new data
field. If a participant selected Asian or Black or African American under the Federal categories for
race/ethnicity, an additional question was asked about which group they identify with. Choices included
African American, Somali, Liberian, Sudanese, Other - Black, Hmong, KaRen and Other - Asian. Agencies with a
breastfeeding peer program were included in the pilot, and all participants in those agencies (not just peer
clients) were included. These agencies included Hennepin, Ramsey, Olmsted and several suburban and
Greater Minnesota agencies (see figure 4.) This information was collected for 9522 of 30,833 WIC participants
born in 2015.
A second pilot question asked about breastfeeding status at infant certification, and included the following
choices: BF & supplemented in hospital, BF Only – not fed anything else and Formula Only.
1
Breastfeeding and in-hospital formula supplementation
by race/ethnicity
Figure 1. The rates of hospital supplementation varied widely by race/ethnicity, with Black/African American
and Asian women who initiated breastfeeding most likely to supplement while in the hospital. White mothers
were the least likely to supplement in the hospital, followed by Hispanic mothers. African American women
were just as likely to initiate breastfeeding as White mothers, but almost twice as likely to supplement with
formula while in the hospital.
Figure 1. Infant feeding during the hospital stay
by race/ethnicity 2015
(n=9522)
100%
19%
80%
60%
16%
32%
61%
47% 43%
26%
35%
42%
American Indian
Asian/PI
33%
60%
17%
14%
55%
52%
40%
20%
51%
40%
34%
28%
34%
White
Hispanic
0%
Bf and formula
Fully Bf
Black
never Bf
% of Bf given formula
* among infants born in 2015 who were served by an agency with a peer program and who had a value entered for
“Breastfeeding Status at Infant Certification”
Breastfeeding and in-hospital formula supplementation
by cultural identity
Among the 9522 infants, 3400 of the Black or Asian mothers had an cultural identity specified. These mothers
were primarily served in Ramsey, Hennepin and Olmsted counties.
Figure 2. Breastfeeding and supplementation among the Black mothers with a known cultural identity. Somali
mothers had the highest breastfeeding initiation rates, at 98%, while the African American group (a mixture of
foreign- and native-born mothers) had the lowest rate at 75%. 3/4 of the breastfed Somali infants and more
than 2/3 of the breastfed Liberian infants were supplemented in the hospital, compared to half of the infants
in the African American category.
2
Figure 2. Infant feeding during the hospital stay
among African Americans 2015
2%
100%
80%
60%
25%
23%
15%
12%
24%
34%
76%
38%
50%
40%
20%
(n=2214)
75%
37%
71%
62%
60%
55%
Liberian
Other Black
0%
African American
Somali
Bf and formula
Fully Bf
never Bf
% of Bf given formula
Figure 3. Among Asian mothers the breastfeeding rates also varied widely. Hmong mothers had far lower
initiation rates (57%) than the other two categories (90%). All the Asian groups had supplementation rates
over 50%, with almost 70% of the Hmong breastfed infants supplemented in the hospital.
Figure 3. Infant feeding during the hospital stay
among Asians by cultural identity 2015
(n=1186)
100%
80%
60%
40%
20%
43%
68%
10%
10%
40%
38%
18%
58%
56%
39%
50%
53%
KaRen
other Asian
0%
Hmong
Bf and formula
Bf only
never Bf
% of Bf given formula
Breastfeeding and in-hospital formula supplementation for selected WIC
agencies
Figure 4. Rates of supplementation in the hospital also varied widely depending on location. Mothers in the NE
area reported very little hospital supplementation (about 15% of breastfed babies). The highest rates of
supplementation were in Olmsted, with 56% of breastfed infants supplemented, followed by St. Paul Ramsey,
with 53% supplemented.
3
Figure 4. Infant feeding during the hospital stay
by peer program agency* 2015
(n=8867)
100%
80%
60%
47%
38%
19%
49%
43%
40%
20%
9%
19%
46%
69%
18%
20%
39%
54%
33%
42%
26%
13% 15%
0%
Bf and formula
Bf only
13%
25%
38%
52% 40%
43%
56% 36%
53%
47%
49%
35%
never Bf
22%
41%
% of Bf given formula
* includes agencies where > 100 participants answered the question on exclusivity
Breastfeeding at 3 months of age, comparing infants who had been given
formula to those exclusively breastfed during the hospital stay
Figure 5. Breastfeeding status at 3 months varied depending on whether breastfed infants had been given
formula during their hospital stay. At 3 months, infants exclusively breastfed in the hospital were more likely
to still be breastfeeding, and 4 times more likely to be fully breastfeeding, than were those who were given
formula in the hospital.
Figure 5. Breastfeeding at 3 months, by infant
feeding status at hospital discharge
(n=7510)
100
80
60
71
56
40
16
20
4
0
any breastfeeding
Breastfed only during hospital stay
fully breastfeeding
BF and formula given during hospital stay
4
Breastfeeding duration and formula usage, comparing infants who had
been given formula to those exclusively breastfed during the hospital stay
Figure 6. Babies not supplemented in the hospital, breastfed on average 28 days longer than those who
received formula in the hospital, and received their first formula vouchers on average more than two weeks
later than supplemented infants. During their first year of life, infants exclusively breastfed in the hospital on
average received less than two-thirds the amount of formula as infants supplemented during the hospital stay.
Figure 6. Comparison of breastfed infants supplemented in the hospital to infants
exclusively breastfed during the hospital stay.
Average days breastfed:
Among those supplemented:
121 days
Among those not supplemented:
149 days
Average number of days until first WIC formula voucher issued to breastfed infants:
Among those supplemented:
26 days
Among those not supplemented:
42 days
Average ounces of formula issued in the first year to breastfed infants:
Among those supplemented:
4845 ounces
Among those not supplemented:
3042 ounces
i
Fernstrom K, Johnson M B., Geppert J, Oberg CN, Himes JH. Breastfeeding duration in Minnesota WIC infants exposed to formula in the hospital. Poster.
PediatricAcademic Society, 2013, Washington DC.
ii American Academy of Pediatrics. Policy Statement: Breastfeeding and the Use of Human Milk, American Academy of Pediatrics Section on Breastfeeding; 2012.
http://pediatrics.aappublications.org/content/129/3/e827.full#content-block . Accessed March 2016. AAP Pediatrics 2012;129;e827-41.
iiiWorld Health Organization, Evidence for the ten steps to successful breastfeeding, WHO Division of Child Health and Development; 1998.
http://www.who.int/nutrition/publications/evidence_ten_step_eng.pdf . Accessed March 2016.
iv Healthy People 2020 - Improving the Health of Americans. U.S. DHSS www.healthypeople.gov/2020/default.aspx. Accessed Nov. 2015.
For more information, contact: WIC Program and CSFP
[email protected] 651-201-4406 5
http://www.health.state.mn.us/divs/fh/wic/index.htm
651-201-3632
[email protected]
………………………………………………………[email protected]
651-201-4905
March 30, 2016