Bailey’s Golden Start Breastfeeding Curriculum for Nursing Students
Section Five: Objectives 11 & 12
8/5/2013
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Bailey’s Golden Start Breastfeeding Curriculum for Nursing Students
Section Five: Objectives 11 & 12
8/5/2013
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Bailey’s Golden Start Breastfeeding Curriculum for Nursing Students
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Image taken by Jennifer DeJong; Carolyn and Christian, 2008.
And, speaking of BEST!
Section Five: Objectives 11 & 12
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Medical contraindications to breastfeeding are rare.
Infant growth should be monitored with the World Health
Organization (WHO) Growth Curve Standards to avoid
mislabeling infants as underweight or failing to thrive.
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."
Pediatrics, March 2012.
Breastfeeding and the Use of Human Milk.
Breastfeeding and human milk are the
normative standards for infant feeding and
nutrition. Given the documented short- and
long-term medical and neurodevelopmental
advantages of breastfeeding, infant nutrition
should be considered a public health issue and
not only a lifestyle choice.
National strategies supported by the US Surgeon General's
Call to Action, the Centers for Disease Control and
Prevention, and The Joint Commission are involved to
facilitate breastfeeding practices in US hospitals and
communities. Pediatricians play a critical role in their
practices and communities as advocates of
breastfeeding and thus should be knowledgeable about
the health risks of not breastfeeding, the economic
benefits to society of breastfeeding, and the techniques
for managing and supporting the breastfeeding dyad. The
"Business Case for Breastfeeding" details how mothers can
maintain lactation in the workplace and the benefits to
employers who facilitate this practice.
The American Academy of Pediatrics reaffirms
its recommendation of exclusive breastfeeding
for about 6 months, followed by continued
breastfeeding as complementary foods are
introduced, with continuation of breastfeeding
for 1 year or longer as mutually desired by
mother and infant.
Section Five: Objectives 11 & 12
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Fill-in-the-Blank Answers:
advertising
samples
healthcare
Advertising, Media, and Free Formula (Macrosystem)
In the 1970s, increased global attention was directed at
breastfeeding when questionable advertising strategies of formula
companies in disadvantaged countries led to an international
boycott of Nestle products (Phillip et al., 2001). In response, the
WHO/UNICEF organized a global assembly on infant and young child
nutrition, with scientific experts, governmental and nongovernmental
organizations, and infant food industry representatives in attendance
(Baumslag, 1995; Palmer, 1993). From this gathering, The International
Code of Marketing of Breastmilk Substitutes, also known as “The
Code” (Table 6), was developed to control inappropriate marketing
practices of infant formula and other products used as breast milk
substitutes.
Almost 10 years later, on May 21, 1981, the World Health Assembly
voted to adopt The Code with a 118 to 1 vote. The lone “no” vote
was cast by the U.S., whose representatives claimed The Code would
violate free speech and infringe on free trade practices. Two officials
of the Agency for International Development resigned in response to
the United States’ vote (Phillip et al., 2001). Meanwhile, the U.S. House
of Representatives condemned the Administration’s position by a
vote of 301-100, and the Senate expressed its concern with a vote of
89-2 (Phillip et al., 2001).
In 1994, the “no” vote cast by the U.S. was reversed by President
Clinton when he signed a follow-up amendment that included an
endorsement of the original code. This reversal was called symbolic
at best, however, (Phillip et al., 2001) because, as of 1997, only 16
countries had achieved “full compliance” with The Code by
adopting laws aimed at enforcing all or nearly all of its provisions;
some countries had taken “some action” (i.e., Israel, Norway, and
Spain had officially prohibited formula donations to hospitals.); and
nine countries had taken “no action” (e.g., the U.S., Croatia, Chad,
Central African Republic, Estonia, Romania, Kazakstan, Republic of
Moldova, and Somalia) (The Progress of Nations, 1997).
Section Five: Objectives 11 & 12
Pre-Class/In-Class Activity: Have students look through parenting
magazines and count how many formula advertisements they can
find. Ask them to bring them to class to share.
Compare/contrast different advertisements from a variety of
companies.
• What do these advertisements promise?
• What are your first thoughts when you see the ads?
• Look at the fine print: do you see anything anywhere that says
“breastfeeding is best”?
Teacher: If possible tape or pull up from You-Tube Formula
Advertisements to play in class.
What do these advertisements promise?
What are your first thought when you see the ads?
What words did the company emphasize?
“DHA”
“comfort proteins”
“easily digestible”
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Lecture:
The World Health Organization (WHO) International Code of Marketing of Breast-Milk Substitutes, was adopted in 1981 by the World
Health Assembly.
It is a comprehensive set of guidelines for those who work and interact with mothers and infants.
It suggests standards for the appropriate marketing and distribution of commercial competitors to breast-feeding (i.e., makers of
infant formula).
It is generally referred to as “The Code.”
Why is this important?
Research has found:
The Cochrane review documented the impact of distributing samples of infant formula and promotional materials to
breastfeeding mothers in the form of hospital discharge packs suggests a negative effect of this direct marketing on the duration
and exclusivity of breastfeeding.14
This review included nine randomized controlled trials involving a total of 3,730 women in North America. These studies evaluated
the impact of both distributing free samples of infant formula and giving out promotional materials on infant formula to new
mothers who were already breastfeeding.
The main outcome measures were (1) breastfeeding at 6 and 13 weeks postpartum, (2) the prevalence of exclusive versus partial
breastfeeding between 0 and 13 weeks postpartum and at 6 months, and (3) the timing of the introduction of solid food. The main
finding was that when compared with not giving a discharge pack or providing a noncommercial discharge pack, distributing
samples of infant formula reduced exclusive breastfeeding at all time points measured. No detrimental effects were found when
discharge packs of commercial infant formula were not distributed.
In addition to the negative impact of distributing samples of infant formula during the mother’s hospital stay, Howard et al. 58
demonstrated in a randomized controlled trial of 547 women that educational materials on breastfeeding produced by
manufacturers of infant formula and distributed to pregnant women intending to breastfeed had a substantially negative effect
on the exclusivity and duration of breastfeeding. This impact was much greater on women with uncertain or short breastfeeding
goals.
The effect of the marketing practices of commercial competitors on breastfeeding is of particular concern because of its
disproportionately negative impact on mothers in the United States who are known to otherwise be at high risk for early termination
Section Five: Objectives 11 & 12
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of breastfeeding, including those who are primiparous (first-time mothers), have less formal education, are nonwhite, or are ill
postpartum.14
Section Five: Objectives 11 & 12
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Fill-in-the-Blank Answers:
representatives
gifts
idealizing
A quick review:
The International Code recommends
No advertising of breast-milk substitutes directly to the public.
No free samples to mothers.
No promotion of products in health care facilities.
No commercial product representatives to advise mothers.
No gifts or personal samples to health workers.
No words or pictures idealizing artificial feeding, including pictures of infants on the products.
Section Five: Objectives 11 & 12
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Fill-in-the-Blank Answers:
• Scientific
• Hazards
Section Five: Objectives 11 & 12
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Image taken by Jennifer DeJong at ToysRUs on Monday July 23, 2012.
Section Five: Objectives 11 & 12
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Fill-in-the-Blank Answers:
• Condensed
• Environment
Quick Review:
The International Code also states:
• Information to health workers should be scientific and factual.
• All information on artificial feeding, including the labels, should explain the benefits of breastfeeding and the
costs and hazards associated with artificial feeding.
• Unsuitable products, such as condensed milk, should not be promoted for babies.
• All products should be of a high quality and take into account the patient’s environment
Section Five: Objectives 11 & 12
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Image taken by Jennifer DeJong in Vietnam, Summer 2011.
“Baby Friendly” is a designation a hospital or birthing site can achieve if it can demonstrate full compliance with the guidelines and
standards summarized in The Ten Steps to Successful Breastfeeding (Table 2). According to Shealy et al. (2005), the term “baby friendly” was
chosen, in part, because it could be appropriately converted into multiple languages all over the world. Indeed, the BFHI Ten Steps have
been accepted globally as the “gold standard” for breastfeeding practices (Lazarov, 1993; Saadeh, 1996). Data, showing that adherence to
The Ten Steps predicts breastfeeding duration and exclusivity long after hospital discharge, continues to accumulate (DiGirolamo, GrummerStrawn, & Fein, 2001; Kramer, et al., 2008; Merewood, Mehta, Chamberlain, Philipp, & Bauchner, 2005; Murray, Ricketts & Dellaport, 2007;
Rosenberg, Stull, Adler, Kasehagen, & Crivelli-Kovach, 2008; WHO, 1998).
Although UNICEF approached governmental officials about the possibility of implementing the BFHI in the U.S. early after its inception, the U.S.
determined that execution of the BFHI would be best undertaken by a non-governmental agency. According to Gartner (1995), The Healthy
Mother-Healthy Baby Coalition was awarded the BF contract, and beginning in 1993, an expert work group was established to study the
feasibility of the initiative in the U.S.
The BF Expert Work Group’s final recommendations, released in 1994, were to revise The Ten Steps, change the name, have hospitals assess
themselves without external assessment of compliance, and not prohibit the availability and promotion of infant formulas in hospitals and
birthing centers. As a result, seven organizations as well as the AAP refused to endorse the work group’s final report, and at least one
physician questioned the influence formula manufacturers may have had on the work group’s final recommendations (Young, 1993, 1995).
According to Phillipp et al. (2001), it was then that Wellstart International and Dr. Audrey Naylor, who were involved in the initial development
of the international BFHI concept, were approached and asked to cultivate a U.S. on-site evaluation tool and external assessment criteria.
With this completed in 1997, the accountability for Baby-Friendly U.S.A was assumed by a group overseen by Dr. Karin Cadwell using the
original UNICEF guidelines, except for a minor revision of Step four to recommend the commencement of breastfeeding within one hour of
life, instead of the international guideline of within one-half hour of birth.
Section Five: Objectives 11 & 12
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• The first step is called the Discovery Phase where facilities register with BFUSA to learn
more about the process.
• The second step is the Development Phase where facilities make a commitment to
the process by providing a registry of intent.
• The third step is the Dissemination Phase where facilities implement the plans they
have developed during the prior phase.
• The finally step, is the Designation Phase where facilities review their implementation
of the steps and implement a quality assurance program. When they are ready, they
undergo an on-site assessment conducted by the BF team and a review by an
external review board.
Section Five: Objectives 11 & 12
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After two years of BFHI implementation in China, UNICEF reports that exclusive
breastfeeding rates have doubled in rural areas and increased from 10% to 47%
in city regions. In Nicaragua, breastfeeding rates have increased from 47% prior
to implementation of BFHI to nearly 100% in 1999. In Poland, between 1995 and
1998, BFHI implementation resulted in increased rooming-in rates from 19% to
60%, and supplementation of infants with formula diminished from 54% in 1988 to
22% in 1998. In Zambia, BFHI implementation was recognized for increasing the
exclusive breastfeeding rate of 16% in 1992 to 35% in 1997 (UNICEF, ProgrammeDivision, 1999). In the Republic of Belarus, a randomized trial examined the
outcome of implementing The Ten Steps to Successful Breastfeeding in 31
Belarussian maternity units and clinics. Results indicated that infants born at the
BF sites were more likely than control infants to be breastfed to any degree at 12
months, were more likely to be exclusively breastfed 3 months and 6 months,
and had a significant reduction in the risk of one or more gastrointestinal tract
infections and atopic eczema (Kramer et al, 2001).
Studies of the Baby Friendly Hospital Initiative Abroad
(Macrosystem).
According to Hornell (2001), lengthening of
breastfeeding duration has been observed for
several decades in Sweden, with a marked increase
since 1992 when the BFHI was launched. At present,
100% of Swedish hospitals and maternity centers are
BF designated. According to Flacking et al. (2007),
breastfeeding is regarded as the cultural norm in
Sweden, with a high breastfeeding frequency of 98%
of infants being breastfed at one week of age and
72% of infants being breastfed at six months of age
(The National Board of Health and Welfare, 2003).
Section Five: Objectives 11 & 12
In 1993, the BFHI was introduced in Switzerland with similar results observed.
Merten, Dratva, Ackermann-Liebrich (2005) reported findings for a national
study about the prevalence and duration of breastfeeding in 2003 throughout
Switzerland to assess compliance with WHO/UNICEF guidelines of hospitals,
comparing breastfeeding results between hospitals that were designated as BF
with those that were non-BF health facilities. Findings revealed increased rates
and duration of breastfeeding nationwide for the last 10 years, with children
born at BF health facilities breastfeeding longer, especially if the hospital
complied with WHO/UNICEF guidelines.
Abolishing hospital-based promotion of infant formula and paying fair market
value for formula would aid hospitals and birthing centers to implement
evidence-based care (Phillipp et al., 2001, 2003). Typically, most hospitals in the
U.S. receive their well-infant formulas free of charge (or significantly discounted)
from name brand manufacturers and, in return, are expected to dispense
commercial discharge bags that advertise that brand, thereby implying both
active and passive endorsement from the health facility. In BF designated
hospitals, the cost of acquiring formula is charged to the patient as a
component of a room and board fee, the same way food for other patients is
handled. Finally, proponents note that implementing The Ten Steps as part of
BFHI designation decreases HMO costs of unused products, such as pacifiers,
nipples, and discharge packs, and saves on labor costs and storage space
necessary for discharge items (Phillipp et al., 2001, 2003). Brennan et al. (2006)
and Rothman et al. (2009) encouraged best practices in their writings,
suggesting hospital leaders and other health professionals distance themselves
from formula industries to circumvent conflicts of interest that could compromise
patient care.
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Studies of the Baby Friendly Hospital Initiative in the United States (Macrosystem).
Baby-Friendly Hospitals (BPHs) in the U.S. have elevated rates of breastfeeding
initiation and exclusivity regardless of demographic factors (Merewood et al.,
2005). Merewood (2005) analyzed breastfeeding data from U.S. BFHs in 2001 (n =
32) to establish whether breastfeeding rates at BFHs differed from standard U.S.
rates. Findings revealed that the mean breastfeeding initiation rate in 2001 was
83.3% among BFHs compared with 69.5% elsewhere. In addition, the mean rate of
exclusive breastfeeding during the hospitalization (16 of 29 hospitals) was 78.4%,
compared with a national mean of 46.3%. Breastfeeding rates were not
associated with the number of births per birth center or with the number of lowincome or Black clients. In this study, geographical location was considered a
possible confounder for elevated breastfeeding rates (Ross Mothers Survey,
Cleveland, OH, 2002; Ryan, 2002).
In the U.S., more babies are being born in
facilities that have made special efforts to
support breastfeeding than ever before.
However, less than 5% of U.S. infants are born in
Baby-Friendly hospitals, a global designation that
indicates best practices in maternity care to
support breastfeeding mothers.
The hospital period is critical for mothers and
babies to learn to breastfeed, and hospitals
need to do more to support them. Hospitals can
participate in the Maternity Practices in Infant
Nutrition and Care (mPINC) survey, and use their
results to improve maternity care practices.
Hospitals can also work together to share
information and experiences on how to achieve
the Baby-Friendly designation.
The Merewood (2005) study reported Steps two, six, and seven as the most
difficult Steps of The Ten Steps to Successful Breastfeeding for U.S. BF institutions.
The most common reason mentioned for not meeting Step six, in particular, was
the requirement that BF-designated hospitals pay fair market value for all infant
formula. Conversely, initiating breastfeeding within the first hour of life, promoting
exclusive in-hospital breastfeeding, and having a printed breastfeeding policy
are the Steps generally found to have the greatest determination on success
(DiGirolamo, Grummer-Strawn, & Fein, 2001, 2008; Grizzard, Bartick, Nikolov,
Griffen, & Lee, 2006).
Vietas and Henly (1995) conducted research in which all North Dakota obstetric
services were questioned using the Newborn Feeding Survey (NFS) to determine
breastfeeding-related practices compared with the BFHI Ten Steps. They
observed poor adherence to nearly all components of The Ten Steps, with only
15% of participants reporting adherence to at least 5 of the 10 criteria. Degree of
implementation was highest (39%) for Step 4, breastfeeding no greater than 60
minutes after delivery, and lowest for Steps 1, policy (2.4%); 9, non-pacifier usage
(4.9%); and 10, community referral to support groups (0%).
Dodgson (1999) evaluated 79 (83%) Minnesota-based hospitals and reported an
average breastfeeding rate of 59%. In 1994, it was determined that four of The
Ten Steps were implemented in Minnesota with a low adherence rate (0-49%),
that five were implemented with a moderate rate (50-89%), and that none were
implemented with a high rate (90-100%). Specifically, Steps 1, 2, 4, 5, and 8 were
implemented in over one-half of the surveyed hospitals, but Steps 6, 7, 9, and 10
had less than 50% adherence statewide.
Section Five: Objectives 11 & 12
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DiGirolamo, Grummer-Strawn, and Fein’s (2001) longitudinal research of 1085 women revealed that, of women who
experienced varying degrees of The Ten Steps, mothers who experienced none of the Steps were almost eight times more
likely to terminate lactation before six weeks postpartum. Conversely, the greater number of Steps the mother encountered,
the greater the continuation of breastfeeding at and beyond six weeks postpartum. In this study, the strongest factors for
premature breastfeeding cessation were late breastfeeding initiation and supplementation of the infant with substances
other than breast milk.
When all of the recommendations of The Ten Steps are followed, the impact is profound. Philipp, Malone, Cimo, and
Merewood (2003) discussed lactation outcomes at Boston Medical Center (BMC), which became the 22 nd BF-designated
hospital in the U.S. in 1999, and found significantly increased breastfeeding initiation rates, ranging from 58% in 1995 to 86.5%
in 1999. Two hundred medical records of full-term, healthy infants who were born at BMC in 2000 and 2001 were reviewed.
All infant feedings during the hospital postpartum stay were totaled, and each infant was then classified into one of four
groups: (a) exclusive breastfeeding, (b) mostly breast milk, (c) mostly formula, and (d) exclusive formula. Breastfeeding
initiation rates remained at high levels--87% (1999), 82% (2000), and 87% (2001)--with infants who received more breast milk
than formula sustaining lactation for longer periods of time: 73% (1999), 67% (2000), and 67% (2001). The authors concluded
that at hospitals where all of The Ten Steps to Successful Breastfeeding were followed as a stipulation of BF designation, the
greater the extended positive impact on breastfeeding rates in a U.S. setting (Philipp et al., 2003).
Before students look ahead to the next slide, have them guess which states will be at the top of the list! Take a vote and
remember to include Alaska and Nebraska. Ask students why this may be so. Any guesses that they have?
Section Five: Objectives 11 & 12
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Who is Baby-Friendly at present?
Data Sources: Baby-Friendly facilities : www.babyfriendlyusa.org
Live Births: CDC NCHS 2009 Live Births by State
Section Five: Objectives 11 & 12
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•
•
•
•
Policy
Train
Inform
1 hour
The Baby-Friendly Ten Steps to Successful Breastfeeding
Have a written breastfeeding policy that is routinely communicated to all health care staff.
Train all health care staff in skills necessary to implement this policy.
Inform all pregnant women about the benefits and management of breastfeeding.
Help mothers initiate breastfeeding within 1 hour of birth.
Section Five: Objectives 11 & 12
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• Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their
infants.
• Give newborn infants no food or drink other than breast milk, unless medically indicated.
• Practice "rooming in"— allow mothers and infants to remain together 24 hours a day.
• Encourage breastfeeding on demand.
• Give no pacifiers or artificial nipples to breastfeeding infants.
• Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the
hospital or clinic.
SOURCE: www.babyfriendlyusa.org/eng/10steps.html
Section Five: Objectives 11 & 12
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SOURCE: www.babyfriendlyusa.org/eng/10steps.html
Section Five: Objectives 11 & 12
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Lecture:
The Breastfeeding Report Card, now in its 5th year (in 2011),
provides perspectives on state and national trends in breastfeeding
data. Since the release of the first Report Card in 2007, there have
been steady improvements in several indicators, especially in 3
month and 6 month exclusive breastfeeding rates, which increased
more than 5 and 4 percentage points, respectively. Changes in
state and national rates are not attributable to any one factor. A
woman's ability to reach her breastfeeding goals is affected by a
host of factors including support from her family, community,
employer and health system.
Pre-class work: Have students go to:
http://www.cdc.gov/breastfeeding/data/reportcard.htm
and spend at least 30 minutes going through the site.
Require that each student prepare a 1 minute paper at
the beginning of class as to what they learned from their
pre-class reading assignment.
In-Class Teamwork (if you have laptops available to
each student or group of students): Each team should be
given a state to review (Teachers can provide the
options or may allow teams to choose a state. Be sure to
include California!)
If the teacher can access a computer: Before class, pull
up information on your classroom computer, minimize
multiple sites, and later project them the screen for the
class.
Section Five: Objectives 11 & 12
Mothers need support from the people and organizations they
interact with to meet their breastfeeding goals. States can use the
Report Card and previous year's Report Cards to track progress,
identify the areas where mothers need more support, and work
within their communities to better protect, promote and support
breastfeeding mothers.
What can mothers and their families do to encourage this:
Talk to doctors and nurses about breastfeeding plans, and ask how
to get help with breastfeeding.
Ask about breastfeeding support practices when choosing a
hospital.
Join with other community members to encourage local hospitals
to become Baby-Friendly.
Data on Website:
Source: Centers for Disease Control and Prevention National
Immunization Survey, Provisional Data, 2008 births.
http://www.cdc.gov/breastfeeding/data/NIS_data/index.htm
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Has this already been discussed in Community Health Nursing?
Even if that is the case, REVIEW:
What is Healthy People?
What were the 2010 goals and were they met nationally?
What are the new national goals?
Three additional Goals:
• Increase the percentage of employers who have worksite lactation programs.
• Decrease the percentage of breast-fed newborns who receive formula supplementation within the first 2
days of life.
• Increase the percentage of live births that occur in facilities that provide recommended care for lactating
mothers and their babies.
Close to home, how did your state do in meeting the goals?
Section Five: Objectives 11 & 12
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We’ve got these goals for our nation. Now how can we make it happen?
For one: we’ve got to FOLLOW THE CODE
Another: we’ve got to FOLLOW THE TEN STEPS
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