Quality nutrition services in the Special Supplemental Food Program for Women, Infants, and Children

              Food and
Nutrition
Service
Quality Nutrition
Services in the Special
Supplemental Food
Program for Women,
Infants, and Children
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United States
Department of
Agriculture
Food and
Nutrition
Service
. Quality Nutrition
Services in the Special
Supplemental Food
Program for Women,
Infants, and Children
Foreword
Acknowledgments
List of Acronyms
Plenary Sessions
Contents
I WIC -An Effective Partnership
(Virgil Conrad, Betty jo Nelsen, Ronald j. Vogel)
II Breastfeeding Promotion
(Kathy Dugas, janice Lebeuf, Brenda Dobson, Mary Kay DiLoreto, Marlene B. Guroff, Carol Suitor)
Ill Alcohol and Other Drug Use Prevention
(Barry Zuckerman, M.D.)
Concurrent Sessions
1 Anthropometric Assessment
(Ibrahim Parvanta)
2 Approaches to Providing Nutrition Education in Large Programs
(Donna T. Seward, joann Godoy)
3 Approaches to Providing Nutrition Education in Small Programs
(Colleen Breker, joyce Ngo)
4 Breastfeeding Projects Utilizing Peer Counselors
(Ellen Sirbu, Lilia Parekh, Carmen Cohen)
5 Breastfeeding Promotion Study and Demonstration Projects
(Linda Lee, Karen Virostek, Brenda Kirk)
6 Computers for Nutrition Education
(Doris Derelian, janice Lebeuf)
7 Coordination Between WIC and Medicaid
(Wilma M. Cooper, Alice Lenihan)
8 Coordination Opportunities Between WIC and Head Start
(Connie Lotz, janet Stammer)
9 Development and Evaluation of Low Literacy Materials
(S. jane Voichick)
10 Dietary Assessment
(Karen Bettin, Carol Suitor)
11 Food Package Tailoring
(Nancy j. Spyker)
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v
vii
1
8
18
25
28
32
35
38
42
45
48
52
55
58
12 Management of Childhood Obesity
(Roslyn G. Weiner)
61
13 MCHING (Maternal and Child Health lnterorganizational Nutrition Group) Activities 65
(Alice Lenihan, Harriet Cloud, Vernice Christian)
14 Nutrition Care Plan Development for Children
(Harriet Cloud)
15 Nutrition Care Plan Development for Infants
(Sarah McCammon)
16 Nutrition Care Plan Development for Pregnant Women
(Diane Dimperio)
17 Nutrition During Pregnancy-Institute of Medicine Report
(Lindsay H. Allen)
18 Nutrition Education Materials for Pregnant Adolescents
(Laurie Miller)
19 Nutrition Education Strategies for Children
(Amy Shuman, Ann O'Neill)
20 Nutrition Surveillance
(Ibrahim Parvanta, Karen Sell, Merryjo H. Ware)
21 Oral Health for Infants and Children
(Thomas G. Salmon, Roslyn Balzer, Barbara Carnahan)
22 Promoting Access to Immunization
(james W. Mize, Debra C. Stabeno, Mary Warr Cowans)
23 Quality Assurance
(Gaye Joyner, Loretta W. Miller, Karen j. Oby)
24 Screening and Referrals for Alcohol and Other Drug Use
(Donna Skoda)
25 Sharpening Counseling Skills
(Patricia Daniels)
26 Training Programs for Paraprofessionals
(Suzanne Wilson, Karen Sell, jacqueline Beard)
27 Use of Paraprofessionals for Providing WIC Nutrition Services
(Michele Lawler, Rosalind Wilkins, Ronald j. Vogel)
Appendixes
1. Speakers/Moderators
2. Conference Registrants
3. Exhibitors
ii
69
72
90
96
100
103
106
110
116
122
126
129
139
143
147
150
168
Challenges,
Changes, and
Choices
U.S. Department of Agriculture (USDA)
Food and Nutrition Service (FNS)
Special Supplemental Food Program for
Women, Infants, and Children (WIC)
Foreword
A National WIG Nutrition Services Conference, entitled "Challenges,
Changes, and Choices-Skill Building and Sharing," was held August 25-
28, 1991 in Memphis, TN. This document, a product of the conference,
has a two-fold purpose. It serves as: 1) a record of the conference pro­ceedings;
and 2) an ongoing reference for State and local agency educa­tors
on various aspects of providing quality nutrition services. FNS hopes
the conference and this document will stimulate new and innovative ideas
and enhance coordination efforts.
The conference emphasized a "hands-on" approach to the delivery of
nutrition services in the WIG Program. The goals of the conference were
as follows:
• To create opportunities for State and local WIG agency staff to enhance
their knowledge and skills on subjects relating to quality nutrition ser­vices.
• To provide a forum for the exchange of ideas and sharing inform­ation
on all aspects of the nutrition services component of the
WIG Program.
• To improve the ability of conference attendees to achieve nutrition ser­vices
goals and objectives and to enhance the quality of nutrition and
health-related services provided to WIG participants.
• The conference was attended by approximately 600 persons from both
the public and private sectors of the community, representing all 50
States plus the District of Columbia, Puerto Rico, and Guam. Most
were WIG State and local agency staff, including program directors,
nutritionists, nurses, lactation consultants, breastfeeding coordinators,
home economists, educators, and nutrition assistants.
iii
iv
The 55 speakers included a cross section of Federal, State, and local
agency WIG staff, plus experts from universities, hospitals, and State and
Federal agencies.
There were three plenary sessions:
• Opening Session, with FNS Administrator Betty Jo Nelsen, FNS South­east
Regional Office Administrator Virgil Conrad, and the Director of
Supplemental Food Programs Division Ronald J. Vogel.
• Breastfeeding Promotion, with four State WIG Nutrition Coordinators,
Marlene B. Guroff, FNS, and Dr. Carol Suitor from the National Acade­my
of Sciences.
• Alcohol and Other Drug Use Prevention, with pediatrician Dr. Barry
Zuckerman, Boston City Hospital.
There were 35 concurrent sessions, 5 during each of the seven time
periods. Eight of these, however, were repeated sessions. The 27 undu­plicated
sessions are listed in the table of contents alphabetically by
name of the session rather than by the time period in which they
occurred.
Acknowledgments
USDA is pleased to acknowledge the efforts of the following FNS staff mem­bers
who served as conference coordinators to help make this event a success:
Supplemental Food Programs Division:
Paula Carney, Doris Dvorscak, Tama Eliff, Rhonda Kane, and Robin Young.
Nutrition and Technical Services Division:
Donna Blum, Michele Lawler, Helen Lilly, and Brenda Lisi.
This document was prepared by james R. Stewart, Ph.D., under a contract
with FNS, USDA. All sessions of the conference were tape recorded,
transcribed, and subsequently condensed by the contractor. Most sessions
were condensed to about 20 percent of their original length with a focus on
the key points. The draft summaries were subsequently reviewed and edited
by USDA. With few exceptions, the draft summaries were not reviewed or
approved by the respective conference speakers. Final editing of the proceed­ings
was provided by Grace I. Krumwiede under a contract with USDA.
In many cases, the speakers had handouts and other references available for
further information about their topics. Some of these additional resources are
included as exhibits with the synopses of the respective sessions. For addition­al
information, write to the speakers at the addresses provided in appendix A.
The views and opinions expressed in the summaries by non-USDA speakers
do not constitute an endorsement, real or implied, by USDA.
v
ACOG
ADA
AFDC
ASTPHND
BBTD
BPC
CAl
CDC
CPA
DHHS
EFNEP
EPSDT
FAS
FDA
FNS
HCFA
MCH
MCHB
MCHING
NAACOG
NAWD
NCHS
NET
NTSD
PedNSS
PHS
PNSS
RDA
SFPD
SPRANS
USDA
voc
WHO
WIC
Acronyms
American College of Obstetricians and Gynecologists
American Dietetic Association
Aid to Families with Dependent Children, DHHS
Association of State and Territorial Public Health Nutrition Directors
Baby Bottle Tooth Decay
Breastfeeding Promotion Consortium
Computer-assisted Instruction
Centers for Disease Control, DHHS
Competent Professional Authority
U.S. Department of Health and Human Services
Expanded Food and Nutrition Education Program, USDA
Early and Periodic Screening, Diagnosis and Treatment Program, DHHS
Fetal Alcohol Syndrome
Food and Drug Administration, DHHS
Food and Nutrition Service, USDA
Health Care Financing Administration (Medicaid), DHHS
Maternal and Child Health
Maternal and Child Health Bureau, DHHS
Maternal and Child Health lnterorganizational Nutrition Group
Organization for Obstetric, Gynecologic and Neonatal Nurses
National Association of WIC Directors
National Center for Health Statistics, DHHS
Nutrition Education and Training Program, FNS
Nutrition and Technical Services Division, FNS
Pediatric Nutrition Surveillance System
Public Health Service, DHHS
Pregnancy Surveillance System
Recommended Dietary Allowances
Supplemental Food Programs Division, FNS
Special Project(s) of Regional and National Significance, DHHS
U.S. Department of Agriculture
Verification of Certification
World Health Organization
Special Supplemental Food Program for Women, Infants, and Children, FNS
vii
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WIC-An Effective
Partnership
Speakers:
Virgil Conrad,
Regional Administrator,
Southeast Regional Office,
FNS, USDA,
Atlanta, GA
Betty }o Nelsen,
Administrator,
FNS, USDA,
Alexandria, VA
Moderator & Speaker:
Ronald}. Vogel,
Director,
Supplemental Food Programs Division,
FNS, USDA,
Alexandria, VA
• Introduction of the FNS
Administrator
-Virgil Conrad
I would like to welcome you to the Southeast Region. We have eight States
here, Tennessee being one of them. We like to think that we are the best in
the Nation, and we are going to try hard this week to impress you. So the first
thing I want to do is offer you an opportunity to join our team. We have an
opening for a full-time State or local person to join the Atlanta office for 1
year, under the Intergovernmental Placement Act, to assist us with program
coordination efforts, particularly in the maternal and child health area.
Now it is my privilege to introduce our speaker for this morning. Betty jo
Nelsen joined our Agency as Administrator in january of 1990, providing
leadership to our 12 food assistance programs totaling $25 billion annually.
Prior to her appointment she served as State legislator in Wisconsin for 1 0
years. During her tenure she served on the Finance Committee and also on
the Welfare Reform Commission.
Sometime ago I read a phrase, "What one person can dream, another can
do." Betty jo Nelsen has those unique qualities of being both a dreamer and a
doer. I am pleased to present to you, Betty jo Nelsen.
• WIC-An Effective Federal­State-
Local Partnership
-Betty jo Nelsen
It is a great pleasure to be here at the first national meeting for WIC nutrition­ists.
I am pleased that more than 600 of you have come, whether you came
across town from a clinic here in Memphis or whether, like Kathryn Guzman,
you flew 38 hours from Guam.
2
In remarks made last year on National Children's Day, President Bush said,
"The Government must not and, indeed, cannot take over the primary
responsibility of parents in caring for their children. However, the Government
can help parents in their sometimes difficult role through wise and carefully
developed measures that strengthen the family and give every child the
opportunity to grow up safe, healthy and well-educated."
WIC's nutrition services are "wise and carefully developed measures" that fit
the President's guidelines of proper Government activity because they
empower parents to improve and protect their own health and that of their
children.
Many Children
Are at Risk
America has made great strides in reducing infant mortality. The rate of
progress has leveled off, however, at about 9.7 deaths per 1,000 births, an
unacceptably high rate compared to that of other industrialized nations. Nor
is that the only area where the well-being of America's children is in danger.
In a recently released report, the National Commission on Children present­ed
a sobering view of the status of children and families today. Among their
findings:
• Most children have a bright future, but far too many do not.
• One child in four is raised by a single parent.
• One in five children is poor.
• One-half million babies are born annually to teenage girls ill-prepared
for the responsibilities of parenthood.
• An increasing number are impaired before birth by their parents' sub­stance
abuse.
• Some live among violence and exploitation, much of it fueled by the
thriving drug trade.
• In sum, many are poor, some are homeless, some are hungry.
How WIC Helps
WIC is one form of assistance for families and children at risk. The program
addresses nutrition problems through supplemental food benefits, and refers
participants to a range of programs, including health care, Food Stamps, and
AFDC (Aid for Families with Dependent Children).
WIC's nutrition educators, like many of you here today, teach participants
how to make good food choices, the benefits of breastfeeding, and the
dangers of smoking and alcohol and other drug use. You deal with a wide
range of nutrition issues, such as giving a pregnant teenager information that
enables her to make better choices for her and her baby's health or encourag­ing
a new mother to breastfeed.
You inform participants about health services, such as where to get immu­nizations
as well as counseling and support services. You assist them in making
changes in their eating habits and lifestyles. We know that this individualized
effort, this education approach, pays off.
The combined efforts of nutrition aid and access to health care were
demonstrated by the WIC/Medicaid study released last year. The study found
that pregnant women who participate in WIC receive more prenatal care,
have healthier babies and higher birth weights, and are less likely to give birth
to premature infants. The study showed the WIC Program saved $2 to $3 in
Medicaid for every dollar spent in WIC. That is why we say WIC works.
As a conservative Republican who hears a lot from taxpayers about manag­ing
our tax dollars, it is just wonderful for me to be able to go out and speak
so proudly of a program that has demonstrated its cost effectiveness and the
fact that it does work. This demonstration of effectiveness, as well as the
dedication of the staff members across the Nation, has led to WIC being a star
in the Federal Government.
WIC is truly a cooperative partnership. Those of us in WIC at the Federal
level are a little frustrated because we don't get to face those clients, to see
those wonderful babies thriving from the nutritious supplemental foods, and
benefiting from the counseling and other services.
We are available to help provide technical assistance, policy direction, and,
of course, to do the battles in the Congress and in the administration. But it is
all of you out there, and thousands of others like you, who really are on the
front lines with the opportunity to see the clients. I envy you in many ways.
New Administration
Initiatives for Children
Because WIC is such an effective gateway to the health care system, it has
a special role in two of the Administration's initiatives for children. President
Bush has called for a new program, "Healthy Start," to focus medical and
social services on 1 0 cities with disturbingly high rates of infant mortality.
Under the direction of Dr. james Mason, Assistant Secretary for the U.S.
Department of Health and Human Services (DHHS), Healthy Start will aim
to reduce infant mortality by 50 percent over 5 years in the selected
communities.
The FNS has asked State and local WIC officials to actively cooperate in this
effort. We hope you will participate through educational efforts and coordina­tion
activities if you are in one of the selected cities, or by reaching out and
serving more women and children in your program.
Another exciting special project involves WIC in the first of the President's
six national education goals: "By the year 2000 all children in America will
start school ready to learn." The President has asked the Surgeon General to
address the health component of learning readiness. And the Surgeon General
has identified WIC as the primary food assistance program involved, because
we touch the lives of so many needy preschool children.
Members of the WIC national staff, along with representatives of the U.S.
Department of Education and DHHS, serve on a task force that is seeking ways
to achieve this goal. The task force is planning a national conference, to be
held in December, that will bring together families, Governors, State officials
and health, education and social service professionals from across the Nation.
Conferees will identify resources and set a common agenda for addressing the
children's health needs.
Uniqueness of WIC
I would like to reflect a little bit on the uniqueness of WIC and what we need
to do to protect that. Did you know that one out of every three babies born in
the United States is on the WIC program? That is why WIC is always involved
when policymakers discuss strategies to improve the lives of children. The WIC
program serves a large proportion of the low-income population at risk of
poor nutrition and inadequate health care.
An example of that is our involvement in immunization efforts. When it was
discovered that a number of young school-age children had not been immu­nized
against common childhood diseases, especially measles, it was apparent
that the WIC program must be included in efforts to increase immunization
efforts in the Nation.
A study in several cities that were particularly hard hit by the recent measles
outbreak showed that 47 percent of the children who had come down with
measles were from families being served by a Federal welfare program.
Clearly, the Federal Government had a role in providing information, encour­agement,
referral, and some onsite services to those families, so that we could
be sure that youngsters were protected.
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4
At a meeting of the National Advisory Council on Maternal, Infant, and
Fetal Nutrition, a person said, "Let's not forget our roots. Let's not forget the
truly important part of the WIC Program-nutrition education. It is not just a
supplemental food program." Of course, the nutrition education is the part
that changes behavior and can change people's lives.
And just because we have so many children and moms in our program,
let's not see WIC as the answer to everything. We have to guard against
diluting the important WIC mission of nutrition education. WIC wants to
continue to be a referral to the health care system, because we know that is
imperative, and we want to participate in other Federal efforts. But we also
want to remember what WIC is there for and protect and preserve that.
WIC recognizes the importance of good nutrition during gestation and
infancy. We also see the need for education for the caregivers-counseling to
those moms about the way they need to feed their families.
The "W/C Exchange" has lots of good ideas about what goes on across the
country. And that is what this conference is about-sharing ideas, asking
questions, and getting names from people who have similar problems to
yours and who have some solutions.
Nutrition Education-A
Priority of the USDA
Nutrition issues are a top priority of USDA's new Secretary, Edward Madi­gan.
He has identified nutrition education with a special emphasis on children
and low-income adults as one of the Department's four strategic goals. He is
disturbed when he sees people make poor choices at the supermarket. He is
disturbed especially when he sees them pay for inappropriate groceries with
food stamps, because he believes we in Agriculture have a responsibility that
goes beyond just providing food stamps. We have a responsibility to low­income
families to provide some help in making wise food choices.
So our Secretary urges us to concentrate on youngsters. Talk to them about
good nutrition. Help them to understand wise food choices, and they will go
home and talk to their parents.
Like Cinderella, nutrition education has been sweeping the hearth unno­ticed
for a long, long time. But now nutrition education has been invited to
the Ball!
Perhaps we will have to be as ingenious as fairy godmothers and godfathers
in outfitting nutrition education for a more glamorous role at a time of fiscal
restraint. But it won't be the first time that WIC magicians have been asked to
make carriages out of pumpkins.
Now let me tell you a little bit about some of the things we are doing at the
Department to make nutrition education accessible to groups at nutritional
risk.
Dietary Guidelines for
Americans
Last fall USDA and DHHS issued a revised "Dietary Guidelines for Americans."
These guidelines provide nutritional advice for healthy Americans age 2 and
over. This project occurs every 1 0 years when the Federal Government looks
at the new nutrition information and decides what to recommend to healthy
adults.
Perhaps the item that has drawn the most attention in the new dietary
guidelines is that for the first time there is a quantitative standard for fat,
which says that people over the age of 2 ought to have no more than 30
percent of their calories from fat in their diet. But the standard of how many
servings of fruits and vegetables to eat a day is even tougher: 5 to 11 servings
a day.
The Department is now in the process of developing a new graphic to
depict the recommendations of the dietary guidelines. We want this graphic
to accurately deliver the message to all Americans, especially low-income
families and children. It is not easy to find a picture to tell the story, especially
one understandable to children. Our partners at DHHS have been participat­ing
with us in developing this graphic. We expect the work to be concluded
by the end of the year, with a graphic available for inclusion in publications
this spring.
Coordination of Services
In addition, Secretary Madigan has established a Department-wide task force
to coordinate and expand Agriculture's nutrition education activities. The task
force is co-chaired by Assistant Secretary Catherine Bertini and Dr. Charles
Hess, the Assistant Secretary for Science and Education. This task force has
identified eight agencies in USDA with nutrition education-related responsibili­ties.
It will determine how these agencies can coordinate activities and focus
on groups that are most vulnerable.
Our fastest growing program in FNS is the Child and Adult Care Food
Program. We provide meals for children in family day care, center-based day
care, and also in the Head Start Program. We plan to develop nutrition
education materials to help child care providers serve nutritious, economical,
and safe meals and snacks. The training will include guidance for teaching
preschool children about nutrition.
The Nutrition Education and Training (NET) Coordinators in the State
education agencies across the Nation are partially funded by USDA. Their
mission is to provide curricula for classroom teachers in their State. They are
working with other States so that good curricula are borrowed from State to
State. We are looking forward toward that NET network to help us in tasks at
the Department.
The Expanded Food and Nutrition Education Program (EFNEP) is a USDA
program that works in cooperation with county extension offices, available in
some counties and not available in others. We are looking for ways to work
more closely with EFNEP and to provide referrals for particularly tough cases in
programs such as WIC, where you might feel a mom would benefit from a
more concentrated and longer exposure to nutrition information. This will not
take the place of nutrition education in the WIC program, but will really be
another resource to WIC nutrition educators.
Nutrition education for WIC moms will continue to emphasize breastfeed­ing
as the healthiest choice for babies. Last year USDA organized a consortium
of health professionals and others to promote the practice of breastfeeding
nationwide. You will hear more about this later in the conference.
I know you are urging your moms and dads to make wise food choices. I
hope you are also urging them to choose low-cost, nutritious alternatives
when they make those choices. We need to help people identify foods which
provide nutrition and are relatively low cost.
I also want to urge coordination of services at the local level, preferably
through co-location. Any time that we can work more closely with other
health care services that provide help to the same client group (pregnant
women, infants, and children) we have a synergy that expands our efforts
tremendously. This is very important to our clients. It is not always possible to
co-locate services, but if we have that as a goal, when we are looking for new
space, we may be able to arrange that.
You are well aware of the nondiscriminatory nature of all our services. But I
would like to urge you to take a step beyond the law, to ensure that the
services you provide to our WIC clients are culturally sensitive, and are accept­ing
of the values you find among them. It is easy to project our values onto
5
6
other people, and that is not fair. We must respect and protect cultural
differences.
And, finally, as you know, many women are in the world of work, and that
means that, in addition to their work hours and their child care hours at
home, they are also trying to fit in a myriad of other chores. We cannot expect
all women to be available to come to clinics between the hours of 8:00 a.m.
and 5:00 p.m., especially if they are pregnant or have new babies or have
young children. Our goal in this administration is to reach eventual full
funding for the WIC program. That doesn't mean full funding just for those
people who can come during the hours of 8:00 a.m. to 5:00 p.m. It means full
funding for everyone who is eligible. Therefore, we must try to establish clinic
hours that will accommodate everyone, including working moms.
This is a team effort of State, Federal, and local folks working together to
make this program the best it can be for women, infants, and children. It is
fun to be involved in a program that works so well.
• Challenges, Changes, Choices
-Ronald}. Vogel
I just want to add that Betty ]o is as serious with us at the national office as
she sounds here at the podium, particularly with respect to breastfeeding.
She took a look around our agency and asked, "How come we don't have a
breastfeeding lounge for working moms here in FNS?" So I lost my con­ference
room.
Normally each year, FNS does a national technical assistance meeting. We
picked the theme for this meeting, "Challenges, Changes, and Choices," for
several reasons.
Challenges
One of the challenges that we are all facing is that we serve one out of every
three babies born in the United States. WIC serves over 60 percent of all
teenage pregnancies. By the end of September of this year, we will be serving
5 million participants per month.
Remember, this program is based on the premise of individual solutions to
individual problems. The model is one-on-one. How do you do that with over
5 million people being served each and every month? That is a big chal­lenge-
especially since, in the near future, there is not going to be more
money specifically for nutrition services and administration (NSA). In fact,
some think the WIC Program already spends too much of the appropriation in
this area.
Changes
The changes in our reauthorization act have put NSA funds at roughly 22
percent of the appropriation that Congress gives us. Some have suggested
putting half of that money into food. So you have a job educating your
congressional delegation and your State legislatures about what WIC does.
The MCHING (Maternal and Child Health lnterorganizational Nutrition
Group) meeting, organized by the DHHS, brought dozens of organizations
together to chart a coordinated path for nutrition services across the country.
There are a lot of resources out there right now available to help us do our
job, if we think smart and we respond creatively. We have to work with our
counterparts in health care and other arenas.
A recent article about the State of Alabama stated that, if a woman delivers
without the benefit of any prenatal care visits whatsoever, the death rate is 59
infants out of 1,000. If the woman sees a medical professional at least once
during each month of her pregnancy, eight visits, the rate in Alabama drops
to 8.4 deaths per 1,000. That is better than the national average. This tells us
something-in the delivery of nutrition services and other WIC benefits, we
must make certain that we are also a major component of the prenatal care
that is delivered.
We cannot forget our roots. We are first and foremost a nutrition services
program. But we also have to remember that we do not operate alone-we
operate in the environment of the public health delivery system.
Remember how Head Start got its beginnings? It started off as a compen­satory
education program. You give the preschoolers some enrichment and
they are going to do a lot better in school. Then Head Start realized that,
while compensatory education is their major mission, they need to deal with
families holistically-with the full range of problems they face.
So Head Start contracts with the Maternal and Child Health Bureau for
nutrition services. They coordinate extensively with the Early and Periodic
Screening, Diagnosis and Treatment Program (EPSDT). They do a lot of work
with parents. Now they do not refer to themselves as a compensatory educa­tion
program-they are a comprehensive child development program.
Similarly, WIC must be linked into the health care community.
Choices
And, lastly, we have choices to make. Are we are going to shoot for the very
best we can deliver, or just try to get by? I know there are days when you feel
you just can't do any more. But remember, kids are the resources of this
Nation's future-we have to do the very best we can. •
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8
Breastfeeding
Promotion
Speakers:
Kathy Dugas, M.S., R.D.,
Nutrition Coordinator,
WIC Program,
Mississippi State Department of Health,
jackson, MS
janice Lebeuf, M.P.H.,
Nutrition Consultant,
Nutrition Services Section,
Division of Maternal and Child Health,
North Carolina Department of Environment,
Health and Natural Resources,
Raleigh, NC
Brenda Dobson, M.S., R.D.,
WIC Nutrition Services Coordinator,
W/C Bureau,
Iowa Department of Public Health,
Des Moines, /A
Mary Kay DiLoreto, R.D., M.S.,
Nutrition Education Coordinator,
WIC Program,
Oregon Health Division,
Portland, OR
Marlene B. Guroff,
Special Assistant to the
Deputy Administrator,
Special Nutrition Programs,
FNS, USDA,
Alexandria, VA
Carol Suitor, D.Sc., R.D.,
Study Director/ Program Officer,
National Academy of Sciences,
Washington, DC
• Overview
-Susan Mayer
Moderator:
Susan Mayer,
Regional Nutritionist,
Supplemental and Indian Food Programs,
Southwest Regional Office,
FNS, USDA,
Dallas, TX
In this session, four State Nutrition Coordinators report some successes in
implementing the breastfeeding provisions of Public Law 101-147, the WIC
Reauthorization Act of 1989. Then Marlene Guroff from the FNS national
- - - - - - - - - - - -- -
office reports on the Breastfeeding Promotion Consortium (BPC) and the
breastfeeding promotion media campaign. Finally, Dr. Carol Suitor summa­rizes
the Institute of Medicine Report, "Nutrition During Lactation".
• Breastfeeding Promotion in
Mississippi
-Kathy Dugas
Since 1983 I have seen many breastfeeding initiatives in Mississippi. We have
done training sessions and purchased materials, resources, and videos for our
staff. We were always able to generate some enthusiasm, but we couldn't
sustain that enthusiasm for long periods of time. The reason was that we were
depending on our existing staff to do it in addition to doing everything else.
We realized that we needed staff specifically assigned for breastfeeding.
WIC services in Mississippi are provided in all 82 of our county health
departments, plus 12 community health centers. There is only one private
provider. About 75 percent of all of our WIC participants utilize the health
department as their major source of health care. That means that we have
access to many women and their infants, not just at certification, but all
through the prenatal period.
Last October we implemented a breastfeeding peer counselor program.
When we went to our personnel board and said we were mandated to do this
under Public Law 1 01-147, we were able to get approval of a District Coordi­nator
and two levels of local staff:
• Peer counselors, mostly WIC mothers who have breastfed, work
with other WIC mothers.
• Lactation specialists, who have more training, such as La Leche
League leaders and certified lactation consultants, teach some prenatal
and breastfeeding classes, and work with our staff on the more special­ized
problems.
Initial promotion continues to be done by existing staff during the WIC
certification and through prenatal clinics. When appropriate, they are referred
to one of our peer counselors, who makes contact with them all through the
prenatal period, and after delivery. Some of them are even making contact
with the woman while she is still in the hospital. After she goes home, they
continue to make contact with her until she weans the baby.
We don't know for sure how much of an impact we are making. We are
struggling to find the best way to collect accurate data on incidence and
duration. The 6-month average of women certified as breastfeeding has
increased from 107 to 152 per month throughout the State. Enrollment of
breastfeeders has increased from 757 to 1,045 in 9 months.
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• Breastfeeding Promotion in North
Carolina
-janice Lebeuf
Our Breastfeeding Promotion Committee, which began in 1987, set three
areas to work in:
• Policies and procedures for WIC, plus a public health position paper
on breastfeeding.
• Professional training, including scholarships for public health person­nel
to attend out-of-State training programs, State-sponsored training,
and a Breastfeeding Educator Program at a private hospital.
• Client education and support, to develop education materials and
implement project grants.
The Breastfeeding Educator Program has 2 days in the classroom, followed
by a 1-day clinical experience. As a result of this training, many public health
staff feel more comfortable with their skills related to breastfeeding education
and support.
We developed breastfeeding education kits, which were distributed to all of
our local health departments and WIC Programs, as well as health libraries, so
that private providers and hospital staff can access them.
We offered all local WIC Programs an opportunity to apply for Breastfeed­ing
Education and Support Project grants in three categories:
• Innovative community-based projects-we funded six innovative projects
at $20,000 each.
• Multi-county lactation clinics.
• Peer counselor projects-we funded 10 projects at $5,000 each. The
peer counselors are used in a variety of different ways. They assist with
prenatal classes, they make postpartum hospital visits and home visits,
and they contact breastfeeding women by phone.
Many of the innovative projects incorporate community-based training,
some involve WIC-hospital coordinated services, and others have purchased
electric breast pumps or made arrangements with rental depots to rent pumps
for WIC moms with special needs babies. In one of the projects, the WIC
Program has subcontracted with EFNEP for a community aide, who is cross­trained
in breastfeeding, to do home visits.
We subcontracted with a university survey research unit to telephone about
1,200 pregnant women to determine attitudes, intentions, and behaviors
related to infant feeding . The second phase of the telephone survey will be on
the same women, postpartum, to see if those that intended to breastfeed did.
If so, how long? If not, what were the barriers? Those surveys are completed,
but we do not have the results analyzed yet.
• Breastfeeding Promotion in Iowa
-Brenda Dobson
Breastfeeding promotion and support activities in Iowa since the early 1980's
have included:
• Revision of our Infant Diet History form to assist staff in evaluating the
breastfeeding relationship.
• Development of an infant feeding survey to determine each pregnant
woman's attitudes and knowledge about breastfeeding.
• Distribution of breastfeeding protocols to assist staff in providing accu­rate
and consistent information during the prenatal and postpartum
contacts.
• Printing several new brochures for use with clients, including Spanish
materials.
• Distribution of client education bags and videotapes.
• Purchase of manual pumps and breast shells, as well as leasing of
portable electric pumps.
• Expanded membership of the Iowa Lactation Task Force.
Iowa Lactation
Task Force
We formed the Iowa Lactation Task Force in 1986 to decide what activities to
pursue in our State to try to reach the 1990 breastfeeding goals. At that time,
about 46 percent of women were breastfeeding immediately after delivery.
We first did a mail survey of hospital breastfeeding practices and found that
health professionals needed access to current information on breastfeeding. As
a result, we did eight workshops across the State. Over 250 individuals attend­ed
these workshops, including hospital nurses, hospital dietitians, public
health nurses, public health dietitians, childbirth educators, nurses from
physicians' offices, health educators, La Leche League leaders, and a few
physicians.
Since then, the workshop has become an annual part of our ongoing
training for public health staff in the State. We also have made the workshop
available at community request and have done six community sessions so far.
The breastfeeding provisions of Public Law 101-147 encouraged us to
expand the membership of the Iowa Lactation Task Force. Now, groups
represented include consumers, the Family Planning Council of Iowa, the Iowa
Academy of Family Physicians, Iowa Association of Nurse Practitioners, Iowa
Chapter of the American Academy of Pediatrics, Iowa Department of Educa­tion,
several programs from the Iowa Department of Public Health, MCH
Public Health Nursing and WIC program, the Iowa Dietetic Association, Iowa
Hospital Association, Iowa Nurses Association, Iowa Section of the American
College of Obstetricians and Gynecologists (ACOG), La Leche League of Iowa,
and Nurse Associates of the College of Obstetricians and Gynecologists
(NACOG).
The group has worked in four areas:
• Position statement, about breastfeeding promotion and support.
• Data collection, for information about the infant feeding decision,
how many breastfeed, for how long, reasons for weaning, and what their
community sources of information and support are.
• Education, including seminars and workshops, client and professional
materials and input on WIC breastfeeding protocols.
• Hospital policy, including doing another mail survey and drafting
model hospital policies .
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• Breastfeeding Promotion
in Oregon
-Mary Kay DiLoreto
We began our breastfeeding promotion efforts in Oregon in 1988, in response
to a local agency needs assessment. The four components we focused on have
been
1. Staff training, which includes:
• Regional conferences.
• Scholarships for people to get more clinical training for managing
breastfeeding problems.
• "Breastfeeding Resource and Training Manual," which incorpo­rates
competency-based training for paraprofessionals, but also
provides basic training for health professionals. It covers individual
counseling as well as group education, plus a resource section to
get further information.
• Resources at local sites, such as education kits, texts, references,
and problem-solving manuals.
2. Client incentives, to provide encouragement and tangible rewards
for moms, such as infant T-shirts saying "I Eat at Mom's," in English or
Spanish, and adult T-shirts saying "I Gave My Baby a Great Start," for
moms who breastfeed for 6 months or longer
3. Local agency nutrition education plans on breastfeeding promo­tion
include:
• Developing support groups.
• Improving clinic image to support breastfeeding.
• Coordinating with hospitals, La Leche League, and other resources.
• Creating a private area in the clinic for breastfeeding.
• Sending postcards with information to new moms.
• Making supportive phone calls to moms shortly after birth.
• Setting up community task forces at the local level.
• Establishing peer counseling/support programs.
• Displaying pictures of moms and their babies in the clinic.
4. Data collection which showed:
• About 78 percent of our moms initiate breastfeeding (this has been
constant for the past 3 years).
• About 40 percent of those moms continue breastfeeding for at
least 6 months.
• Breastfeeding Promotion
Consortium (BPC) and Media
Campaign
-Marlene B. Guroff
The BPC began in the spring of 1990, when members of the American Acade­my
of Pediatrics met with Catherine Bertini, USDA Assistant Secretary for Food
and Consumer Services. The BPC, which is chaired by Ms. Bertini, is a group of
22 health professional, Government, and public health organizations. We are
now looking to invite a representative from the business community.
USDA, with the support and the endorsement of other BPC organizations,
agreed to accept the lead responsibility for developing a nationwide media
campaign to promote breastfeeding as the optimal method of infant feeding.
This idea was further strengthened in the 1990 report to Congress by the
National Advisory Council on Maternal, Infant and Fetal Nutrition. The cam­paign
also derives from a commitment to help realize the Year 2000 Health
Objectives for the Nation, which include a goal of increasing to at least 75
percent the proportion of mothers who breastfeed their infants in the early
postpartum period, and to at least 50 percent those who continue to breast­feed
until the infant is 5 to 6 months of age.
Activities of BPC
Activities of the BPC include:
• Sharing resources and ideas among member organizations.
• Public education, including the media campaign and distribution of
information by member organizations.
• Professional education, health professional curriculum reform, especially
development or review of the curricula for nurses.
• Establishing a network of State and local coalitions.
• Increasing the awareness of health care providers on how to better pro­mote
and support breastfeeding.
• Drafting a survey on health professionals' knowledge, attitudes, prac­tices,
and barriers to promoting breastfeeding.
• Legislation and advocacy. The Center on Budget and Policy Priorities will
look at further advocacy or possible legislation. The Senate Select Com­mittee
on Hunger may hold a hearing on breastfeeding.
• Sharing ideas on workplace support.
• Looking at enhancement of the hospital environment to support breast­feeding.
• Changing breastfeeding images in the media. Ms. Bertini will be talking
with producers of TV and movies to encourage story lines that are more
supportive of breastfeeding.
Goals of the Media
Campaign
These goals are:
• To increase awareness and knowledge about breastfeeding as the opti­mal
method of infant feeding among the general public.
• To create a supportive, accepting public environment with respect to
breastfeeding.
• To motivate and support women to initiate and continue optimal breast­feeding.
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• To increase awareness of and encourage concrete action among those
who influence infant feeding decisions on ways to promote and support
breastfeeding.
• To form a network of State and local coalitions to support the campaign
and to continue promoting breastfeeding after the campaign ends.
The work plan identifies the primary target audience as the Nation as a
whole. Secondary audiences include health care providers, hospital adminis­trators,
media representatives, employers, educators, policymakers, mother-to­mother
support groups, and other community groups.
In june 1991, the BPC Technical Consultant Group decided to recommend
an upbeat emotional appeal, a warm and fuzzy kind of approach, that would
give women confidence in their ability to breastfeed. Some of the possible
titles suggested were, "A Gift That Only You Can Give," "A Moment That Lasts
A Lifetime," "Nature Provides Its Best," and "Make Yours Nature's Way."
We are working on a logo, slogan, public service announcements (PSA's),
media kits, and organizer's kits, which must be in everyone's hands before we
hit the air waves with PSA's. Later on, we will prepare a health professional kit
and an employer's kit.
Planning and
Implementation
Phases
The Planning Phase includes:
• Liaison with the administration (for overall approval of the campaign).
• Compilation of background information and reports of examples from all
across the country.
• The process of going through Office of Management and Budget (OMB)
and then to Congress to obtain separate funding authority for the cam­paign.
Funding is not coming from the $8 million that you now receive
for breastfeeding promotion. We have a small amount of seed money.
• Consideration of other promotional activities, including a Presidential
proclamation, various nationwide kickoff activities, awards programs for
individuals and programs making a significant contribution to breast­feeding,
and maybe a "most beautiful breastfeeding baby" contest.
• Development of an organizational structure and process.
• Development of the campaign plan, including the message, possible
recruitment of a spokesperson, materials development, communication
plans, a possible toll free number, plus the coalition building.
The Implementation Phase includes:
• Materials production
• Materials distribution
• Liaison and promotion with the media
• Evaluation
We hope to have an organizer's kit available in all States in 1994, and plan
the kickoff with media, PSA's, posters, brochures, etc., in january 1995. We
have not put an ending date on the campaign, as it depends on the funding
we receive.
• Findings in the Institute of
Medicine Report "Nutrition
During Lactation"
-Carol Suitor
"Nutrition During Lactation", published in 1991 by the Institute of Medicine
focused on the following questions: What are the nutrient needs of a breast­feeding
woman? How can they be met? What happens if they are not met?
What effects may breastfeeding have on the long-term health of the woman
and of her infant?
Charge to the Committee
"Nutrition During Lactation" was written by a nine-member panel, chaired by
Margit Hamosh of Georgetown University. The charge to the committee
was to:
• Evaluate the current scientific evidence concerning breastfeeding and
formulate recommendations for the nutrient needs of lactating women.
• Give special attention to teens, women over the age of 35, and minority
groups, such as women of African-American, Hispanic, or Southeast
Asian origin or descent.
• Determine effect of breastfeeding on the nutritional status and long-term
health of the woman.
• Determine effect of the mother's nutritional status on the volume of
human milk, its composition, and changes in infant health.
Conclusion:
Breastfeeding is
Recommended
The report focused on the mother, but also includes considerable information
about the infant. In fact, the report shows postneonatal mortality rates are
lower for breastfed than bottlefed infants. The general conclusion was,
"Breastfeeding is recommended for all infants in the United States under
ordinary circumstances."
A literature review found very little useful data on dietary intake of breast­feeding
women. The average volume of milk produced was found in many
studies to be between 600 and 850 milliliters (about 20 to 26 ounces) per
day, whether in developing countries or industrialized countries.
Factors Influencing
Volume of Milk
Factors that influence let-down or volume of human milk are:
• Nutritional status
• Stress
• Drug abuse
• Cigarette smoking
• Alcohol consumption
• Oral contraceptive agents
The factors that are most influential for the infant's health, however, are the
infant's nursing practices, and the frequency and the intensity of the nursing
itself.
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Composition of Milk
and Supplements
Maternal factors that influence the composition of human milk are principally
length of gestation and number of weeks postpartum, with maternal diet and
nutritional status less important. The vitamin content is dependent upon the
mother's intake and stores, but is not apt to change as a result of day-to-day
changes in maternal diet. It generally takes a prolonged period of low intake
to make a difference. You can find sharp increases as a result of supplementa­tion
with certain vitamins, but that is going to abnormally high levels. The
only problems are in women with diets very low in B-12 and thiamine, which
are generally not a problem in this country.
The recommendation is to encourage lactating women to obtain their
nutrients from a well-balanced, varied diet, rather than from vitamin/mineral
supplements. Lactating women require more of all nutrients than women at
any other stage of life, with the exception of iron. But if they follow eating
patterns that are consistent with those reported by women in the Continuing
Survey of Food Intake by Individuals, and they meet their calorie needs, they
will get nutrient intakes comparable to recommended dietary allowances
(RDA).
It is not essential to have a perfect diet to have good milk. If intake is lower
than recommended, the milk is fine, but the woman may be depleting her
stores. The nutrients that require the most attention are calcium, zinc, folate,
magnesium, and vitamin B-6. So encouragement of dairy foods and vegeta­bles
can be very helpful.
If the woman consumes less than an 1,800 calorie diet, which is not a
recommended practice, then the committee says she should take a multivita­min
supplement. She may need supplements if she has no source of vitamin
B-12 (only applies to strict vegetarians), if she is avoiding calcium-rich foods,
or if she gets no exposure to vitamin D and no vitamin D-fortified foods.
Fluid intake doesn't really make much difference. If you quench your thirst
while you are nursing, that should be adequate.
The Committee recommended the development of a well-defined plan for
the health care of the lactating woman, including screening for nutritional
problems and providing dietary guidelines. Diet is of less immediate concern,
however, than breastfeeding practices that help the mother establish an
ample milk supply.
Women are concerned about their weight, but you should give realistic
advice about weight change during lactation. The weight loss rate may be 1
to 2 pounds a month. There were a substantial number of women who did
not lose weight at all or who even gained weight when they were nursing.
Problems From Drugs,
Cigarettes, and Alcohol
Do the substances that women eat or drink pass into the milk and affect the
infant? Studies of colic and allergy show little indication of effects on the
infant. The committee recommends that if allergies are suspected, basic foods
should not be eliminated from the diet without adequate testing to document
an allergic reaction.
Substance use, however, is a big problem. The committee recommends
active discouragement of drugs, cigarettes, and alcohol. They found no
scientific evidence that alcoholic beverages provided any benefit for breast­feeding.
In fact, milk volume is impaired by high intake of alcohol, such as two
glasses of liquor, 8 ounces of table wine, or two bottles of beer.
The effects of breastfeeding on maternal health were unclear. We are not
sure of the long-term effects of breastfeeding on obesity. As far as breast
cancer is concerned, some studies suggested a decreased risk, but others saw
no difference at all. Since the calcium needs are so high during lactation, you
might expect to see a higher problem with osteoporosis, but the evidence
suggests that breastfeeding may be protective.
Slower Weight Gain
Is No Problem
The Committee looked at differences in growth between healthy breastfed
and formula-fed infants. After the first 2 to 3 months, healthy breastfed
infants, fed on demand, tend to gain weight somewhat more slowly than do
those fed formula, but there are no ill effects. Sometimes there is a tendency
to have women stop breastfeeding because their infants are not gaining at
quite the expected rate. You should monitor weight so that you don't miss
growth problems, but don't take a woman off breastfeeding unnecessarily.
Copies of the summary can be obtained from the Maternal and Child
Health Clearinghouse. The Committee on Nutritional Status During Pregnan­cy
and Lactation is in the process of preparing a "Clinical Applications Guide"
based dn both reports, "Nutrition During Pregnancy" and "Nutrition During
Lactation". The guide is targeted mainly toward practitioners, with a focus on
physicians and nurses, rather than on dietitians. "Nutrition Services in Perinatal
Care" is being revised and will be available in Spring 1992. •
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Alcohol and Other Drug
Use Prevention
Speaker:
Barry Zuckerman, M.D.,
Chiet
Division of Developmental and
Behavioral Pediatrics,
Boston City Hospital,
Boston, MA
• Barry Zuckerman
Moderator:
Paula Carney,
Acting Chiet
Policy and Program Development Branch,
Supplemental Food Programs
Division,
FNS, USDA,
Alexandria, VA
I am delighted to be here because I have great admiration for all of you who
work with WIC. Clearly, it is one of the best, most effective, and critically
important programs we have for children.
My remarks today are based both on common sense and good empirical
data. I will show that, except in extreme situations, babies are actually well
protected in utero. I think drugs and excessive alcohol have had devastating
effects on families and communities-resulting in devastating effects on
children. But I am going to show you the data that some reasonable drinking,
even up to one or two drinks per day, if there is good nutrition and otherwise
good health, is not harmful to the fetus. I would suggest to you that that is
also based on common sense. I assume a good many of you had mothers who
drank during pregnancy, and you don't seem much the worse for it.
I also want to talk about cocaine and separate fact from sensationalism and
talk about models of how we can help children. I will give you a few hints
about observations you can make about mothers and children to incorporate
into your work regarding nutritional counseling.
Advice on Parenting
just for a little fun, let me start off with a brief review of advice about parent­ing
from experts over the past century.
Emmitt Holt, one of the first pediatricians in our country, published in
1894, "The Care and Feeding of Children" in which he said,
"At what age may playing with babies be begun? Never until4 months, and
better not until 6 months. The less of it at any time, the better for the infant.
What harm is done by playing with very young babies? They are made nervous
and irritable, sleep badly and suffer in other respects. When should children be
played with? If at all, in the morning or after the midday nap; never just before
bedtime."
About 30 years later in 1928, john Watson published "Psychological Care
of Infant and Child." Dr. Watson, as the father of behaviorism in this country,
emphasized the importance of behavioral strategies of parents shaping
children.
"There is a sensible way of treating children. Treat them as though they are
young adults. Dress them, bathe them with care and circumspection. Let your
behavior always be objective and kindly firm. Never hug and kiss them. Never
let them sit in your lap. If you must, kiss them once on the forehead when they
say goodnight. Shake hands with them in the morning. Give them a pat on the
head if they have made an extraordinarily good job of a difficult task. Try it out.
In a week's time you will find how easy it is to be perfectly objective with your
children and at the same time kindly. You will be utterly ashamed of the mawk­ish,
sentimental way you have been handling them."
Listen to what Dr. Benjamin Spock said in 1945,
"Don't take too seriously all that the neighbors say. Don't be over-awed by
what the experts say. Don't be afraid to trust your own common sense."
I think this last statement is critical for all of us who give advice to parents,
whether it is about nutrition or parenting. We should identify what the
parents are doing and find strengths in that, and not always tell them what
they are doing is wrong. By undercutting their confidence and their authority,
we are really undercutting their ability to raise their child.
Our strategies have to be to support parents, to empower them to feel
competent with their children. When they feel competent and comfortable, it
will be transmitted to their child, and then their child will grow up feeling
competent and comfortable. When they are anxious, confused, undecided
about what is right to do, whether it is feeding or behavior, then the children
will also grow up confused and not as competent as we would like.
Problems Facing Children
I have just completed 2 years serving as a member of the National Commis­sion
on Children. We looked at problems facing children, and also at pro­grams
that may work for children. The biggest problem we see facing children
is poverty. The 1990 poverty rate for children was 19.9 percent, while the rate
for the elderly was only 12.2 percent. The wonderful programs for the elderly
have put most of them out of poverty. There has been a significant downward
trend over the past 30 years.
On the other hand, after an initial downward trend, the poverty rate for
children has gone up since the late 1960's. Children now are the number one
poor group in our country. Almost 20 percent of all children and 44 percent
of African-American children are living in poverty. And with poverty comes a
variety of medical stresses, such as lead poisoning, prematurity, undernutrition
and anemia, plus social stresses, all of which impact on children's growth and
development.
I think that, over the next 4 to 6 years, children will become the corner­stone
of domestic policy in this country. That will have big implications for
you because WIC and Head Start and health insurance are the keys to provid­ing
a framework for all children. I believe the future of our country depends
on our ability to support children to become productive members of society.
To do that, most parents need one sort of support or another from the
Government, whether it is State colleges or a variety of other types of benefits.
Almost all families are somewhere on this continuum of need and should be
helped by the Government.
Alcohol Use During
Pregnancy
Now I will review the issue of alcohol during pregnancy, with a quick overview
on the notion of fetal alcohol syndrome (FAS), and then discuss what is a safe
level of drinking. Remember that during gestation, each organ system has two
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stages of growth. One stage is an increase in cell numbers, so as you get more
cells you get bigger. The second overlapping stage is an increase in cell size.
If you have an insult late in pregnancy, cell size will stay small. They will all
be there, but they will be small. After birth, with nutritional supplementation,
these babies grow quickly. They are usually long, skinny babies, but within 2
or 3 weeks, these babies grow well.
On the other hand, if an insult, such as heavy alcohol use, starts early in
gestation and continues, you get a smaller number of cells per organ. Then all
of the postnatal supplementation in the world may not allow you to catch up.
At birth these babies look better than the long skinny babies, but they are
shorter, which indicates chronic malnutrition. Other outcomes are central
nervous system impairment, including microencephaly and characteristic facial
dysmorphology.
I think that there are many unanswered questions about FAS. There is not a
single model that says alcohol causes all of it. I think nutrition plays a critical
role-not many of us have ever seen a well -nourished alcoholic. Good parent­ing
afterwards, good nutrition both before and after, certainly can have a
preventive effect.
Not all children of alcoholics have FAS. As a matter of fact, the vast majority
do not. Even in one study of twins, one twin had FAS and one twin did not.
How much is nutrition? How much is genetics? What are the other protective
factors? I don't think we know.
The typical amount of drinking in a mother with an FAS baby is 14 drinks
per day. We are talking heavy alcoholism.
It is usually linked with cigarette smoking. Women who smoke a pack per
day, compared to those who don't smoke, produce 194 grams lower birth­weight.
When you control for other confounding variables, however, such as
weight gain during pregnancy, prepregnancy weight, other drugs, and other
demographic risk factors, the amount attributed to cigarettes in our study is
only 83 grams. A smoker of marijuana versus nonsmokers, has a 300-gram
difference in birthweight. But when you control for the interrelated confound­ing
factors, it is only a 1 05-gram difference, but still statistically significant.
Looking at alcohol alone, we find drinking two or more drinks per day
produces a 228-gram lower birthweight. But when we control for the other
factors, alcohol impact is down to 51 grams, which is not statistically signifi­cant.
A study by B. B. Little, which was reported in the mid 1970's in "The
American journal of Public Health" showed that 1 ounce of absolute alcohol
(two drinks per day) prepregnancy was associated with a decreased birth­weight
of 90 grams. This same amount of drinking mid to late pregnancy, 5
to 8 months, was associated with a decreased birthweight of 160 grams. She
did not control for prepregnancy weight, weight gain, and marijuana, howev­er.
The first two are major nutritional variables. In every study of pregnancy
outcome these two factors account for more of the birthweight than any
other factor except gestational age. It raises questions in my mind about the
validity of those findings, and of other studies that did not control for these
and other important factors.
What is my argument against the policy of saying, "There is no safe level of
drinking?" Well, first of all, there is no scientific evidence. Second, there could
be unnecessary abortions. I frequently get calls, such as "I didn't know I was
pregnant. I had four or five beers. I don't want to have a deformed baby. I
want to get an abortion." There is also unnecessary anxiety by mothers if they
do have a drink before they know they are pregnant, let alone if they do it
afterwards. And that anxiety may affect their other health behaviors, let alone
their peace of mind.
I also wonder whether the policy detracts from an emphasis on nutrition
and general physical health. If we give women too many things to do, then
we may not emphasize the important things. Cigarettes are much more
dangerous than alcohol. Good nutrition is also much more important.
I don't want to trivialize the problem. Alcohol abuse is dangerous and
deadly. But my reading of the literature is that there is no apparent detrimen­tal
effect of one or two drinks per day in an otherwise healthy, well-nourished
woman. Remember, we are not talking about "averaging" one or two per
day, by saving it all up and having 14 drinks on Friday or Saturday. That heavy
dose over a short period of time could be harmful.
Dealing With
Heavy Drinkers
What is needed? Number one is the identification of heavy drinkers. One in
every eight adults in this country is an alcoholic, making alcoholism your
number one problem. Second, we need to provide treatment. Excessive
alcohol during pregnancy is harmful to the fetus, and certainly the caretaking
by an alcoholic parent is also a problem. The effect of alcoholism extends
much beyond the prenatal period.
Misinformation
About Cocaine
There has been a lot of misinformation published regarding cocaine. It seems
that some professionals may have been giving the press inaccurate informa­tion
. In 1990, "Newsweek" described the "crack kids" as "a lost generation."
"The New York Times" said, "The parents and researchers say a vast majority of
children exposed to significant amounts of drugs in the womb appear to have
suffered brain damage that cuts into their ability to make friends, know right
from wrong, control their impulses, gain insight, concentrate on tasks and feel
and return love."
These messages suggest a universality and permanency of brain damage to
cocaine-exposed children. Universality means that all of the children are
permanently brain damaged. That is absolutely not true. I am particularly
concerned about the associated stigma.
Because of this, a very large group of children is in danger of being "written
off." Moreover, a social sentiment has arisen that the loss of these children is
entirely attributable to the prenatal effects of cocaine (a permanent biological
factor). Such a conviction works toward exempting society from having to
face other possible explanations of the children's plight- explanations such as
poverty, community violence, inadequate education, and diminishing employ­ment
opportunities that require deeper understanding of wider social values.
Cocaine Children
Can Be Helped
Cocaine is a serious problem-it impacts prenatally, as well as on families and
communities. But the last thing that is true is that the children can't be
helped-and the labels themselves are damaging. For example, the research,
particularly by Rosenthal, shows the effects on pupil outcomes of labeling by
teachers. Some 47 percent of low-income children, whose teachers were told
that they were late bloomers, gained 20 or more IQ points in a year, com­pared
to 19 percent of the controls. The teachers who saw these kids as late
bloomers said to themselves at the beginning of the year, "They will do well."
And by the end of the year they did-that is the impact of a self-fulfilling
prophecy.
Another example of the damaging effect of labels is that one adoption
agency in this country won't take cocaine-exposed children because, based on
all of these images, they say they are not adoptable. So the main thing these
children need-good homes-is being denied to them due to this stigma,
which is not substantiated by the data. As Sherlock Holmes said, "It is a capital
21
22
mistake to theorize before one has data, else one begins to twist facts to suit
theories instead of theories to suit the facts."
It appears policy decisions have been made on preliminary observations,
which did not use good science. Biased study populations is one problem.
Many data come from women and children in drug treatment programs­clearly
they are a special group of women, and the findings are not generaliz­able
to other populations.
Another problem is the lack of control of confounding variables. Let's just
look at birthweight. For women who did not use cocaine, it was 3,254 grams.
For women who had a positive urine assay for cocaine during pregnancy, it
was 2,847 grams. A 400- gram difference in birthweight is pretty big-about
a pound. When you look closely, however, women who use cocaine also
smoked cigarettes, drank more alcohol, used more marijuana, and were more
likely to use opiates. They also had fewer prenatal care visits. Their weight
before pregnancy was 1 0 pounds less and their weight gain during pregnancy
was 8 pounds less-significant nutritional factors. And they had more sexually
transmitted diseases.
When we controlled for all that, cocaine contributed about 25 percent of
that 400-grams decrease in birthweight-about 93 grams. Cigarette smoking
contributed more and nutrition contributed more. Therefore, we need com­prehensive
programs for women which include all the factors.
We really don't know much about the prevalence of cocaine. There are no
good, reliable, national estimates. Among women giving birth in Boston City
Hospital, it was 18 percent, and at Yale New Haven Hospital some studies
showed 50 percent. The prevalence outside the inner cities is really unknown.
A statewide survey in Rhode Island showed 2.6 percent of women. When they
looked at zip codes, it was five times more prevalent among poorer neighbor­hoods.
How Cocaine Affects
the Body
Cocaine blocks the reuptake of neurotransmitters. The result is a magnification
of the signal at the nerve synapse. So you get higher blood pressure, higher
pulse rate, more sweating, just like the "flight or fright" response. You also get
magnification of the dopamine response-which makes you feel good. That is
the high.
Cocaine is a very rewarding compound, probably because of the
dopamine, but it is short-lived (1 0 to 15 minutes). There is a depletion of
dopamine, however which is associated with a very bad, biologically based
depression. You feel lousy-and the only way you can feel better is to take
some more cocaine. That contributes to its repetitive use, because when
people come down so quickly they want to go back up where they were, stay
feeling good.
Cocaine is metabolized by the enzyme cholinesterase, which is usually
lower during pregnancy but not always. The higher the level of that enzyme,
the more protection children will get-which contributes to the variability of
outcomes. For people with a low level of that enzyme, a normal dose can have
a devastating impact.
Dealing With
Cocaine Addicts
Let's talk about the way addiction controls people. All of us get angry at
women who do things that potentially can harm their fetus, let alone harm
their child after birth. It is understandable why we are angry, except it inter­feres
with our job to help mothers and children. We have to understand our
own feelings and get beyond them to help people. The power of addiction is
known by those of you who have tried to stop cigarette smoking or lose
weight-and cocaine is certainly much more difficult to battle. But with a lot
of help, many can overcome it.
· I know dealing with addicted women engenders a lot of feelings of anger
and hostility that frequently come out despite your best intentions. And then
you end up pushing people away-instead of getting them into a treatment
program. What we are learning is that perhaps 80 - 90 percent of them had
been sexually abused or physically abused as children. Part of the addiction is
a way of self-medicating for the pain and memories that the abuse created.
Effects of Cocaine
on Newborns
Consistent findings clearly show impaired growth and smaller head circumfer­ence
in some cocaine-exposed newborns. In the largest study to date, 1 0
percent of the infants had microencephaly, which is three times the normal
rate. Inconsistent findings show prematurity, congenital abnormalities, and
perhaps neurobehavioral difficulties. We are not sure there are any withdrawal
symptoms. There are some transient findings, including minor EEG findings,
auditory-evoked potentials, eye changes, but all of those are minor and revert
to normal within 3 to 6 months.
Cocaine causes symmetrical growth retardation with decreased fat and lean
body mass. Since we control for mother's weight gain during pregnancy and
other nutritional factors, it may be due to decreased nutrient transfer caused
by vasoconstriction. Cocaine use may cause the blood vessels to constrict,
decreasing oxygen and nutrients to the baby. Since dopamine decreases
appetite, the mothers may not want to eat. Those are indirect effects of
cocaine.
Are there any direct effects? We know cocaine goes to the brain of the
fetus. But we don't know if it alters neurotransmitters or if it has any effects on
the developing brain.
Women with a positive urine test for marijuana produced newborns with
symmetrical growth retardation, showing decreased lean body mass, suggest­ing,
as in the case of cigarette smoking, a hypoxic-type mechanism, perhaps
associated with some changes in the lungs during pregnancy.
Cocaine, marijuana, and cigarettes all contribute to hypoxia. The real
deleterious effect is when they are combined, which is often the case. Infants
of women who gained only 1 0 pounds during pregnancy (the nutrition
factor), smoked one pack of cigarettes per day, used marijuana, and used
cocaine, were 416 grams (nearly 1 pound) smaller. Each of those factors
contribute to that difference. Therefore, our interventions have to address all
those factors, as well as any others.
Our study on depression showed that mothers who were depressed were
more likely to smoke cigarettes, drink alcohol, use marijuana, and gain less
weight during pregnancy. I would argue that the cigarette smoking, alcohol,
and marijuana are coping strategies of a mother who is feeling depressed.
Helping Cocaine­Addicted
Mothers
So it may not be good enough to tell people to stop smoking, eat better, etc.
If these behaviors are either coping strategies for other stresses or symptoms
of a depression, one has to address the psycho-social stresses of that mother.
When they feel depressed, they may need other strategies, such as calling or
visiting a friend, taking a walk around the block, going to church.
There are no published studies of outcomes of the cocaine-exposed child's
development beyond the newborn period. For those exposed to opiates, the
children seem to do almost as well as controls in general developmental
scores, which really points to their plasticity. I am not saying these drugs
23
24
aren't harmful-1 am saying the newborn brain has a marvelous capacity for
recovery, if there are interventions, including good nutrition and caretaking.
A study by Emmy Werner shows that, even in the face of severe perinatal
stress, a high family stability, compared to children with medium or low family
stability, protects against lower developmental scores. It is only in the combi­nation
of perinatal stress and medium or low family stability that the child is
ultimately compromised. A disorganized baby in a disorganized environment
is not going to do well. But give them a good caretaking environment and
there is a lot of opportunity for recoverability.
A "One Stop Shopping"
Treatment Model
In response to the drug problem, we have developed a "one stop shop­ping"
model-with all the services together in one place. This service delivery
model meets the needs of the whole child and the whole family.
We emphasize the therapeutic relationship with the mother in drug treat­ment.
The most important thing is getting a mother to admit that she is
addicted. We also help mothers recognize what triggers their drug use, such
as feelings of loneliness or depression. We suggest alternative strategies they
can use.
We emphasize the parent/child relationship, pointing out maternal compe­tencies,
such as when the mother does something that the baby responds to.
We really support her for that. •
Anthropometric
Assessment
Speaker:
Ibrahim Parvanta, M.S.,
Public Health Nutritionist,
Field Services Branch,
Division of Nutrition,
Moderator:
Penny Rieley, M.S., R.D.,
WIC Nutrition Coordinator,
Vermont WIC State Agency,
Burlington, VT
Center for Chronic Disease Prevention
and Health Promotion,
Public Health Service,
Centers for Disease Control (CDC), DHHS,
Atlanta, GA
• Ibrahim Parvanta
Rather than explain how to do heights and weights, I
would like to look at anthropometry from an epidemio­logical
perspective-what you should emphasize in
your State or your clinics, and how surveillance can
help you improve anthropometry in your clinics.
Definition of
Anthropometry
Anthropometry is defined as, "a branch of anthropolo­gy
which deals with measurement of body size,
weight, and proportions." By making accurate mea­surements
and comparing them to standardized
growth curves, such as the National Center for Health
Statistics (NCHS)/CDC growth curves, one can track
individual growth, detect abnormalities, monitor nutri­tional
status, evaluate the effects of nutritional interven­tion
or the treatment of disease, and monitor growth
of groups of people. Remember, the key idea is not to
rely on one measurement, but to track a child over
time.
Even if you have a long history of tracking for
anthropometry, it is still just one part of your assess­ment.
Just because one point goes up or down does
not mean that you get alarmed without checking out
other measures such as the medical conditions and
medical history.
The data for the development of the growth charts
came from two large data sources. The Fels Research
Institute data, which provides information from birth to
36 months, is based on recumbent length. The HANES
(Health and Nutrition Examination Surveys), which
provides data for 2-to 18-year-olds, uses standing
height. Since they came from two different sources,
you must use the correct curves for the measurements,
i.e. for recumbent length use the birth to 36-month
growth curves, for standing height use the 2-to 18-
year-old curves.
Reliability and Accuracy
Remember the two factors:
• Reliability is the extent to which the same number
is obtained on repeated measurements. For
example, if you measure a child five times on one
day and you get the same number every time,
that is perfect reliability.
• Accuracy is the nearness of a measurement to the
true value, so that if a child is actually 28 inches
long and you get a measurement of 28 inches,
then you are perfectly accurate.
Measurements may be reliable but not accurate. You
may get 25 inches several times in a row for 1 00 per­cent
reliability. But if the kid is really 27 inches, you are
not accurate. CDC has materials for an excellent 4-hour
training session on the issues of reliability and accuracy.
You can send for the packet and use it to teach your
staff.
Measurement Errors
To have good data you have to do anthropometry
correctly. If you make a measurement error of about 1
pound in body weight, you can displace an infant fr~m
around the 1Oth percentile to below the 5th percentile.
With an error of 1 inch in length, which is easy to do,
you can do the same. Especially since young children
25
are growing so fast, measurement errors can make a
big difference.
It is always important to use measuring boards. If
you don't have a measuring board, you are doing it in
a way that was different from the way those growth
charts were developed.
Sources of measurement errors are:
• Motivation: Measurers may be making errors
because they do not realize how easy it is to make
the errors, do not appreciate the importance of
anthropometry, may be getting mixed messages
from clinical personnel, or they may have unrea­sonable
workloads (too many children for too few
staff with not enough time to do it correctly).
Show those volunteers and local staff how impor­tant
their job is. It helps to stroke their egos a
little.
• Equipment: Errors may occur if clinics use impro­vised
or improperly maintained equipment. Try to
convince people to use good scales and measur­ing
boards. I have always told staff, if you are
going to do it, then do it right or don't do it at
all. The equipment must be maintained well and
the accuracy checked regularly. The use of appro­priate
equipment is absolutely essential and can­not
be overemphasized. (See exhibit, Guidelines
for Selecting Anthropometry Equipment.) Go to
your State Maternal and Child Health (MCH) or
WIC staff for the names of companies carrying
equipment. If they need additional information,
they can call CDC.
• Technique: Develop standard written procedures
and make sure people follow them. Periodic
assessment of technique is important.
Quality Assurance
As a part of quality assurance, you should have written
procedures for doing anthropometric measurements.
Periodic reviews of client records and other measures
are probably already being carried out in your clinics as
part of quality assurance reviews.
An easy source of information for these reviews is
the Pediatric Nutrition Surveillance System. Monthly
surveillance reports highlight individual children with
measurements above the 95th and below the 5th per­centiles.
Also, quarterly and annual surveillance reports
provide information on the prevalence of biologically
implausible values (BIV) by clinic so you can identify
problems.
Since growth patterns follow a normal distribution
pattern, we identify BIV as the outside ends of the
graph, a little more than three standard deviations at
either end. Because these measurements are so far
from normal that there is only a 1 in 1,000 chance that
they are correct, you need to check them. More than
26
EXHIBIT
Guidelines for Selecting
Anthropometry Equipment
1. Equipment for Measuring Length
a. Measuring Tape
• attached to firm, horizontal surface
• marked in 1 /8" or 1 mm increments
• made of nonstretchable material
b. Immovable Headboard
• at a right angle to the tape
c. Movable Footboard
• always perpendicular to the tape
2. Equipment for Measuring Stature
a. Measuring Tape
• attached to vertical, flat surface (e.g., wall)
• marked in 1 /8" or 1 mm increments
• made of nonstretchable material
b. Movable Headboard
• always at a right angle to the measurement
surface
• wide enough to measure QQ]y. at the crown of
the head
3. Equipment for Weighing (Recumbent)
• a beam balance scale with tray
• scale with nondetachable weights
• scale marked in increments of not less than 1/2
oz or 1 0 grams
• a provision for immobilizing the .zeroing weight
4 Equipment for Weighing (Standing)
• a beam balance with platform
• scale with nondetachable weights
• scale marked in increments of not less than 4 oz
or 1/4 lb or 100 grams
likely they result from an error of some sort, either a
measurement error, a recording error, or maybe an
error on the date of birth of the child. An infant or
child, however, may have a BIV which is still correct for
that child.
You can monitor all your clinics for the prevalence of
BIV at the State, or the county level. If one or two clin­ics
have more BIV than the rest, you may want to find
out what is going on. There could be staff turnover or
problems with equipment. A stuck scale could cause
many errors. We also provide information on hematol­ogy
values so that you can identify problems if the
centrifuges are not properly maintained.
Some people have asked whether we should have
special growth curves for different groups, such as
Asians. In the early 1980's, about 25 percent of the
children of Southeast Asian background were classified
as short stature. But over time that prevalence has
steadily decreased, making it clear that if they are in
the right environment, getting the right type of food,
then they grow at the same rate as any other person.
At this point it is CDC's and the World Health Organi­zation's
(WHO) position that the standard curves that
are now used apply to all population groups.
Cut-off Values
for At-Risk
When you look at growth curves it is important to real­ize
that there is a normal distribution curve. The major­ity
of children fall towards the middle of the
distribution curve. There are others at the extreme
ends who are still healthy. At the CDC we use the 5th
and 95th percentiles as the cutoffs for the Pediatric
Nutrition Surveillance System (Ped NSS). I know that
the WIC Program in some States uses the 1Oth per­centile,
saying that, since it is a prevention-related pro­gram,
they want to catch at-risk children a little sooner.
What the real cutoff value is for underweight or
overweight, nobody knows for sure. There are so many
different factors that affect one's health, you can't
always be certain whether somebody who is less than
the 5th or above the 95th percentile is at risk.
We use 2,500 grams as the cutoff for low
birthweight, which is very close to the 5th percentile.
Since we know from research that children with a
birthweight less than 2,500 grams have a higher risk of
morbidity and mortality, we use the 5th percentile as a
cutoff for weight for age. If you pick the 5th percentile,
you know you will pick almost no one that is not at
risk. You may, however, miss some who are at risk.
The same kind of comparison is not available for
height for age, or weight for height, or weight for
length. Which percentile curve do you use in these
cases? The decision is based on the issues of probability
and practicality. The higher the percentile you use, the
more children you will pick up. For example, if you are
looking at short stature and use the 50th percentile as
your cutoff, you are going to be putting a lot of kids on
a program. The problem is that even though you may
pick up a few extra kids that may be at risk, you will
pick up many more who are not at risk at all.
So it is a matter of resources. If you have enough
staff and money, go ahead and use a higher cutoff,
pick up as many kids as possible, and put them on the
program. •
27
Approaches to
Providing Nutrition
Education in Large
Programs
Speakers:
Donna T. Seward,
WIC Director,
Moderator:
El Paso City-County Health District,
El Paso, TX
Marilyn A. Lynch, M.S., R.D.,
Coordinator of Nutrition Services,
New jersey State WIC Program,
Trenton, Nj
joann Godoy, R.D.,
WIC Coordinator,
WIC Program,
Monterey County Health Department,
Salinas, CA
• Nutrition Education in
El Paso, Texas
-Donna T. Seward
Our caseload in El Paso grew from 1 0,000 clients in
1980 to 35,000 clients in 1991 . But I don't think about
35,000 people, I think about each clinic. Our clinic
sizes vary from 600 clients a month, open 2 days a
week, to 7,500 clients a week, open 5 days a week. We
spend 20 percent of our funding for nutrition educa­tion,
and we always present nutrition education as the
biggest benefit of WIC.
The basic components to our nutrition education
plan are:
• Individual counseling
• Group classes
• Kiddie classes
• Newsletters
• Special information packets
Individual Counseling
Individual counseling is done by the nutritionists at
certification and subcertification for all clients. Because
of the high volume of people, individual counseling
sessions are limited to one topic, which is chosen by
the nutritionist based on looking at the future classes
28
that they will attend and other education that they are
going to have.
Group Classes
Our group classes are in categories: Mondays, preg­nant
women; Tuesdays, infants; Wednesdays, postpar­tum
women and midpoint screening for infants;
Thursdays, child subcerts and new children; and Fri­days
are whatever topic that particular clinic needs.
We have 1 day of the week dedicated to each ser­vice.
So on the day we are certifying new pregnant
women, we are also providing classes for new pregnant
women. We are doing diet recalls on pregnant women.
We are talking about maternal histories, breastfeeding,
etc.
In addition, we have special classes every month. For
example, the first class for every pregnant woman is a
breastfeeding class. We also do an infant feeding class,
covering when to start juice, solids, etc. Those special
classes are taught by the nutritionist; other classes are
taught by community service aides.
All classes are in both English and Spanish. At one of
our clinics we provide classes with a deaf interpreter.
All deaf clients either transfer to that clinic, or they
bring their own interpreter if they wish to come to
other clinics. We design our classes for maximum par­ticipation
by the clients, so they are limited to 20 to
25. We have oral testing which requires them to at
least raise their hand.
Kiddie Classes
Kiddie classes are for any age child, but primarily for
the 3- to 4-year-olds who are in the clinic or the class
with their mother. These are taught by community
service aides either in waiting rooms while moms are
waiting for certification appointments, or while the
mom is watching her video and her lesson. We found
that by pulling kids over, mom pays more attention to
her class, and we get to educate the kids. We also use
the Childbirth Graphics coloring book. All materials in
El Paso are both in English and in Spanish.
All classes for teen pregnant women are grouped
together on Saturday. They are taught by the nutrition­ist
instead of the community service aide. We find
teens are more participatory in a separate environment.
We are open two Saturdays a month in all of our full­time
clinics. (We are closed on Monday, so it is not an
overtime situation.)
For our introduction to breastfeeding, we bought
the Childbirth Graphics dolls that are anatomically
correct, 6-week-old newborns. We use them for a lot
more than just the positioning-they get them think­ing
very seriously about the pregnancy and how they
are going to feed the baby.
Staff Planning and
Training
We make nutrition education a priority with every
member of the staff. Our biggest challenge is in the
planning and scheduling. It takes time to figure out the
number of classes in each language, how many people
to put in each class, etc.
On the last day of every month, we bring together
everyone who teaches a class, in addition to the nutri­tionist,
who is the clinic supervisor, to go over the five
or six lessons they teach each month. We go over the
video, lesson plan, and background information and
answer their questions to prepare them to teach a dif­ferent
class. We feel that it is very hard for a person to
teach effectively the same material 2 months in a row.
Therefore we arrange the schedule so that it is approxi­mately
6 months later for a person to teach the same
class.
Newsletters
Newsletters are given to clients with their advance
issuance vouchers. The envelope for the advance
vouchers has instructions about not redeeming them
early, plus a little nutrition education. So every time
they pull it out of their purse, they are exposed to that
little message.
Special Information
Packets
Other nutrition education materials are provided in a
very special packaging that makes the client feel impor­tant.
We give them a packet at the time of certification,
but by specifically telling them the materials are for
later reference, we don't overload with too much at
one time. One packet is designed for all pregnant
women. Another is a special packet for teen-age moth­ers.
One is for pregnant women who have decided to
breastfeed. Another, for women who haven't decided
yet, is a sales packet with the reasons why we hope
they will breastfeed.
A package of materials for mothers of infants who
are breastfed covers everything from immunization to
introducing them to their breastfeeding peer coun­selor.
We have a similar packet for formula-fed infants
with the information that their mothers may need.
Each of these is also prepared in a special packet for
teens that contains the same information, plus some
special information for teens.
When we give them their first infant cereal card, we
give them a little plastic-tipped infant feeding spoon
and a flyer that says cereal should be fed with a spoon,
not from a bottle. When we give them infant juice for
the first time, we give an infant training cup.
Report Cards
The following exhibit shows a sample of our "report
cards" with the baby's height, weight, hemoglobin,
and diet requirements. The cards allow the conditions
of need to be marked so the nutritionist can make the
appropriate counseling choice. There is also space for
the mother's commitments to work on improving areas
of concern.
• Nutrition Education in
Monterey, California
-joann Godoy
Monterey County is primarily an agricultural area locat­ed
on the central California coast. With a caseload of
7, 150, we are the 18th largest WIC agency in Califor­nia.
Our caseload is comprised of pregnant and breast­feeding
women, infants, and some of the higher
priority younger children. We are not able to serve
postpartum moms or many children over 24 months
old.
Why We Work With the
Salinas Adult School
We work with the Salinas Adult School Parent Educa­tion
Program to conduct 1 32 classes each month to
fulfill the second, third, and fourth nutrition education
contacts for our participants. The classes generate ADA
(Average Daily Attendance) reimbursement for the
Adult School at the rate of $2.96 per hour per student.
This totals approximately $4,500 per month.
29
30
Exhibit
After talking to the nutri­tionist,
I agree to work
to improve the following:
El Paso City-<:o un ty Health District
WIC Project 33
222 S. Campbell
El Paso, TX 79901
Today, I am __ _
inches tall.
********************
I weigh __ pounds.
********************
********************
Fl12 1)7/91
The Iron in my blood
is which is
fine I low.
My WIC Check-up
Name __________________ _
Date
Yesterday, I ate:
20 - 40 oz Breastmilk Yes No
or Iron Fortified
Formula
If over 4 months old
Infant cereal Yes No
Fruits Yes No
Vegetables Yes No
****************************
Today was just a checkup
for me.
****************************
I had already qualified for
WIC until I am one year old.
Why do we work with the Salinas Adult School (SAS)?
• The mission of public adult education in Califor­nia
is to provide quality, lifelong educational
opportunities and services, such as WIC, that
respond to the unique needs of individuals and
communities.
• SAS is a student-focused, service-oriented agency,
just as is WIC.
• SAS pays the instructor, who is our WIC lactation
consultant and education coordinator.
• SAS provides ongoing staff development.
• SAS assists and oversees curriculum development,
so that WIC classes are developed to the high
standards of the SAS strategic plan.
• SAS provides resources and support services, such
as printing and duplication of class hand-outs and
use of a computer.
• SAS also participates in community-wide task
forces and committees.
• SAS registration fees are waived for WIC partici­pants.
• And we think the biggest thing is that participat­ing
in SAS classes adds to the self-esteem of WIC
participants.
What does WIC provide?
• WIC provides the classroom site.
• WIC provides the scheduling for participants.
• WIC provides a "captive audience," for easy
recruitment of students. WIC coupons act as an
incentive to come to class.
• WIC allows the SAS to reach a typically "hard-to­reach"
clientele by holding classes at a site famil­iar
and comfortable to the participants or
students.
• WIC classes provide a bridge for students to enroll
in other SAS classes, such as English as a second
language, the high school diploma class, voca­tional
education, parent education, health and
safety, and home economics classes.
Newly Designed Curriculum
Previously, we taught basic nutrition with the typical
anemia, iron, formula preparation type of classes, and
frankly, we were getting bored. And I am sure that our
participants weren't very excited either. Since teaming
up with the Adult School, we have completely
redesigned our curriculum. We are now talking with
moms about things that are important to them and
that will really make a difference in their lives.
We have a core curriculum of four classes in an
infant feeding series, and then every month, we have a
general nutrition class. Classes are in English, Spanish,
and Vietnamese. Our core curriculum consists of a four­part
infant feeding series:
• Infant Feeding I is our breastfeeding encourage­ment
and motivation class.
• In Infant Feeding II, we cover breastfeeding tech­niques.
We also teach bottlefeeding and position­ing,
just as if a mom were breastfeeding.
• Infant Feeding Ill, for infants from 1 to 6 months,
covers basic feeding skills. We also talk about
breastfeeding and going back to work; and
breastfeeding an older infant. (We have 25 elec­tric
breast pumps available at no charge.)
• Infant Feeding IV, for infants from 7 to 12
months, discusses the development of appropri­ate
feeding skills for the older infant. We have an
active program to exchange the bottles for the
cups.
A fifth is a general class for infants, children, and
prenatals for participants who have completed the core
curriculum. It teaches basic nutrition, integrated with
other healthy living skills, such as safety in the family,
postpartum issues, family planning, AIDS and sexually
transmitted diseases, immunization, dental care and
baby bottle tooth decay (BBTD) prevention, and prena­tal
alcohol, tobacco, and other substance abuse pre­vention.
Class Attendance More Than
80 Percent
All participants receive their WIC coupons only at class.
Thus our attendance rate is at least 80 percent. From a
purely administrative perspective, the classes are a
great way to keep 20 or 30 participants entertained in
another room while the vouchers and necessary docu­mentation
are being completed .
Classes are taught by our nutrition assistants, nutri­tionists,
and lactation consultants as well as guest
speakers from other agencies. We always have at least
one credentialled teacher on site.
Since both WIC and SAS see ourselves in the business
of education, we share the following credo (originally
from the L. L. Bean Company):
• A WIC participant/ student is the most important
person ever in this office-in person or on the
phone.
• A WIC participant/student is not dependent on us,
we are dependent upon her.
• A WIC participant/ student is not an interruption of
our work-she is the purpose of it. We are not doing
a favor by serving her-she is doing us a favor by
giving us the opportunity to serve.
• A WIC participant/student is not someone to argue
or match wits with. Nobody ever wins an argument
with a participant/ student.
• A WIC participant/ student is a person who brings us
her wants. It is our job to handle them profitably to
her and to ourselves. •
31
Approaches to
Providing Nutrition
Education in Small
Programs
Speakers:
Colleen Breker, L.R.D.,
WIC Director,
WIC Program,
Moderator:
Mary Kay DiLoreto, M.S., R.D.,
Nutrition Education Coordinator,
WIC Program,
Richland County Health Department,
Wahpeton, NO
Oregon Health Division,
Portland, OR
joyce Ngo, M.P.H., R.D.,
State WIC Nutritionist,
Massachusetts WIC Program,
Department of Public Health,
Boston, MA
• Empowering Clients in
North Dakota
-Colleen Breker
I serve Richland County, North Dakota, which has
about 400 WIC clients. In addition to Wahpeton, I have
outreach clinics in three rural communities.
I am very interested in leadership and empower­ment.
The empowering approach focuses on develop­ing
relationships between the educator and
participants within the WIC community. It is in the
day-to-day activities in participants' lives, including the
visit to the WIC clinic, that empowerment takes place.
Small WIC sites can empower people by genuine car­ing,
by a willingness to be open oneself. I like to call it
approachable, able to expose our doubts and
concerns, skills and strengths, and in turn listen atten­tively
to the stories of others.
A Friendly, Caring
Atmosphere
Let me describe some of the things within our WIC
clinic that promote empowerment and self-esteem.
Our office is very friendly and bright. We have the lat­est
magazines. We have a receptionist who is a warm,
fun, caring person. When our clients walk into the
32
office, they are treated well because we want them to
come back.
I am the only nutritionist for those 400 clients. I
have a support person who works 2 days a week with
me. I work with clients 4 days a week, on the average.
We are housed with the health department. My office
is next door to the family planning person. Many times
I can see pregnant women right after they have had a
pregnancy test, and can get them on the program
· immediately. When I first started, pregnant women
were getting on WIC after about 11 or 12 weeks. Now
most are coming on at 5 or 6 weeks.
If I can't get them on immediately, I try to do some
kind of nutrition education while I am scheduling an
appointment. Or, if they smoke, I might do some quick
nutrition education that has to do with smoking. We
use the SCIP methods (smoking cessation in pregnan­cy)
that were developed in Colorado. Afterward I send
them a thank you card for joining my WIC Program,
and include a little reminder of their next appointment.
I find this little investment of a stamp is quite helpful
and people enjoy it.
Our offices are very confidential, so clients can
feel good about that. I try to have a very optimistic
and cheerful attitude. I use lots of eye contact and real­ly
listen to people. I try to gauge where they are com­ing
from because I find this useful during nutrition
education.
We have lots of toys and dolls. I try to encourage
kids to come in because I do nutritional education
directly with the preschoolers. Often a pregnant
woman will have a friend with them, and I always
invite that person to come in the office also.
I like to know what the providers in other offices are
telling people, particularly physicians, so I can either
complement their information or fill in the gaps. I try
to send them letters once in awhile so they know what
I am doing too. I work very closely with an MCH nurse
who does home visits for many of my WIC clients. She
will repeat some of the nutrition education at the
home.
I have a lending library with books and videotapes,
including the "Taking Charge of Your Pregnancy," a
March of Dimes video, and an infant care video with
Dr. Brazelton. I have books such as "Your Premature
Baby" and "My Fussy Baby," infant care books, etc.,
with a simple little library card method of checking
them out. I go to service club meetings like Kiwanis,
and they often give me a little money to buy books.
Coordination of
Appointments
I try to coordinate my appointments with their EPSDT
appointments whenever possible so clients can go to
more than one appointment that day. We are fortunate
to have social services located at the other end of our
building, so we can coordinate appointments with
them. I invited the nurses to ou~ outreach clinics out­side
of Wahpeton to do immunizations, which has
worked out well. Folks come in for WIC appointments
and shots at the same time. I have only a 2-3 percent
no show rate.
I like to let other people know what I am doing and
find out what they are doing. I am on a Head Start
committee, so I also can do nutrition education with
Head Start parents. We have a tracking team in our
county, and I attend those meetings once a month. 1
have planned a parent fair with Extension Services. We
have a 2-year college in Wahpeton with a dental
hygienist program. They come to check our WIC 3-
year-olds and older. One time they had a teeth clean­ing
session for postpartum and pregnant women.
At one time in my life, when I wasn't feeling good
about myself, I came across this quote by Eleanor Roo­sevelt:
"No one can make you feel inferior without your
permission." So my philosophy is to help people feel
good about themselves.
• Staff-Client
Interaction in
Massachusetts
- joyce Ngo
Effective nutrition education begins with you. We all
are programmed and conditioned to respond in ways
that can actually distort reality. As we receive stimuli or
information from the world, we take that information
and put it through an internal process, which is based
on our world view, also called the vantage point, or
how we see the world. This process results in our exter­nal
behavior or output.
Our Internal
Filtering Process
This process depends on filters, which affect our inter­pretation
of the outside information or stimuli. Filters
reflect our individual life experiences, and the culture
we came from. Based on the filters, we select cues that
indicate to us the nature of what is being perceived.
And cues are affected by expectations and assump­tions.
From this kind of process we form perceptions
which determine how we behave.
For example, we are socialized to value conformity,
rather than diversity. So, based on this filter, we select
cues that read "different is bad," rather than "differ­ences
make someone unique or distinct." As a result
we put distance between ourselves and others. My
point is that when we talk about empowerment educa­tion,
we are talking about education that enables peo­ple
to achieve their full potential. And that process
begins with you and me and how we view people and
their potential.
The key is to become aware of this internal
filtering process:
• Know what our filters are.
• Know what our perceptions of reality are.
• Take responsibility for our behavior.
For example, I realized one of my own needs is to
feel needed by others. This may be detrimental to the
goal of empowering other people, because if I need to
help people, I may try to keep them helpless, and
needing me.
Five Important Awarenesses
To be an effective educator, you must be an effective
communicator. First, you need to be clear, and second,
you need to lay aside judgment and try to see where
that other person is coming from. To do this, you need
to know what your filters and perceptions of reality are,
and you need to lay aside judgments. I recommend
33
looking at your experience from five distinct
perspectives:
• Sense, what you actually see or experience.
• Meaning, what this reality means to you, how
you interpret it, what is the thinking process
behind it.
• Feel, how you feel about this issue or these
stimuli.
• Wants, what you want or what your intentions
are.
• Action, what can or what will you do.
For example, if a participant comes to you and says
that she regularly feeds her 1-year-old pureed pork and
beans with a bottle that has a nipple which has been
cut out (this is a true case), your response would prob­ably
be to think, "I can't believe it! How horrible."
But if we apply this five-point framework of reality,
we might get a completely different interpretation of
her actions. For example, she is feeding her baby the
best way that she knows how. This makes her feel
good in her role as a caretaker. Look at the wants, the
intentions behind that action, because they are very
noble-she wants to nourish her baby with nutritious
food. So, by focusing on the intentions behind the
actions, you can find those positive aspects to build on,
instead of having a negative or patronizing interaction.
Task Forces
Massachusetts WIC has established three task forces:
• Nutrition Education Task Force consists of a
group of nutritionists, both WIC and MCH, that
create all the educational materials for both the
WIC and MCH programs. They also evaluate
audiovisual materials and make recommendations
to local programs throughout the State.
• Multicultural Task Force consists of WIC nutri­tion
paraprofessionals, who translate materials
and adapt them to each cultural or ethnic group.
• Breastfeeding Task Force promotes
breastfeeding.
Handbooks
Our "Nutrition Education Handbook" shows how to
make education meaningful by asking participants,
eliciting their feedback, and making specific tips on
counseling one-on-one. It also provides lesson plans for
group activities. The "EMPOWER" handbook tells how
to evaluate materials to promote optimal use of WIC
education resources.
Link with Other
Resources
Remember to utilize existing resources. Look at groups
like Visiting Nurses Association (VNA), EFNEP, and oth-
34
ers. One of our local agencies does a lot with junior
League volunteers. They have gotten groups from the
community to come in and establish play groups or
activities with children while their caretakers are being
seen by the nutrition staff. We also have linkages with
community colleges and other schools that provide
nutrition interns for periods from 6 weeks to 3 months.
Seek Participation
and Input
We actively seek participation, using feed-forward
instead of feedback, at three levels:
• The State level gets feedback from local programs
primarily through bimonthly business meetings.
• At the local level, program staff interact with
planners and providers. The planners are the
directors and senior nutritionists who produce the
ideas for nutrition education, while the providers
are the actual teachers, the nutritionists, parapro­fessionals,
and program staff.
• A third level involves staff and participants. The
WIC "Nutrition Exchange" and a publication put
out by the National Cancer Institute called "Mak­ing
Health Communications Work" are two excel­lent
resources for learning how to obtain
participant feedback. You can do it in structured
ways like focus groups or more one-on-one with
questionnaires or interviews.
If there is any particular ethnic group that comprises
1 0 percent of a caseload, we ask that staff from that
ethnic group provide services. We specify the need for
not only bilingual staff, but bicultural staff.
We promote client interaction. For example, we
leave space in our pamphlets for participants to fill out
action steps. We say, "Okay, Mary, we talked about
these ways of getting vitamin A in Billy's diet, what is it
that you think you can do? What one or two things do
you think you could work on?" When she writes it
down, she takes ownership for the decision. In group
settings, we use short quizzes, following the format of
popular magazines. They are not collected, but they
help to keep people focused and get discussion going.
David Werner's book called "Helping Health Workers
Learn" shows how to pose situations to participants
and then ask them to list why a certain outcome hap­pened.
He calls it the "but why" theory of making edu­cation
happen.
So, remember that the empowerment education
process starts within each one of us. We can provide
both participants and staff the means and the opportu­nity
to participate in making their learning experiences
meaningful and empowering for them. •
Breastfeeding
Projects Utilizing
Peer Counselors
Speakers:
Ellen Sirbu, M.S., R.D.,
WIC Coordinator,
Moderator:
City of Berkeley WIC Program,
Berkeley, CA
Kathy Dugas, M.S., R.D.,
Nutrition Coordinator,
WIC Program,
Mississippi State Department of Health,
jackson, MS
Lilia Parekh, M.P.H., R.D.,
WIC Coordinator,
WIC Program,
Community Pediatric Health Center,
Children's Hospital,
Washington, DC
Carmen Cohen, /BCLC,
Regional Breastfeeding Coordinator,
West Tennessee Regional Health,
jackson, TN
• The Berkeley WIC
Program
-Ellen Sirbu
The Berkeley WIC Program is unique because it not
only serves Berkeley residents and parts of Oakland, but
it serves many international students. Our caseload is
1,665 participants a month.
Program Initiation
When I started in 1990 to plan the peer counselor pro­gram,
I first obtained my supervisors' support for the
program and a commitment to fund a trainer, materi­als,
babysitters, and food. I selected as trainer, a board­certified
lactation consultant with many years of
hands-on experience. She had her own private practice
and could be reached days, evenings, and weekends, if
a counselor needed to consult her. She also was an
enthusiastic speaker.
Potential peer counselors were WIC participants who
had not picked up formula vouchers for at least 6
months and, in most cases, much longer. I personally
reviewed all files and contacted all potential trainees.
At the time of the first training, potential counselors
were told they would be trained to be volunteers. We
started with 50 women who were interested in partici­pating
in the training. When the dates were set, 30
women confirmed they would attend, but only 1 2
women actually attended the training. Public health
nurses from the Health Department were also invited,
and about five attended.
Eleven of the 12 women completed the initial 6
hours of training, received certificates, and were invited
to attend an additional 3-hour session, which included
presentations by a public health nurse, social worker,
and the lactation consultant on counseling techniques
and when to make referrals.
Then in july I realized I had money left in the budget
to actually hire some of the trainees. Of the 11 women
who completed the course, only 4 wanted to be hired.
They did not represent the ethnic population of our
program, but I went ahead anyway. All counselors
accepting employment had to be willing to give out
their home phone numbers, be available evenings,
days, and weekends. They averaged about 5 hours a
week per counselor of paid time.
The main problem was I had no money in my bud­get
to pay for the counselors after September 30. I was
able to obtain, however, a $3,500 contribution from a
35
restaurant to employ the counselors for about 3-1 /2
months. I spent a lot of time trying to raise additional
funds, but only received $1,000 from a foundation.
just as the money was running out, the State WIC
Program advised me I could apply for special project
funding, which not only saved our program, but
enabled us to develop a more comprehensive peer
counselor program. We did a special training session
and hired four more counselors to provide more lan­guage
and ethnic diversity.
Program Operation
Assignments to WIC mothers were made during the
seventh month of pregnancy. When possible, they
were based on similarity of language, ethnicity, age,
and residence. Counselors were instructed to contact
their clients at least once during the pregnancy by
phone.
Depending on the woman, the counselor may con­tact
her several times more and cover various topics,
such as advantages of breastfeeding, why she had
problems in the past, etc. Most importantly, she
stressed that she was available after delivery if the
woman had any questions or problems. She left her
phone number with the client.
Some of the problems that the counselors ran into
were disconnected phone numbers, clients not calling
postpartum, and counselors not knowing when the
client delivered, which eliminated the necessary post­partum
intervention.
The counselors run weekly support groups for both
pregnant and breastfeeding women. We also now have
a required breastfeeding class for women in the sev­enth
month of pregnancy. During this class, not only
do the women hear about breastfeeding, but they hear
about the breastfeeding project just about the time the
counselors will be calling them.
I found that regular staff meetings for the counselors
were a must. We have now hired a part-time public
health nurse to be the liaison between the local hospi­tals
and the WIC Program, so that we will know when
every WIC client delivers, and the peer counselors in
turn will be informed when the clients deliver. The
nurse has also assisted with the development of chart­ing
forms for the peer counselors so that we have a
system for documenting all contacts.
36
Peer Counseling
Training Project in
Washington, DC
-Lilia Parekh
We started a breastfeeding peer counseling training
project in Washington, DC in 1984. Our training man­ual,
which was developed in 1989, has been distrib­uted
to all the State nutrition coordinators.
We distribute many pamphlets. We also invite moth­ers
to come and see how to breastfeed, although there
are very few who do in our community, because we
serve an inner-city, mostly black population.
A problem is finding peer counselors. Our first
approach to t raining was to invite all the women we
knew who were breastfeeding. Of the 67 we identified,
20 responded, 12 were trained, and all 12 graduated.
In 1989, we sent letters to all the breastfeeding
women in the WIC Program enrolled at the time, invit­ing
them to participate in a peer counseling training
program. Of the 360 we invited, 50 said they were
interested, 26 attended our first meeting, which was an
orientation meeting, 12 came to the training class, and
1 0 completed the 1 0 weeks of training. So far we have
graduated 55 peer counselors from eight classes.
Our problem is attrition, because the peer coun­selors
are working part-time at only $4.50 an hour (a
maximum of 20 hours a week). Some of the mothers
have become empowered; they want to go out and
work full-time.
There is a great need to nurture peer counselors.
They need a lot of what we call "warm fuzzies." just
telling them, "You are doing very well," is important.
Monthly staff meetings are also very important, and I
write personal notes to the peer counselors when I
send them their stipend check. If you have agency
goals, make the counselors aware of how they have
contributed to achieving the goals.
The Tennessee Peer
Counseling Program
-Carmen Cohen
The Tennessee Peer Counseling Program, which
began in june of 1987, has used three types of peer
counselors.
• Volunteers, who come to the classes, bring their
breastfed babies, and help with the discussion.
• Peer mothers, who lead mother-to-mother sup­port
groups.
• Peer professionals who work in the Health Depart­ment
as full- or part-time employees. They
become part of the breastfeeding team, and
are supervised by a regional breastfeeding
coordinator.
The professionals are paid by separate grants. We
have had grants from Ben and jerry's Natural Ice
Cream, the National Presbyterian Hunger Foundation,
and others. This year, we are currently using a $46,000
grant from the Mary Reynolds Babcock Foundation.
Program Operation
My region has 19 counties but only three peer profes­sional
counselors. One works in three counties, the
others have only one a piece, but are going to expand
to another county or two each.
The counselors become part of a breastfeeding
team. They are supervised by a regional breastfeeding
coordinator, and they also work with local health
department nurses and nutritionists to promote and
support breastfeeding. Their main role is to offer moth­er-
to-mother support to increase the incidence and
duration of breastfeeding. Their main responsibility is
to run the breastfeeding clinic. Prenatally, a mother is
first surveyed to learn her concerns. At the second con­tact,
an individual discussion is held to address the
concerns. We have found that our mothers already
know that breastfeeding is best-they just can't quite
make that jump from knowing about it to actually
doing it.
At the third contact, counselors lead an infant feed­ing
discussion, which includes not only prenatals, but
other support persons, such as the baby's father,
grandmother, grandfather, cousins, aunts, neighbors.
The discussion begins with the question, "Most people
bottle feed-what is so great about bottlefeeding? Why
do people choose it?" Then we ease into how breast­feeding
works.
During the postpartum session, the peer counselors
do hospital visits, home visits, and clinic visits. There is
also· phone counseling. We try to talk to all the mothers
by the first week, and then again at the end of the
second week, the fourth week, the sixth week, 3
months, 6 months, and 1 year. In the postpartum peri­od,
we also loan breast pumps, etc.
Can peer counselors really do all of this? Yes,
because breastfeeding is a skill learned from practical
experience, reading, and studying. Our peer counselors
can truly relate to patients as an equal, rather than as a
business professional.
The patients want to know, "What was it like when
you breastfed?" They think of the peer counselors as a
friend, a confidant, a teacher, and a role model. In all
probability, peer counselors will find themselves
involved in many different aspects of the breastfeeding
mother's life. That is because breastfeeding is not just
feeding, but a very personal feminine experience that
helps a woman to be more receptive to positively
changing her life and improving her child's life. Breast­feed
ing truly empowers women.
For the WIC Program, peer counselors are a very
cost-effective use of WIC dollars.
Choosing and Training
Counselors
To find counselors, we sought women, usually former
WIC clients, who had good attitudes towards other
women, some breastfeeding knowledge, and a recep­tiveness
to learning. We required a high school diplo­ma
and access to a car. We preferred women who had
breastfed, but two of our counselors have never breast­fed
. We wanted good verbal communication, and the
ability to make sound practical decisions. They also
needed basic writing and clerical skills.
Training peer counselors is ongoing. Some books we
have found helpful include "Successful Breastfeeding, 11
"The Womanly Art of Breastfeeding, 11 "Counseling the
Nursing Mother, 11 and "La Leche League's New Begin­nings.
11 For the trainer, the La Leche League leader
handbook is excellent.
Breastfeeding Promotion
Our breastfeeding promotion efforts include a bulletin
board in the waiting room, a book full of pictures of
mothers in the area who have breastfed, nursing pads,
baby contests (the Best Breastfed Baby), pamphlets,
infant feeding discussions, T-shirts ("I Eat at Mom's")
and more. We sometimes use "Outside My Mom" by
the March of Dimes, or the "Best Start" tape. We
have diffe rent pumps to loan. Bras are given to moth­ers
at 1 month if they are totally, or almost totally
breastfeeding.
The results of the project show that, when given
adequate support, low-income women will breastfeed,
regardless of their problems. •
37
Breastfeeding
Promotion Study
and Demonstration
Projects
Speakers:
Linda Lee, M.S.,
Nutrition Services Director,
WIC Program,
Moderator:
La Crosse County Health Department,
La Crosse, WI
Minda Lazarov, M.S., R.D.,
Director of Tennessee
Breastfeeding Promotion Program,
Tennessee MCH and ~IC Services,
Nashville, TN
Karen Virostek, M.S., R.D.,
Field Supervisor/Nutrition
Education Coordinator,
Family Health Council, Inc.,
Pittsburgh, PA
Brenda Kirk,
WIC Director,
Cherokee Nation WIC Program,
Tahlequah, OK
• Breastfeeding
Promotion in La Crosse,
Wisconsin
-Linda Lee
In 1988, before we began our breastfeeding promotion
efforts, about a third of WIC women in La Crosse
County were breastfeeding. Now, after 2-1 /2 years of
fairly intense effort about 47 percent are breastfeeding.
For our subpopulation of Hmong women, the rates
rose from 19 percent to 34 percent during the same
period.
Our promotion project has four components: a pre­natal
component, a very small in-hospital component,
a postpartum component, and a coordinating commit­tee
that helps to provide extensive support in the com­munity
for our breastfeeding women.
Prenatal Component
Our prenatal component consists of individual counsel­ing
sessions for all WIC pregnant moms. They meet for
38
20 minutes with a breastfeeding educator or peer
counselor to address their individual needs. We use
Hmong peer counselors with our Hmong population
because we have found they are better at reaching
these women.
We made our clinic atmosphere more supportive of
breastfeeding. We eliminated all signs of formula. We
put up posters instead that promote breastfeeding. We
provided incentives to women to encourage them to
breastfeed, including layettes, T-shirts, sweaters, etc.­all
obtained with non-WIC money. The State of Wis­consin
received a grant from Ross Labs and Mead­johnson
to promote breastfeeding and purchased Avon
incentive packages.
In-Hospital Component
The breastfeeding educator contacted the information
areas at both hospitals in La Crosse several times a
week asking if our mothers were in the hospital. We
contacted about 25 percent of our women this way
and found that an in-hospital contact increased the
incidence and duration of breastfeeding.
Postpartum Component
After delivery, we make weekly telephone contact to
problem-solve and to support the women. Those with­out
telephones are mailed a small packet of informa­tion
on breastfeeding about 2 weeks before they are
due to deliver.
We make WIC recertification appointments for 2
weeks after their due date. These recertification
appointments allow us to actually watch moms nurse
early in the postpartum period, which has been helpful
in problem solving. If moms cannot get in for their
recertification appointments early and they are having
problems, our nutritionist or breastfeeding educator
will go out to their homes and work with them.
Coordinating Committee
The WIC Breastfeeding Council is an advisory body to
our breastfeeding program. It involves representatives
from the hospitals and clinics in the area. It has really
helped us to support our breastfeeding women much
better than we were able to before. The people on our
council are much more willing to go the extra mile for
our clients because they have a stake in making our
program work.
Team Work
Staff team work is very important. A nonsupportive
clerk can undo in 5 minutes what a breastfeeding edu­cator
or a nutritionist just spent an hour doing. When
we began our breastfeeding promotion effort 2 years
ago, we held meetings and provided in-service training
for all the staff on how to promote breastfeeding.
Evaluation
We learned that ongoing evaluation is important. We
met as a staff on a monthly basis to provide feedback
to each other. At one point we found the Hmong
women did not like the postpartum phone calls the
peer counselors were making. We realized we had not
set the women up for the postpartum followup calls.
Once we did that the problem stopped.
• Breastfeeding
Promotion in Western
Pennsylvania
-Karen Virostek
In 1988, we were asked by the Pennsylvania State WIC
Agency to write a proposal to participate in the Breast­feeding
Promotion Study and Demonstration Grant.
We hired a part-time project coordinator, which
enabled us to try many new ideas to promote breast-feeding
in the three activity areas of the grant: coordi­nation,
prenatal, and postpartum activities.
We began to coordinate efforts with other agencies,
including hospitals, physicians, offices, and clinics. We
organized meetings of key people from the hospitals
and other human service agencies.
Before the grant, our prenatal activi