National WIC Association Conference, April 2017 Predictors of Optimal Breastfeeding among Predominately Hispanic Women Participating in a Local WIC Program National WIC Association Conference, April 2017 Janine Rethy MD,MPH1 Amara Channell Doig, MPH2 Jennifer Brady, BS1 David Goodfriend, MD, MPH1 Sina Gallo, RD, PhD2 1Loudoun County Health Department, Leesburg, VA; 2Nutrition & Food Studies, George Mason University, Fairfax, VA J

Loudoun County Health Department Obesity & Chronic Disease Prevention Division Community based prevention model to create a culture of health in Loudoun County David Goodfriend, MD, MPH - Health Director Janine Rethy, MD, MPH, FAAP, FABM - Physician Advisor Jennifer Brady, BSc - Health Educator Internship/Practicum students Collaboration with George Mason University since 2014 Sina Gallo, RD-PhD - Assistant Professor Amara Channel Doig, MPH - Research Associate

Funding 1. Community Partnerships for Healthy Mothers & Children National WIC Association & Centers for Disease Control To develop and implement community-driven plans to reduce and prevent chronic disease in high-risk areas 2. Preventive Health and Health Services Program Virginia Department of Health Preventing and Controlling Obesity and Chronic Disease Through Evidence Based Programming

Objectives By the end of the session, participants will be able to: Describe factors differentiating positive deviants from other women in the study of barriers and facilitators to infant feeding among African American women and the implications for WIC practice Define optimal breastfeeding and list two predictors of optimal breastfeeding among low-income Hispanic women List at least two strategies public health professionals can use to recruit and retain hard-to-reach mothers in community breastfeeding programs   

Optimal Breastfeeding “The American Academy of Pediatrics reaffirms its recommendation of exclusive breastfeeding for about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant.” Pediatrics, 2012.

Costs Associated with Suboptimal Breastfeeding in US $ 4.7 x 109 $ 1.8 x 109 $ 2.6 x 109 If 90% infants exclusively breastfed for 6 months US would save $17 billion / year, prevent an excess of 3,340 deaths Bartick & Reinhold. Pediatrics, 2010. Bartick et al. Maternal & Child Nutrition 2017

Disparities in Breastfeeding Reported as % Breastfeeding Ever Exclusive 3 mo Exclusive 6 mo Any 12 mo White 84 53 27 58 36 Hispanic 83 40 19 46 26 Black 66 29 15 39 Acculturation Decreases initiation, duration and exclusivity in Hispanic women Each additional year in the US decreases breastfeeding rates by 4% 1 CDC Breastfeeding Report Card, 2016 (NIS); 2Ahluwalia et al. J Hum Lact, 2012 (PRAMS)

Excessive Burden of Suboptimal Breastfeeding Among Ethnic Minorities Reported as Excess Disease per 100,000 / Relative Difference (95% CI) White Black Hispanic Otitis Media 25,382 42,694 36,261 [Reference] 1.68 (1.66-1.71) 1.43 (1.41-1.45) Enterocolitis 53 174 106 3.3 (2.92-3.69) 2.01 (1.84-2.19) GI Infection 115,312 153,454 158,710 1.32 (1.31-1.33) 1.38 (1.37-1.38) Child Death 30 66 46 2.23 (1.63-2.84) 1.53 (1.17-1.90) Bartick et al. J Pediatr, 2017.

Loudoun County, Virginia 20% born outside the United States Increasingly diverse 17% Asian 14% Hispanic ~40% increase in a decade 7% Black 4% living below federal poverty line 12% Hispanic / Latinos Individuals living below the Federal Poverty Line

WIC Breastfeeding Assessment Aims: Among women participating in a local WIC program, Determine current infant feeding practices. Describe breastfeeding intention and goals. Describe timing and reasons for introduction of formula. Identify the predictors for reaching optimal breastfeeding at 3 and 6 months.

Methods Self-administered online survey using tablets (via Qualtrics) at both Loudoun County WIC clinics Available in English and Spanish 5 sections, 58 questions ~25 min. to complete Anonymous and de-identified, 18 years + IRB approval from George Mason University and VDH Completed between July - August 2016

Maternal Demographics Race / Ethnicity 74% Latino / Hispanic 90% Spanish speaking 14% Black / African American 5% Asian Primary Language 68% Spanish Education 45% did not complete high school

Family Income & Assistance 66% earned less than the federal poverty line WIC income criteria <185% of federal poverty line 71% of mothers are uninsured or unable to afford healthcare 51% worried about running out of food in the last year 26% ran out of food and unable to purchase more

Specific Aim 1 To determine current infant feeding practices.

Infant Feeding - 3 Months

Infant Feeding - 6 Months Previous Mixed Feeding

Breastfeeding Rates 32

Specific Aim 2 To describe breastfeeding intention and goals.

Breastfeeding Intention & Reaching Goals 50% reached their breastfeeding duration goal Exclusivity 49% planned to breastfeed exclusively 34% planned to exclusively breastfed for at least 6 months

Specific Aim 3 Describe timing and reasons for introduction of formula.

Introduction of Formula

Introduction of Formula 91% gave some formula

Introduction of Formula 91% gave some formula 60% gave formula within the first few days

Introduction of Formula 91% gave some formula 60% gave formula within the first few days 43% gave formula before leaving the hospital 18% at the first feeding

Survival of Never Introducing Formula

Reasons for Introduction of Formula

Specific Aim 4 Identify the predictors for reaching optimal breastfeeding at 3 and 6 months.

Logistic Regression Model: Optimal Breastfeeding 3 months (n=117) Variables Odd Ratio 95% Confidence Interval Maternal age, years 1.04 0.95, 1.13 Number of children 1.29 0.80, 2.08 Education (ref= Completed High school) Elementary school 0.79 0.16, 3.75 Some high school 3.12 1.01, 9.62 Country of birth North America 2.43 0.81, 7.25 Frequency pediatrician discussed breastfeeding (ref = Rarely) Sometimes 4.03 1.02, 15.86 Often 4.72 1.22, 18.20 Set exclusivity goal 2.89 1.08, 7.75 Breastfeeding duration goal (ref=1 - 3 months) 3 - 6 months 7.58 0.67, 85.83 Greater than 6 months 9.10 1.01, 85.8

Logistic Regression Model: Optimal Breastfeeding 6 months (n=94) Variables Odd Ratio 95% Confidence Interval Maternal age, years 1.03 0.95, 1.12 Number of children 0.79 0.48, 1.31 Education (ref= Completed High school) Elementary school 2.86 0.61, 13.49 Some high school 3.94 1.30, 11.93 Country of birth North America 1.60 0.56, 4.61 Frequency pediatrician discussed breastfeeding (ref = Rarely) Sometimes 2.70 0.69, 10.53 Often 2.42 0.64, 9.16 Set exclusivity goal 1.12 0.42, 2.93 Breastfeeding duration goal (ref=1 - 3 months) 3 - 6 months 4.51 0.61, 33.37 Greater than 6 months 5.93 1.04, 33.97

Conclusions & Recommendations High percentage of WIC infants receiving formula within the first few days of life. Improve prenatal education about normal volumes of early feeds as well as the risks of any non-human milk in first few days. Setting breastfeeding goals is associated with increased duration and exclusivity of breastfeeding. Prenatal counseling imperative with culturally adapted messaging. WIC breastfeeding package may influence breastfeeding exclusivity. Consider educating on WIC food packages earlier in care. Consider not offering formula for first month, except in special circumstances.

Acknowledgments Funding Centers for Disease Control and Prevention (CDC) National WIC Association (NWA) WIC Staff Graduate & Undergraduate Trainees Julizza Canales Study Participants