Objetivos: Objetivos: Avaliar o crescimento de crianças amamentadas cujas mães haviam inserido um implante de liberação de etonogestrel no pós-parto imediato. Métodos: Ensaio clínico aberto, randomizado, controlado e paralelo de mulheres pós-parto que foram randomizadas em blocos para inserção precoce (até 48 horas pós-parto antes da alta) ou convencional (6 semanas após o parto) de um implante etonogestrel. O desfecho primário foi o peso médio do bebê aos 12 meses (360 dias), e uma diferença de >=10% entre os grupos foi considerada clinicamente significativa. Os desfechos secundários foram a comprimento da criança, o perímetro cefálico e a circunferência braquial. Estas variáveis foram medidas no início e aos 14 e 40, 90, 180, 270 e 360 dias pós-parto. O modelo de regressão linear de efeitos mistos foi utilizado para avaliar os desfechos, com um poder de 80%, e um nível de significância de 1% para o desfecho primário e 0,3% para os desfechos secundários, devido à correção para múltiplas hipóteses. Resultados: De junho a agosto de 2015, um total de 100 mulheres foram randomizadas para inserção precoce ou convencional do implante de etonogestrel no pós-parto. As características sociodemográficas foram semelhantes entre os grupos, exceto no nível de escolaridade, que foi maior no grupo de inserção convencional (88% vs. 70% no grupo de inserção precoce, p = 0,02). Não houve diferença no peso do bebê em 360 dias entre os grupos [precoce: (média ± desvio padrão) 10060,3 ± 1156,0 g vs convencional: 9812,1 ± 1270,3g, estimativa da diferença de média 321,6g, intervalo de confiança 95% (IC): -183,5 A 495,7]. As curvas de crescimento do comprimento e as curvas dos perímetros cefálico e braquial também não diferiram entre os grupos. Conclusões: Não há diferença no crescimento das crianças amamentadas, em 12 meses, cujas mães receberam a inserção do implante liberador de etnogestrel precocemente comparado com a inserção pós-parto convencional. / Objective: To evaluate the growth of breastfed children whose mothers had inserted an etonogestrel-releasing implant in the immediate postpartum period. Methods: An open, randomized, controlled, and parallel trial of postpartum women who were block randomized to early (up to 48 hours postpartum before discharge) or conventional (at 6 weeks postpartum) insertion of a etonogestrel implant. The primary outcome was average infant weight at 12 months (360 days), and a difference of >=10% between groups was considered clinically significant. The secondary outcomes were infant\'s lenght, head and arm circumferences. These variables were measured at baseline and at 14 and 40, 90, 180, 270, and 360 days postpartum. The mixed-effects linear regression model was used to evaluate the outcomes, with a power of 80%, and a significance level of 1% for primary outcome and 0.3% for secondary outcomes, due to correction for multiple hypothesis testing. Results: From June to August of 2015, a total of 100 women were randomized to either early or conventional postpartum etonogestrel insertion. Sociodemographic characteristics were similar between the groups, except for educational attainment, which was higher in the conventional insertion group (88% vs. 70% in the early insertion group, p=.02). There was no difference in infant weight at 360 days between the groups [early: (mean ± standard deviation) 10060.3 ±1156.0 g vs conventional: 9812.1 ± 1270.3g, mean difference estimate 321.6g, 95% confidence interval (CI): - 183.5 to 495.7]. The growth curves of the lenght and the curves of the head and arm circumferences did not differ between the groups. Conclusion: There is no difference in growth at 12 months among breastfed infants whose mothers underwent early compared with conventional postpartum insertion of the etonogestrel implant.

Background: Breastfeeding is known to have many benefits for both mothers and infants. With the Surgeon General's Call to Action to Support Breastfeeding, health professionals have increased their attention on breastfeeding competency. Objectives: This study aimed to evaluate breastfeeding curricula that are currently being covered in didactic programs in dietetics (DPDs) and dietetic internships (DIs) across the United States. Methods: Two-part surveys were sent to all directors of DPDs and DIs (n=475) with instructions to forward the second portion of the survey to instructors of classes that taught about breastfeeding. Qualtrics software was used for data collection. Descriptive statistics were used to illustrate what was currently being done to educate students about breastfeeding. Two independent researchers used qualitative analysis to categorize course names that were provided as a free response. Results: Over 80% of DPDs taught the topics of other components of human milk and breastfeeding and health for infants most thoroughly. The topic of breastfeeding and health for infants was taught most completely in DIs (65%). Course instructors had an International Board Certified Lactation Consultant teach part of the breastfeeding material about a fourth of the time (DPDs=26.8%; DIs=21.9%). Interns participated in breastfeeding counseling the most during WIC rotations (DIs=90%). Course instructors usually taught about breastfeeding themselves (DPDs=91%; DIs=44%) and used lectures in their instruction (DPDs=93%; DIs=75%). Conclusion: This research provides background in the current status of breastfeeding curricula in DPDs and DIs across the United States. This knowledge could be used to determine standards for breastfeeding curricula, implement improvements to breastfeeding curricula, and set precedence for further evaluations in DPDs and DIs.

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Purpose Breastfeeding affords numerous benefits for mothers, infants, families, and communities. Rates of breastfeeding are disproportionately low in rural Appalachia. We will describe how use of the AAP CATCH Grant process aided in building a community breastfeeding coalition, conducting a breastfeeding support needs assessment, and developing interventions to promote and support breastfeeding in the region. Methods In 2005, members of a multidisciplinary regional breastfeeding coalition in Northeast Tennessee wrote and received an AAP CATCH Planning Grant. Funds supported regular meetings of the coalition, a needs assessment consisting of surveys and focus groups conducted with patients and healthcare providers in the region during 2007-2008, and dissemination of the group's findings and recommendations. Patient participants were recruited from three health departments and one Pediatric clinic in the region. Provider participants were recruited from three regional professional conferences. Surveys were entered into and analyzed using SPSS 17. Recordings of focus groups were transcribed and transcripts were reviewed to identify themes. Results 19 pregnant women in their second and third trimesters of pregnancy, 38 new mothers, and 58 healthcare providers completed a survey. Fifty five percent of new mothers reported ever having breastfed their baby. Thirty seven percent of healthcare providers identified Pediatrics, 21% Obstetrics and Gynecology, and 37% Family Medicine/Primary Care as their primary specialty. 52.6% and 81.6% of pregnant women and new mothers, respectively, reported that their healthcare provider had encouraged breastfeeding. Patients described that their healthcare providers discussed little about breastfeeding other than its benefits. Eighty-four percent of providers reported usually recommending exclusive breastfeeding during the first month of life. Only forty-eight percent of providers considered their advice on breastfeeding to be very important to mothers. Twenty-five percent of providers felt that exclusive breastfeeding for the first sixth months of life is unrealistic for many of their patients. The most commonly cited barrier by providers was that mothers had already decided not to breastfeed before they encountered them. Lack of time and lack of referral resources were other common barriers reported. Providers expressed the lowest levels of confidence in their own skills in evaluating latch, resolving problems of low milk production and breast tenderness, and knowing what referral services exist. Conclusion Patients in this sample described receiving little information about breastfeeding from their healthcare provider. Many health care providers in this region do not recognize the importance of their advice on breastfeeding and feel that breastfeeding is unrealistic for many of their patients. The use of study results by a community breastfeeding coalition to increase community awareness of the importance of breastfeeding promotion and support and to address provider concerns about barriers and educational needs will be discussed.

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Background and Objectives: Tennessee has low breastfeeding rates and has identified opportunities for improvement to enhance maternity practices to support breastfeeding mothers. We sought a 10% relative increase in the aggregate Joint Commission measure of breastfeeding exclusivity at discharge (TJC PC-05) by focusing on high-reliability (≥90%) implementation of processes that promote breastfeeding in the delivery setting. Methods: A statewide, multidisciplinary development team reviewed evidence from the WHO-UNICEF “Ten Steps to Successful Breastfeeding” to create a consensus toolkit of process indicators aligned with the Ten Steps. Hospitals submitted monthly TJC PC-05 data for 6 months while studying local implementation of the Ten Steps to identify improvement opportunities, and for an additional 11 months while conducting tests of change to improve Ten Steps implementation using Plan-Do-Study-Act cycles, local process audits, and control charts. Data were aggregated at the state level and presented at 12 monthly webinars, 3 regional learning sessions, and 1 statewide meeting where teams shared their local data and implementation experiences. Results: Thirteen hospitals accounting for 47% of live births in Tennessee submitted data on 31,183 mother–infant dyads from August 1, 2012, to December 31, 2013. Aggregate monthly mean PC-05 demonstrated “special cause” improvement increasing from 37.1% to 41.2%, an 11.1% relative increase. Five hospitals reported implementation of ≥5 of the Ten Steps and two hospitals reported ≥90% reliability on ≥5 of the Ten Steps using locally designed process audits. Conclusion: Using large-scale improvement methodology, a successful statewide collaborative led to >10% relative increase in breastfeeding exclusivity at discharge in participating Tennessee hospitals. Further opportunities for improvement in implementing breastfeeding supportive practices were identified.

Purpose While rates of breastfeeding have been increasing in the United States in recent decades, disparities exist among certain populations, including residents of the rural Southeast. Mothers’ perceptions of embarrassment, convenience, and social support related to breastfeeding may affect whether they choose to breastfeed and for how long. This study evaluated the effectiveness of a video intervention in improving perceptions of breastfeeding among pregnant women presenting for a prenatal clinic visit in rural Appalachia. Its effectiveness in increasing reported likelihood of breastfeeding was also assessed. Methods A multidisciplinary course team established a partnership with an OB/GYN clinic that serves a high volume of pregnant women. A 15 minute video addressing issues of embarrassment, convenience and social support related to breastfeeding was shown in the clinic waiting room. The video, Breastfeeding: Another Way of Saying I Love You, had been previously developed and evaluated by the Mississippi Department of Health. Pregnant women visiting the clinic during 8 days in 2009 were invited to complete an anonymous written survey immediately before and after viewing the video. The survey included items on demographics, perceptions of breastfeeding, and intention to breastfeed. Descriptive statistics were calculated. The proportion of women reporting improved perceptions of breastfeeding was compared between subgroups using chi-square testing. Mean breastfeeding perception scores were compared between subgroups and changes in women’s intention to breastfeed were evaluated. Results Before watching the video, of the 77 participants, 38.9% reported previously breastfeeding a child, 51.3% planned to breastfeed, and 25% were undecided. Consistent with demographics of the region, participants were predominantly white (91%). Twenty-six percent were teenagers and 71.5% reported having a high school education or less. After viewing the video, perceptions of embarrassment, convenience, and social support related to breastfeeding improved in a range of 39-44.2%, 37-40%, and 33.3-63% of women, respectively. Mothers who watched the video with a supportive other were more likely to report improved perceptions of embarrassment than mothers who watched the video alone (t=3.577, df=73, p=.001). Of the mothers who reported being undecided about breastfeeding prior to watching the video, 57.9% reported being more likely to breastfeed after watching the video (chi2=10.22, df=2, p=0.006). Conclusion The findings suggest this time-efficient video intervention was an effective means of improving perceptions of breastfeeding during the prenatal period among a sample of rural Appalachian women. Results indicate that its efficacy is significantly improved if pregnant women view it with a supportive other, and it is most useful in increasing likelihood of breastfeeding in women who are undecided about how they will feed their child.

Exclusive breastfeeding for at least six months and continued breastfeeding for the first year or two is promoted as the preferred method for feeding infants. In the United States, about 79% of infants are ever breastfed and less than 27% are breastfed through the first year (Centers for Disease Control and Prevention, 2014b). The purpose of this study was to understand the role of breastfeeding experiences and underlying factors that may facilitate the maintenance of breastfeeding one’s first child as well as the re-engagement in breastfeeding with one's second child. This dissertation includes two quantitative studies using secondary data and one qualitative study involving data specifically collected for this study. The quantitative studies used data from the Infant Feeding Practices Study II and the Year 6 Follow Up surveys. Findings indicate barriers in the early breastfeeding experience (pain, trouble with milk supply, and trouble with the baby’s suck or latch) are associated with less time spent in breastfeeding maintenance among first-time mothers and experiencing trouble with the first baby’s suck or latch is associated with non-initiation with one's second child. Conversely, as levels of perceived breastfeeding self-efficacy, opinion about the best way to feed a baby, and belief about breast milk increased, or became more pro-breastfeeding over time, time spent in breastfeeding maintenance among first-time mothers also increased. Those with a high level of response efficacy were also more likely to initiate breastfeeding with a second child. In the qualitative study, 28 first-time mothers who recently stopped breastfeeding and live in Iowa participated in semi-structured interviews. The objectives of this third study were to understand and describe first-time mothers’ experiences of infant feeding throughout the entire breastfeeding maintenance period, and explore how contextual factors may act as facilitators or barriers to breastfeeding maintenance by identifying common turning points. Turning points were defined as events or periods in time perceived as personally significant, that promoted a change, maintenance, or where a new meaning associated with the experience was acquired. Findings include seven turning points (breastfeeding problems, overcoming the unknown, recurring stressors, learning how to live life with the new baby, re-entering social roles, special occasions, and letting go) that were usually associated with stressful situations. The availability of intrapersonal (e.g., individual determination) and interpersonal (e.g., social support from others) coping resources at these turning points facilitated breastfeeding maintenance. The first study is significant in the longitudinal consideration of both experiences and changes in intrapersonal and interpersonal factors and how these changes relate to breastfeeding maintenance. The second study is significant with the focus on multiparous mothers and the effect of previous breastfeeding thoughts and experiences on breastfeeding initiation with a second child. The third study is unique in the identification of breastfeeding turning points that may lead to identifying opportune times and strategies for maintenance interventions. Findings from these studies have implications for intervention planning and future research. The synthesis of findings across the three studies suggests the early breastfeeding period is paramount to breastfeeding maintenance, along with the role of one’s social environment, particularly the perceived availability of social support to meet mothers' needs. Finally, findings from this dissertation can be used to improve social support provision and multi-level interventions targeting mothers’ most salient needs at the most opportune times.

Background To date, the vast majority of studies on infant feeding behavior of Chinese population have been conducted in Asian and some western countries but not the U.S. As the fastest growing Asian subgroup and with the largest Chinese community outside of Asia, studies that focus on their health choices in the U.S. are long overdue. Where studies are available, the overseas Chinese population is often regarded as high formula feeding and low breastfeeding. Chinese mothers often cite family, cultural, and social expectations as the determining factors for their choice of infant feeding. Given the cultural beliefs and traditions of Chinese immigrant population in the U.S., this study argues for the importance of including the input of the overall community, as opposed to only mothers, as a more data-based explanation of the prevalence of formula feeding among the Chinese community in New York City, and in addition, why this community continues to accept formula feeding as the norm. Methods Guided by Theory of Planned Behavior, this study incorporated both quantitative and qualitative components. A total of 434 surveys and 20 in-person interviews were collected in Chinese populated areas in New York City. Results In examining the prevalence of formula feeding in the Chinese community, both quantitative and qualitative findings consistently identified the central role friends and family played in motivating certain groups to use formula. These less acculturated, educated, and China-born subgroups are likely to conform to the idea that breast milk supplemented by infant formula is necessary in order to meet the nutritional demand of a growing infant. For the first-generation immigrants who breastfeed for health benefits and tradition, their attitudes towards infant feeding shifted after seeing other formula-fed children in populated Chinese communities as evident by shorter breastfeeding durations for the child born in the U.S. as compared to previous child born in China. As for the second-generation, who are more acculturated and educated, although they are aware of the benefits of breastfeeding and intend to breastfeed, they are expected by the older generation to continue the formula feeding tradition in the family. Conclusion When investigating why infant formula remained as the popular choice of feeding and is often perceived as the norm by this community, the current study identified the psychosocial variables that motivated individual subgroups and the context underlay. The findings provided new insights to the current literature and are intended to help guide future studies and to develop educational policy interventions to improve the overall infant feeding experiences for the Chinese community in New York City.