This document reviews factors that influence mothers in the WIC program to choose formula feeding over breastfeeding for their infants. Several studies examined found that parents who formula feed generally have less knowledge of the health benefits of breastfeeding and a less positive attitude towards it. A cohort study found that breastfed infants enrolled in WIC programs saved over $400 in expenses in their first 6 months compared to formula fed infants. A review also showed that education and support services are effective at increasing the duration of breastfeeding. The document suggests WIC programs develop policies to better promote and educate mothers on breastfeeding.

1. What influences the choice of infant feeding for WIC mothers?

2. Abstract Breastfeeding is the best method of infant feeding and is an important public health strategy which reduces health care costs. Breastfeeding in the United States is significantly lower than in developing countries. Also, infants receiving WIC services have a lower initiation and duration rate compared to infants not receiving WIC services. (James & Lessen, 2009) This project reviews studies that identify factors that influence the choice of infant feeding and makes suggestions for clinical applications.

3. Introduction Breastfeeding is an important public health strategy for improving infant and child morbidity and mortality, improving maternal morbidity and mortality and helping to control health care costs.” (James & Lessen, 2009) The United States ranks 28th in the world in infant mortality. (CDC, 2007) Breastfeeding in the United States is lower than in developing countries. (CDC) Infants receiving WIC services have a lower initiation and duration rate and fewer are exclusively breastfeeding at 6 months compared to infants not receiving WIC services (James et al., 2009) In the WIC adult female population does the focus of education or availability of infant formula influence the decision to formula feed? The aim of this study is to determine what influences mothers in WIC to choose formula over breastfeeding.

4. METHODS 1. A review of studies to include Convenience sample that compared infant feeding attitude of parents who formula fed to those who breast fed Cohort study of WIC breastfeeding and formula feeding women to determine economic value of breastfeeding 2. A review of evidenced based clinical guidelines for breastfeeding 3. A meta-analysis review of studies that addressed effect of primary care intervention on breastfeeding.

5. Results Convenience Sample using a survey design, sampled 108 pregnant women and their partners and found: Parents of breastfed infants had a more positive attitude toward breastfeeding Parents of breast fed infants were more knowledgeable of health benefits and nutritional value of breastfeeding Parents believed their chosen option of infant feeding to be the most convenient (both breastfeeding and formula feeding) (Shaker, Scott & Reid, 2003)

6. Results cont. Cohort Study of WIC enrolled healthy infants; 406 breastfed and 470 formula fed found: Breastfed infants saved $478 in WIC and Medicaid expenses during first 6 months of infant’s life (If 50% of women continued to breastfeed for 5-6 months, the savings nationwide would be $6.5 million per month) (Montgomery & Splett, 1997) Systematic Review of literature studying effect of primary care intervention on duration of breastfeeding. Included 30 randomized and non randomized controlled trials and 5 systematic reviews of breastfeeding counseling which found: Education and support services increased duration of breastfeeding Written material was least effective (Guise, Palda, Westhoff, Chan, Helfand & Lieu, 2003)

7. Discussion Parent attitudes about infant feeding strongly influence the choice of infant feeding. (Shaker, Scott & Reid, 2003) Parents of formula feeding infants have poorer knowledge of breastfeeding (Shaker et. al) It is important to understand parent knowledge and attitudes towards infant feeding when designing breastfeeding promotion. (Shaker et. al) The role of the father in infant feeding choices is important and neglected. (Shaker et. al) The cost savings of medical care of breastfeeding infants compared to formula fed infants is significant. (Montgomery & Splett, 1997) Evidence based clinical guidelines direct breastfeeding implementation and education. (ILCA, 2005) Review of studies indicates education and support services increase the duration of breastfeeding. (Guise, Palda, Westhoff, Chan, Helfand & Lieu 2003)

8. WIC Overseas clinical application suggestions Develop policies and procedures that specifically outline promotion of breastfeeding and breastfeeding education to include: Not supplying pregnant women with sample infant formula (unless specifically declared they will formula feed) Not suggesting they take the formula of their choice to the German hospital in the event they can not breastfeed Following the clinical guideline for establishment of exclusive breastfeeding as it pertains to breastfeeding education and promotion found at http://www.guideline.gov/summary/summary.aspx?doc_id=7662&nbr=004461&string=breastfeeding Continue to promote breastfeeding through appropriate education. Actively include fathers in breastfeeding education. Develop and guide peer support breastfeeding groups.

9. References Centers for Disease Control. (2007). Eliminate disparities in infant mortality. Retrieved March 15, 2010 from http://www.cdc.gov/omhd/amh/factsheets/infant.htm Guise, J., Palda, V., Westhoff, C., Chan, B., Helfand, M., & Lieu, T. (2003). The effectiveness of primary care-based interventions to promote breastfeeding: systematic evidence review and meta-analysis for the US preventive services task force. Annals of Family Medicine. 1. 70-78. doi: 10.1370/afm.56. International Lactation Consultant Association. Raleigh, N.C. Retrieved from National Guideline Clearinghouse.: http://www.guideline.gov/summary/summary.aspx?doc_id=7662&nbr=004461&string=breastfeeding James, D. & Lessen, R., (2009). Position of the American Dietetic Association: Promoting and supporting breastfeeding. Journal of the American Dietetic Association. November 1926-1942. Montgomery, D., & Splett, P. (1997). Economic benefit of breast-feeding infants enrolled in WIC. Journal of the American Dietetic Association, 97 (4), 379-385. Shaker,I., Scott,J., & Reid ,M. (2003). Infant feeding attitudes of expectant parents: Breastfeeding and formula feeding. Journal of Advanced Nursing, 45(3), 260-268. Marcia L. Brodersen for 483-Evidenced-Based Nursing Class, University of Wisconsin, Green Bay