Texas Ten StepStar Achiever Training Toolkit

ITexas Ten Step Star Achiever Intro

Texas Ten Step Star Achiever Program Guide to the Ten Steps to Successful Breastfeeding

The Texas Ten Step Star Achiever Program uses a rapid-cycle quality improvement approach to help participating

Texas birthing facilities complete a systems level, facility-wide paradigm shift. This step-by-step training kit is

one tool to use in that process and will give you a strong foundation toward understanding and implementing

each of the Ten Steps to Successful Breastfeeding (the Ten Steps).

Background and Rationale

Worldwide, increasing the prevalence of any and exclusive breastfeeding is a public health imperative. In

developing countries, breastfeeding has been demonstrated to be among the most cost-effective public health

interventions.1–4 It is estimated that up to 13 percent—or more than 1.3 million—of all deaths worldwide for

children under five could be prevented by promoting exclusive and continued breastfeeding.5 Thanks to basic

public health infrastructure in the United States, including water sanitation, hygiene and high immunization

rates, the child mortality rate is much lower here than in the developing world. Still, the impact of sub-optimal

breastfeeding in the United States is substantial.

A recent cost analysis concluded that a minimum of $13 billion and 911 lives could be saved in the United States by

increasing exclusive breastfeeding for the first six months of life to 90 percent.6 The cost analysis considered just

some of the pediatric health outcomes for which breastfeeding—particularly exclusive breastfeeding—has a clear

and significant impact. It was based on data from an extensive systematic review of maternal and infant outcomes

of breastfeeding in developed countries, sponsored by the Agency for Healthcare Research and Quality (AHRQ).

The AHRQ review found that breastfeeding is associated with significantly reducing the incidence of: 7

• Acuteotitismedia

• Non-specificgastroenteritis

• Severelowerrespiratorytractinfections

• Atopicdermatitis

• Obesity

• Type1diabetes

• Type2diabetes

• Childhoodleukemia

• Suddeninfantdeathsyndrome

• Necrotizingenterocolitis

• Maternalbreastandovariancancers

• Maternaltype2diabetes

It also found that “early cessation of breastfeeding or not breastfeeding was associated with an increased risk of

maternal postpartum depression.”

Intro

Texas Ten Step Star AchieverII Intro

Another recent series of systematic reviews completed for

theWorldHealthOrganizationdrewsimilarconclusions

and additionally found that breastfed infants had lower

systolic blood pressure, lower cholesterol and better

performance in intelligence tests later in life.8 In addition,

many other health outcomes as well as psychological,

developmental, socio-emotional, economic and

environmental outcomes associated with breastfeeding

are well substantiated in the literature.9

Despite the overwhelming evidence for the importance

of breastfeeding, few infants are breastfed in accordance

with current recommendations. All major health

organizations recommend that infants, with rare

exception, be exclusively breastfed, receiving no other

foods or fluids for about the first six months of life, with

continued breastfeeding in addition to complementary

foods for at least the first one to two years of life and

beyond.9–27

Local, National and International Participation and Support

TheNationalQualityForumandtheJointCommission

have adopted, as a core measure of quality for perinatal

care, feeding newborns breastmilk exclusively

throughout the hospital stay. An increase in exclusive

breastfeeding cannot be achieved simply by removal

of formula supplementations. These supplements must

be replaced with the skills, knowledge and supports

necessary to ensure maternal confidence, accurate

assessment of breastfeeding and establishment of

effective breastfeeding. Research and expert consensus

demonstrate that removing ineffective policies and

practices from birthing facilities and replacing them

with effective policies and practices is necessary for achieving optimal infant-feeding outcomes.

TheAnnualCDCBreastfeedingReportCardusesthepercentoflivebirthsoccurringinhospitalsdesignatedas

Baby-Friendlyasanindicatorformeasuringtheproportionofwomenreceivingrecommendedcareforlactation.

This is now the standard used to measure progress toward our nation’s public health goals, as outlined in the

HealthyPeople2020initiative.

The Ten StepsandtheBaby-FriendlyHospitalInitiativearerecommendedstrategiesintheUSSurgeonGeneral’s

CalltoActiontoSupportBreastfeeding,theCDC’sGuide to Breastfeeding Interventions,the2010WhiteHouse

TaskforceonChildhoodObesity’sReporttothePresident:Solving the Problem of Childhood Obesity Within a Generation,andtheNationalPreventionCouncil’sNationalPreventionStrategy.27–30

H E A LT H Y P EO P L E 20 20 B R E A S T FEED I N G O B J EC T I V E S

• Increasetheproportionofmotherswho

breastfeedtheirbabies:Ever;Atsix

months;Atoneyear;Exclusivelythrough

threemonths;Exclusivelythroughsix

months.

• Increasethepercentageofemployerswho

have worksite lactation programs.

• Decreasethepercentageofbreastfed

newborns who receive formula

supplementation within the first two days

of life.

• Increasethepercentageoflivebirths

that occur in facilities that provide

recommended care for lactating mothers

and their babies.

III

Raising the Bar for Texas

Results of the CDC Maternity Practices in Infant Nutrition and Care Survey, a self-administered survey with

participation from over 80 percent of hospitals in the United States, indicate that practices in Texas hospitals

diverge greatly from the standards of care embodied in the Ten Steps and the International Code of Marketing of Breastmilk Substitutes (the Code).Texasranked39thinthe2007survey,withameancompositescoreof58/100.In

the2009survey,Texasranked33rdwithameancompositescoreof62/100.Furtherstate-specificresultscanbe

viewedathttp://cdc.gov/breastfeeding/pdf/mPINC/Texas.pdf.

Results from the 2009 Texas WIC Infant Feeding Practices Survey demonstrate that only a small proportion of the

TexasWICpopulationreportsexperiencingmanyrecommendedpracticesinthefacilitieswheretheygavebirth.

20 09 Te x a s W I C I nfa n t- Feeding P r ac t ice s S urv e y

Source:TexasDepartmentofStateHealthServices,OfficeofProgramDecisionSupport,2010.

Maternity care practice% reporting desired outcome (response)

Breastfedbabyinfirsthour 37.6%(Yes)

Received breastmilk at first feeding 45.9%(Yes)

Exclusivelybreastfedduringentirehospitalstay 22.4%(Yes)

Assisted with breastfeeding 67.2%(Yes)

Roomed-in through out hospital stay 53.3%(Yes)

Babyspentoneormorenightsoutofroom 57.6%(No)

Told how to recognize when baby is hungry 77.2%(Yes)

Told to breastfeed whenever the baby wanted 61.1%(Yes)

Told to limit length of breastfeedings 42.1%(No)

Babygivenpacifierwhileinhospital 26.8%(No)

Mothergivenphonenumberforsupport 58.9%(Yes)

Received free samples of formula 16.4%(No)

ThemajorityofTexaswomendochoosetobreastfeed.In2008,75.2percentofinfantsborninTexaswere

breastfed, meeting the Healthy People 2010 objective for initiation.31 However, breastfeeding duration and

exclusivity continue to fall below target objectives and the national average. And initiation rates fall well below

those of many other states. Disparities in breastfeeding are marked, and rates are significantly lower than the

general population for non-Hispanic blacks and economically disadvantaged groups.32

Texas Ten Step Star Achiever Intro

Texas Ten Step Star AchieverIV Intro

H e a lt h y P eop l e 20 1 0 O b jec t i v e s for B r e a s t feeding

Healthy People Objective2010 Target

2020 Target

US Prevalence (2008 births)

TexasPrevalence(2008 births)

Ever 75% 81.9% 74.6% 75.2%

At 6 months 50% 60.5% 44.3% 42.2%

At 1 year 25% 34.1% 23.8% 23.0%

Exclusivelythrough3months 40% 44.3% 35.0% 30.6%

Exclusivelythrough6months 17% 23.7% 14.8% 13.5%

With so much progress to be made, the process of fully integrating the Ten Steps at a systems level can seem

extremelydaunting.TheCentersforDiseaseControlandPrevention’sGuide to Breastfeeding Interventions recognizes that incremental integration of these practices can be an effective strategy for improving outcomes.28

Hospitals participating in the Texas Ten Step Program have already made significant strides in the right

direction. However, hospitals that have more fully integrated the Ten Steps at a systems level, as evidenced by

achievingtheBaby-FriendlyHospitalInitiative,haveevenbetterbreastfeedingoutcomes.

Informing Infant Feeding Choices

Though infant care choices can be highly

personal, the discrepancies between

breastfeeding recommendations and actual

infant-feeding practices cannot be reduced only

to individual choice or preference. Research

suggests that many factors, including personal,

cultural, psychosocial, healthcare-related,

biomedical and policy attributes can influence

choicesaboutbreastfeeding.Choicesmade

after families receive complete and accurate

information are more likely to lead to exclusive

breastfeeding.Onceinfant-feedingdecisions

are made, the environment must support the

choices the mother has chosen in order for the

decision to be fully realized.33, 34

These contribute to a particular outcome/effect: Infant-Feeding Behaviors

Proportion of any and exclusive BF at 2-days for non-designated, Texas Ten Step,

and Baby-Friendly Facilities in Texas, 2009.

Data Source: Texas DSHS Office of Program Decision Support. Texas Vital Statistics, Provisional Live Births, 2009. Newborn Screening, 2009.

100

90

80

70

60

50

40

30

20

10

0Non-TTS / Non-BFHI TTS BFHI

Perc

ent (

%)

Any BreastfeedingExclusive Breastfeeding

Designation Status of Birthing Facility

74.1

33.3

79.8

49.1

79.9

70.8

Underlying Determinants• Maternal characteristics• Commercial pressure• Community policies

and norms

Intermediate Determinants

• Information and support in the perinatal period

Proximate Determinants

• Maternal choices

• Opportunity to act on choices

Infant-Feeding

Behaviors

V

Addressing Barriers to Breastfeeding

In many cases, mothers do not breastfeed exclusively or even at all because of hospital routines and practices that

interrupt or do not encourage breastfeeding or because of cultural and practical challenges they meet once they

havereturnedhome.Oftentheywillexperiencedifficultybreastfeedingafterhospitaldischargeandthennot

seek or be aware of help from lactation professionals. They may also meet disapproval when breastfeeding publicly

and have little support transitioning to the workplace and adopting strategies to feed their babies or express milk

when separation is necessary.28

Experienceswithbreastfeedingpromotioninterventionsoverthepastdecadeshavemadecleartheneedfor

effective support within the family, community, workplace and health system to initiate and sustain optimal

breastfeeding and complementary feeding practices.21,25,28,35–38 The focus of this guide is on one component of

support within the health system—support within maternity care facilities through full implementation of the

WHO/UNICEFTen Steps and the Code.Eachstepincludesdetailedrecommendationsandideasforaddressingand

overcoming potential barriers to breastfeeding.

The Ten Steps and the Code

The care that a new mother receives during her hospital stay for delivery, postpartum and newborn care can

greatly influence breastfeeding initiation, exclusivity and duration outcomes. Institutional changes through

adoption of evidence-based policies to support breastfeeding can significantly increase rates of breastfeeding.28

Changesmaybemadetoincreaseindividual,evidence-basedpracticesthatsupportbreastfeeding,such

as rooming-in,39 or to discontinue policies that are not evidence-based, such as routine use of pacifiers or

supplementalformulafeedingsforbreastfedinfants.Comprehensivepolicychangesincludefullintegrationof

theWHO/UNICEFTen Steps and adherence to the Code,requiredwhenahospitalseeksBaby-FriendlyHospital

Initiative(BFHI)designation.

The Ten Steps are an evidence-based bundle of maternity care practices that are demonstrated to support optimal

breastfeeding as well as to improve the care experience and outcomes for non-breastfeeding families.40, 41 These

stepsareendorsedbytheAmericanAcademyofPediatricsandTheAmericanAcademyofFamilyPhysiciansand

arepromotedbytheAmericanCollegeofObstetriciansandGynecologists.

The Ten Steps include the following practices:42

1. Have a written breastfeeding policy that is routinely communicated to all healthcare staff.

2.Trainallhealthcarestaffinskillsnecessarytoimplementthispolicy.

3. Inform all pregnant women about the benefits and management of breastfeeding.

4.Helpmothersinitiatebreastfeedingwithinhalfanhourofbirth.(Note:ThisStepisnowinterpretedas

“Place babies in skin-to-skin contact with their mothers for at least an hour immediately following birth.

Encouragemotherstorecognizewhentheirbabiesarereadytobreastfeedandofferhelpifneeded.”)

5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from

their infants.

6.Givenewborninfantsnofoodordrinkotherthanbreastmilk,unlessmedicallyindicated.

7.Practicerooming-in—allowmothersandinfantstoremaintogether24hoursaday.

8.Encouragebreastfeedingondemand.

9.Givenopacifiersorartificialnipplestobreastfeedinginfants.

10.Fostertheestablishmentofbreastfeedingsupportgroupsandrefermotherstothemondischargefromthe

hospital or clinic.

Texas Ten Step Star Achiever Intro

Texas Ten Step Star AchieverVI Intro

In addition to the Ten Steps,theBaby-FriendlyHospitalInitiativealsorequiresfacilitiestoupholdtheCode. The

Code is a set of regulations for the infant-feeding industry, adopted by all member nations of the 31st World Health

Assembly in 1981, which aims to protect breastfeeding by ensuring the proper use of breastmilk substitutes

(including infant formula, other infant foods and beverages when marketed for use to replace breastfeedings,

and infant-feeding bottles and nipples). It refers to quality and availability of factual information, appropriate

marketing and appropriate distribution of these products.

The Code prohibits the following:

• Advertisingofbreastmilksubstitutestothepublic.

• Donationsofbreastmilksubstitutesandsuppliestomaternityhospitals.

• Distributionoffreesamplestomothers.

• Promotionofbreastmilksubstitutesinhealthcareservices.

• Facilitypersonnelprovidingadviceaboutbreastmilksubstitutestomothers.

• Provisionofgiftsorpersonalsamplestohealthcareworkers.

• Useofspace,equipmentoreducationalmaterialssponsoredorproducedbybreastmilksubstitute

companies when teaching mothers about infant feeding.

• Picturesinthebirthingfacilityofinfantsorotherpicturesidealizingartificialfeeding.

The Code also requires that:

• Informationprovidedtohealthworkersbescientificandfactual.

• Informationonartificialfeeding,includinglabels,explainthebenefitsofexclusivebreastfeedingandthe

costs and dangers associated with artificial feeding.

• Productsunsuitableforinfantnutrition—suchassweetenedcondensedmilk—notbepromotedforbabies.

While provisions to implement the Code are encoded in governmental policy in most countries, adherence to the

Code is voluntary in the United States. Hospital administrators and staff play an important role in upholding the

Code as part of a policy of breastfeeding protection, promotion and support.27

Facilities can ensure adherence to the Code by having policies by which:

• Freeorlow-costsuppliesofbreastmilksubstitutesarenotacceptedbythefacility.

• Thefacilitypurchasesbreastmilksubstitutesforawholesalepriceinthesamewayotherfoodsand

medicines are purchased.

• Promotionalmaterialsforcommercialinfantfoodsordrinksarenotpermittedinordistributedbythefacility.

• Materialsthatpromoteartificialfeedingarenotdistributedtopregnantwomen.

• Demonstrationoffeedingwithbreastmilksubstitutesisdemonstratedonlybytrainedhealthworkersand

only for the purpose of instructing pregnant women, mothers or family members who need to use them

and in the context of informed consent.

• Breastmilksubstitutesarenotdisplayedinpublicareasofthefacilityandarekeptoutofareasthatcanbe

accessed by pregnant women and mothers.

• Samplegiftpackswithbreastmilksubstitutesorrelateditemsthatinterferewithbreastfeedingarenot

distributed by the facility to pregnant women, new mothers, or other patients or their families.

• Acceptancebyfacilityemployeesorfamilymembersofemployeesoffundsormaterialitemspromoting

any products that fall within the scope of the Code is prohibited.

• Fulldisclosureofanycontributions(e.g.,fellowships,researchgrants,trips,conferences,continuing

education, etc.) to the facility or to facility employees by manufacturers or distributers of products within

the scope of the Code is made.

VII

Why the Ten Steps and the Code?

In2001,theInstituteofMedicine(IOM)publishedagroundbreakingreport,Crossing the Quality Chasm: A New Health System for the 21st Century.43

BuildingontheextensiveevidencecollectedbytheIOMcommitteeanditspredecessors,thecommittee

turned the overarching statement of purpose into a set of six “Aims for Improvement,” which the committee

recommends be embraced by healthcare stakeholders throughout United States. Implementing the Ten Steps and

The Code addresses all six of these “Aims of Improvement” for healthcare.

The six “Aims of Improvement” set forth by the IOM and their relation to the Ten Steps are:

1. Safety: Patients should be as safe in the hospital setting as they are in their own homes.

Facilitiescanimprovethesafetyandstabilityofallinfantsbyusingevidence-basedpracticesthatprotect

against infection, hypothermia, hypoglycemia, jaundice and dehydration. The Ten Steps promote optimal

nutritional outcomes for the newborn and optimal short- and long-term health outcomes for babies and their

mothers.

2. Effectiveness:Careshouldbeevidence-based.

Overuseofineffectivecareandunderuseofeffectivecareshouldbeavoided.ImplementationoftheTen Steps promotes evaluation of current practices within a framework of evidence and challenges facilities to replace

ineffective practices with universally recognized evidence-based practices for maternity care.

3. Patient-centeredness:Careshouldhonorandempowerpatientsasindividualsandshouldoccurwithin

a context of respect for the patient’s choices, culture,

social context and specific needs.

Implementation of the Ten Steps places families at the

center of care, promotes informed decision-making,

facilitates achievement of patients’ infant-feeding goals

and results in higher customer satisfaction rates.

4. Timeliness:Careshouldbeaccessedanddelivered

with minimal delay for both patients and staff.

Byincreasingcapacityandcontinuityofsupport,

implementation of the Ten Steps results in reduced

delays for families when accessing the help they need

for optimal infant care.

5. Efficiency: Waste of resources, including space,

supplies, technologies, human resources, human spirit,

ideas and capital should be avoided.

A2009costanalysispreparedfortheTexas

Department of State Health Services concluded that

overall expenditures for implementing the Ten Steps are nominal and reduced each year, making the cost of

the initiative essentially cost-neutral to the facility. 44

Meanwhile,savingsinspace,time,supplies,capitaland

improved health outcomes continues to increase.

Texas Ten Step Star Achiever Intro

Texas Ten Step Star AchieverVIII

6. Equity: Systems should strive to improve health equity by reducing disparities.

When implemented together, the Ten Steps greatly reduce racial and ethnic disparities in exclusive breastfeeding

during the hospital stay. Texas Ten Step Hospitals have higher exclusive breastfeeding rates and narrower

disparitygapsthannon-TexasTenStepHospitals.ThiseffectisevenmorepronouncedinTexasBaby-Friendly

Hospitals.

Racial and Ethnic Health Disparities in Texas and the Modifying Effects of Infant Feeding:

75.9

53.5

65.8

71.5

68.4

33.2

33.2

45.6

51.4

21.9

23.2

39.9

0 10 20 30 40 50 60 70 80 90 100

White

Black

Hispanic

Mot

her’s

Rac

e/Et

hnic

ity

Percent Infants Receiving Only Breastmilk Feedings on Day 2 Postpartum

Other

Non-Texas Ten Step, non-Baby-FriendlyTexas Ten Step, non-Baby-Friendly

Texas Baby-Friendly Facilities

Texas exclusivebreastfeeding prevalence, all facilities, all births: 41.6%

Prevelance of Exclusive Breastfeeding on Day 2 Postpartum by Mother’s Race/Ethnicity and Birthing Facility’s Designation Status, 2009.

Data Source: Texas DSHS Office of Program Decision Support. Texas Vital Statistics, Provisional Live Births, 2009. Newborn Screening, 2009.

Intro

C RO S SI N G T H E Q U A L I T Y C H A S M:

“ The purpose of the

healthcare system is

to continually reduce

the burden of illness,

injury, and disability

and to improve the

health status and

function of the people

of the United States.”

C A N C ER

African-American women in Texas are 60% more likely to die of breast cancer than white women.45

Womenwhobreastfedhadarelativereductionintheirriskofbreastcancerbyapproximately4.3%

for each year spent breastfeeding.46-47

TheAmericanCancerSocietylists“notbreastfeeding”asoneofsevenlifestyle-relatedriskfactors

for breast cancer.48

C A R D I OVA SC U L A R D I S E A S E

In 2007, rates of death from diseases of the heart were 24% higher among African-American adults than among white adults.49

Lactating significantly reduces a woman’s risk of developing cardiovascular disease.50Onestudyfoundthat

womenwhobreastfedforalifetimetotaloftwoyearsormorehada23%reducedriskofcoronaryarterydisease

in middle to late adulthood than women who never breastfed, even when adjusting for other risk factors.51

IX

Using This Toolkit

The information and materials provided in this toolkit are designed for use by hospital facility management

and staff to support in achieving a facility-wide paradigm shift toward increased breastfeeding support and

exclusivity. This toolkit includes detailed definitions of each step, rationales and strategies for implementation,

and resources for further reading and review. It is recommended that you approach the steps and the goals in

themannerbestsuitedtoyourfacility.Forinstance,itisnotnecessarytoworkthroughthestepssequentially.

Instead, create a plan for implementation that is most appropriate and effective in the context of your facility, staff,

patients and community.

Followingthisintroduction,youwillfindinthetoolkittensectionsoutliningeachoftheTenSteps.

Texas Ten Step Star Achiever Intro

O B E SI T Y

In 2009, African Americans were 38% more likely, and Hispanics were 41% more likely to be obese than non-Hispanic whites.49

Ameta-analysisconcludedthatbreastfeedingoffersa4%reducedriskofobesitypermonthof

breastfeeding for up to nine months.46

TheCentersforDiseaseControlandPreventionestimatesthatbreastfeedingreducestheriskof

childhood obesity by 15-30 percent.52

Obesechildrenaremorelikelytobecomeobeseadults.53

The longer a child breastfeeds, the less likely he or she is to be overweight.52

D I A B E T E S

In 2009, African Americans were 80% more likely, and Hispanics were 21% more likely to have diagnosed diabetes compared with non- Hispanic whites.49 The diabetes death rate for African Americans and Hispanics was greater than two times higher than for non-Hispanic whites.54

Riskoftype1diabetesisreducedby19-27%forchildrenwhowerebreastfed.46

Riskoftype2diabetesisreducedby39%forchildrenwhowerebreastfed.46

Maternalriskoftype2diabetesisreducedbyupto12%peryearofbreastfeeding.46

I N FA N T M O RTA L I T Y

In 2007, African-American infants in Texas were more than twice as likely to die in the first year of life than white infants.54

Breastfeedingreducesriskofpostneonataldeathby21%.55

Breastfeedingreducesriskofsuddeninfantdeathsyndromeby36%ormore.46, 56

If90%ofU.S.familiescouldcomplywithmedicalrecommendationstobreastfeedexclusivelyforsixmonths,

the U.S. would prevent an excess 911 deaths per year, nearly all of which would be infants.57

Texas Ten Step Star AchieverX

The section for each step includes:

• Acleardefinitionofthestepanditsassociatedgoals.

• Background.

• Rationaleandevidenceforefficacy.

• Relevancetothesix“AimsforImprovement.”

• Recommendedapproachestoimplementation,includingpreparatorystepsandhowtoimplement.

• Overcomingrealandperceivedbarrierstoimplementingeachstep.

• Adetailedlistoffurtherprintedanddigitalresources.

• Alistofnotesforallreferencescitedinthesectionforfurtherreadingandreview.

AdditionaltoolsareprovidedintheAdditionalResourceDocumentssectionatthebackofthistoolkit—action

plans,checklistsandsurveytools—tohelpyouplan,document,auditandreviewyourprogressthrough

eachstep.

Aglossaryisalsoincludedtoclarifyanddefineanynew,uncommon,orparticularlycomplextermsorconcepts.

1. JamisonDT,BremanJG,MeashamAR,etal.Disease Control Priorities in Developing Countries.2nded.NewYork(NY):OxfordUniversityPress;2006

2. TheWorldBank.2006.RepositioningNutritionasCentraltoDevelopment:AStrategyforLarge-ScaleAction.Washington(DC).TheInternationalBankforReconstructionandDevelopment/TheWorldBank.Availablefrom:http://siteresources.worldbank.org/NUTRITION/Resources/281846-1131636806329/NutritionStrategy.pdf

3. HortonS,SanghviT,PhillipsM,etal.Breastfeedingpromotionandprioritysettinginhealth.Health Policy Plan. 1996;11(2):156–68.

4. LINKAGES.2005.CostandEffectiveness.Washington(DC).Availablefrom:http://www.linkagesproject.org/media/publications/Experience_LINKAGES_Cost&Effectiveness.pdf

5. JonesG,SteketeeRW,BlackRE,etal.Howmanychilddeathscanwepreventthisyear?Lancet.2003;362(9377):65–71.

6. BartickM,ReinholdA.TheburdenofsuboptimalbreastfeedingintheUnitedStates:Apediatriccostanalysis.Pediatrics.2010;125(5):e1048–56.

7. IpS,ChungM,RamanG,ChewP,etal.Breastfeedingandmaternalandinfanthealthoutcomesindevelopedcountries.In:EvidenceReport/TechnologyAssessment,No.153.(PreparedbyTufts-NewEnglandMedicalCenterEvidence-basedPracticeCenter,underContractNo.290-02-0022).AHRQPublicationNo.07-E007.Rockville,MD:AgencyforHealthcareResearchandQuality.April2007.

8. HortaB,BahlR,MartinexJ,etal.2007.EvidenceontheLong-TermEffectsofBreastfeeding:SystematicReviewsandMeta-Analyses.Geneva,Switzerland:WorldHealthOrganization.Availablefrom:http://whqlibdoc.who.int/publications/2007/9789241595230_eng.pdf

9. GartnerLM,MortonJ,LawrenceRA,etal.Breastfeedingandtheuseofhumanmilk.Pediatrics.2005;115(2):496–506.

10.AcademyofBreastfeedingMedicineBoardofDirectors.Positiononbreastfeeding.Breastfeed Med.2008;3(4):267–70.Availablefrom:http://www.bfmed.org/Media/Files/Documents/pdf/ABM%20Position%20Statement%20(12-2008).pdf

11.AmericanAcademyofFamilyPractitioners(AAFP).Breastfeeding.PolicyStatement.Leawood(KS):AAFP,2007.Availablefrom:http://www.aafp.org/online/en/home/policy/policies/b/breastfeedingpolicy.html

12.AmericanOsteopathicAssociation.2007.Breast-feedingexclusivity.Chicago(IL):AmericanOsteopathicAssociation.Availablefrom:http://www.osteopathic.org/pdf/cal_hod07resh206.pdf

13.AmericanPublicHealthAssociation(APHA).2007.Acallto

actiononbreastfeeding:Afundamentalpublichealthissue.Washington(DC):APHA.Availablefrom:http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1360

14.AssociationofWomen’sHealth,ObstetricandNeonatalNurses(AWHONN).2007.Breastfeeding.PositionStatement.Washington(DC):AWHONN.Availablefrom:http://www.awhonn.org/awhonn/content.do?name=05_HealthPolicyLegislation/5H_PositionStatements.htm

15.FiocchiA,Assa’adA,BahnaS.Foodallergyandtheintroductionofsolidfoodstoinfants:Aconsensusdocument.AdverseReactionstoFoodsCommittee,AmericanCollegeofAllergy,AsthmaandImmunology.Ann Allergy Asthma Immunol.2006;97(1):10–20.

16.AmericanDieteticAssociation.PositionoftheAmericanDieteticAssociation:Promotingandsupportingbreastfeeding.J Am Diet Assoc.2005;105(5):810–8.Availablefrom:http://www.eatright.org/About/Content.aspx?id=8377

17.AmericanCollegeofNurseMidwives.Breastfeeding.2004.Positionstatement.SilverSpring(MD):AmericanCollegeofNurseMidwives.Availablefrom:http://www.midwife.org/position.cfm

18.AmericanCollegeofObstetriciansandGynecologists.2003.Breastfeeding.Washington(DC):AmericanCollegeofObstetriciansandGynecologists.Availablefrom:http://www.acog.org/departments/underserved/breastfeedingstatement.pdf

19.WorldHealthOrganization(WHO)/UNICEF.2003.GlobalStrategyforInfantandYoungChildFeeding.Geneva,Switzerland:WorldHealthOrganization.Availablefrom:http://whqlibdoc.who.int/publications/2003/9241562218.pdf

20.NationalAssociationofPediatricNursePractitioners(NAPNAP).Positionstatementonbreastfeeding.J Pediatr Health Care.2001;15(5):22A.Availablefrom:http://www.napnap.org/PNPResources/Practice/PositionStatements.aspx

21.U.S.DepartmentofHealthandHumanServices.2000.HHSBlueprintforActiononBreastfeeding.Washington(DC):U.S.DepartmentofHealthandHumanServices,OfficeonWomen’sHealth.Availablefrom:http://www.womenshealth.gov/archive/breastfeeding/programs/blueprints/bluprntbk2.pdf

22.DepartmentofHealthandHumanServices.2000.HealthyPeople2010.2nded.WithUnderstandingandImprovingHealthandObjectivesforImprovingHealth.2vols.Washington(DC):U.S.GovernmentPrintingOfficeAvailablefrom:http://www.health.gov/healthypeople.

23.InternationalLactationConsultantAssociation(ILCA).2000.PositionPaperonInfantFeeding.Morrisville(NC):

N o t e s

Intro

XI

ILCA. Available from: http://www.ilca.org/i4a/pages/index.cfm?pageid=3933

24. United States Breastfeeding Committee. 2000. Statement on exclusive breastfeeding. Raleigh (NC): United States Breastfeeding Committee. Available from: http://www.usbreastfeeding.org/AboutUs/PublicationsPositionStatements/tabid/70/Default.aspx

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