Get ready for World Breastfeeding Week! Protect Breastfeeding: A Shared Responsibility

Mark your calendars for one of the globe’s greatest celebrations! Next week, we come together for the 29th Annual World Breastfeeding Week (WBW) (August 1-7) and everyone is invited. There are no unlikely guests at this party; protecting breastfeeding is a shared responsibility, in line with this year’s WBW theme.

The Protect Breastfeeding: A Shared Responsibility theme is aligned with area 2 of the WBW-SDG 2030 campaign which highlights the links between breastfeeding and survival, health and wellbeing of families and nations.

Support at the individual level is a crucial part of this shared goal, but breastfeeding must be considered a public health issue that requires investment at all levels. The concept of ‘building back better’ after the COVID-19 pandemic will provide an opportunity to create a warm chain of support for breastfeeding that includes health systems, workplaces and communities at all levels of society. A warm chain of support will help build an enabling environment for breastfeeding and protect against industry influence, as explained here.  

Organizations from locations all over the map have RSVPed to the celebration, answering the call to action by pledging their participation in WBW 2021. You can too through a simple process found here

WBW’s Relevant Resources page includes articles and documents about breastfeeding as not only an investment in improving health and saving lives, but as an investment in human capital development. A Save the Children document details strategies to effectively influence political commitment to breastfeeding. Another piece identifies successful multicomponent public health strategies. Together, these resources offer ample evidence and motivation to continue pushing for change for healthy families, nations and a healthy planet. 

The WBW 2021 Social Media Kit offers scheduled activities leading up to and during #WBW2021.   Use these hashtags in your social media posts: 

#WBW2021 #WABA #ProtectBreastfeeding #SharedResponsibility #breastfeeding #SDGs #worldbreastfeedingweek2021 #ProtectBreastfeedingaSharedResponsibility #protectbreastfeedingtogether #buildingbackbetter #warmchain4breastfeeding #breastfeeding4publichealth

In the aftermath of the COVID-19 pandemic and its persisting challenges, it has never been more important to protect healthy infant feeding; there’s no better time than now to inform, anchor, engage and galvanize action to protect breastfeeding at all levels.

The movement continues beyond WBW and into the month of August for National Breastfeeding Month (NBM). This year’s theme: Every Step of the Way with weekly observances:

Week 1: World Breastfeeding Week

  • Theme: Protect Breastfeeding: A Shared Responsibility

Week 2: Native Breastfeeding Week

  • Theme: Nourishing Our Futures

Week 3: Asian American Native Hawaiian and Pacific Islander Week

  • Theme: Reclaiming Our Tradition

Week 4: Black Breastfeeding Week

  • Theme: The Big Pause: Collective Rest for Collective Power

 In anticipation of NBM, you can Register for the launch event webinar for the “Continuity of Care in Breastfeeding Support: A Blueprint for Communities” on August 24, 1 p.m. ET.

You can celebrate in style during this vital, global initiative with Health Education Associates’ World Breastfeeding Week party pack. Get the swag here.  The United States Breastfeeding Committee (USBC) is also offering Limited Edition NBM 2021 Designs at their store here.

Integrating mental health services into primary care

Through play, children learn. Play teaches them how to process information, express themselves, self-regulate, and concentrate among its many other functions.

Photo by Rajesh Rajput on Unsplash

Early in her psychology studies, Laura Harford, PsyD, Licensed Clinical Psychologist and HealthySteps Specialist with the Mother and Child Integrated Mental Health Program (MAC-IMP) at NewYork-Presbyterian Columbia University Irving Medical Center became fascinated by the role that play plays curatively. 

“When you’re working with very young children therapeutically, it becomes nearly impossible to treat the child without addressing the parents’ needs as well,” Harford begins. 

Using play as a parental teaching tool and providing the parent with strategies and support, can promote more secure attachments and facilitate communication and understanding between a parent child dyad.

Photo by Larry Crayton on Unsplash

Play can increase parents’ understanding of their children’s needs and help them to feel more confident overall, Harford continues.  

Healthy Steps is part of the Zero To Three program designed to support new families around bonding, child development, and parenting concerns. 

More specifically, Zero to Three supports parents with practical resources, professionals with knowledge and tools that help them support healthy early development and policymakers in advancing comprehensive and coherent policies which support and strengthen families, caregivers and infant toddler professionals. 

The Healthy Steps model has identified five outcomes important to healthy child development and family well-being which include:

  • Breastfeeding
  • Child social-emotional development
  • Early childhood obesity
  • Maternal depression and 
  • Well-child visits.

As such, Harford was encouraged to complete the Lactation Counselor Training Course (LCTC) to help fulfill these priority outcome areas. 

Infant feeding can affect parental mental health, and the reverse is true too. 

Harford explains that if a mother is feeding her child “well” (“well” in quotes because this definition varies from individual to individual and family to family), she will likely feel more confident in her parenting abilities overall. If the child is not feeding “well”, feelings of anxiety and failure may creep into the picture. 

A mother who  presents with mental health issues may be less responsive to her child’s feeding cues in particular, contributing to a potentially fussy and irritable infant or to an infant who fails to thrive, Harford goes on.  

While breastfeeding can be preventative against perinatal mood disorders, support isn’t always easy to come by.   

 “There is no shortage of lactation specialists at [NewYork-Presbyterian Columbia University Irving Medical Center], but I wanted to be a more direct resource to ensure that any mother who is enrolled in my program and needs help can access support,” Harford explains.  

Harford works solely with individuals who receive Medicaid; as such, these families are often up against systemic barriers that challenge their ability to access health services. 

In the instance of virtual support, access to technology can be a barrier. Harford shares that as healthcare services shifted virtually as a result of the pandemic, their institution had various initiatives to support patients in maintaining connection to clinical care. 

Sometimes cost is prohibitory. Generally, navigating mental health care systems can be overwhelming and sustaining the effort to initiate services can be exhausting. 

That’s why Columbia University Irving Medical Center is working to provide these services directly through primary care, Harford says. 

Integrating health services allows for better continuity of care. 

“If there is one provider that the family trusts, then they will readily engage with the next they come across when these direct connections are made,” Harford explains.

There’s more time and energy available to facilitate those invaluable moments of play and connection between parents and their children when health services are integrated and the stressors of seeking out help are eliminated.

National Baby-Led Weaning Day and appropriate complementary feeding

We at Healthy Children Project  are so excited to see philosopher of the baby-led weaning (BLW) movement Gill Rapley’s work celebrated  this month. July 1 is now recognized as National Baby-Led Weaning Day!

In honor of this declaration, we are sharing one of our most popular Our Milky Way pieces originally published in 2018,  Food before one is NOT just for fun: appropriate complementary feeding and long-term health.


Unhealthy diets are costly for both children and the societies in which they live. (UNICEF 2016, page 90)

The United States performed poorly on almost all indicators set by the World Breastfeeding Trends Initiative (WBTi), an international tracking, assessment and monitoring system for national implementation of the Global Strategy on Infant and Young Child Feeding.

We did, however, score 10 out of 10 on Indicator 10: Mechanisms of Monitoring and Evaluation System, because in the words of Healthy Children Project Executive Director Karin Cadwell, “We are really good at keeping track of what we aren’t doing.”

The U.S. also managed 10 out of 10 on Indicator 15: Complementary feeding — Introduction of solid, semisolid or soft foods, which measures the percentage of breastfed babies receiving complementary foods at 6 to 8 months of age. The U.S. WBTi panel reported that although more than 80 percent of U.S. babies begin to breastfeed, only 22.3 percent are exclusively breastfed at 6 months, and by eight months, almost every baby has been introduced to complementary foods.

Actually, 20 to 40 percent of babies in the U.S. are introduced to complementary foods at younger than four months. []  

WHO/PAHO advise complementary food be introduced to infants’ diet at 6 months of age. Human milk is meant to be the primary staple of infants’ diets, but human milk alone cannot provide everything babies need nutritionally, especially micronutrients like zinc and iron… Food before one is NOT just for fun.

“While food is certainly a fun sensory experience, it’s also really important babies between 6 and 12 months get a broad exposure to healthy foods,” Healthy Children Project’s Cindy Turner- Maffei, MA, ALC, IBCLC said during one of her presentations at the latest International Breastfeeding and MAINN Conference.

But inconsistent messaging about feeding persists, as detailed in the WBTi U.S. report.

For instance, “…the American Academy of Pediatrics has inconsistent messaging regarding when to begin complementary feeding with a breastfed baby (4 versus 6 months); FDA child care guidelines differ significantly from WIC guidelines regarding infant feeding, etc.” (p 31)

Interestingly, it was after the Clean Label Project investigated pet food that consumers expressed interest in contaminants found in infant formula and baby food, perhaps a testament to our national priorities.

What’s more, the concept of which foods offer an appropriate complement to the diet of a breastfed infant as well as the food environment, including a booming baby food industry, have changed dramatically over the past 50 years, Turner-Maffei pointed out.

The packet apocalypse, where the convenience of “ready-to-feed-super- glop” has largely replaced the art of dining and sharing meals, is upon us in the U.S. Stocked shelves offer an overwhelming array of mostly highly processed snacks and meals in a pouch that generally lack texture diversity, can lead to tooth decay, and “may be predictive of future eating habits”. (UNICEF 2016)   

In light of National Nutrition Month, let’s take a look at what appropriate complementary feeding looks like and the importance of appropriate complementary feeding for long-term health through a summary of what Turner-Maffei and colleagues found after conducting a multi-source literature search and thematic review on complementary foods/feeding and child health/outcomes.

Importance of appropriate complementary feeding (CF)

Children with inadequate or inappropriate CF are at increased risk for growth stunting, potential changes to the microbiome, being overweight, and having micronutrient deficiencies.

Stunting and chronic nutrient deficiencies have significant consequences for health, growth and cognitive development and performance.

For instance, appropriate iron levels are needed for proper brain development; deficiency is associated with thought-processing and motor development issues.

Zinc is related to immune function and optimal cell growth and repair; deficiency is associated with impaired growth, increased susceptibility to infection and an increased risk of diarrhea.  

UNICEF’s From the First Hour of Life report points out that “If appropriate complementary feeding practices were scaled up to nearly universal levels, approximately 100,000 deaths in children under five could be averted each year.” (p. 17)

Guidelines to appropriate CF

Turner-Maffei detailed that foods offered to infants must be nutrient-dense because of their small stomach size. Dietary diversity, where babies are offered a wide variety of healthy foods, help ensure nutrient needs are met. How babies are fed matters too. That is, social interaction plays an important role in appropriate feeding.

PAHO/WHO set forth Guiding Principles for Complementary Feeding of the Breastfed Infant (2003) which states:

  1. Practice exclusive breastfeeding from birth to 6 months, and introduce complementary food at 6 months of age (180) days while continuing to breastfeed.
  2. Continue frequent, on-demand breastfeeding until 2 years of age or beyond.
  3. Practice responsive feeding, applying the principles of psychosocial care.
  4. Practice good hygiene and proper food handling.
  5. Start at 6 months of age with small amounts of food and increase the quantity as the child gets older, while maintaining frequent breastfeeding.
  6. Gradually increase food consistency and variety as the infant grows older, adapting to the infant’s requirements and abilities.
  7. Increase the number of times that the child is fed complementary foods as the child gets older.
  8. Feed a variety of nutrient-rich foods to ensure all nutrient needs are met.
  9. Use fortified complementary foods or vitamin-mineral supplements for the infant, as needed.
  10. Increase fluid intake during illness, including more frequent breastfeeding, and encourage the child to eat soft, favorite foods. After illness, give food more often than usual and encourage child to eat more.

Another important document, Indicators for assessing infant and young child feeding practices (WHO 2008), provides core indicators for infant and young child feeding.

It sets a minimum meal frequency guideline:

  • 2 meals for BF infants 6-8 months
  • 3 meals for BF infants 9-23 months
  • 4 meals for non-BF infants 6-23 months.

Children aged 6 to 23 months should consume from at least 4 of 7 food groups which are:

  1. Grains, roots, and tubers
  2. Legumes and nuts
  3. Dairy products (milk, yogurt, cheese)
  4. Flesh foods (meat, fish, poultry)
  5. Eggs
  6. Vitamin-A rich fruits and vegetables
  7. Other fruit and vegetables

Iron-rich or iron-fortified food should be consumed daily. In fact, “Vegetarian diets cannot meet nutrient needs at this age unless nutrient supplements or fortified products are used.” (PAHO/WHO, 2003, p. 37)

What can we do?

Three themes that arose from Turner-Maffei and colleagues’ study help direct our efforts to encourage ongoing healthy eating habits.

Theme one, the flavor bridge, refers to the flavors babies are exposed to through amniotic fluid and breastmilk. This exposure is linked to later acceptance of aromatic foods.

“A wide variety of flavors either ingested (e.g., fruit, vegetables, spices) or inhaled (e.g., tobacco, perfumes) by the mother are transmitted to her amniotic fluid and/or milk, significantly increasing in intensity in milk within hours after consumption. Infants’ experience with these volatiles and tastes modifies their acceptance in mother’s milk, formula, and solid foods.” (Mennella, 2014, p 706s)

Mennella makes clear, “breastfeeding confers greater acceptance of healthy foods…only if they are part of the mothers’ diet…” (2014)

The second theme Turner-Maffei, et al explored was dietary diversity. Part of the Global Exploration of Human Milk Study (GEHM) shows that the dietary diversity of an urban U.S. city falls significantly below that of the diversity achieved by the Shanghai site. (Woo, et al 2015)

The authors write: “Of particular concern is that only 28% of the highly breastfed Cincinnati infants between 6 and 12 months of age achieved adequate complementary diet diversity. This prevalence is consistent with infants in several developing nations, where obtaining adequate nutrition is a concern. Thus, the likelihood of achieving adequate nutrition may be lower in this group, even when concerns about food scarcity in the US are minimal.” (p. 5)

Increasing awareness of the “biologically-driven dependence of breastfed infants on high-quality, nutrient-dense complementary foods” could help shift this phenomenon.

With the prevalence of iron in U.S. diets, Turner-Maffei notes that iron absorption differs from non-heme elemental sources (like fortified cereals) and heme sources (meat). Unabsorbed iron can encourage the growth of unwanted microbes like Enterobacter, Salmonella, and Listeria.

Parental feeding styles make up theme three.  

Savage, Fisher and Birch define an ideal feeding style as responsive, supportive, non-manipulative, and authoritative.

Townsend and Pitchford found that Baby-Led Weaning (BLW) had a positive impact on the liking of foods that make up healthy nutrition.

Turner-Maffei, along with all of us at HCP, encourage you to help shift awareness that Food Before One is NOT Just for Fun!

Blue Cross Blue Shield of Tennessee team advances lactation care

A few years ago, Blue Cross Blue Shield of Tennessee (BCBST)’s Supervisor of Maternity Case Management Amy Griffin RN, BSN, CCM, CLC completed the Lactation Counselor Training Course (LCTC) in an effort to bring more lactation support capability to her team. Having been a nurse for 25 years, she says she found herself blown away by the comprehensiveness of the course. 

“It was just so impactful to me,” Griffin begins. “It totally changed the way that I taught our members.” 

Griffin goes on to say that she felt very strongly about getting as many of their nurses certified as possible, to better serve their members.

Photo by Sergey Zolkin on Unsplash

Set to host in March 2020, the LCTC was cancelled due to COVID-19. 

“Truthfully I was devastated at the missed opportunity for our staff,” Griffin shares. 

Not long after though, Healthy Children Project launched the online LCTC for the first time ever. 

Griffin calls it their “wonderful silver lining” as they were able to enroll the majority of their team.

With three nurse case managers previously certified, seven additional maternity nurse case managers have enrolled in the LCTC or completed the course to date. Seven NICU nurse case managers have enrolled as well. 

Of those nurses is BCBST Nurse Case Manager Rebecca Provine, RN who says that she has been able to implement her education immediately into practice. Most notably, Provine shares that the course has allowed her to weed out “old wives’ tales” for her members and practice purely on an evidence-based agenda.

In January 2020, BCBST launched their maternity care digital platform where members have access to perinatal support including breastfeeding care.  

“It’s been amazing being able to connect better to our members,” Provine shares. 

Especially in light of the COVID-19 pandemic, it keeps care providers and their members connected through an otherwise isolating experience. 

Provine points out that sometimes the support she offers feels small and intimate, but that it has lasting impacts. 

Photo by Reynardo Etenia Wongso

“Ultimately, we want people to live their best lives,” she says. “This is a great way to start.” 

Provine also notes that the LCTC offers a great launching pad for working toward national and global efforts like the Baby-Friendly Hospital Initiative (BFHI) and obtaining goals like those detailed in the UN’s Sustainable Development Goals (SDGs).

BCBS Tennessee made a specific commitment to expecting families in 2016 when they launched their Healthy Maternity program  and continue to enhance their commitment to their members.

Griffin highlights BCBST’s mission statement: “Peace of mind through better health.”

“I feel like we live up to that,” she says. 

While she notes the benefit of the online LCTC platform, Griffin says it’s still a big goal of hers to host the in-person course in the future.

Support the Providing Urgent Maternal Protections (PUMP) For Nursing Mothers Act


Source: United States Breastfeeding Committee.

Among 41 nations, the U.S. is the only country that does not mandate any paid leave for new parents. So, as long as we accept this structural agreement where parents and their infants/young children are separated for extended periods, it is imperative — both biologically and morally — that we make workplace accommodations for lactating people, explains U.S. Breastfeeding Committee (USBC) Deputy Director Amelia Psmythe Seger.

Accommodating lactating employees requires only simple arrangements, and decades of experience show that it is possible to support the expression of breastmilk in a wide range of workplaces.  

In 1998, Minnesota enacted the first state workplace lactation accommodation law, and since then, different states have been working on various approaches. Among these, in 2005 and 2007, members of the Nursing Mothers Counsel of Oregon, including Psmythe Seger and other passionate advocates, alongside then State Representative Jeff Merkley, worked to pass legislation that requires workplace accommodations for nursing mothers in Oregon.

Source: United States Breastfeeding Committee.

Then in 2010, when Merkley was a brand new U.S. Senator, he proposed the Break Time for Nursing Mothers provision, which passed unanimously out of a bipartisan committee.

USBC Senior Advocacy & Communications Manager Cheryl Lebedevitch says that it’s been rewarding to work on legislation built from the community level and up to a national framework.   

The Break Time provision was the first time federal law addressed breastfeeding workers.

Tempering the celebration, however, Psmythe Seger recalls that because of the placement of the provision within the Fair Labor Standards Act, the legislation unintentionally excluded nearly 9 million workers, including teachers and many registered nurses. 

“It was pretty devastating,” she recalls. “What we thought was a giant step forward was going to be inadequate, so we went right back to work.” 

Currently, USBC is working with partners at ACLU, A Better Balance, Center for WorkLife Law, and passionate advocates across the country to pass the Providing Urgent Maternal Protections (PUMP) For Nursing Mothers Act. This bipartisan bill would close this coverage gap and strengthen enforcement of the Break Time law. 

Source: United States Breastfeeding Committee.

Each year, Lebedevitch says, advocates build and strengthen congressional relationships while listening to parents and employers about what is working and what could be improved. These insights have allowed us to strengthen the bill language and associated advocacy materials each congressional session. 

All of that work is paying off. The bill has been advanced by the House and Senate committees, clearing it for a vote. Now, USBC urges advocates to raise their voices so that Congressional leaders will bring the bill to the House and Senate floor for a vote. Getting involved and showing support is easy, thanks to USBC online tools and suggestions.

Both Psmythe Seger and Lebedevitch emphasize the importance of storytelling to move this legislation forward.

Source: United States Breastfeeding Committee.

“Stories from families are so powerful,” Lebedevitch begins. “They can make the difference between a bill becoming a law or not.” 

Local breastfeeding coalitions can make a big impact with their own story tools, Psmythe Seger goes on to point out. Coalitions provide insights and compelling connections for legislators about the constituents they serve, she explains. Parents’ and employers’ stories alike help demonstrate where and how lactation accommodations are working.  

In all of their iterations, workplace laws were intended to have flexibility built into them, Psmythe Seger says. The Office on Women’s Health provides an online resource that breaks down potential lactation space solutions in all industry sectors. 

Source: United States Breastfeeding Committee.

Lactation accommodation can look like a screen partition set up in a warehouse, a pop-up tent in a field, an empty cubicle space in a library, and even butcher paper taped up over a window for privacy. 

 There are also businesses that go above and beyond existing laws, knowing well that there is a strong Business Case for Breastfeeding 

For instance, Psmythe Seger describes a company that provides employees with a stipend to bring along their infant and child care provider while traveling for work or covers the cost of shipping milk back home. 

Lebedevitch points out that Breastfeeding-Friendly awards, often offered through health departments and breastfeeding coalitions, can be a great way to lift up breastfeeding support. 

“The awards can really dig in and see who is doing this right and for [individuals or other businesses] to find examples,” she says.  

Source: United States Breastfeeding Committee.

The Missouri Breastfeeding Coalition’s Breastfeeding Friendly Worksite Program, the Michigan Breastfeeding Network’s tool pages list Breastfeeding Anytime- Anywhere sites, and the South Carolina Program for Infant/Toddler Care’s (SCPITC) Breastfeeding Friendly Child Care designation program are all great examples of lifting up the businesses supporting families. 

Because the challenges families face are ever-evolving, Lebedevitch explains that break time for nursing parents is just one piece of the larger puzzle

“PUMP is a big priority for us,” she begins. “But it’s not the only priority.” 

The lactation field has identified several important policy priorities for this congressional session, including federal funding for breastfeeding, infant and young child feeding in emergencies, paid family and medical leave, access to lactation support and supplies, and maternity care practices. Together, these policy changes can create the critically needed structures that support an equitable and healthy nation.

“Infants who have optimal nutrition and warm and healthy attachments do better across the lifespan, and everyone has a stake in that,” Psmythe Seger concludes. “The connection and harmony within families ultimately become communities that are mutually supportive and [influences] public health outcomes.”