Breastfeeding in the healthiest county in Virginia

Janine A. Rethy, MD, MPH, FAAP, FABM, IBCLC is a general pediatrician in Loudoun County, Va. dedicated to improving breastfeeding outcomes in her community. She currently leads the Obesity and Chronic Disease Prevention team at the Loudoun County Health Department where she and her colleagues focus on a community-based approach to reduce disparities in obesity and chronic disease, with a focus on breastfeeding and healthy food access. 

Dr. Rethy also serves as the American Academy of Pediatrics’ Childhood Obesity Advisor for Continuing Health and says she’s pleased to have been appointed as Virginia Chapter of the American Academy of Pediatrics’ Co-Chair for Breastfeeding.  She also serves on the Virginia Breastfeeding Advisory Committee, as the physician advisor on the Loudoun County Head Start Health and Mental Health Advisory Committee and on the Loudoun County Public Schools Wellness Policy Committee.

In February, The Loudoun County Health Department hosted The Lactation Counselor Training Course as part of an effort to increase knowledge about best practice in their community.

“The training was successful by every measure,” Dr. Rethy says.

Of the 65 participants, present were six out of seven Loudoun WIC staff, nineteen other Virginia WIC staff, physician assistants, nurses, occupational therapists and doulas from around the region, and a participant who came in from a US military base in Japan, Dr. Rethy reports.

“After the course, many people from our community attended our quarterly Loudoun Breastfeeding Coalition meeting with additional pride at their accomplishment and increased knowledge,” she says.  

With an understanding that our medical system often strips mothers’ confidence to feed their own babies, she says she finds it most rewarding to demystify breastfeeding and help mothers feel confident.

“My favorite stories are the ones where we can peel away the complications we have often created on the mother-baby feeding process, and go back to the basics of skin-to-skin, mother and baby enjoying each other and often just facilitating and reassuring the re-emergence of the feeding instincts of the dyad,” she explains.

Below, Dr. Rethy shares fascinating insights into the state of breastfeeding in her community including results from a summer 2016 WIC survey, and the pivotal work she and her colleagues are doing to ensure healthy outcomes for all families.

Q: Loudoun County ranks highest in mean household income in the U.S. How does this affect maternal child health outcomes in your community? What else is unique about Loudoun county? 

A: Loudoun County does have the highest mean income in the US and is the healthiest county in Virginia.  What those numbers do not reveal is the more difficult situations for our lower-income families:  We have seen more than a four-fold increase in immigrants over the last 15 years and we have significant pockets of poverty in the county.  These communities are particularly struggling because the cost of living is very high and the infrastructure for services is less available since the demographic change happened so fast.  We have seen the pediatric obesity rates in our community health center, which serves the lower income community double that of the rest of the county.  In our recent WIC study, we found very high rates of early introduction of formula and poor access to lactation services.

Q: Please tell us more about the 2016 WIC survey you conducted with Dr. Sina Gallo of George Mason University.

A: This study was conducted at our two WIC clinics in Loudoun County in the summer of 2016.  The study looked at infant feeding patterns, Vitamin D, healthy food access, and utilization of assistance programs and community resources.  The study was funded as a part of a National WIC Association and the Centers for Disease Control Community Partnerships for Healthy Mothers and Children (CPHMC) grant we received at the Loudoun County Health Department. The grants larger goals are to develop policy, system and environmental changes to decrease obesity and promote health.

In regards to the breastfeeding piece of our study, we found fairly high rates of breastfeeding compared to HP2020 goals and recent US and Virginia scorecards with 84% ever breastfed and 58% still breastfeeding at 6 months.  However, looking more closely, 91% of mothers gave formula at some time. It turns out that 43% gave formula before they ever left the hospital, 17% at the first feed!  This tells us a lot of things and opens the door for some positive solutions.  Half of women intended to breastfeed exclusively, and only 9% never gave formula.  We as a health care system and community can do better to help women reach their goals and protect their infants from the harm that early introduction of formula can do.  We know that exposure to exclusive breastmilk in the first few days of life is critical for immune priming and development as well as intestinal maturation, the effects of which last a lifetime. Not to mention the improved chances of for successful lactogenesis 2 and overall success at reaching breastfeeding goals.  Interestingly we saw an increase in exclusive breastfeeding at 6 months compared to 3 months which corresponds with the time that the WIC package is greatly expanded for mother and infant if they are exclusively breastfeeding.   Our results lead us to believe that the non-exclusive breastfeeding we are seeing is likely modifiable with good counseling, especially in the prenatal period and right after birth.

Another result worth mentioning is the low rate of Vitamin D – only 27% of infants ever received Vitamin D, only 14% of exclusively breastfed infants received daily Vitamin D as recommended.  We found that less than half of mothers knew about the recommendations, those who did not give Vitamin D cited the fact that their pediatrician had not recommended Vitamin D as the primary reason they didn’t give it. Only 39% said that a pediatrician had recommended Vitamin D.  In response to this, we created a Vitamin D educational handout targeted in language and content to both the families and the physicians.  This document was recently approved and accepted by Virginia WIC to be distributed to all WIC offices in the Virginia.

Q: You and your colleagues have produced many amazing breastfeeding resources like the Breastfeeding Friendly Workplace document and the Breastfeeding Support Implementation Guide for the Outpatient Setting (which includes information on how to bill insurance for lactation services.) Please tell us more about these documents.

A: The Breastfeeding Support Implementation Guide for the Outpatient Setting was created in response to a study we did in 2015 of primary care providers in our county.  We looked at knowledge, attitude and practice in the area of infant feeding and found several gaps we wanted to address.  The Breastfeeding Friendly Workplace toolkit we created as a local adaptation of the HHS Business Case for Breastfeeding. We presented the toolkit at local Chamber of Commerce and Society for Human Resources events.  We worked with several businesses and agencies to take them through the process of implementing a Lactation Support Program.  Our biggest success was the Loudoun County Government, which has about 3,000 employees.  We worked with their HR department and health insurance company (Cigna) and helped them develop a comprehensive employee policy, HR systems and training to create a process for mothers returning to work, and educational materials including how to access support and equipment benefits afforded under the ACA. We also helped them open two permanent breastfeeding rooms.   We have recently expanded our toolkit to include information on the Virginia law which protects breastfeeding in public.

Q: What’s next?

A: We are currently partnered with the Loudoun County Chamber of Commerce (LCCC) and the Virginia Department of Health (VDH) to recognize businesses as Breastfeeding Friendly Businesses.  We have incorporated elements of breastfeeding friendly businesses into the annual LCCC Healthy Business Challenge.  Those businesses that complete all the elements, including educating employees on the recent Virginia law protecting breastfeeding in public, will receive a Breastfeeding Welcome Here decal for their businesses.

Dr. Gallo and I would like to continue our work at WIC and have recently applied for a grant to conduct a randomized controlled study looking at the effect of shared-decision making prenatal counseling on the early introduction of formula in the WIC population.

Q: Anything else you’d like to highlight about the work you’re doing? 
A: The Loudoun Breastfeeding Coalition was founded in 2012 and includes active participation from WIC, our local hospital system, La Leche League, doulas, and local health care providers.  It has become an important referral and information sharing network both for providers and for people in the community through the Facebook page.  We have also created and regularly  update a printed resources guide for our community. We were accepted to be represented on the Virginia Breastfeeding Advisory Committee, a body which advises the VDH.

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