Comments to USDA re: WIC Breastfeeding Promotion

March 7, 2014

Desk Officer for Agriculture
Director, Supplemental Food Programs Division
Food and Nutrition Service, USDA
3101 Park Center Drive, Room 520
Alexandria, VA 22302

RE: Comment Request: Recognition of Exemplary Breastfeeding Support Practices (OMB Control Number: 0584—NEW)

Dear Sir or Madam:

The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments related to the Food and Nutrition Service's (FNS) February 7, 2014 comment request regarding its "The Loving Support Award of Excellence." With over 75,000 members, the Academy is the largest association of food and nutrition professionals in the United States and is committed to improving the nation's health through food and nutrition across the lifecycle. The Academy's members demonstrate this commitment to the nation's most vulnerable through direct work with WIC participants, in public health agencies, and in formulating evidence-based nutrition criteria and public policy. As you may know, Academy members with expertise in maternal and child nutrition were also involved in the research and review process for the recent changes to the WIC food packages. We also wish to acknowledge Academy members who serve in the USDA and their positive influence on nutrition policy.

The Academy supports recent efforts by USDA and FNS to promote and increase breastfeeding among WIC participants, including implementation of this initiative to recognize exemplary breastfeeding support practices at WIC local agencies and clinics. Increasing breastfeeding among participants is shown to significantly improve the lifelong health of child and mother and accords with the Department of Health and Human Services' Healthy People 2020 initiative and the twenty steps in the Surgeon General's Call to Action to Support Breastfeeding.1 Breastfeeding also produces significant individual and societal economic benefits by reducing medical expenses and increasing worker productivity.2

Additional Elements Recommended for FNS's Selection Criteria

The Academy recommends ensuring the inclusion of criteria elements that enhance the quality of data necessary to analyze and compare the efficacy of various program components likely to be significantly correlated to a program's success while balancing the need to avoid an overly burdensome amount of time to respond to the collection. The Academy's recommended criteria elements offer FNS additional data points to distinguish and recognize truly exemplary breastfeeding support practices. In addition, the robust data obtained may be useful post-selection when determining the components necessary in a successful model and ascertain the extent to which differences in each criteria element may have impacted success.

Support Staff Size and Training

  • Number of lactation consultants (with and without IBCLC credential);
  • Amount/length of staff and peer counselor training;
  • Ratio of peer counselor hours to participants;
  • Diversity of peer counselor and staff versus caseload diversity data to determine correlation between demographic similarity of counselor/participant and effectiveness of program;
  • Effectiveness of peer counselor program, including initiation, duration, and exclusivity percentages of breastfeeding mothers being counseled;
  • Extent to which agency has created supportive breastfeeding environment in the agency workplace; and
  • Recognition for individual staff efforts of complimentary registration at national conference.

Structure and Participation Rates

  • Number of lactation classes for participants during pregnancy as well as post- partum;
  • Increase in rate of breastfeeding participation over previous year to show improved breastfeeding rates;
  • Percentage of prenatal participants attending class;
  • Peer counseling or WIC lactation consultant visits while WIC participant is still in the hospital;
  • Network of postpartum support when a higher level of care is needed, including partnering with state and local professional organizations and faith-based institutions;
  • Rates of initiation, duration, and exclusivity (not combined with infant formula) for WIC breastfeeding participants;
  • Rates of participation in follow-up efforts; and
  • Participation demographic data relative to maternal characteristics that may influence lactation rates should be maintained, including but not limited to age, parity, delivery method, prior breastfeeding experience, and ethnicity.

Nature of Promotional Activities and Community Outreach
Extent of WIC involvement with local agencies with prenatal and infant participants;

  • Hospital involvement to urge lactation care and services that follow the Ten Steps to Successful Breastfeeding;
  • Community wide and media promotion activities;
  • Workplace initiatives to assist in creating worksite accommodations for breastfeeding mothers;
  • Number of innovative initiatives to encourage breastfeeding after hospital discharge but before WIC recertification;
  • Effectiveness of telephone support system for breastfeeding WIC participants; Recognition for the involvement of community organizations should be considered; and
  • Nature of follow-up efforts.


  • Breast pump data, including:
    • Availability of hospital-grade pumps;
    • Amount of staff training in use; and
    • Amount of participant training in use.
  • Data to suggest whether project would/should differ from state to state;
  • Age of introduction to solid food and agencies' efforts to educate mothers on timing of solid food introduction;
  • Consider implementing a regional or national mentoring process of agencies struggling with getting participants to initiate or continue breastfeeding; and
  • Return to work data for participants and continuation of breastfeeding by broad job categories

Recognition Criteria Should Account for Unique Cultural and Geographic Challenges

Academy members work in every state supporting the WIC program and its participants and as a result share strategies for improving the program's functionality. A member working in Alaska as a Regional WIC Coordinator and as state staff offers insight into the way in which cultural and geographic challenges in Alaska compel flexible policies and processes. As a result, when developing the recognition criteria for outstanding WIC breastfeeding practices, FNS should endeavor to ensure that the criteria treat states equitably and such that a unique state's use of effective, creative, and culturally appropriate breastfeeding support is encouraged and recognized.

Breastfeeding continues to be an important tool to ensure a healthy start for Alaska children, especially in the 229 remote Alaska villages, most of which are not connected to Anchorage, Juneau or Fairbanks by road. Travel from small villages to a regional hospital are inconvenient, time consuming, and prohibitively expensive. Flight times range from thirty minutes to several hours and high ticket prices make it impracticable for WIC to require Alaska mothers to travel routinely to regional WIC offices for recertification.

Instead, Alaska WIC officials travel to the villages to certify WIC participants. The Alaska WIC model also reflects and accommodates cultural differences, in that services are contracted through regional Native health care organizations rather than paid state staff. In contrast, Florida provides WIC services through its state funded public health offices.

The Academy offers FNS three suggestions for developing recognition criteria that equitably compare WIC breastfeeding programs and practices, notwithstanding unique state policy variations:

  1. Recognition criteria could compare solutions among similar-sized WIC agencies. Solutions evolved from smaller-sized agencies have merit and could serve as models; FNS should encourage a variety of effective practices through this recognition program. A program's success or failure is often directly attributable to its funding levels. Thus, state-funding criteria should reflect certain differences between large and small states.

    Economies of scale dictate that small states have a higher cost-per-client than larger states, which often spend per-client cost savings on additional services. As a result, larger programs often provide participants additional resource staff such as infant learning specialists, specialized pediatric dental staff, etc. that is expensive and impractical elsewhere. Agencies with larger administrative staffs also have greater flexibility to respond to unfunded mandates. In contrast, Alaska must allocate significant funds for travel adequate to train regional WIC service staff and peer breastfeeding counselors that travel to remote areas.
  2. The criteria should compare solutions developed by WIC agencies with similar delivery models. The WIC service model in Alaska is fundamentally different from that in large urban areas, where WIC clients come to the WIC office instead of WIC going to the clients' villages.
  3. FNS should consider the program's demonstrated ability to work within identified cultural norms of the community. Successfully fostering community involvement has measurable benefits that are different from, but no less important than, successful breastfeeding results. Strong communities that focus on the health of a child will provide ongoing societal benefits and resources long after meeting individual breastfeeding goals.
  4. Given recent changes in the breastfeeding package that either minimize participant food selections or make them substantially similar to non-breastfeeding participants' selections, FNS should consider the feasibility of allowing programs to recognize breastfeeding mothers with incentives such as increased food package selections or enhanced WIC services.
  5. FNS should track solutions for various special populations, including preterm infants, teenage mothers, older mothers, and racially and ethnically diverse populations.

Breastfeeding and Obesity

Given that obese women are less likely to initiate and continue to breastfeed, special consideration should be given to agencies that improve breastfeeding in this special population. Infants born to obese women are more likely to become obese as adults and would benefit from the protection that breastfeeding offers against obesity. Likewise, obese women who breastfeed may have better post-partum weight loss than those who do not breastfeed. Researchers have suggested that women who are obese may experience delayed lactogenesis. This may result in early use of artificial milk which further perpetuates establishment of the maternal milk supply. Given the known risk for lack of initiation and continuation in this population, those agencies that provide pre-and post- partum high risk consultation with the RDN and Lactation Consultant (IBCLC) that results in increased initiation and duration rates should be tracked.

Breastfeeding Awards and Caseload Allocation

The Academy believes that agencies that demonstrate improved breastfeeding rates among participants, especially those from specific populations at-risk for unsuccessful lactation, should receive additional caseload opportunities outside of that inherently granted through equity based on priorities. We suggest that these agencies be given a one-time "bonus" equity increase in addition to any funds awarded through the recognition process and routine adjustments.

The Academy appreciates the opportunity to comment on this important initiative; please contact either Jeanne Blankenship at 202/775-8277, ext. 6004 or by email at or Pepin Tuma at 202/775-8277, ext. 6001 or by email at with any questions or requests for additional information.


Jeanne Blankenship, MS, RDN
Vice President, Policy Initiatives and Advocacy

Pepin Andrew Tuma, Esq.
Director, Regulatory Affairs

1 The Surgeon General's Call to Action to Support Breastfeeding (2011). Washington DC: United States Public Health Services, Accessed November 24, 2014.
2 Weimer, J. (2001). The economic benefits of breastfeeding: a review and analysis (Report No. 13). Washington DC: U.S. Department of Agriculture, Economic Research Service.