The work plan included interventions among healthcare and childcare providers, hospitals, as well as pregnant women and mothers of infants – thereby influencing virtually all environments within which infants early eating habits are established. Several partnerships were pursued as a means to address this goal. Project staff ultimately forged a relationship with the Department of Pediatrics and Obstetrics & Gynecology at Nassau University Medical Center (now known as NuHealth) and Winthrop University Hospital in Nassau County, and in Suffolk County, Stony Brook University’s Departments of Pediatrics and Family Medicine (now Family, Population and Preventive Medicine).
Utilizing the partnerships that were developed, project staff had the opportunity to offer professional education to health care providers in their offices, at grand rounds (6), at resident trainings (5), and at offsite conferences (8). In total, 1,112 providers were reached through these initiatives. A rough estimate of the indirect reach of these activities is 22,850 patients.
Evidence also exists to support the impact that the academic detailing has on the Family Medicine providers at Stony Brook Medical Center. Project staff worked regularly on improving patient materials, EMR templates and directly educating providers on the evidence-based best practice as it pertains to women of child-bearing age, weight management, prenatal nutrition and breastfeeding support. In fiscal year 2011, the Family Medicine Practice provided care to 10,390 patients. Data regarding documentation practices among resident and attending Family Medicine physicians were analyzed between 2011 and 2012. Women of childbearing age (18-44 years) represented an average of 20.12% of all patients in the practice, and 37.7% of all women. Among all patients, 3.56% of women of childbearing age were obese and 4.48% were overweight. Among only women of childbearing age, 17.11% were obese and 21.05% were overweight.
A number of positive trends were observed between 2011 and 2012 in terms of physician documentation practices which resulted from this project’s academic detailing intervention efforts. Documentation of height improved from 69.31% to 82.7%. Weight documentation improved from 73.7% to 85.5% over this time period and BMI documentation improved from 68.77% to 80.6%. Importantly, among those women of childbearing age who were documented to be obese and among those who were documented to be morbidly obese, 83.02% and 94.34% respectively had their BMI and BMI category communicated to them. Approximately 24% of physicians documented discussing nutrition/exercise with their patients, while 38% discussed their patients’ weight trends. These are important findings in that such communication is often the first step towards addressing this issue in a proactive manner.
Project staff recruited 15 child care centers as partners for this project with 8 located in Suffolk County and 7 in Nassau County. Twelve of those centers participated in Child and Adult Care Food Program, CACFP, and all accepted infants into their programs. Resources provided to child care centers included staff development and training, parent education, items to improve the food/breastfeeding environment (i.e. rocking chairs, appropriate books and cookbooks) and technical expertise in the development of new policies and procedures related to breastfeeding support and menu modifications.
Project staff facilitated breastfeeding-friendly recognition offered by the state CACFP office among partnering child care centers. The process of becoming recognized by this program involves ensuring that procedures followed are in line with best practice as it relates to infant feeding cues, scheduling, staff training and parental support. Agency administrators must also provide a copy of the centers breastfeeding policy including language regarding breastfeeding promotion and support. Surprisingly, at the start of this project, no child care agencies in Suffolk or Nassau counties had received the recognition and fewer than 25 agencies statewide were recognized. Since that time, project staff has worked with child care administrators and all eligible partnering child care centers have been awarded the designation of “breastfeeding-friendly”. The 12 eligible centers received their initial 2-year recognition between 2007 and 2009, and at the present time all centers have either renewed their designation or are in the process of doing so. In addition, three child care centers in Suffolk County have received the Let’s Move Child Care recognition which includes breastfeeding promotion as a goal along with other healthy habits linked to diet and activity. Two additional centers, one in Suffolk and one in Nassau have completed the application process for this additional recognition and their status is pending. Mainly as a result of the breastfeeding-friendly recognition process, 100% of participating centers developed new policies or updated existing policies to incorporate language about breastfeeding promotion and support. Since not all of our centers were eligible for the recognition, this provides evidence that even those that did not apply for the recognition still made changes to provide a more supportive atmosphere for parents.
Among the Suffolk and Nassau partnering child cares, there were improvements in various policies related to introduction to solids and physical activity among infants. In Suffolk County, the following improvements were made: 1) percentage of child care agencies that reported delaying feeding solids to infants until six months of age increased from 60% to 100%; 2) percentage of child care agencies that reported promoting tummy time for infants (including the opportunity for hills, steps, etc.) increased from 80% to 100%; 3) percentage of child care agencies that use nutrient guidelines in determining what food is not allowed in the center increased from 80% to 100%. In Nassau County the following improvements were made: 1) percentage of child care agencies that reported delaying feeding solids to infants until six months of age increased from 57% to 85%; 2) percentage of child care agencies that reported promoting tummy time for infants (including the opportunity for hills, steps, etc.) increased from 85% to 100%; 3) percentage of child care agencies that use nutrition guidelines in determining what food is not allowed in the center increased from 83% to 100%.
Among our partnering child cares, it is estimated that a total of 6,000 children were impacted by the improved menu offerings and/or breastfeeding education and promotion. This estimate is based on total enrollment in the centers at the time of post-data collection, as well as the children who attended but have “graduated” out of the centers during the time of the partnership. This estimate also does not account for the impact the initiatives may have had on parents, siblings or other members of the households in which these children reside.
The successes associated with this project focus heavily on the promotion of breastfeeding friendly environments, as well as collaborations with other state-funded projects and the widespread marketing of best practices via professional development avenues and mass media. In 2007, at the outset of this project, zero child care providers on Long Island appeared on the list of NYS breastfeeding-friendly child care centers. Within the first two years of the establishment of the LI Center for Pediatric Obesity Prevention, those numbers grew quickly with twelve being a direct result of partnerships cultivated by project staff. As a result of the work with child care providers it became evident that one stumbling block to the promotion of providing expressed breastmilk in child care environments was the way in which these sites were being inspected. Following a conversation with a child care administration, project staff contacted the local department of health to learn how expressed breastmilk was referred to during site inspections by food sanitarians. Due to the fact that breastmilk did not have its own category within the sanitation code, it was included in the same category as foods such as raw poultry. As a result, child care administrators were frequently being told that expressed breastmilk required costly and time-consuming methods to store it such as a separate refrigerator or a shelf of its own as well as additional restrictions placed on how parents bring in the milk. One administrator was told by a sanitarian that breastmilk should be considered a “biohazard”. Project staff worked with the county office to provide references that allowed them to change the training given to their staff and align the language more closely with the CDC definition of breastmilk.
