76 RESPONSE OF THE SURGEON GENERAL As previously noted, participants in this Surgeon General’s Work- shop were selected for their expertise and for representation of profes- sional organizations, voluntary organizations, and government agencies with an interest in breastfeeding. Diverse groups have joined together in focusing on breastfeeding and human lactation—a topic considered as top priority by the Office of the Surgeon General. The Recommendations presented this afternoon become a national statement, synthesized and promulgated by the Office of the Surgeon General with the active in- volvement of the many organizations that you represent. This shared ap- proach has been a major factor in the continuing success of the two pre- vious workshops. The report of each has been a national, not a federal, statement. : The first report, Report of the Surgeon General’s Workshoo on “ater- nal and Infant Health—published in January 1981—reviewed the status of perinatal health at that time and outlined social strategies for improve- ment. Professional and voluntary organizations and state and local gov- ernments have utilized the report for policy and program initiation. The report became the basis for the Healthy Mothers/Healthy Babies Coali- tion and its subsequent activities. The second report, Report of the Surgeon General’s Workshop on Children With Handicaps and Their Families, was published in February 1983. From this report many ensuing activities serve as examples of the effectiveness of this approach: * The scope of the problem has been further defined by the Van- derbilt Policy Study on Chronic Illness in Children; ¢ Standards for regionalized, comprehensive care are being devel- oped through a diabetes project at Michigan State University and a program of projects for juvenile rheumatoid arthritis throughout the nation; © Several efforts involving insurers from both the public and pri- vate sectors to improve the financing of care for these children has been ongoing since the Workshop. Professional organizations have collaborated in this activity; ° Three projects in Illinois, Louisiana, and Maryland are focusing on moving ventilator-dependent children from institutional set- tings to home or home-like settings through the use of multidisci- plinary teams; ¢ A network project for agencies serving disabled children is pro- viding consultation, technical assistance, and resource sharing in approximately 20 states. We expect no less from the report of this Workshop. 77 Now, in response to your specific recommendations, please remem- ber that the one hour between your presentations and my response is in- sufficient to reply in the depth and breadth your efforts deserve. Some of your recommendations are the responsibility of other cabi- net departments; that doesn’t mean we won't address them. Some recom- mendations are impossible without legislation. While I will not ignore these concerns, neither can I make any promises. Finally, it is inevitable that some of your recommendations overlap those coming from other groups. Several themes seem recurrent. One is the establishment of breast- feeding as the norm. The issuance of the Workshop Report by the Sur- geon General will, in effect, reply to this recommendation by providing a basis for promotion by professional and voluntary organizations. A second theme is universal education. We can and will encourage formal education of professionals through curricula of health providers via the Bureau of Health Professions and of the public through the media: magazines, newspapers, radio, and TV. We can and will encourage continuing education for health provid- ers in practice. We will ask state Maternal and Child Health (MCH) agencies to work with local chapters of professional organizations to ac- complish this goal. When it comes to education of public officials, I suggest that legisla- tive and regulatory approaches and models like those in New York State we heard about last night be made available to people in a position to do something about the issue. In reference to the workplace, the Division of Maternal and Child Health and I will, through this Report and other means available to us, emphasize the problems in the workplace and address the issue by every avenue open to us through private industry and public employers. We will inform them about the concerns raised by the Workshop partici- pants. I will continue to enunciate in public addresses the challenges facing employers and possible solutions. In the long run, legislation is necessary to accomplish some of your goals. I promise that your concern will be communicated. We will attempt to develop a continuum of postpartum care which involves immediate follow-up, and to encourage public health agencies to adopt promotion and support of breastfeeding as standard practice. We will continue to work with professional organizations (providers and hospitals) to promote breastfeeding in the private sector. I am enthusiastic about the details enunciated in the recommenda- tions. The best way I know to express your concerns is to transmit spe- cific recommendations to the Assistant Secretary for Health and appro- priate agencies and to ask for a response. Please remember that mine is a quick response to a number of issues with high priority in your work groups. My office and the MCH staff will carefully consider your written and oral reports and attempt to come up with a more detailed and appropriate response. We are grateful for your participation in this Workshop and are 78 counting on your commitment to share your recommendations and to promote them within your organizations. The Report will be sent to selected groups of those people able to effect the recommended changes—for example, members of Congress, staff members of appropriate House and Senate committees, and appro- priate members of agencies and of the private sector. I give you my per- sonal assurance that your suggestions and recommendations at this Workshop will receive the attention of the Office of the Surgeon Gen- eral. We will: e Disseminate this Report widely; ¢ Follow through on your recommendations where possible—even when they cross departmental lines; ¢ Keep you informed of the results of this Workshop; ° Be responsive to your concerns. 719 80 EXCERPT FROM CLOSING REMARKS Frank Young, M.D. We at the University of Rochester are very proud of the contribu- tions of Dr. Lawrence in the development of a lactation cluster and in the subsequent plans for a Surgeon General’s Workshop at this universi- ty. As members of the university, it is our pleasure to participate in this conference with other organizations and agencies devoted to Maternal and Child Health. We appreciate the opportunity it has given us to learn, and I have been pleased by the Workshop’s focus on education. The edu- cational experiments that have been suggested by this group will take months, even years to accomplish. For myself, as a bacteriologist who deals with a process of cellular division—a process occurring every 22 minutes—I recognize impatience. An experiment in bacteriology can be accomplished in a few hours. The experiments and learning processes of this conference will take far longer, and you—the participants—will be able to show the required patience. I challenge you to continue your ef- forts to see how public education, both in the media and in traditional academic settings, will serve our very important objectives. As a corollary to the educational aspect of this conference, you can be proud of the Workshop’s focus on the recognition that education must be universally directed. As your deliberations reinforced, we are not dealing with a particular segment of society. We are a diverse society with many needs and contributions. In this diversity, we recognize the partnership of the professional, the government, and the individual. You, the participants of this conference, represent this partnership through your varied backgrounds, agencies, and areas of expertise. You came to the conference with the responsibility of honestly and soundly exploring the topic of breastfeeding and human lactation, not to serve your own egos, but to serve mankind. You have met your responsibility. Madonna and Child School of Burges Flemish, 15th c. colored drawing Reproduced with permission from Memorial Art Gallery of the University of Rochester. 81 APPENDIX A PARTICIPANTS John E. Alden, C.N.M., M.S. Public Health Service Indian Health Center Poplar, MT 59255 Diane M. Anderson, M.S., R.D. Rainbow Babies & Childrens Hospital Department of Pediatrics, Room 706 2101 Adelbert Road Cleveland, OH 44106 Joyce O. Arango, M.P.H., R.D. U.S. Department of Agriculture 3101 Center Drive, Room 609 Alexandria, VA 22302 U.S. Department of Agriculture Jeanne F. Arnoid, M.D. St. Elizabeth Hospital 2209 Genesee Street Utica, NY 13354 American Academy of Family Physicians Maria Teresa Asquith Institute for Medical Research Mothers’ Milk Bank 2260 Clove Drive San Jose, CA 95128 Richard H. Aubry, M.D. SUNY Upstate Medical Center 750 E. Adams Street Syracuse, NY 13210 American College of OB/GYN Kathleen G. Auerbach, Ph.D. Department of Sociology University of Nebraska Medical Center 42nd and Dewey Avenue Omaha, NE 68105 Rosemary Barber-Madden, Ed.D. Center for Population and Family Health Columbia University, School of Public Health 60 Haven Avenue New York, NY 10032 Association of Teachers of Maternal and Child Health 82 Chery] Bittle, R.D., Ph.D. Food & Nutrition Department Oregon State University Corvallis, OR 97331 Sara B. Bonam, R.D., M.S. Bureau of Family Health Kansas Department of Health and Environment Forbes Field, Building 740 Topeka, KS 66620 Association of State and Territorial Public Health Nutrition Directors Elizabeth Brannon, M.S., R.D. Department of Health & Human Services Room 6-22 Parklawn Building 5600 Fishers Lane Rockville, MD 20857 Elaine B. Bratic Office of Public Affairs, OASH, PHS 200 Independence Avenue SW 721H Hubert H. Humphrey Building Washington, DC 20201 Theodore M. Brown, Ph.D. Department of History University of Rochester RR Lib 585 Rochester, NY 14627 Carol A. Bryant, Ph.D. Lexington Fayette County Health Department 650 Newton Pike Lexington, KY 40508 Elizabeth Burkett, R.N.C., M.S.N. Department of OB/GYN Duke University Medical Center Box 3974 Durham, NC 27710 Anthony T. Carter, Ph.D. Department of Anthropology University of Rochester Harkness 334 Rochester, NY 14627 Solan Chao, M.D. Department of OB/GYN Harlem Hospital Center 506 Lenox Avenue New York, NY 10037 Kate Clancy, Ph.D. Department of Human Nutrition 307 Slocum Hall Syracuse University Syracuse, NY 13210 Society for Nutrition Education Elizabeth M. Cooper, C.N.M., M.S. Department of OB/GYN University of Rochester Medical Center 601 Elmwood Avenue, Box 668 Rochester, NY 14642 Betty Ann Countryman, R.N., MLN. 4140 E. 75th Street Indianapolis, IN 46250 La Leche League International Catherine Cowell, Ph.D. Bureau of Nutrition New York City Department of Health 93 Worth Street, Room 714 New York, NY 10013 Carole A. Davis, M.S. Human Nutrition Information Service U.S. Department of Agriculture Room 330, Building 307, BARC-East Beltsville, MD 20705 Roselyn Payne Epps, M.D., M.P.H. Department of Pediatrics & Child Health Howard University College of Medicine 2041 Georgia Avenue NW Washington, DC 20060 Ruth R. Faden, Ph.D., M.P.H. The Johns Hopkins University School of Hygiene & Public Health 615 N. Wolfe Street Baltimore, MD 21205 Thorsten A. Fjellstedt, Ph.D. Department of Health & Human Services Room 7C-09 Landow Building 7910 Woodmont Avenue Bethesda, MD 20505 Judith G. Flanagan, C.N.M., R.N., M.S. U.C.S.F.G.H. 10001 Potrero San Francisco, CA 94110 American College of Nurse-Midwives Gilbert B. Forbes, M.D. Department of Pediatrics University of Rochester Medical Center 601 Elmwood Avenue, Box 777 Rochester, NY 14642 Michele Forman, Ph.D., M.S.P.H. Division of Nutrition Centers for Disease Control Building 3, Room SB48 Atlanta, GA 30333 Henry W. Foster, Jr., M.D. Department of OB/GYN Meharry Medical College 1005 D. B. Todd Boulevard Nashville, TN 37208 Paul S. Frame, M.D. Tri-County Family Medicine Box 339 Red Jacket Street Dansville, NY 14437 Karen L. Freeburn, R.D. Migrant & Rural Community Health Association P.O. Box 130 Bangor, MI 49013 Ayala Gabriel, Ph.D. Department of Anthropology University of Rochester Harkness Hall 324 Rochester, NY 14627 David Gagnon, M.P.H. Women & Infants Hospital 50 Maude Street Providence, RI 02908 Lawrence M. Gartner, M.D. Wyler Children’s Hospital 5825 S. Maryland Avenue Chicago, IL 60637 Cutbero Garza, M.D., Ph.D. Baylor College of Medicine Department of Pediatrics 1 Baylor Plaza Houston, TX 77030 Robert C. Gelardi Suite 500-D 5775 Peachtree-Dunwoody Road Atlanta, GA 30342 Infant Formula Council 83 Doris Haire 439 E. 51st Street New York, NY 10022 Jerianne Heimendinger, D.Sc. Division of Family Health Department of Health 75 Davis Street, Room 302 Providence, RI 02908 William Heird, M.D. Babies Hospital Ist Floor, Room 116 South Department of Pediatrics New York, NY 10032 David Heppel, M.D. Division of Maternal & Child Health 5600 Fishers Lane, Room 6-22 Rockville, MD 20857 Jan L. Herr, M.D. Kaiser Permanente 2200 O'Farrell Street San Francisco, CA 94115 Residency Review Committee in OB/GYN Frederick C. Holmes, M.D. RD. #1 Fairfax, VT 05454 American Academy of Pediatrics Mary T. Horan, R.N. HQ Department of Army Office of the Surgeon General HQDA (DASG PSP-D) Pentagon, Room 2D529 Washington, DC 20310 Department of Defense Kathryn Montgomery Hunter, Ph.D. University of Rochester Medical Center 601 Elmwood Avenue, Box 644 Rochester, NY 14642 Vince L. Hutchins, M.D., M.P.H. Department of Health & Human Services Room 6-05 Parklawn Building §600 Fishers Lane Rockville, MD 20857 Bernard B. Keele, Ph.D. Office of Public Affairs University of Rochester Medical Center 601 Elmwood Avenue, Box 643 Rochester, NY 14642 John H. Kennell, M.D. Rainbow Babies & Childrens Hospital 2101 Adelbert Road Cleveland, OH 44106 84 C. Everett Koop, M.D., Sc.D. Department of Health & Human Services Room 716G HHH Building 200 Independence Avenue SW Washington, DC 20201 Mary Grace Kovar, Dr.P.H. National Center for Health Statistics 3700 East-West Highway, Room 2-58 Hyattsville, MD 20782 Gail Kowalski Genesee Ecumenical Council 17 S. Fitzhugh Street Rochester, NY 14614 Anthony H. Labrum, M.D. Division of Psychosomatic OB/GYN University of Rochester Medical Center 601 Elmwood Avenue, Box 668 Rochester, NY 14642 Paul J. Lambiase Office of Continuing Professional Education University Of Rochester Medical Center 601 Elmwood Avenue, Box 677 Rochester, NY 14642 Ruth A. Lawrence, M.D. Department of Pediatrics—Neonatology University of Rochester Medical Center 601 Elmwood Avenue, Box 651 Rochester, NY 14642 Morton A. Lebow, M.A. American College of OB/GYN 600 Maryland Avenue SW Washington, DC 20024 Milton B. Lederman, Ph.D. Office of Public Affairs University of Rochester Medical Center 601 Elmwood Avenue, Box 643 Rochester, NY 14642 Viola Lennon 5745 Newcastle Street Chicago, IL 60631 Alice S. Linyear, M.D., M.P.H. Bureau of Maternal & Child Health State Department of Health 109 Governor Street Richmond, VA 23219 Ruth E. Little, Sc.D. Alcohol & Drug Abuse Institute University of Washington NL-15 Seattle, WA 98195 Vivian M. Littlefield, R.N., Ph.D. School of Nursing University of Rochester Medical Center 601 Elmwood Avenue, Box 619 Rochester, NY 14642 Gilbert A. Martinez, M.B.A. Market Research Ross Laboratories 625 Cleveland Avenue Columbus, OH 43216 Elizabeth R. McAnarney, M.D. Department of Pediatrics University of Rochester Medical Center 601 Elmwood Avenue, Box 690 Rochester, NY 14642 Michael McGinnis, M.D. Department of Health & Human Services Room 2132 Switzer Building 330 C Street SW Washington, DC 20201 U.S. Department of Health and Human Services Jeanne Meurer, C.N.M., M.S. Birthing Program College of Medicine University of South Florida Tampa, FL 33612 Solbritt Murphy, M.D. Bureau of Maternal & Child Health New York State Department of Health ESP—Corning Tower Albany, NY 12237 Anthony W. Myres, Ph.D. Health & Welfare Canada Jeanne Mance Building, Room 428 Tunney’s Pasture Ottawa, Ontario Canada KIA 184 Martin Nacman, M.S.W., D.S.W. Social Work Division University of Rochester Medical Center 601 Elmwood Avenue, Box 650 Rochester, NY 14642 Audrey Naylor, M.D., Dr.P.H. San Diego Lactation Program Mercy Hospital 4077 Fifth Avenue San Diego, CA 92103 Marianne R. Neifert, M.D. University of Colorado Health Sciences Center—C-219 4200 E. 9th Avenue Denver, CO 80262 Margaret C. Neville University of Colorado School of Medicine Department of Physiology C240 VCHSC Denver, CO 80262 Jennifer R. Niebyi, M.D. The Johns Hopkins Hospital Harvey 108 Baltimore, MD 21205 American College of OB/GYN Joel L. Nitzkin, M.D., M.P.H., D.P.A. Monroe County Health Department 111 Westfall Road—Caller 632 Rochester, NY 14692 Julie H. Norris, R.N. St. Vincent’s Wellness Center—Carmel 2001 W. 86th Street Indianapolis, IN 46260 American Hospital Association Carolyn A. O’Neil, M-S., R.D. Cable News Network 1050 Techwood Drive Atlanta, GA 30318 Christine M. Olson, Ph.D., R.D. Division of Nutritional Sciences 376 MVR Cornell University Ithaca, NY 14853 Society for Nutrition Education Betty Oseid, M.D. Department of Pediatrics Louisiana State University Medical Center 1542 Tulane Avenue New Orleans, LA 70124 Judy Perkin, Dr.P.H., R.D. Department of Health Education and Safety Room 4, Florida GYM University of Florida Gainesville, FL 32611 The American Dietetic Association Linda Randolph, M.D., M.P.H. Office of Public Health New York State Department of Health Empire State Plaza Albany, NY 12237 Dana Raphael, Ph.D. The Human Lactation Center Ltd. 666 Sturges Highway Westport, CT 06880 85 Herbert Ratner, M.D. Child and Family Quarterly 244 Wesley Road Oak Park, IL 60303 Nancy K. Rice, M.S.W. Social Work Division University of Rochester Medical Center 601 Elmwood Avenue, Box 650 Rochester, NY 14642 Walter J. Rogan, M.D., M.P.H. Epidemiology Branch National Institute of Environmental Health Sciences Mail Drop A3-02, P.O. Box 12233 Research Triangle Park, NC 27709 Jeanne Rose, M.S. 1711 Lake Shore Drive Escanaba, MI 49829 International Childbirth Education Association Ruth B. Rosenberg, J.D. Nixon, Hargrave, Devens & Doyle Lincoln First Tower P.O. Box 1051 Rochester, NY 14603 Pearl W. Rubin Daisy Marquis Jones Foundation 945 Crossroads Building 2 State Street Rochester, NY 14614 Gardenia B. Ruff, M.S.W. South Carolina Department of Health and Environmental Control Division of Maternal & Child Health 2600 Bull Street Columbia, SC 29201 Sarah Samuels, Dr.P.H. Institute for Health Policy Studies University of California School of Medicine 565 CED San Francisco, CA 94143 Susan Scrimshaw, Ph.D. School of Public Health University of California Los Angeles, CA 90024 Donald L. Shapiro, M.D. Neonatology Division University of Rochester Medical Center 601 Elmwood Avenue, Box 651 Rochester, NY 14642 86 Andrew Sorenson, Ph.D. Division of Public Health School of Health Sciences University of Massachusetts Amherst, MA 01003 Marilyn G. Stephenson, MS., R.D. Office of Nutrition and Food Sciences Center for Food Safety and Applied Nutrition U.S. Food and Drug Administration 200 C Street SW Washington, DC 20204 Mary Story, Ph.D., R.D. Adolescent Health Program Box 721 Mayo, 420 Delaware Street SE University of Minnesota Minneapolis, MN 55455 Robert C. Tatelbaum, M.D. 220 Alexander Street Suite 707 Rochester, NY 14607 Rochester Academy of Medicine, OB/GYN Section Janet Taylor-Leahman, R.D., M.S. Brownsville Community Health Clinic 2137 E. 22nd Brownsville, TX 78520 Henry A. Thiede, M.D. Chairman, Department of OB/GYN University of Rochester Medical Center 601 Elmwood Avenue, Box 668 Rochester, NY 14642 Edith P. Thomas, Ph.D., R.D. U.S. Department of Agriculture Extension Service Room 3443 South Building 14th & Independence Avenue SW Washington, DC 20250 Jewel M. Thomas, M.Ed. 4504 N. Roseneath Drive Houston, TX 77021 Alpha Kappa Alpha Sorority, Inc. Edith Tibbetts, M.Ed. Health Education Associates, Inc. 211 S. Easton Road Glenside, PA 19038 Terry Tobin, M.P.H., R.N. Marquette University Milwaukee, WI 53233 Joel Tolliver, M.P.H. 16 Rawhide Road West Henrietta, NY 14586 Michael Weidner, M.B.A. Highland Hospital South Avenue at Bellevue Drive Rochester, NY 14620 Francine Rae White, M.S.P.H. 1625 ‘I’ Street, NW Suite 420 Washington, DC 20006 National Association of Community Health Centers Nancy Whitley, C.N.M., R.N. 125 Pearl Street Mt. Holly, NJ 08060 Nurses Association of the American College of OB/GYN John T. Wilson, M.D. Louisiana State University Medical Center P.O. Box 33932 Kings Highway Shreveport, LA 71130 Beverly Winikoff, M.D., M.P.H. The Population Council One Dag Hammarskjold Plaza New York, NY 10017 Kenneth Wolfe 110 Blackmore Road Camillus, NY 13031 United States JAYCEES Kenneth W. Woodward, M.D. Xerox Corporation 800 Phillips Road Building 208M Webster, NY 14580 Bonnie Worthington-Roberts, Ph.D. Child Development Center University of Washington CDMRC WJ-10 Seattle, WA 98195 87 APPENDIX B FACILITATORS Marilyn J. Aten, Ph.D., R.N. School of Nursing University of Rochester Medical Center 601 Elmwood Avenue, Box HWH Rochester, NY 14642 Susan MacKrell, Ph.D. Education & Human Development University of Rochester Latimore 509 Rochester, NY 14627 Joel L. Nitzkin, M.D., M.P.H., D.P.A. Monroe County Health Department 111 Westfall Road, Caller 632 Rochester, NY 14692 Betty Oppenheimer Health Association of Rochester & Monroe County 973 East Avenue Rochester, NY 14607 Nancy K. Rice, M.S.W. Social Work Division University of Rochester Medical Center 601 Elmwood Avenue, Box 650 Rochester, NY 14642 Ruth Rockowitz, M.S.W., A.C.S.W. Social Work Division University of Rochester Medical Center 601 Elmwood Avenue, Box 650 Rochester, NY 14642 Doreen Smethurst, C.S.W., A.C.S.W. Social Work Division University of Rochester Medical Center 601 Elmwood Avenue, Box 650 Rochester, NY 14642 Andrew A. Sorensen, Ph.D. University of Massachusetts—Amherst 106 Arnold House Amherst, MA 01002 RECORDERS Lizabeth Berkeley, M.P.H. NYS Department of Health Office of Public Health Office for New York City Affairs 8-10 E. 40th Street New York, NY 10016 Rosellen Bohlen, R.N. 202 Clovercrest Drive Rochester, NY 14618 Myra Citrin, M.D. Department of Pediatrics University of Rochester Medical Center 601 Elmwood Avenue, Box 777 Rochester, NY 14642 Judy Gussler, Ph.D. Ross Laboratories 625 Cleveland Avenue Columbus, OH 43216 Joan Merzbach, M.S.W. Social Work Division University of Rochester Medical Center 601 Elmwood Avenue, Box 650 Rochester, NY 14642 Elizabeth Naumburg, M.D. Family Medicine Program 885 South Avenue Rochester, NY 14620 Marsha Nielson Health Association of Rochester & Monroe County 973 East Avenue Rochester, NY 14607 Marie Stahl, R.N. 3616 Connecticut Avenue NW Washington, DC 20007 89 APPENDIX C KEY ELEMENTS FOR PROMOTION OF BREASTFEEDING IN THE CONTINUUM OF MATERNAL AND INFANT HEALTH CARE 1. Primary-care settings for women of childbearing age should have: . * a supportive milieu for lactation ¢ educational opportunities (including availability of literature, per- sonal counseling, and information about community resources) for learning about lactation and its advantages * ready response to requests for further information * continuity allowing for the exposure to and development over time of a positive attitude regarding lactation on the part of the recipient of care. 2. Prenatal-care settings should have: * a specific assessment at the first prenatal visit of the physical ca- pability and emotional predisposition to lactation. This assess- ment should include the potential role of the father of the child as well as other significant family members. An educational pro- gram about the advantages of and ways of preparing for lacta- tion should continue throughout the pregnancy. * resource personnel—such as nutritionists/dietitians, social work- ers, public health nurses, La Leche League members, childbirth education groups—for assistance in preparing for lactation * availability and utilization of culturally suitable patient-education materials * an established mechanism for a predelivery visit to the newborn care provider to insure initiation and maintenance of lactation ¢ a means of communicating to the in-hospital team the infant- feeding plans developed during the prenatal course. 3. In-hospital settings should have: * a policy to determine the patient's infant-feeding plan on admis- sion or during labor ¢ a family-centered orientation to childbirth including the mini- mum use of intrapartum medications and anesthesia * a medical and nursing staff informed about and supportive of ways to facilitate the initiation and continuation of breastfeeding (including early mother-infant contact and ready access by the mother to her baby throughout the hospital stay) 90 e the availability of individualized counseling and education by a specially trained breastfeeding coordinator to facilitate lactation for those planning to breastfeed and to counsel those who have not yet decided about their method of infant feeding * on-going inservice education about lactation and ways to support it. This program should be conducted by the breastfeeding coor- dinator for all relevant hospital staff. * proper space and equipment for breastfeeding in the postpartum and neonatal units. Attention should be given to the particular needs of women breastfeeding babies with special problems. * the elimination of hospital practices/ policies which have the effect of inhibiting the lactation process, ¢.g., rules separating mother and baby ¢ the elimination of standing orders that inhibit lactation, e.g., lac- tation suppressants, fixed feeding schedules, maternal medications e discharge planning which includes referral to community agen- cies to aid in the continuing support of the lactating mother. This referral is especially important for patients discharged early. * a policy to limit the distribution of packages of free formula at discharge only to those mothers who are not lactating ° the development of policies to support lactation throughout the hospital units (€.g., medicine, surgery, pediatrics, emergency room, etc.) e the provision of continued lactation support for those infants who must remain in the hospital after the mother’s discharge. 4. Postpartum ambulatory settings should have: * a capacity for telephone assistance to mothers experiencing prob- lems with breastfeeding ¢ a policy for telephone follow-up 1-3 days after discharge ¢ a plan for an early follow-up visit (within first week after dis- charge) © the availability of lactation counseling as a means of preventing or solving lactation problems * access to lay support resources for the mother ¢ the presence of a supportive attitude by all staff ¢ a policy to encourage bringing the infant to postpartum appoint- ments ¢ the availability of public/community-health nurse referral for those having problems with lactation * a mechanism for the smooth transition to pediatric care of the infant, including good communication between obstetric and pe- diatric care providers. 91 APPENDIX D SELECTED READINGS Baranowski T., Bee D.E., Rassin D.K., Richardson C.J., Brown J.P., Guenther N., and Nader P.R.: Social Support, Social Influence, Ethnic- ity and the Breastfeeding Decision. Social Science and Medicine 17:1599- 1611, 1983. Cowie A.T., Forsyth IA., Hart LC.: Hormonal Control of Lactation. Berlin: Springer-Verlag, 1980. Eckhardt K.W. and Hendershot G.E.: Analysis of the Reversal in Breast Feeding Trends in the Early 1970s. Public Health Reports 99:410-414, July-August 1984. Ellis D.J.: Secondary School Students’ Attitudes and Beliefs About Breastfeeding. Journal of School Health 53:600-604, December 1983. Gussler J. and Bryant C. (eds): Helping Mothers Breastfeed: Program Strategies for Minority Communities. Health Action Paper No. 1, Lexing- ton, KY: Lexington-Fayette County Health Department and University of Kentucky Medical Behavioral Science Department, 1984. Hally M.R., Bond J., Crowley J., Gregson B., Phillips P., and Russell IL: What Influences a Mother’s Choice of Infant Feeding Method? Nursing Times 65-68: January 25, 1984. Lawrence R.A.: Breastfeeding: A Guide for the Medical Profession. St. Louis: C.V. Mosby Company, 1980 (2nd edition, 1984). Martinez G.A. and Dodd D.A.: 1981 Milk Feeding Patterns in the United States during the First 12 Months of Life. Pediatrics 71:166-170, February 1983. Neville M.C. and Neifert M.R. (eds): Lactation: Physiology, Nutrition, and Breastfeeding. New York: Plenum Press, 1983. Oseid B., Carter J., Sullivan J., and Braud S.: Promoting Breastfeeding in Louisiana. Journal of the Louisiana State Medical Society, 4-6: December 1983. Shand N. and Kosawa Y.: Breast-Feeding as Cultural or Personal Deci- sion: Sources of Information and Actual Success in Japan and the United States. Journal of Biosocial Science 16:65-80, 1984. , 92 Van Esterik P. and Greiner T.: Breastfeeding and Women’s Work: Con- straints and Opportunities. Studies in Family Planning 12:184-197, April 1981. Vorherr H.: The Breast: Morphology, Physiology, and Lactation. New York: Academic Press, Inc., 1974. 93 U.S. GOVERNMENT PRINTING OFFICE : 1984 O ~- 447-700