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Texas WIC News July August 2011

Texas WIC News

July/August 2011 Volume 20, Number 4

August: World Breastfeeding Month

WIC is Working to Meet Breastfeeding Goals
Encouraging Hospitals to Adopt the Ten Steps to Successful Breastfeeding
Every Ounce Counts: Helping Moms Achieve Their Breastfeeding Goals
Texas WIC Peer Counselor Program Celebrates 20 Years of Breastfeeding Success
Hidalgo County WIC's Community Peer Counselor Program: A Big Hit!
WIC Wellness Works
Breastfeeding Counseling: Using New Technology
Human Milk Fortifiers: Added Nutrition in a Small Volume
Local Agency Spotlight: Dallas Lactation Care Center Opens
Milk Banking: A Life-Saving Investment
Eaton Wright: Test Your Breastfeeding IQ

WIC Is Working to Meet Breastfeeding Goals

From the Texas WIC Director
— Mike Montgomery

Texas WIC is proud to be a nutrition program at its core. During Texas WIC World Breastfeeding Month 2011, we celebrate the very first source of good nutrition for us all —breastmilk. The Surgeon General made a call in January of this year to improve breastfeeding rates, and make it easier for moms to start and sustain breastfeeding. Recent statistics show that most mothers in the United States (and Texas) want to breastfeed, and are trying to do so. But in 2009, 78 percent of Texas moms still said they didn't breastfeed as long as they had intended. Texas WIC staff are diligently working to help Texas moms meet The Healthy People 2020 objectives for breastfeeding: 82 percent ever breastfed, 61 percent at 6 months, and 34 percent at 1 year. This month's issue of Texas WIC News focuses on all the ways WIC staff are encouraging baby-friendly feeding practices and mom-friendly services and support from birth and beyond.

Find out how the Texas Department of State Health Services is helping Texans meet Healthy People 2020 goals by improving hospitals' maternity care practices with the "Better by Breastfeeding" campaign and adoption of the Texas Ten Step program (page 4). You'll find all you need for a successful Texas WIC World Breastfeeding month in your clinics on page 6, as well as tips for helping WIC moms achieve their breastfeeding goals this year. Our Texas WIC Peer Counselor Program has been helping moms (and hospitals!) meet breastfeeding goals for 20 years now, and your new Peer Counselor Coordinator Kristina Arrieta, MPH, IBCLC, goes over the program's past successes and looks to the future on page 8.

World breastfeeding month celebrates breastmilk as the ideal nutrition for all infants. But for some mothers and their babies, breastmilk may not be possible or sufficient because of medical conditions or special circumstances. Read how human milk fortifiers can provide a big boost in a small package for some preterm infants on page 12. In "Milk Banking: A Life-Saving Investment," see how some local agencies have paired up with Texas milk banks as milk depot collection sites, to help ensure infants all over Texas get the incomparable benefits of breastmilk. Texas WIC recognizes that statewide breastfeeding success is dependent on local efforts, and in this issue we celebrate local breastfeeding support centers as invaluable resources for our participants. We spotlight the grand opening of the Dallas Lactation Care Center on page 15, and see how breastfeeding counseling is just a click away with "web cam" lactation consulting from Houston's Lactation Foundation on page 11.

Texas WIC staff is answering the Surgeon General's call with strong community and mother-to-mother counseling for breastfeeding mothers, and advocates breastmilk as the optimal nutrition for our youngest clients. Thanks to your hard work and dedication, we help communities and most importantly WIC clients continue to meet their breastfeeding goals on a daily basis.


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Encouraging Hospitals to Adopt the Ten Steps to Successful Breastfeeding

by Tracy Erickson, R.D., I.B.C.L.C., R.L.C.
WIC Breastfeeding Coordinator

A new breastfeeding mom and baby come into your clinic for certification. Mom started breastfeeding in the hospital but her labor and delivery did not go as planned. She was separated from her baby in the hospital. Her baby's first feeding was formula and she was not offered the opportunity to breastfeed until five hours after birth. She never felt like she learned to latch her baby to her breast correctly while in the hospital and she was given free formula on her way out. Her baby is only three days old but is already being supplemented with 15 ounces of formula a day.

This is a common scenario in Texas. Forty-eight percent of our WIC moms revealed they did not breastfeed as long as their intentions indicated in the 2009 WIC Infant Feeding Practices Survey. Seventy-three percent of those moms said they introduced formula for reasons that could have been addressed by evidenced-based maternity care practices. Those reasons included:
•Not enough milk
•Difficulty latching
•Baby lost interest
•Can't tell how much my baby is getting
•Too painful

A Cochrane review released in 2000 found that institutional changes in maternity care practices effectively increased breastfeeding initiation and duration rates. These changes can be part of a comprehensive set of changes, such as those implemented in pursuit of World Health Organization (WHO)/United Nations Children's Fund (UNICEF) Baby Friendly designation, or they can be individual interventions such as increasing the rooming-in of mothers and babies or discontinuing policies that are not evidence based (e.g. unnecessary separation of infant from mother). The Centers for Disease Control and Prevention (CDC) later published this finding in their 2005 Guide to Breastfeeding Interventions.

In 2003, the CDC convened an expert panel to improve hospital practices related to breastfeeding. The panel consisted of researchers with specific experience in surveillance and monitoring of hospital practices related to breastfeeding. At the time, no system to collect national data on these practices existed. The expert panel recommended the establishment of an ongoing, national system to monitor and evaluate hospital practices related to breastfeeding. The outcome of this recommendation was the CDC Maternity Practices in Infant Nutrition and Care (mPINC) survey.

The first mPINC survey was conducted in 2007 with a 75 percent response rate from Texas hospitals and birthing facilities. Texas scored 58 out of 100—in the lowest quartile of the nation. Hospitals that participated in the survey later received benchmark reports that included comparisons of how their hospital scored compared to regional scores and highlighted needed areas for improvement and recommendations. Since the first mPINC results were released, several other initiatives have specifically called for improvements in hospital maternity care practices.

• Joint Commission Perinatal Care Core Measure Set
— Requires hospitals reporting on this core measure set to report rates of exclusive breastfeeding at discharge.
• Healthy People 2020 Goals
— New objective to increase the percentage of live births that occur in facilities that provide recommended care for lactating mothers and their babies.
• The Surgeon General's Vision for a Healthy and Fit Nation 2010
—Hospitals, work sites, and communities should make it easy for mothers to initiate and sustain breastfeeding as this practice has been shown to prevent childhood obesity.
• The Surgeon General's Call to Action to Support Breastfeeding 2011
— Ensures that maternity care practices throughout the United States are fully supportive of breastfeeding.

The Department of State Health Services is taking advantage of the national drive to improve maternity care practices by implementing a multi-phased state initiative to improve hospital staff awareness of how maternity care policies and practices can affect breastfeeding outcomes, to improve awareness of DSHS breastfeeding resources to help them make improvements, and to provide training and technical assistance to aid hospitals in achieving full adoption of the Ten Steps to Successful Breastfeeding.

Phase One —The Better by Breastfeeding/Right from the Start Campaign
Launched earlier this year, the Better by Breastfeeding campaign materials went out to all hospitals and birthing centers. Campaign materials report rates of any amount of breastfeeding and exclusive breastfeeding on day two, and encourage facilities to make incremental changes toward adoption of the Ten Steps to Successful Breastfeeding to improve those rates. All facilities also received a hospital-specific report including their own data compared to regional data.

Phase Two —Texas Ten Step Program Promotion
This phase is currently underway and is designed to improve awareness of the Texas Ten Step (TTS) program via mailers and webinars. The TTS program gives facilities recognition for 85 percent compliance with Ten Steps to Successful Breastfeeding and encourages pursuit of Baby Friendly designation, which requires 100 percent compliance.

Phase Three —Texas Ten Step Star Achiever Program
This phase will introduce a new Star Achiever Program to provide additional training and technical assistance to currently certified TTS facilities. TTS facilities will compete for placement into the program this fall and will begin their training shortly thereafter. By the end of the training and technical assistance program, hospitals should have already started the process of acquiring Baby Friendly designation through Baby Friendly USA.

Through this multi-phased approach, we anticipate increases in the number of Texas Ten Step facilities as well as facilities seeking and achieving Baby Friendly designation. As we see a rise in Texas Ten Step and Baby Friendly facilities, improvements in rates of breastfeeding duration will follow. For more information on the Better by Breastfeeding campaign or Texas Ten Step program, visit www.texastenstep.org. For more information on the Baby Friendly program, visit http://www.babyfriendlyusa.org/.

Fairbank L, S. O'Meara, M.J. Renfrew, M. Woolridge, A.J. Snowden, D. Lister-Sharp. 2000. A systematic review to evaluate the effectiveness of interventions to promote the initiation of breastfeeding. Health Technology Assessment. 4(25):1 —171.

2005 Guide to Breastfeeding Interventions http://www.cdc.gov/breastfeeding/resources/guide.htm

CDC Maternity Practices in Infant Nutrition and Care (mPINC) survey http://www.cdc.gov/breastfeeding/data/mpinc/index.htm

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Every Ounce Counts: Helping Moms Achieve Their Breastfeeding Goals

by Cristina Garci­a, R.D., L.D.
Breastfeeding Promotion Nutritionist

Every year during the month of August, Texas WIC joins a worldwide campaign to increase public awareness of the many benefits of breastfeeding. When it comes to breastfeeding, every ounce counts towards the health of mom and baby. This year's Texas WIC World Breastfeeding Month (WBM) theme is Every Ounce Counts: Helping Moms Achieve their Breastfeeding Goals.

Small Steps
All breastfeeding moms have one main goal — to feed their child. But contained within this main goal are a wide range of smaller, related goals. It can mean making it through a sleepless night with a newborn, adjusting to a baby's feeding demands during a growth spurt, planning on returning to work or school, providing expressed breastmilk to the compromised or premature infant, or anything supporting their breastfeeding relationship.

As WIC staff, our job is to help moms navigate through challenges by helping them define small steps they can make towards their breastfeeding goals. When counseling moms, focus on the most important thing they can do to achieve their current breastfeeding goal and give them tips on how to achieve that one thing.

For example, a small step goal for a new mom might be to try different breastfeeding positions to find which is the most comfortable for her infant and herself. Trying different positions could be especially helpful for moms who are experiencing discomfort related to their delivery. This small step may also help the baby with achieving a better latch, allowing mom to rest or keeping the baby alert and interested in breastfeeding.

Small steps like this are less intimidating and can quickly add up to a list of achievements. The key to setting breastfeeding moms up for success is to help them define realistic, achievable goals.

Think Outside the Box
Sometimes helping moms achieve their goals means getting creative. Offer suggestions, such as taking photos, videos, or recordings of their baby's voice on their cell phones as a quick tip to offer a working mom who is planning on pumping. These images and sounds can help moms stimulate a let-down, allowing the milk to flow freely from the breast, by appealing to the mom's senses while pumping. This is something very easy for moms to do since they probably already have some photos, videos, and recordings on their cell phones and can use them to achieve this goal.

Cell phones can also be helpful by enabling peer counselors to be reached for questions outside of clinic hours. WIC offices can utilize them to send timely reminders to new moms to encourage them to set their first postnatal appointment with a breastfeeding peer counselor as soon as possible after discharge from the hospital.

Most moms turn to the internet as a resource and for support. WIC staff should stay abreast on the latest internet trends, including social media and networking, so you can help moms navigate through credible websites, blogs, forums, etc. Routinely visit these sites and update your local agency breastfeeding referral lists to ensure they reflect the most up-to-date information.

Phew, We Made It!
There are no set standards (duration of breastfeeding, amount of expressed breastmilk, number of challenges conquered) to define breastfeeding success. That can only be determined by each mom's achievement of her personal goals. Often, as counselors and supporters —all we have to do is show breastfeeding moms that they are well on their way to achieving their goals.

Materials Available for Breastfeeding Promotion 2011
As this year's Texas WIC World Breastfeeding Month theme compliments the 2009 and 2010 Every Ounce Counts campaigns, materials from both years are available for ordering on the Texas WIC catalog online. These items include:

• The 2010 WBM poster
• Every Ounce Counts logo and website stickers
• Pregnancy Journals
• The 2009 Every Ounce Counts poster series
• License to breastfeed in public pocket-sized cards
• Breastfeeding-Friendly Establishment decals and business flyers
• Breastmilk Storage Guidelines magnet

Check out our latest breastfeeding promotion item, WBM photo cards.

Similar to greeting cards with a photo insert, these cards provide a fun and personalized way to include participants in breastfeeding promotion. These cards can be given to participants at WBM celebrations, nutrition carnivals, or during counseling sessions. Participants can insert their baby's photo into the card to display in their homes or at their worksites. They serve as a great, portable incentive item for working moms who are pumping at work or school.

Please visit the DSHS Web site for further 2011 Texas WIC World Breastfeeding Month information, WBM activity ideas, or to place an order for breastfeeding promotion materials from the Texas WIC catalog: www.dshs.state.tx.us/wichd/wiccatalog/contents.shtm.

Look for Texas WIC's lactation support and training centers on the web:

Mom's Place

Lactation Foundation

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Texas WIC Peer Counselor Program Celebrates Twenty Years of Breastfeeding Success!

By Kristina Arrieta, M.P.H., I.B.C.L.C.
Peer Counselor Coordinator

Wow! It's hard to believe that it has been twenty years since the start of the Texas Peer Counselor Program. This program began with a small group of WIC breastfeeding mothers who wanted to help their peers breastfeed. Today, peer counselors are helping mothers in almost every WIC clinic in Texas and in more than 200 Texas hospitals. And it's not just for moms anymore.

Texas now has Peer Dad Programs. Fathers play an important role in mom's infant feeding decisions and her breastfeeding success. Peer dads have a unique point of view on breastfeeding. They discuss myths, fears, and the father's role in supporting breastfeeding with other WIC dads. This program helps new fathers provide the encouragement that breastfeeding moms need.

Texas peer counselors serve as role models. In some clinics, clients are introduced to breastfeeding as soon as they walk into the waiting room and see a breastfeeding peer counselor nursing her baby. Peer counselors are making breastfeeding the norm in Texas. Through role modeling and providing education, peer counselors helped Texas WIC surpass the Healthy People 2010 initiation goal of 75 percent. These peer counselors are actively working towards meeting the Healthy People 2020 goals.

The Healthy People 2020 objectives put emphasis on exclusive breastfeeding. Many agencies are working towards meeting this objective by putting peer counselors in the local hospitals. Hospital care and support is predictive of the success of exclusive breastfeeding as well as the length of time that mom will continue breastfeeding. The support provided by hospital peer counselors makes an enormous impact on our clients' continued breastfeeding success.

Other agencies promote exclusive breastfeeding by providing follow up phone calls to clients soon after discharge or home visits to clients struggling with latch. Peer counselors can see mothers prenatally, postpartum and for difficulties with the nursing toddler. Each counselor has unique experiences that can be shared with clients.

One agency is using the experiences of their counselors to provide NICU peer counselor services. These peer counselors have experienced having an infant in the NICU and know that it can be a scary and frustrating time. The peer counselors provide information on pumping and how to maintain a milk supply as well as listen and relate to parents as they share their fears. The neonatologist at the hospital agrees that this program has had a significant impact on the mothers' success.

Peer counselor training allows counselors to effectively assist mom to latch, pump, or wean her baby from the breast. But it is their breastfeeding experience that gives them the perspective that allows them to relate to their clients. I think all WIC staff would agree that peer counselors make a huge impact on breastfeeding success in our clinics. We would like to thank peer counselors for twenty years of breastfeeding success! Let's keep going and put Texas at the top of the nation when it comes to breastfeeding rates.

What Peer Counselors are Doing...

"I have noticed that when I tell moms that I was a WIC mom and I breastfed my babies, something changes in the way that they look at me. They know that I am one of them."
— Carolyn Putnam, Peer Counselor Coordinator

"Fathers have the incredible ability to either support or impede the success of breastfeeding. Peer dads in the Dallas WIC program target fathers to help combat barriers to breastfeeding success. WIC peer dads' model good parenting skills. They are helping fathers to understand the importance of their role and equipping them to assist their breastfeeding partner."
— Muswamba Mwamba, Peer Dad Coordinator

"The WIC BFPC's have made a world of difference for us! I can't imagine not having them now. They are wonderful, supporting our mothers and providing instruction, encouragement and support for breastfeeding. The patients appreciate them and the nurses appreciate them. I cannot imagine how we would have been able to support our moms as well as we have without them."
— Debbie Fowler, R.N., M.S.N.

"I think it's great when the hospital calls us!  We can be there to help the mom latch the baby on right from the start and moms are so amazed when they see how easy it can be." 
— Sandra Galvez, WIC Peer Counselor

"We are excited about starting a peer dad program! One of our nutritionists visited the Dallas WIC Peer Dad Program. He and our director were SO IMPRESSED with the program that they came back ready to GO! We are looking for peer dad candidates to do a peer counselor/peer dad training! "
— Rowena Tucker, Breastfeeding Coordinator

"We are busy starting a moms group in each one of our clinics.  We feel that after we have helped the moms through the tough times they think of us as friends and we would like to connect them with other parents going through the same experiences.  We also are busy with our Breastfeeding Support Classes.  These classes are set up in the third trimester of pregnancy and the mother brings her family and friends (her support group) in to a class with the peer counselor to get the basics of breastfeeding, discuss community resources, show dads what to look for with a good latch, and to answer any question the support group or mom have before the bundle of joy comes."
— Shawna Baker, Breastfeeding Coordinator

"To encourage breastfeeding duration, we will be giving moms of babies who breastfeed for longer than 6 months a brown/pink onsie with the 'Every Ounce Counts Logo' on it!"
— Shannon O'Quin Wingo, Breastfeeding Coordinator

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Hidalgo County WIC's Community Peer Counselor Program: A Big Hit!

Hidalgo County WIC program celebrated the success of the WIC Community Peer Counselor Program's at the Women's Hospital at Renaissance. Sandra Escamilla, WIC breastfeeding peer counselor and trained breastfeeding educator, received her first "Breastfeeding Champion Award" on October 27, 2010, for her excellent and enthusiastic work at the hospital.

Sandra Escamilla started as a WIC Peer Counselor and hospital volunteer in April 2010. At the hospital, Sandra Escamilla helps around 420 new mothers every month! She helps patients to breastfeed during the first hours after birth, and explains the benefits of breastfeeding. WIC pumps are provided to WIC participants separated from their infants who are medically fragile.

Gabriela Reyna, I.B.C.L.C., R.L.C. at Women's Hospital at Renaissance states, "I have noticed a decrease in the percentage of mothers with low milk supply. Before we received peer counseling support the percentage was 14.6 percent and as of today it is only at 2 percent. It was hard for them [mothers] to continue pumping after discharge with the lack of an electric pump at home. Many of the mothers would not go to WIC immediately due severe conditions, bed rest, etc. Therefore the milk supply would be low since they were not using a hospital grade electric pump. Now that the peer counselor is able to provide mothers with an electric pump at discharge complemented with prompt referrals to the WIC clinic has increased quantity of milk supply for all the compromised infants in NICU Level 3. I want to thank you for the support we receive from Hidalgo County WIC and your dedicated Peer Counselor Sandra Escamilla. The information she gives to mothers reinforces the education we give to them here in NICU, and promotes breastfeeding among mothers with ill, premature and compromised infants."

The initiative supporting WIC Community Peer Counselors in the Hidalgo County area hospitals has increased the breastfeeding rates. WIC peer counselors have helped mothers maintain lactation even when they are separated from their newborns. This helps hospitals move toward being designated Baby Friendly. Our percentage of breastfeeding infants enrolled in WIC at certification increase from 95 percent to 97 percent.

For more information contact Veronica Riojas, I.B.C.L.C., R.L.C., nutritionist and breastfeeding coordinator, Hidalgo County WIC, at 1-800-889-5595.


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WIC Wellness Works: Solving the Puzzle of a Lifetime of Good Health, One Piece at a Time

Although gastric bypass surgery has become a more common weight loss strategy in the last 20 years, it still remains deeply misunderstood. People often view the procedure as a route to instant weight loss, a "silver bullet" that, once performed, will cause pounds to melt away with little effort. Debra Estrada, with the WIC Clinic in Seven Points, is a gastric bypass success story. But she is the first to tell you that the surgery merely opened the door; she still had to take every step toward better health and a new life. Five years ago, Debra Estrada weighed 450 pounds. She has now lost 250 pounds. This is her story, in her own words.

"I can't really explain how I got that overweight. I do know I was super morbidly obese, and miserable. In 2006, I woke up one morning and said to myself, 'is this me, is this really me?' I felt so trapped inside of my own body. I had to find a way out. I feared that I wouldn't live to see my kids grow up. I didn't even know if I would see them tomorrow. That is when I decided to have gastric bypass surgery."

"The procedure is done by cutting and bypassing the stomach. A pouch the size of an egg is made with the top part of the stomach; this limits the amount of food that can be taken in. The bigger portion of the stomach is still there but is bypassed to a different part of the intestines. Some may say I have taken the easy way out, but from experience this is not in any way easy. The surgery was just one piece of the puzzle. I decided to start putting the rest of the puzzle together to become the new me. First, I decided that I needed to eat healthier. The WIC Wellness Works program definitely changed the way I eat. My whole family is eating whole grains and more fruits and vegetables now. I still sneak in something good every once in a while, I am human, but it is very important to me to make sure I stay on track and maintain a healthy lifestyle."

"Another piece to my puzzle is exercise. I go to the gym four to six times a week and I love it. At one point in my life I could barely walk across the room and now I work out a minimum of 60 minutes at a time. I do things that I was never able to do before like jumping on the trampoline with my kids, riding bikes with them, and going horseback riding. I have learned over these past few years that I have to stay focused, keep my mind set on what I am doing, and give all that I can possibly give."

"Walking with the wellness program got me to the gym more. For instance, Walk the World with WIC helped me notice how much activity I was doing each day. Writing down how much I walked showed me where I was and what I still needed to do. I began parking at the end of the parking lot and walking the longer way at work just to get more steps into my day. It really got me motivated."

"My job plays a piece in my puzzle as well. I am employed with a program that is all about nutrition. Coming to work every day and helping others understand the benefits and importance of a healthy lifestyle keeps me on track. If we were to only convince one person out of the day to make smarter choices, even one a week, or maybe even one a year, that counts for something. That is one life that we may have saved, one child that may not get diabetes or suffer high blood pressure."

"I have made those smart choices, I am living that dream, and I am going to live to see tomorrow. I hope you will use this journey of mine to start your own or even help someone else to lead a healthier life."

Grilling Summer's Bounty
Unleash and intensify flavors of fruits and vegetables by cooking them on the grill! Not only will you reap their many health benefits, but you'll also enjoy a new range of tastes. You can also offer WIC participants another flavorful and easy way to use fresh fruits and vegetables during the summer.

Grilling Vegetables
There are two ways to grill vegetables — directly on the grill grates or wrapped in foil. Placing vegetables directly on the grill grates applies intense heat and imparts a smoky flavor. Wrapping vegetables in foil creates an environment similar to a steamer and allows any type of vegetable to be prepared on the grill.

All vegetables should be washed before grilling. Vegetables to be placed directly on the grill should be sliced into ½ inch thick pieces and the skin should stay on. If the vegetable is going to be placed directly on the grill, you should brush it with a very small amount of olive oil or other vegetable oil so they don't stick to the grill. You can also season the vegetables with herbs and spices (fresh or dried) before placing them on the grill. Some vegetables require special preparation. For example, asparagus should have the tough bottom-ends removed or shaved with a peeler. Carrots should be peeled unless you prefer the earthy taste of the skin (in that case, scrub with brush and remove the ends) and then sliced. Corn can be grilled in the husk or out of the husk depending on your preference or the recipe you are using.

If you are using the foil packet technique, just follow the preparation instructions above but leave out the oil (unless your recipe calls for it). When the vegetable is ready for grilling, wrap it in foil and place the foil packet on the grill grates directly above the flames (for a quicker steam) or on the rack farther above the flames (reserved for items that need less heat and can be steamed longer). Vegetables that work well in the foil steamer include: cabbage, mushrooms, snow peas, and onions. Almost any vegetable you would normally put in the steamer or boil or microwave can be steamed in a foil packet on the grill.

Grilled vegetables can be served as is or with additional herbs and spices to enhance the grilled flavor.

Grilling Fruits
Grilling fruit concentrates and caramelizes the sugar, intensifying the natural sweetness. Fruits are grilled in the same way as vegetables — either directly on the grill grate or wrapped in foil. Fruits that can be sliced in large, thick slices and are firm are best for grilling (e.g., pears, apples, pineapples). Stone fruits (something with a pit) and very soft fruits like bananas may also be grilled but require special attention as the cooking time required is short. Very soft or ripe fruits and small fruits (like berries) should be cooked on the grill wrapped in foil.

All fruits should be washed before grilling. Fruits with a core or a pit should have them removed. Skin does not need to be removed unless it is not edible or will be removed after grilling. Leaving the skin on allows the fruit to hold its shape.

Before placing the fruit directly on the grill, make sure any left-over food particles are gone from the grill (see "A Clean Grill is Key"). To prevent sticking, lightly coat the fruit with butter or vegetable oil. Medium to low grill heat is best.

Grill time depends on the ripeness of the fruit and the heat of the grill. In general, grill the fruit long enough to make grill marks on both sides and to heat the fruit without causing it to stick to the grill.

Grilled fruits can be served as is, topped with a complimentary sauce, or be served with frozen yogurt, low-fat ice cream or low-fat pudding.

A Clean Grill is Key
Start with a clean grill — free of left-over charred food particles. The easiest way to do this is to always clean your grill thoroughly after each use. Cleaning the grill after you use it saves time when you are ready use it again (essential for mid-week after-work grilling). Check the instructions that came with your grill, or if those are long gone, investigate online or at the store where you bought the grill. Most can be cleaned with soap, water, and a stiff grill brush. Proper cooking techniques will also help you keep your grill clean — use a non-stick spray made for grilling before you heat your grill and don't turn the food you are grilling before it is seared to avoid food sticking to the grill.


1 large zucchini
1 teaspoon olive oil

Slice zucchini into ½ inch slices. Toss in olive oil. Place on hot grill and grill for 4 to 5 minutes or until grill marks appear and the zucchini has softened.

Grilled Peaches
with Berry Sauce

½ (10 ounce) package frozen
raspberries in syrup, slightly thawed*
1 ½ teaspoons lemon juice
2 fresh peaches, peeled and halved
5 teaspoons brown sugar
¼ teaspoon ground cinnamon
½ teaspoon vanilla extract
1 teaspoon butter or margarine

In a blender or food processor, process raspberries and lemon juice until pureed. Strain and discard seeds. Cover and chill. Place the peach halves, cut side up, on a large piece of heavy-duty foil (about 18 x 12 inches). Combine brown sugar and cinnamon; sprinkle into peach centers. Sprinkle with vanilla; dot with butter. Fold foil over peaches and seal. Grill over medium-hot coals for 15 minutes or until heated through. To serve, spoon the raspberry sauce over peaches.

*For a lower calorie recipe, use fresh raspberries or frozen raspberries without syrup.


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Breastfeeding Counseling: Using New Technology

by Hellen Sullivan, R.N., I.B.C.L.C.
Breastfeeding Training Specialist

Facebook, Twitter, Blogs!
We live in a highly technical world, and our clients are becoming more familiar with using technology in their daily lives. The Lactation Foundation in Houston has found a way to assist mothers with breastfeeding problems from a distance. Alisa Sanders, RN, IBCLC, director of the Lactation Foundation, began a pilot program using web cameras to consult with mothers who are unable to come into the clinic.

Alisa has received positive feedback on the pilot program. "Houston's Lactation Foundation has begun using web cams for lactation consults," said Alisa. "Today's techno-savvy moms have welcomed modern technology in their WIC offices. Initial concerns over the less than personal approach seem to have been unfounded. Clients have been responsive to the use of the camera because it has provided them instant access to a lactation consultant. Each mother offered the opportunity for web cam consults have agreed without hesitation. The greatest difficulties that arose were technology related. The Lactation Foundation is happy to assist other local agencies in the use of their web cams. The Peer Counselors have enjoyed knowing they have a lactation consultant readily available. Providing access to a lactation consultant for our customers ensures greater breastfeeding success for the client and better breastfeeding rates for our local agencies."

Any agency can set up a web cam to use for consultation with the Lactation Foundation. In order to maintain privacy a few simple steps need to be taken. The web cam needs to be connected to a computer that is not the Texas WIN computer, and it will need to be located in a private room where the door can be closed. The agency may use lactation funding to purchase the web cam. An appointment should be made to make sure the Lactation Foundation counselors are available. Alisa Sanders will be happy to assist anyone in setting up this new form of consultation for your clients. She can be contacted at 1-877-550-5008.

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Human Milk Fortifiers: Added Nutrition in a Small Volume

by Elizabeth Bruns, R.D., L.D.
Nutrition Training Specialist

Human milk is the best source of nutrition for babies. It's the best source for preterm babies too.

However, preterm babies are typically born with low birth weights and have increased requirements for nutrients for their immature body systems and for catch-up growth. Depending on their medical conditions, birth weight, and development, some preterm infants may need human milk fortifiers.

Early Feeding Regimen for Preterm Babies
For the first two weeks of life, preterm babies need unfortified preterm human milk only. Preterm milk is higher in calories, protein, fat, iron, and other nutrients than full-term milk. It is also higher in the anti-infective, secretory immunoglobulin A. This is important because a preterm infant's immune system is typically immature and not functioning at the same level as a full-term infant's. During this time, a preterm baby's nutrient needs can be fully met by consuming his or her mother's milk.

After the first two weeks of life, a preterm infant's need for calories, minerals, and other nutrients for bone mineralization and growth will be greater than what their mother's milk can provide. Some preterm infants have fluid-restricted conditions such as broncho-pulmonary dysplasia; others simply cannot consume enough breastmilk to meet all their nutrient needs.

Metabolic complications can occur in preterm babies who do not receive fortified human milk. They can develop hyponatremia, hypoproteinemia, osteopenia, zinc deficiency, etc. The bottom line is that they need a whole lot of nutrition packed into a small volume. This is the time for human milk fortifiers.

Human Milk Fortifiers
There are currently two powdered and one liquid human milk fortifiers on the market. Both Mead Johnson and Abbott make powdered products, Enfamil Human Milk Fortifier and Similac Human Milk Fortifier, available in 0.71 g and 0.9 g dose use packets, respectively. Mead Johnson is now producing a liquid product also, Enfamil Human Milk Fortifier Acidified Liquid, available in a 5 ml vial. The following table lists the nutrient composition of the three fortifiers.


Nutrient composition of the three fortifiers.
Nutrients Similac HMF
(1 packet)
Enfamil HMF
(1 packet)
Enfamil HMF Acidified Liquid
(1 vial)
Calories 3.5 3.5 7.5
Protein, g 0.25 0.275 0.56
Fat, g 0.09 0.25 0.58
Carbohydrate, g 0.45 <0.1 0.15
Calcium, mg 29.25 22.5 29
Phosphorus, mg 16.8 12.5 15.8
Iron, mg 0.08 0.36 0.44
Zinc, mg 0.25 0.18 0.24
Sodium, mg 3.75 4.0 6.8
Potassium, mg 15.75 7.25 11.3
Vitamin A, IU 155 237.5 290
Vitamin D, IU 30 37.5 47
Vitamin E, IU 0.8 1.15 1.4
Vitamin K, mcg 2.1 1.1 1.42
Thiamin (B1), mcg 58.3 37.5 46
Riboflavin (B2), mcg 104 55 66
Vitamin B6, mcg 53 28.75 35
Vitamin B12, mcg 0.16 0.045 0.16
Niacin, mcg 893 750 920
Folic Acid, mcg 5.75 6.25 7.7
Vitamin C, mg 6.3 3.0 3.8

Looking at the table, you will notice that there are differences between the fortifiers. For example, the Similac fortifier is higher in carbohydrate; the Enfamil products are higher in fat. The Enfamil liquid fortifier is quite a bit higher in protein than either of the powdered fortifiers. The Enfamil products are higher in iron than the Similac product. (The reason for the difference in iron content between the products is that Similac intends for iron to be supplemented as needed, whereas Enfamil intends for their fortifiers to reduce the need for additional iron supplementation.)

Human milk fortifiers are made from milk and milk products, oils, carbohydrates, minerals and vitamins. Similac lists non-fat milk, whey protein concentrate, corn syrup solids, medium chain triglycerides (MCT), and soy lecithin as the primary ingredients in its' powdered fortifier. Enfamil lists MCT oil, milk protein isolate, whey protein isolate hydrolysate, soy oil, corn syrup solids, and soy lecithin in its powdered fortifier. The difference in the Enfamil liquid fortifier compared with the powder is that the protein source is 100 percent whey protein isolate hydrolysate; oils include ARA and DHA in addition to the MCT and soy oils; and pectin and citrate are added as carbohydrate sources.

Human milk fortifiers come in individual dose packets and vials. The amount of human milk added to a packet or vial depends on the desired calories per ounce. See the chart below for concentration information:

Recipes to Prepare Human Milk fortifiers
(powdered or liquid)


Human Milk Fortifiers
Total Calories/Ounce of Fortified Human Milk Number of
Amount of
Human Milk
22 calories/ounce 1 50 ml
24 calories/ounce 1 25 ml

When using the liquid fortified, the vial should be shaken vigorously prior to adding to human milk. When using the powdered fortifier, the manufacturers suggest to shake the container with human milk prior adding the powder and then again after to aid in blending.

It is recommended not to use more than 20 vials of the Enfamil Liquid HMF a day; not more than 25 packets a day of the powdered fortifiers. Excessive intake could lead to a vitamin or mineral toxicity, such as hypercalcemia. Similac recommends that their fortifier not be used after an infant reaches a weight of eight pounds. Enfamil recommends that their fortifiers be used full-strength (24 calories) up until an infant reaches a weight of five and half pounds; after that, at half-strength up until 18.5 pounds or nine months corrected age. The company cautions that blood of infants using fortifiers should be monitored to determine levels of calcium, albumin, nitrogen, urea, and sodium.

Texas WIC can authorize the use of human milk fortifiers up to a weight of eight pounds. Issuance is limited to one month at a time to prevent issuance beyond this weight limit.

Liquid Human Milk Fortifier
The advantage to using a liquid human milk fortifier is that it is a sterile product. Powdered nutritionals are not sterile. A preterm baby with an immune disorder should not use a powdered fortifier.

The pH of Enfamil liquid fortifier is 4.3, hence the product name Enfamil Human Milk Fortifier Acidified Liquid. When the fortifier is added to human milk, the pH is lowered to 4.7 —this is mildly acidic. The manufacturer explains that "this lower pH level enables a heat treatment that eliminates bacteria" and "also preserves the nutrition and the integrity of the product." Be aware that the pH of a preterm baby's stomach is 2.0, so the liquid fortifier cannot make the stomach acidic —it already is.


pH Primer
pH Primer
pH is a measure of the acidity or the alkalinity of a substance. Neutral substances, those that are neither acid or alkaline like water, have a pH of 7.0. Substances with a pH of more than 7 are considered alkaline; substances with a pH of less than 7 are considered acidic. Coffee has a pH of 5, soda a pH of 3.5, vinegar 3, lemon juice 3, gastric juice/"stomach acid" 1.5, battery acid 0.

Breast vs. Bottle
When using a human milk fortifier, direct breastfeeding is interrupted. To fortify human milk, it must be expressed or pumped out first.

In one study by O'Connor, preterm babies in an intervention group were fed approximately 50 percent fortified human milk and 50 percent unfortified human milk directly from the breast or expressed. Babies in a control group were fed unfortified human milk only. The study lasted 12 weeks following hospital discharge. Both groups received intensive lactation support at home.

At the end of the study, the babies in the intervention group had greater weight gain, greater growth in length, and larger head circumferences than the babies in the control group. Their intakes of protein, zinc, calcium, phosphorus, and vitamins A and D were also higher than the intakes of the control group. There was no significant difference between the amount of human milk fed to either group. The authors note that the percentage of infants in this study receiving human milk at 12 weeks post discharge was much higher than typical. They credit this to the fact that these infants were all receiving human milk at hospital discharge and that they received lactation support for the duration of the study.

The authors conclude that preterm infants can benefit from receiving about half their milk fortified without completely interrupting breastfeeding.

Human milk is the perfect food for babies. When babies are born preterm, they should be fed their mother's milk for the first two weeks of life. After that, they will need fortified human milk. Various products are available to fortify human milk. The infant's health-care provider will determine how much and how long a human milk fortifier should be used. Texas WIC staff can work with participants and providers to meet the needs of our tiniest Texans.

O'Connor D.A., et al. 2008. Growth and nutrient intakes of human milk-fed preterm infants provided with extra energy and nutrients after hospital discharge. Pediatrics. 121 (4):766-776.

Morales Y. and R.J. Schanler. 2007. Human milk and clinical outcomes in VLBW infants: How compelling is the evidence of benefit? Seminars in Perinatology. 2 (2): 83-88.

Chan, G. 2003. Effects of powdered human milk fortifiers on the antibacterial actions of human milk. Journal of Perinatology. 23: 620-623.

Abbott Nutrition. 2009. Human Milk Supplementation. Pediatric Nutrition Product Guide. 57-65.

Mead Johnson Nutrition. 2010. Enfamil Human Milk Fortifier. Pediatric Products Handbook. 76-80.


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Local Agency Spotlight: Dallas Lactation Care Center Opens

by Frances Darlene Irwin
Manager, City of Dallas WIC Program

On Thursday, December 16, 2010, the City of Dallas WIC program celebrated the grand opening of their new Lactation Care Center. The new center is a state of the art breastfeeding support center whose mission is to help WIC program eligible mothers reach their breastfeeding goals with the help of certified lactation consultants and peer counselors. All services are free to WIC eligible participants who otherwise might not be able to afford these services. The Lactation Care Center will also provide training and educational opportunities to the health care community, and is one of only three such centers in Texas.

The funds used to open the Lactation Care Center, located at 2600 N. Stemmons Freeway, Suite 188, were awarded to the City of Dallas WIC program through the Department of State Health Services grant contract. The decision to open the Dallas center was based in part on the WIC program's excellent record of high breastfeeding initiation rates. With the support of the lactation consultants at this center, we anticipate increased duration rates and successful long-term breastfeeding experiences for our WIC moms.

U.S. Department of Agriculture, state, and local officials participated in the official ribbon cutting ceremony, including Deputy Administrator Audrey Rowe, Special Nutrition Programs in the Food and Nutrition Service; Southwest Regional Director Eddie Longoria, Supplemental Foods Program (WIC), FNS USDA; Unit Manager Linda Brumble, Nutrition Education/Clinic Services Unit, Texas Department of State Health Services; Breastfeeding Coordinator Tracy Erickson, Texas Department of State Health Services; Assistant Director Karen Rayzer, City of Dallas Housing/Community Services Department; WIC Program Manager F. Darlene Irwin; and WIC Breastfeeding Coordinator Deborah Parnell. Many hospital and community partners also attended.



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Milk Banking: A Life-Saving Investment

by Lindsey Randall
Breastfeeding Promotion Nutritionist

Do you have moms who tell you they make too much milk?

Although low milk supply is more commonly seen, it is important for staff and clinics to have the resources available to support women who have a generous or an oversupply of milk. With this in mind, what kind of information or resources are you sharing with women who have a generous or an oversupply of milk? How is your WIC clinic equipped to support women who are producing more milk than their infants need?

Local agencies such as the City of Dallas WIC program (07), Denton County WIC program (35), Outreach Health Services WIC program (76), and Brazos Valley Community Action Agency, Inc. (32) are among the few agencies in Texas who have resourcefully joined forces with the Mothers' Milk Bank of North Texas and the Mothers' Milk Bank at Austin. By reaching out to the Mothers' Milk Bank of North Texas and the Mothers' Milk Bank at Austin, WIC clinics within these agencies have become approved milk depot collection sites in an effort to support women who are producing more milk than their infants need.

Milk banks always need more donor human milk. Offering easy access to milk banks by becoming milk depot collection sites is valuable to both donors and recipients. Many women who donate their surplus milk feel a sense of honor, personal satisfaction, and involvement. Donating milk has, in many cases, become a coping mechanism for bereaved or surrogate mothers dealing with feelings of loss. According to Mary Bryant, breastfeeding coordinator for Denton County WIC office, "When our participants can give donor milk they feel good. This is especially true if they have or have had a baby in the NICU. They know the benefits of breastmilk and want to share their breastmilk with other infants." It is a win-win for everyone involved.

Human milk is the ideal nutrition for all infants, but it is particularly important for preterm or otherwise compromised babies. Unlike formula, a mother's milk is easily digested, reduces the incidence of necrotising enterocolitis (NEC), contains special growth factors that help babies develop, as well as anti-viruses that attack harmful cells, and antibodies that help protect against germs and infections. Even though preterm infants are at a greater need for human milk, their mothers typically struggle with milk supply. In times when a mother's milk is unavailable, donor human milk from a milk bank is the next best thing —in fact it can be life-saving.

Having milk depot collection sites in the clinic has increased milk donations. Those who have implemented milk depot collection sites within their clinics have found the convenience is a factor in a woman's decision to donate surplus milk. Deborah Parnell, breastfeeding coordinator from the City of Dallas WIC program, said, "Being a collection site is an important part of the donor channels, which are necessary for any milk bank to function. Everything about being a drop-off site is positive. There is no cost to WIC as the milk bank provides the freezer and a courier to pick up the donated milk. It's convenient for WIC moms as well as other mothers, who are making a difference in the lives of others and we are happy to be helping in that process."

Local agencies are encouraged to collaborate with Texas milk banks to help recruit donors and to contact them about potentially serving as milk depot collection sites. These small contributions have a huge impact on lives, from the donor, to the recipient, to the family members involved as well as the community at large.

To learn more about milk banking in Texas or how to get involved, visit Mothers' Milk Bank of Austin http://www.milkbank.org/ or Mothers' Milk Bank of North Texas http://www.texasmilkbank.org/.


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Test Your Breastfeeding IQ

by Eaton Wright, B.S., NUT
Nutrition Expert

Eaton Wright here and it's that time again. Time to write about one of my favorite topics: the SUPER benefits of breastfeeding. This issue's Test Your Breastfeeding IQ quiz is a real head scratcher, so dust off your thinking caps and get ready.


1. True or False. New infant formulas are designed to be just like breastmilk.

2. How long can breastmilk be stored in the refrigerator?
a. 1 hour
b. 5 days
c. 3 months
d. 6 months

3. True or False. Infants breastfed for six months or longer do considerably better in school at age 10 compared to children who were breastfed for less than 6 months.

4. The benefits of breastfeeding are not just for baby. Mom receives many benefits of breastfeeding too. Which of the following is NOT a benefit of breastfeeding?
a. Breastfeeding saves time. No messy bottles to fix or clean at night.
b. Breastfeeding helps mom lose weight.
c. Breastfeeding lowers mom's risk of breast and ovarian cancer, diabetes and heart disease.
d. Breastfeeding adds 3 hours to a typical 24 hour day. Mom can do whatever she wants with those 3 hours and nobody can tell her nothin' about it.


1. The answer is False. Infant formula is nothing like breastmilk. Breastmilk changes as your baby develops, from the first drop of colostrum to mature milk and from foremilk to hind, breastmilk changes to meet the infant's unique needs. The higher concentration of antibodies, protein and minerals in colostrum make it the perfect food for newborn babies. As breastmilk begins to mature, a week or so after delivery, it is produced in greater quantity and has a higher fat content. No formula will ever be able to do that!

2. The answer is B. Breastmilk can be stored in a refrigerator (temperature less than 40˚F) for up to five days. Breastmilk may be stored in a freezer for up to three months (temperature less than 32˚F), or in a deep freezer for six months (temperature less than 0˚F).

•  Store small amounts of breastmilk in clean containers.
•  Thaw breastmilk in the refrigerator or by placing the container under warm running water.
•  Never microwave or boil breastmilk.
•  Do not refreeze breastmilk once it has been thawed.

For further assistance, please call 1-800-514-6667 or visit www.breastmilkcounts.com.

3. The answer is True. Yep, according to a study published December 20, 2010, in Pediatrics, 10-year-old children who were predominantly breastfed for six months or longer in infancy had higher academic scores than children who were breastfed for less than six months. The effect of breastfeeding on educational outcomes differed according to gender; boys were particularly responsive (in mathematics, spelling, reading, and writing) to a longer duration of breastfeeding. Take home message: Mothers should be encouraged to exclusively breastfeed for the first six months and beyond as long as mutually desired by mother and child.
— Source: Pediatrics. January 2011. Vol. 127 No. 1. pp. e137-e145.

4. The answer is D. Breastfeeding can work wonders for mom's postpartum waistline, but it can't help mom get more hours of sleep or another hour to catch up with her best friend!

As always… breastfeed for a BIG baby brain.

About the author: Eaton Wright is a certified NUT based in Austin, Texas.

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Last updated December 10, 2014