Development of a WIC Single-User Electric Breast Pump Protocol

Abstract

Objective:

This project describes the development of a protocol that compared issuing multi-user electric breast pumps to single-user breast pumps for Special Supplemental Nutrition Program for Women, Infants and Children (WIC) participants.

Methods:

Forty breastfeeding mothers participating in WIC who were separated from their infants ≥30 hours a week, planned to offer breastmilk until their infants turned 1 year, and used a WIC-loaned electric breast pump for at least 1 month were enrolled in the project.

Results:

Results of this project indicate that an appropriate protocol to administer single-user electric breast pumps was developed and may provide some benefits to both WIC and WIC mothers.

Conclusion:

Recommendations to successfully continue using the single-user breast pump protocol include strengthening policies, procedures, and future issuance criteria.

Introduction

Breastfeeding is the recommended form of feeding for all infants throughout the first year of life.^1,2 Infants receive a multitude of benefits from breastmilk, including resistance to infectious diseases, enhanced immune system, nutritional and growth benefits, and reduced risk for chronic diseases.^1,2 In addition, mothers who breastfeed often experience improved maternal health and socioeconomic benefits.^1,2 A large proportion (>50%) of mothers who have infants work outside of the home full-time; roughly one-third of these mothers return to work within 3 months and two-thirds within 6 months of delivering their infants.³ Approximately 40,000 mothers of infants (under 12 months of age) are in the Colorado labor force.⁴ This is a distressing reality given the challenges it creates for breastfeeding during a vital time for setting the stage for an infant's short- and long-term health outcomes. A single-user breast pump can assist women who have already established a good milk supply maintain their supply and enable them to offer additional feeds of breastmilk to their infants.⁵

A major goal of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is to encourage and support WIC participants to breastfeed their infants.⁶ In Colorado, WIC mothers consistently breastfeed for a shorter duration than do mothers who are not enrolled in WIC.⁷ The fourth most common reason Colorado WIC participants cited for ceasing breastfeeding was because of returning to work or school.⁷ Meehan et al.⁸ determined that WIC working mothers who received an electric breast pump were 5.5 times as likely not to request formula at 6 months compared to those mothers who did not receive a breast pump. WIC participants who are committed to breastfeeding their infants may benefit from the use of an electric breast pump. However, as more WIC mothers continue breastfeeding upon returning to work, WIC staff is challenged with managing large numbers of multi-user electric pumps and providing mothers with knowledge to succeed with pumping in the workplace.

The purpose of this article is to describe the development of a protocol that compared issuing multi-user electric breast pumps to single-user electric breast pumps for WIC participants. WIC staff feedback and WIC participant feedback were the primary outcomes that were assessed to determine if the protocol was successful. WIC infant food package issuance and cost to the WIC program were also assessed.

Protocol Development

Participants included a convenience sample of 40 WIC breastfeeding mothers from six WIC clinics, both urban and rural locations, who were separated from their infants ≥30 hours/week and who wanted to express their breastmilk. Participants were issued an electric single-user breast pump if they met the following criteria: (1) infants were at least 6 weeks postpartum; (2) had already used a WIC electric multi-user pump for at least 1 month; (3) returned to work or school and were separated ≥30 hours/week from their infants; and (4) planned to offer breastmilk for a minimum of 1 year. Twenty single-user electric breast pumps were obtained from a breast pump company, and three protocol forms (pre/post questionnaire, breast pump release form, and flow sheet) were developed. Content and face validity were established for each form. Participants were screened for participation eligibility using a questionnaire and had to meet the criteria listed previously. All participants consented to participate in this project, and procedures followed were in accord with the ethical standards for protocol development by the Colorado Department of Public Health and Environment. WIC mothers who already received formula from WIC for their infant were ineligible to participate. Once a participant was identified for the project, she either continued to borrow the multi-user electric breast pump, or it was exchanged for the single-user electric breast pump. Participants using either breast pump received the exclusively breastfeeding food package (containing milk, cheese, eggs, cereal, juice, tuna, carrots, peanut butter, and dried beans) and no formula from WIC for their infants.

WIC staff members involved in the project were trained in lactation management. Twenty electric multi-user breast pumps and 20 single-user electric breast pumps were issued alternately to the first 40 participants who met the criteria. WIC staff was directed to alternate the breast pumps that were offered. For example, if a multi-user pump was issued to the first mother who met the project criteria, a single-user pump was given to the next mother. For the project, each clinic identified the same number of participants for each type of breast pump. Staff was instructed to educate each mother on assembly, use, disassembly, cleaning of the breast pump, and handling and storage of expressed breastmilk. Participants had to read and sign a breast pump release form. WIC staff who issued the breast pump also signed the release form and provided a copy to the mother. As participants were identified and enrolled in the project, monthly follow-up information was documented on a flow sheet. The information collected included the date of contact with the WIC staff member, the average number of pumping sessions in a 24-hour period, the average number of hours a day the mother was separated from her infant, the number (if any) of cans of formula the mother received from WIC, and additional comments (e.g., pumping experiences at work or school). If a mother requested WIC formula, she was referred to the WIC dietitian or nurse, so they could understand and discuss the following: (1) Her reasons for wanting to supplement breastfeeding; (2) review the effect supplementation has on breastfeeding; and (3) determine if supplementation was the best solution or if other breastfeeding support could be provided. If the infant was issued formula, staff was instructed to follow program guidelines for determining the minimum amount of formula for breastfed infants. The mother was encouraged to continue to breastfeed and use the electric breast pump. Participants who received the pump were offered a breastfeeding support letter to provide to their employer or school administrator. The letter requested the worksite/school support the mother's need to regularly pump, collect, and store her milk. [Since this protocol evaluation, Colorado has signed into legislation the Workplace Accommodation for Nursing Mothers Act requiring employers make a reasonable effort to provide break and/or meal time to express milk.] In addition, participants who received the single-user electric breast pumps were instructed that the pumps were for their personal use only and should not be resold, lent, or shared with others. They were encouraged to keep their breast pumps for future children. Participants completed a questionnaire upon completion of the use of the breast pump at 1 year postpartum (whichever came first).

At the completion of the development and evaluation period, the eight WIC staff members who implemented the project in their respective clinics met as a group and were asked the following: (1) To describe the number of hours on average needed to loan, follow-up, and track the multi-user electric breast pump and the number of hours on average to issue the single-user electric breast pump; (2) to identify the apprehensions or concerns participants communicated to them regarding expressing breastmilk at work and/or at school; (3) to discuss their overall experiences issuing the two electric breast pumps and their recommendations for future use; and (4) to discuss their perceived challenges and strengths to offering the single-user electric breast pumps to select participants.

Protocol Development Outcomes

WIC staff assessment

WIC staff reported that issuing the single-user electric breast pump saved time (e.g., staff did not have to sanitize and clean pumps between participants, and minimal tracking was needed). In a 12-month period for each WIC participant, 1½ hours were spent issuing the electric single-user breast pump, and 5 hours were spent issuing, tracking, and cleaning the electric multi-user breast pump (on average). All breast pumps provided support to WIC breastfeeding mothers and gave mothers access to express their milk long-term per WIC staff. Challenges identified by staff included how to adequately screen participants to find those mothers who will breastfeed long-term, how to deal with the potential for participants selling the single-user electric breast pumps when they no longer require them, soliciting the additional time needed to have the dietitian or nurse meet with the mother if she requested formula at follow-up visits, and having adequate storage space to store the single-user breast pumps in the clinic prior to issuance. Staff offered the following suggestions to improve the protocol: (1) Use a paraprofessional staff member trained in lactation management to provide the counseling for participants who verbalized an interest in supplementing with formula rather than only professional staff (RD/RN). (2) Issue the multi-user electric breast pump for a longer period of time (3–4 months) before issuing the single-user electric breast pump to be more certain of the mother's commitment to expressing breastmilk. (3) Make the guidelines more flexible to enable staff to have additional subjective input on who receives the pump. (4) Imprint a statement of the risk for reuse by another person on the single-user electric breast pump carrying case. Overall, WIC staff believed that both pumps provided support to WIC mothers and that the single-user electric breast pump required minimal tracking (e.g., only documentation of issuance), increased support for breastfeeding mothers, and saved WIC staff time because of a decrease in time spent to track and ensure pumps are returned and cleaned between users.

WIC participant assessment

Forty (100%) participant evaluations were completed. Few comments were written regarding workplace/school environment attitudes. Seventeen WIC participants reported that they believed their colleagues' attitudes changed about breastfeeding or expressing breastmilk as a result of their experience and/or as a result of breastfeeding information shared. Fifteen participants reported they “didn't know” if attitudes changed, and eight thought attitudes had not changed. Twelve participants commented on their work or school environment and expressing their breastmilk. Six participants reported they pumped in the bathroom at work, while six others stated they had a quiet, private room. Overall, WIC participants were extremely satisfied (4.6 out of 5.0 on a Likert scale) with both breast pumps. Participants who had first used the multi-user electric breast pump and then were issued the single-user electric breast pump reported more often that they would not have expressed their breastmilk for as long without the single-user electric breast pump, and they were pleased to have it to express milk for future children as well as the pump was easier to use and not as “bulky.”

WIC infant food package issuance assessment

A review of the food packages issued to all 40 participants over the time they participated in WIC during their infants' first year of life was completed. Fifty percent of infants whose mother used the single-user electric breast pump received formula from WIC during their first year of life, and 35% received formula during their first 6 months of life. Eighty percent of the infants whose mother used the multi-user electric breast pump received formula from WIC during their first year of life, and 65% received formula during their first 6 months of life. WIC participants who used the single-user electric breast pump breastfed or expressed breastmilk without formula supplementation from WIC for an average of 9 months, while those WIC participants who used the multi-user electric breast pump breastfed or expressed breastmilk without formula supplementation for an average of 6 months (Table 1).

Table 1.

Average Number of Months per Type of Feeding by Breast Pump Type for the 40 WIC Participants

Type of breast pump	No WIC formula	Partial WIC formula	Full WIC formula
Multi-user	6	3	4
Single-user	9	2	2

WIC, Special Supplemental Nutrition Program for Women, Infants and Children.

Cost assessment

The cost of formula redeemed for the two groups differed (Table 2). Total formula costs for the group of participants with the multi-user electric breast pump who supplemented with formula amounted to $8,564.77 for the year, or an average of $570 for each infant who received standard infant formula. Four of twenty infants remained exclusively breastfed through their first birthday. Total formula costs for the group of participants with the single-user electric breast pump amounted to $5,287.16 for the year ($3,277.61 less than the users of the multi-user pump), or an average of $528 for each infant who received standard infant formula. Nine of the 20 infants remained exclusively breastfed through their first birthday. The formula redemption for two infants, one in each group, was not included in the cost evaluation because of their need for specialized infant formulas. In addition, projected cost savings, which included a comparison of both staff time (issuance, tracking, and cleaning) and pump costs, was $65 less for each WIC participant if she used the single-user electric breast pump.

Table 2.

Total Formula Costs per Breast Pump Type

Type of breast pump	Total formula costs	Average cost per infant
Multi-user	$8,564.77	$570.00
Single-user	$5,287.16	$528.00
Total cost difference	$3,277.61	$42.00

Discussion

This article describes the development of a protocol that compared issuing multi-user electric breast pumps to single-user electric breast pumps to WIC participants. The three protocol forms (pre-/post-use questionnaire, breast pump release form, and flow sheet) were deemed as appropriate and user-friendly by the WIC staff and WIC participants. WIC staff and WIC participants felt that any electric breast pump may provide support for women who work outside of the home or attend school to continue to breastfeed. Specifically, with the single-user electric breast pump, less WIC formula was issued, and less WIC staff time was needed to issue the breast pumps. This is comparable to the results that Meehan et al.⁸ found in their study. In regard to support in the workplace, this protocol was developed before the Workplace Accommodation for Nursing Mothers Act was signed into legislation, so this factor would need to be changed in the protocol forms. As with any evaluation, limitations did exist. Even though WIC staff was instructed to alternate the issuance of the two pumps, staff was on their honor to choose every other participant. Based on the staff records, this did happen; however, it is difficult to be certain because randomization did not occur prior to the start of this project. Staff only tracked formula issued by WIC. It was not recorded if mothers used formula from other sources. The use of manual breast pumps was not investigated in this project.

Conclusions

Discussions and evaluations from WIC staff and participants indicate that an appropriate protocol to administer single-user electric breast pumps was developed. Also, the single-user breast pump was determined feasible by WIC staff because of possible projected time and cost savings to the Colorado WIC Program. The single-user breast pump also appeared to possibly increase the duration of offering breastmilk to WIC participants' infants. Both multi-user and single-user breast pumps offered support to WIC participants. Future interventions to confirm whether or not single-user electric breast pumps enable WIC mothers to offer breastmilk to their infants for longer period of times are warranted. In addition, determining the average volume of breastmilk and number of times a day breastfed and if workplaces are in line with the current legislation might also be beneficial variables for future research. Recommendations to successfully continue using this protocol include strengthening policies and procedures regarding the electric single-user breast pump for future use, especially in regard to issuance criteria.

Footnotes

Acknowledgments

The authors would like to acknowledge Medela, Inc. for the single-user breast pumps, the WIC staff and participants who assisted with this project, and Gabriel Kaplan and Jenna Raymond for manuscript assistance.

Disclosure Statement

No competing financial interests exist.

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