CCHAP Newsletter Six

Contents:

- Breastfeeding and Early Combination Feeding (‘los dos’) in Latinas -
- Incorporating an Interpreter into Your Office -
- What is new in CCHAP? -
- Parental smoking and childhood asthma -
- Cross-Cultural Health Care Workshop -

- Integrating Developmental Screening in Primary Care Practice -
- Medical Spanish Training For Office Staff  -

- Next Practice Liaison Teleconference -

Breastfeeding and Early Combination Feeding ‘los dos’ in Latinas
Maya Bunik, MD, MSPH and Mary E. O’Connor, MD, MPH

Despite what is known about the benefits of breastfeeding to both the infant and mother, racial and ethnic discrepancies exist regarding decisions about breastfeeding, hospital initiation, and duration. According to national data from Pediatric Nutritional Surveillance Survey, Latina women have breastfeeding initiation rates of 73%, but only 30% are breastfeeding at 6 months, which is well below the Healthy People 2010 goals of 50% at 6 months. Mothers with lower socioeconomics status and those enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) have even lower initiation rates of 53% initiation and 21% duration at 6 months of age.

We and others who work with this population had noticed that many of the Latina mothers in Denver initiate breastfeeding with ‘los dos’ (combination of breast- and bottle-feeding in the newborn nursery).  Frequent bottle feedings of formula (topping off after each feeds and other variations on supplementation) in the first week of life often result in lowering of mother’s milk supply. As a result, babies refuse to latch onto the breast and by 2 weeks of age mothers fear of  “no tengo leche” (‘I don’t have milk’) becomes a reality. We recently published a qualitative study in Breastfeeding Medicine where we explored this issue of combination feeding with Latino families at Denver Health (see reference at end of the article). Although non-Hispanics may also be using this combination feeding method, this appears to be more common in Latinas than in other cultures and in those Latinas who live in the United States in contrast to Latinas in their country of origin (increased bottle feeding with acculturation).

Focus groups and interviews with Latina mothers and their family members (fathers and grandmothers) revealed some common themes:

1) By giving both breast milk and formula, Latina mothers feel they are insuring the baby gets the ‘best of both’-healthy aspects of breast milk and the vitamins in formula. Mothers told us that they want to provide insurance by having the baby get both, in case there was something in formula (i.e. vitamins and other things) that was necessary. They also said that they get mixed messages from medical providers regarding formula supplementation and from receiving formula samples from hospital at discharge.

2) Breastfeeding is natural but it is associated with problems (or hardship). Many  first-time Latina mothers were surprised that breastfeeding causes pain, sore nipples, embarrassment/discomfort in public, and can change the appearance of breasts postpartum. Latinas commonly reported that they heard that mothers who ate chile, spicy foods and beans would cause problems in the baby, particularly colic. Mothers also reported that if mothers do not eat well their milk would be more watery. Most participants also were told of the importance of drinking atole (cornstarch gruel protein drink) for breastfeeding mothers. This information is shared widely among Latinas, although it is never specifically linked with professional advice or instruction.

3) Mothers want to breastfeed, but things can happen to them that are beyond their control (fatalismo). Violation of La Cuarentena (40 days postpartum period) offers explanation for milk supply issues and other problems. Going outside or getting cold exposure to the back was often used to explain low milk supply or milk supply going away. Evaluation by a medical expert was not sought for problems of milk supply. Being away from the baby for school or work or social reasons was another reason given for formula supplementation. Mothers pumped (using a manual pump) only to remove milk and relieve full and engorged breasts, but usually discarded this milk. For these women, pumping was extraneous to the breastfeeding experience. Some babies were reported to have a ‘preference’ for formula. Mothers with anatomic issues or illness again did not consider contacting a health care provider or ask for professional advice for breastfeeding difficulties.

4) Hispanic parents and grandparents want what is best for the baby and give strong messages about cultural beliefs. We found that families who were involved with raising animals in Mexico (rancheros) came with a knowledge and appreciation for colostrum and breast milk. Mothers reported family members advising supplementation with formula if the infant has excessive crying or is not gordito e.g. Mothers expressed concern that others make comments on the infant’s body size or shape implying a chubby child is more desirable and a leaner child may be associated with not getting enough breast milk.  It is common knowledge among Hispanic families that any negative emotion can affect breast milk in mothers—coraje, pathologic anger, is believed to spoil breast milk or susto, a sudden disturbance of emotions, also is believed to affect milk and both are to be avoided.
 
Our work and research in this population leads us to several recommendations for those providing breastfeeding support in Latino populations:

1. Providers need to acknowledge the hardships of breastfeeding, but clearly explain to new mothers about the importance of doing it.  Emphasize the importance of delayed supplementation and perhaps provide specific recommendations, such as a maximum of one bottle of formula a day and coming to see their provider if they have concerns about perceived insufficient milk supply may also prove helpful.
2. Emphasize that breast milk from a mother who is taking vitamins has everything in it needed by the baby initially.  Later, they can add vitamins for the baby.
3. Ask the mother about her concerns about breastfeeding and breast milk.  And ask the mother what she has heard from others about breastfeeding and breast milk.  As myths arise, provide her with current medical information to counter the myth.
4. Emphasize the benefits of feeding pumped milk to the baby rather than discarding it.  This should be communicated to mothers and family members. This may also require working with the mother on the appropriate storage, manipulation and time limit of pumped milk. Improving access to breast pumps through WIC and limiting access to free formula, as well as raising awareness among employers that facilitate pumping milk and milk storage in work places are important policies that influence this population and need to be addressed on a community level.
5. Providers should appeal to the traditional family values by including other persons in the family that the mother thinks can support the breastfeeding mother (fathers, grandparents, comadres) especially during the critical period of la cuarentena.

References
Bunik M, Clark L, Zimmer LM, Jimenez LM, O’Connor ME, Crane LA, Kempe A. Early Infant Feeding Decisions in Low-Income Latinas. Breastfeeding Medicine 2006. 1(4): 225-235. If you are not able to get access to Breastfeeding Medicine, contact us for reprints.

Your Colorado AAP Chapter Breastfeeding Coordinators:

Maya Bunik, MD, MSPH,
Assistant Professor, Pediatrics, UCDHSC          
The Children’s Hospital
1056 E.19th Ave
Denver, CO 80218
Bunik.maya@tchden.org

Dr. Bunik offers a New Breastfeeding
Clinic —outpatient consults and referrals
303-837-2740

Mary E. O’Connor, MD, MPH
Associate Professor, Pediatrics, UCDHSC
Westside Family Health Center
Denver Health
Mary.O’Connor@dhha.org

Commentary by Angela Sauaia, MD, PhD.  Head of Cultural Competence Program, UCHSC.

Utilizing a cross cultural communication model such as LEARN  (see Newsletters 2 and 5) may assist in identifying potential barriers to successful breastfeeding. Once the barriers are identified, the provider may be able to counsel the mother on appropriate ways to deal with those barriers, and /or direct her to existing resources.  Understanding and exploring Latino core values (refs Sauaia 2004, Welsh 2005, Sauaia 2007) of family, fatalism and trust  may be of assistance in solving breastfeeding problems.

Be aware that socio-economic reasons are among the most frequent causes of breastfeeding failure (e.g., unable to take time off work), and always explore this issue. Don't be quick to attribute failure to cultural values or beliefs.  (see ref below)

Engage the family in the process: ask about her family's ideas and traditions on breastfeeding (pros and cons), look for positive aspects; engage the family in assisting her in the process (can Grandma assist in latching, can someone take over family roles so she can breast feed, etc); make sure the rest of the family knows how important it is to breastfeed (especially the husband).   Always build on the positive aspects that already exist, carefully but firmly clarify misconceptions that can be harmful and offer current medical ideas. 

Acknowledge fatalism by working with her and her family to understand that she can and should actively influence the success of breastfeeding for the sake of her baby.

Ask her who she most trusts for advice on breastfeeding (and what that person advises).
Suggest that person come with her to the breastfeeding-related appointments.

Reference:
Welsh AL, Sauaia A, Jacobellis J, Min S, Byers T. Effect of a Church-Based Approach to Increase Breast Cancer Screening Among Latinas on Medicaid. Preventing Chronic Disease Prev Chronic Dis [serial online] 2005 Oct. Available from: URL: http://www.cdc.gov/pcd/issues/2005/oct/04_0140.htm.  2005. 
 

Incorporating an Interpreter into Your Office

In  Newsletter #2, we described the literature on health care for children whose parent has limited English proficiency (LEP) and the importance of trained interpreters.  In Newsletter #3, we described the effective interactions of an interpreter and a provider.   Using untrained family members or volunteers can result in poor clinical outcomes.   Research shows positive benefits from utilizing trained interpreters: fewer errors and better compliance, clinical outcomes and satisfaction with care.  For most practices, hiring a professional interpreter is not an affordable alternative.  A cost-efficient option is  to have bilingual staff trained in medical Spanish (or other languages that predominate in the population served by your clinic) and trained in the methods  used by professional interpreters. 

The key steps for having a practice staff member serve as an interpreter:

1. Commit to developing a formal process and identifying someone to be in charge of that process.  The practice will benefit from having the practice manager, a provider and the interpreter discuss the issues and process described here.
2. Require office interpreters to take a course in which they learn about:
        a.  HIPPA rules and confidentiality
        b.  Professionalism and etiquette
        c.  Medical terminology
        d.  Ethical issues
        e.  Cultural issues
        f.   Positioning
        g.  Professional boundaries
3. Agree that the interpreter and the provider will talk for a few moments before seeing the patient to prepare for the visit. (see newsletter #3 for a discussion of effective interactions between interpreter and provider)
4. Discuss how the interpretation role will interface with other responsibilities.  Interpretation should not be just an add-on to an already full job. It produces stress to pull someone away from their full-time duties to interpret and then expect them to return and rush to complete their regular duties.
5. Discuss how you will acknowledge the importance of this role in the practice.   How will this person be compensated for the extra training and responsibility?  [It is often taken for granted, but it deserves extra pay and status in the practice]
6. Develop guidelines for schedulers to be sure all patients needing an interpreter are scheduled when the interpreter will be available. Also, develop guidelines for notifying the interpreter when families will be coming in (or are in and ready) for interpretation.
7. Decide how you will handle errors in translation and how you will communicate it to the interpreter.  How will you make it a learning experience for all interpreters in the office in a non-punitive manner.
8. Arrange periodically to set aside time to discuss how things are going and to discuss problems and issues.

As you develop your processes, the following mnemonic may be helpful in thinking of all of the issues to address:

What’s New?

Expansion:
          CCHAP now provides 12 support services for 27 metro area pediatric practices 
          (1/2 of metro pediatric practices) and 7 metro family practices.

New Staff:
          Lorena Reyes has joined CCHAP as a care coordinator to work with Erlinda Diaz
          Regina Kelley has joined CCHAP as an administrative assistant.

Improve reimbursement:
          CCHAP has begun working with the new leadership in the Colorado Department 
          of Health Care Policy and Financing (HCPF) to develop a plan to share savings 
          with CCHAP practices (the savings that HCPF will experience by having a Medicaid 
          child in your practice) and reward good health outcomes.  We will be discussing 
          this at the next practice manager’s meeting.

          Colorado Access has begun to assess a proposed pay-for-performance plan for 
          CHP+ children. 

Parental smoking and childhood asthma: What you can do to clear the air

Major Conclusions from the US Surgeon General’s 2006 Report: “The Health Consequence of Involuntary Exposure to Tobacco Smoke”:

• “Secondhand smoke (SHS) causes premature death and disease in children and adults who do not smoke.”
• “There is no risk-free level of exposure to SHS.”
• “Children exposed to SHS are at an increased risk for sudden infant death syndrome, acute respiratory infections, ear problems, and more severe asthma.  Smoking by parents causes respiratory symptoms and slows lung growth in their children.” 

Other Key Points from this Report:

• SHS exposure is greater in persons with lower incomes.  So, minority families are more at risk than the general population to the extent they are poor.
• The home is now the major source of SHS exposure for children.  Workplace and public smoking bans have lead to reduced SHS exposures, but these reductions are much greater in adults than children.  Biomarker studies suggest that children now have, on average, double the exposure of adults.
• Maternal smoking during pregnancy causes persistent adverse effects on lung function across childhood.
• Postnatal exposures to SHS cause increased respiratory symptoms (e.g., cough, wheeze, breathlessness), increased incidence of wheezing illnesses, increased chance of ever having asthma, and lower level of lung function during childhood.  Evidence is suggestive that most of these adverse effects persist into adult years, even among children who themselves never smoke.
• Childhood SHS exposure appears to increase the risks of cancer during childhood and later in life.

Other relevant points:

• Once a child has developed asthma, more than 20% of all child asthma attacks are triggered by tobacco smoke in the children’s homes. 
• Despite this causal connection between parental smoking and asthma exacerbation, children with asthma are as likely to live in a home with smokers as healthy children.
• Although some “harm reduction” strategies (e.g., always smoking outside) can reduce the risk of parental smoking to children, even the best of these strategies does not remove all smoke (and hence risk to children) from the home.  As such, helping parents quit smoking is the best way to improve the health of their children.
• There are brief and effective steps you can take in your practice to reduce asthma incidence, morbidity and mortality.

Are you doing all you can to clear the air around your patients and safeguard their health?
You can make a huge difference.  Brief (≤ 3 minute), routine, and systematic inquiry and counseling about personal smoking and SHS exposure by health care professionals are clinically effective and extremely cost-efficient interventions.  For example, following the “5A’s” (Ask, Advise, Assess, Assist, Arrange) with tobacco smokers triples cessation rates.  These procedures work best when they are built into the flow of your clinic operations (e.g., personal smoking and SHS exposure recorded every visit as a “vital sign;” the required resources to advise, motivate, and assist patients to change are easy for clinicians to access).
 
Our question to you is, “Are you doing all you can to clear the air around your patients and maximize their chances of optimal health as a child and on into their adult years?”  If you think you are, are you willing to have us visit your practice and learn from your success?  If you think you are not, may we provide a free consultation to you about ways you might implement brief, evidence-based tobacco control strategies in your practice?

With support through our local EPA office, a team comprised of practice change specialists from National Jewish, TCH and UDCHSC, will come to your clinic at a time convenient to you and conduct a brief (2-4 day) card study your current tobacco control practices, getting info from clinicians and patients.  We then will share the results of this card study with you, and based on your thoughts and wishes, discuss options that you might want to consider to improve what you are doing.  For more information about this project, please feel free to contact Fred Wamboldt, MD, at 303-398-1827 or wamboldtf@njc.org.

Cross-cultural Health Care Workshop
Thursday, May 3, 2007
1:30 to 5:00 PM

Earn 2 ERS premium discount points with COPIC
Earn 7 category 1 CME credits (transferable for nursing CE credit, too)

The workshop has been developed by the cross-cultural care faculty at the University of Colorado School of Medicine. 

The curriculum:

“I got a lot out of the workshop.”  Roxann Headley, MD
“The seminar was very effective. It certainly raised my awareness, understanding and sympathy. I would endorse this with my physicians and staff.” Mike Ripperton, practice administrator

To register, contact Joanie Muzzulin at
303-861-6309 or Muzzulin.joan@tchden.org

Integrating Developmental Screening in Primary Care Practice
Training Workshop
Wednesday, May 9, 2007, 12 – 4 PM

This presentation will include an overview of

Locations:

Denver (Live Site)
The Children’s Hospital, 1056 E. 19th Avenue, 6th Floor Lecture Hall, Denver (Parking available in the garage at Downing & 20th for $2)

Webconferencing – The live presentation will be available online through any computer with an internet connection with speakers.  Limited spots are available for webconferencing, so we encourage groups to gather to view the presentation by projection through an LCD from a laptop with speakers.  If you are a group gathering, only 1 person from the group should register and that person will be emailed directions and the URL for the seminar.

Check for registration information at http://www.jfkpartners.org/workshops.asp

Spanish Interpretation Training for Pediatric Practices

Our Next Session Begins in May  

CCHAP offers a convenient, time-efficient, cost-efficient medical Spanish interpretation training program for pediatric office staff and providers.  It is provided as a telephone conference, during practice office hours at lunch time

Training in medical Spanish interpretation includes:
          Medical (pediatric) terminology
          The subtle differences in the two languages in word selection and grammar
          Culturally appropriate communication skills
          Professionalism and etiquette of interpretation
          Confidentiality and HIPPA issues

Who: This program is for people in the practice who already speak Spanish and English

How:  The sessions will be conducted via telephone, using handout materials and the Internet, and will also include role-playing.

When: Wednesdays from 12:15 to 1PM

Starting: May 2, 2007

How long: 45 minute sessions

How long: 6 weeks

Registration - Each individual can register using the registration form, which will be sent to each practice administrator and be available in the CCHAP Newsletter.  Each class participant will fill out the form and send it in by emailing it to ilssoto@aol.com. 

Price: $20 per session.  Please send check for $120, payable to International Language Services, 12572 West Brandt Place, Littleton CO 80127.

An assessment of each individual’s skill level will be done during a 5-10 minute phone call prior to first telephone conference/class – during lunch hour.  Schedule this initial individual telephone call during the week of April 23, during the lunch hour via email at ilssoto@aol.com. 

A certificate of completion will be given after completion of all 6 sessions.

The faculty is Maria Soto, a certified Spanish interpreter and trainer, with International Language Services.

Contents:

- Breastfeeding and Early Combination Feeding (‘los dos’) in Latinas -
- Incorporating an Interpreter into Your Office -
- What is new in CCHAP? -
- Parental smoking and childhood asthma -
- Cross-Cultural Health Care Workshop -

- Integrating Developmental Screening in Primary Care Practice -
- Medical Spanish Training For Office Staff  -

- Next Practice Liaison Teleconference -

- newsletter archive - home -