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.E 1. Mean total and subscale maternity practice scores, by state Maternity Practices in Infant Nutrition and Care Survey, d States, 2007
Mean subscale scores*
Breast- Nurse/birth Structural Standard
feeding attendant and organizaNo. of
Mean error of the Labor Breast- Mother- Newborn support breastfeeding tional factors respondent %
total mean total
and feeding newborn feeding after training and related to facilities$ responding score1 score delivery assistance contact practices discharge education breastfeeding States 2,687
72 of Columbia 4
59 mpshire 23
76 arolina 71
85 arolina 37
53 um possible mean score is 100. Subscale definitions: Labor and delivery = mother-newborn skin-to-skin contact and early breastfeeding initiation. I feeding assistance = assessment, recording, and instruction provided on infant feeding; not giving pacifiers to breastfed newborns. Mother-newborn
t = avoidance of separation during postpartum facility stay. Newborn feeding practices = what and how breastfed infants are fed during facility stay. feeding support after discharge = types of support provided after mothers and babies are discharged. Nurse/birth attendant breastfeeding training lucation = quantity of training and education that nurses and birth attendants receive. Structural and organizational factors related to breastfeeding cility breastfeeding policies and how they are communicated to staff, 2) support for breastfeeding employees, 3) facility not receiving free infant 1, 4) prenatal breastfeeding education, and 5) coordination of lactation care. Additional information regarding survey questions and scoring is le at http://www.cdc.gov/mpinc. cribing the results of this study, the District of Columbia and Puerto Rico are referred to as states. als and birth centers. unded mean of the subscale scores.
FIGURE. Mean total maternity practice scores,* by quartile Maternity Practices in Infant Nutrition and Care Survey, United States, 2007
TABLE 2. Mean total maternity practice scores, by amell number of births and facility type - Maternity Practices i. Infant Nutrition and Care Survey, United States, 2007
No. of Mean
facilities total score Annual number of births 0-249
06 >5,000 71
15 Facility type Birth center
0.3 * Maximum possible mean score is 100. Additional information recaring survey questions and scoring is available at http://www.cdc.govimpre *One birth center and 22 hospitals had missing data that prevented caal lation of at least four subscales; therefore, a mean total score could be calculated.
64 66 63
O Quartile 1 (48-58)
Quartile 2 (59-62)
* Maximum possible mean score is 100. Additional information regarding survey questions and scoring is available at http://www.cdc.gov/mpinc.
ing a telephone number for mothers to call for breastfeeding consultation after leaving the birth facility, 56% of facilities reported initiating follow-up calls to mothers. Facility-based postpartum follow-up visits were offered by 42% of facilities, and postpartum home visits were reported by 22% of facilities.
For newborn feeding, 24% of facilities reported giving supplements (and not breast milk exclusively) as a general practice with more than half of all healthy, full-term breastfeeding newborns, a practice that is not supportive of breastfeeding (7,10). When asked whether healthy, full-term breastfed infants who receive supplements are given glucose water or water, 30% of facilities reported giving feedings of glucose water and 15% reported giving water, practices that are not supportive of breastfeeding. In addition, 17% of facilities reported they gave something other than breast milk as a first feeding to more than half the healthy, full-term, breastfeeding newborns born in uncomplicated cesarean births. Reported by: AM DiGirolamo, PhD, Rollins School of Public Health, Emory Univ, Atlanta, Georgia. DL Manninen, PhD, JH Cohen, PhD, Battelle Centers for Public Health Research and Evaluation, Seattle, Washington. KR Shealy, MPH, PE Murphy, MLIS, CA MacGowan, MPH, AJ Sharma, PhD, KS Scanlon, PhD, LM Grummer-Strawn, PhD, Div of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion; DL Dee, PhD, EIS Officer, CDC. Editorial Note: This report summarizes results from 2,687 hospitals and birth centers in the first survey of breastfeedingrelated maternity practices conducted in the United States. These results provide information regarding maternity practices and policies in birthing facilities and can serve as a baseline with which to compare future survey findings. Individual facilities and states can use this information to improve
maternity practices known to influence breastfeeding in the early postpartum period and after discharge.
The findings indicate substantial prevalences of maternity practices that are not evidence-based and are known to interfere with breastfeeding. For example, 24% of birth facilities reported supplementing more than half of healthy, full-term breastfed newborns with something other than breast milli during the postpartum stay, a practice shown to be unneces sary and detrimental to breastfeeding (7,10). In addition, 10% of facilities reported giving breastfeeding mothers gift bags com taining infant formula samples. Facilities should consider continuing these practices to provide more positive influens on both breastfeeding initiation and duration (5,6,8).
The findings demonstrate that birth centers had higher man total scores, compared with hospitals. Facility size (based annual number of births) was not related to differences scores. Further research is needed to better understand difference in scores for birth centers and hospitals. Previous research has indicated that the more breastfeeding-supperton maternity practices that are in place, the stronger the postin effect on breastfeeding (5,6,9). Comparison of the findingsel this report with state breastfeeding rates also suggests a come lation between maternity practice scores and prevalence breastfeeding. For example, in the 2006 National Immuns tion Survey, seven states (Alabama, Arkansas, Kentucky, Lod siana, Mississippi, Oklahoma, and West Virginia) had di lowest percentages (<30%) of children breastfed for 6 mece The same seven states were among those with the lowest ma total maternity practice scores (48–58) in mPINC.
The findings in this report are subject to at least one limit. tion. Data were reported by one person at each facility at might not be representative of actual maternity practices use. However, CDC sought to prevent inaccuracies by reque
hat the survey be completed by the person most knowlable about the facility's maternity practices, in consultawith other knowledgeable persons when necessary. The
ey was pretested with key informants in nine facilities is the country, with follow-up visits to each facility to
ate responses. Information from the key informants geny was found to be accurate. Further validation through ent interviews or medical chart reviews has not been lucted. July 2008, mPINC benchmark reports will be provided ch facility that completed a survey, comparing the facility's cale and total scores with the scores of all other particing facilities, other facilities in the state, and facilities of a ar size nationally. These reports also will provide the ty score for each item comprising the subscales, which help facilities identify specific maternity practices that it be changed to better support breastfeeding. Aggregate will be shared with state health departments to facilitate
work with birth facilities to improve breastfeeding care. - plans to repeat the mPINC survey periodically to assess
Centers for Public Health Research and Evaluation, Seattle, Washington; M Pessl, Evergreen Perinatal Education, Bellevue, Washington; L Feldman-Winter, MD, Univ of Medicine and Dentistry of New Jersey, Newark, New Jersey; and A Spangler, MN, Amy's Babies, Atlanta, Georgia. References 1. Ip S, Chung M, Raman G, et al. Breastfeeding and maternal and
infant health outcomes in developed countries. Rockville, MD: US Department of Health and Human Services, Agency for Healthcare Research and Quality; 2007. Available at http://www.ahrq.gov/downloads/
pub/evidence/pdf/brfout/brfout.pdf. 2. CDC. Breastfeeding trends and updated national health objectives for
exclusive breastfeeding-United States, birth years 2000-2004.
MMWR 2007;56:760–3. 3. US Department of Health and Human Services. Healthy people 2010
midcourse review. Washington, DC: US Department of Health and Human Services; 2005. Available at http://www.healthypeople.gov/
data/midcourse. 4. United Nations Childrens Fund/World Health Organization. Promot
ing, protecting, and supporting breastfeeding: the special role of maternity services. Geneva, Switzerland: United Nations Childrens
Fund/World Health Organization; 1989. 5. DiGirolamo AM, Grummer-Strawn LM, Fein S. Maternity care prac
tices: implications for breastfeeding. Birth 2001;28:94-100. 6. Murray EK, Ricketts S, Dellaport J. Hospital practices that increase
breastfeeding duration: results from a population-based study. Birth
2007;34:202-11. 7. Dewey KG, Nommsen-Rivers LA, Heinig MJ, Cohen RJ. Risk factors
for suboptimal infant feeding behavior, delayed onset of lactation, and
excess neonatal weight loss. Pediatrics 2003;112:607–19. 8. Rosenberg KD, Eastham CA, Kasehagen LJ, Sandoval AP. Marketing
infant formula through hospitals: the impact of commercial hospital
discharge packs on breastfeeding. Am J Public Health 2008;98:290-5. 9. Chien LY, Tai CJ, Chu KH, Ko YL, Chiu YC. The number of baby
friendly hospital practices experienced by mothers is positively associated with breastfeeding: a questionnaire survey. Int J Nurs Stud 2007;
44:1138–46. 10. Swenne I, Ewald U, Gustafsson J, Sandberg E, Ostenson CG. Inter
relationship between serum concentrations of glucose, glucagon, and insulin during the first two days of life in healthy newborns. Acta Paediatr 1994;83:915-9.
ges over time.
te American Academy of Family Physicians, ** American emy of Pediatrics,SS and Academy of Breastfeeding icineSS all recommend that physicians provide intraparcare that is supportive of breastfeeding. Hospitals and centers provide care to nearly all women giving birth in Jnited States. Thus, improving maternity practices in these ties affords an opportunity to support establishment and nuation of breastfeeding. Establishing these practices as ards of care in birth facilities throughout the United States mprove progress toward meeting the Healthy People 2010 tfeeding objectives and improve maternal and child health nwide.
Acknowledgments is report is based, in part, on contributions by E Adams, PhD, on Health & Science Univ, Portland, Oregon; K Rosenberg, Oregon Dept of Human Svcs; A Grinblat, MD, State Univ of York at Buffalo; CL Quinn, MD, Albert Einstein College of cine, Bronx, New York; M Applegate, MD, New York State of Health; K Cadwell, PhD, C Turner-Maffei, MA, Babylly USA, East Sandwich, Massachusetts; A Crivelli-Kovach, Arcadia Univ; E Declercq, PhD, Boston Univ School of Pub-alth; A Merewood, MPH, B Philipp, MD, Boston Medical r, Massachusetts; J Dellaport, RD, L Tiffin, MS, California of Health Svcs; MK Dugan, MA, E Miles, MPH, Battelle
Escherichia coli 0157:H7 Infections in Children Associated with Raw Milk and Raw Colostrum From Cows
California, 2006 On September 18, 2006, the California Department of Public Health (CDPH) was notified of two children hospitalized with hemolytic uremic syndrome (HUS). One of the patients had culture-confirmed Escherichia coli O157:H7 infection, and both patients had consumed raw (unpasteurized) cow milk in the week before illness onset. Four additional cases of E. coli O157:H7 infection in children who had consumed raw cow milk or raw cow colostrum produced by the same dairy were identified during the following 3 weeks.
ilable at http://www.aafp.org/online/en/home/policy/policies/h/ puseinfantformulabreastfeeding.html. ilable at http://aappolicy.aappublications.org/cgi/reprint/pediatrics;115/ 96.pdf. ilable at http://www.bfmed.org/ace-files/protocol/mhpolicy_abm.pdf.
In California, intrastate sale of raw milk and raw colostrum is legal and regulated. This report summarizes the investigation of these cases by CDPH, the California Department of Food and Agriculture (CDFA), and four local health departments and subsequent actions to prevent illnesses. As a result of this and other outbreaks, California enacted legislation (AB 1735), which took effect January 1, 2008, setting a limit of 10 coliforms/mL for raw milk sold to consumers. Raw milk in several forms, including colostrum, remains a vehicle of serious enteric infections, even if the sale of raw milk is regulated.
In mid-September 2006, the parent of one of the two children hospitalized with HUS notified CDFA that both children had consumed raw skim milk from dairy A in the days before illness onset. CDFA notified CDPH and the local health departments of the reports. Dairy A, a licensed raw milk dairy, sells raw milk, raw cream, raw butter, raw cheese, raw colostrum,* and kefir throughout California at retail stores and nationwide via Internet sales, all under a single brand (brand A).
On September 21, 2006, based on the reports from CDPH, CDFA issued a recall and quarantine order for all raw milk, raw cream, and raw colostrum produced by dairy A. The order was extended on September 22 to include all raw products from dairy A, except for cheeses aged at least 60 days according to California and Food and Drug Administration (FDA) standards. Dairy A also was placed under a separate restriction by CDFA during September 21–29 that prevented it from bottling fluid milk and cream because of persistent high standard plate counts.
For this investigation, a case was defined as illness with an onset date of August 1, 2006, or later in a California resident with 1) culture-confirmed E. coli O157:H7 infection with the outbreak strain or 2) HUS with or without culture confirmation, and exposure to raw milk. Case finding was conducted by notifying all California local health departments and infection-control practitioners and reviewing molecular subtyping results from the CDPH Microbial Diseases Laboratory. The 61 health jurisdictions in California were notified on September 20, 2006, to be alert for cases of E. coli O157:H7 and other Shiga toxin-producing E. coli associated with consumption of raw milk. They were asked to report immediately to CDPH any enteric illnesses associated with raw milk or colostrum consumption.
Six cases were identified; four persons had culture-confira infections, one had a culture-confirmed infection and H. and one had HUS only. The median age of patients w. years (range: 6-18 years), and four of the patients (6701, *** boys. The six cases identified during this investigatior. geographically dispersed throughout California. All six patic reported bloody diarrhea; three (50%) were hospitalized ness onset occurred during September 6–24, 2006. La from the five patients with culture-confirmed infections ha indistinguishable pulsed-field gel electrophoresis (PFGE, FE terns. The PFGE pattern was new to the PulseNet it National Molecular Subtyping Network for Foodborne Dease) database and differed markedly from the pattern of E. coli O157:H7 strain associated with a concurrent multis. outbreak linked to spinach consumption (1). Four of the .. E. coli O157:H7 isolates were subtyped by multiple-locus iaable-number tandem repeat analysis (MLVA) according to i protocol used by CDPH laboratory and were found to be closely related MLVA patterns (2).
Five of six patients reported they had consumed branu. raw dairy products in the week before their illness onset: th: sixth patient denied drinking brand A raw milk, although family routinely purchased it. Among the five patients w consumed brand A dairy products, two consumed raw umane milk, two consumed raw skim milk, and one consumed as chocolate-flavored colostrum. Four of the five patients feutinely drank raw milk from dairy A. One patient was expect to brand A dairy product only once; he was served raw chini. late colostrum as a snack when visiting a friend. No era food item was commonly consumed by all six patients. We other illness was reported among household members it's consumed brand A dairy products.
To assess the level of exposure to raw dairy products anc7 patients with E. coli O157:H7 infection, CDPH epidemi. gists reviewed exposure histories for the 50 most recent E 0157:H7 cases reported to CDPH during 2004-24 Among patients who had been asked about exposure to ** milk on the case report, only one of 47 (2%) had consun: raw milk in the week before illness onset. Exposure to the milk was similarly low (3%) among Californians * responded to a population survey (3).
* Raw colostrum is secreted during the first few days after giving birth. It contains higher amounts of protein and antibodies than regular raw milk, but is processed in the same way as raw milk. + The 60-day curing process has historically been considered sufficient to eliminate or reduce pathogens that were in the milk; however, its efficacy has been questioned, and FDA is reviewing the safety of raw milk cheeses.
Using purchase information supplied by the patients tank lies, investigators determined that the patients consumed 118 milk from lots produced at dairy A during September 3-1 2006. Milk samples from these production dates were na available for testing. Fifty-six product samples from several lots with code dates of September 17, 2006, or later wat retrieved from retails stores and dairy A and were tesicdan
-LE. Microbial testing results for dairy A raw milk product samples with code dates of September 17 through October 9, 2006—California Standard plate counts
Coliform counts >15,000 >250,000
>1,500 CFU/mL CFU/mL
coliforms/mL coliforms/mL Range uct sample
(n) (coliforms/mL) skim milk (n = 13)
75 to >10,000 whole milk (n = 18)
O to >10,000 colostrum (n = 4)
110 to >10,000 chocolate colostrum (n = 3) 3
98 to >20,000 cream (n = 11)
39 to 6,200 kefir (n = 3)
12 to 270 butter (n = 4)
110 to >3,300
pic microflora, total coliform, fecal coliform, and E. coli 7:H7. The outbreak strain of E. coli O157:H7 was not din any product samples. However, standard aerobic plate its and coliform counts of collected samples with code - ; of September 17 through October 9, 2006, were indicaof contamination (Table). Colostrum samples had high dard plate counts and total coliform counts, and fecal orm counts of 210-46,000 MPN/g. California standards
standard plate counts for raw and pasteurized milk to :00 CFU/mL and total coliform counts for pasteurized
to 10 coliform bacteria/mL. At the time of this outbreak, ifornia did not have a coliform standard for milk sold raw insumers. California also classifies colostrum as a dietary lement, for which it has no microbiologic standards, rather
a milk product. "FA and CDPH conducted an initial inspection and
onmental investigation of the milk plant and dairy on : ember 26. E. coli O157:H7 was not isolated from
of : environmental samples. Samples from three heifers yielded
li O157:H7, but the PFGE and MLVA patterns of these li O157:H7 isolates differed from the outbreak pattern. rted by: ) Schneider, MPH, J Mohle-Boetani, MD, D Vugia, MD, irnia Dept of Public Health. M Menon, MD, EIS officer, CDC. orial Note: Raw cow milk and raw milk products have implicated in the transmission of multiple bacterial patho
including Campylobacter spp., Brucella, Listeria cytogenes, Salmonella spp., and E. coli. In a recent review
coli O157 infections, raw milk products accounted for of outbreaks during a 20-year period (4). E. coli O157:H7 ponsible for an estimated 73,000 cases of illness annuind serious sequelae, including HUS and death (5). Chil
older adults, and persons with low levels of gastric acid articularly vulnerable (6). w milk products tested from dairy A were not produced ng the same time as the products consumed by the nts in this outbreak. Although the outbreak strain of i 0157 was not isolated from dairy A products, the tested ucts did have high standard plate counts, many exceed
ing California standards for raw milk, and total coliform counts that exceeded California standards for pasteurized milk. Nonoutbreak strains of E. coli O157 also were isolated from samples from dairy A cows, indicating shedding of this pathogen in the herd. Raw milk from dairy A was the likely vehicle of transmission, but the exact mode of milk contamination in this outbreak was not determined. Asymptomatic cows can harbor pathogens and cause human illness by shedding pathogens in untreated milk or milk products. These findings suggest that if raw milk had been subject to the same coliform standard as pasteurized milk in California, milk from dairy A might have been excluded from sale and this outbreak might have been averted.
FDA mandates that all milk and milk products for direct human consumption be pasteurized in final package form if they are to be shipped for interstate sale (7. States regulate milk shipped within their state. Currently, 21 states require pasteurization of all milk products for sale. However, 25 states, including California, allow raw milk to be sold in some form to the public. Those states that permit the sale and consumption of raw milk report more outbreaks of foodborne disease attributed to raw milk than those states that have stricter regulations. During 1973–1992, raw milk was implicated in 46 reported outbreaks. Nearly 90% of these outbreaks (40 out of 46) occurred in states that allow the sale of raw milk, suggesting that even the regulated sale of raw milk might not be adequate to prevent associated illnesses (8).
This is the first outbreak reported to CDC in which colostrum has been an implicated food vehicle. This outbreak represents the first time colostrum has been reported to CDC as a form of raw milk consumed by any patients in raw milkassociated outbreak, although information on the type of raw milk is reported inconsistently in outbreak surveillance. Colostrum is purported to have increased concentrations of nutrients and protective antibodies and is marketed as a dietary supplement in California; consequently, it is regulated by the CDPH Food and Drug Branch. The colostrum products tested in this investigation were nearly as contaminated