Promoting Responsive Bottle-Feeding Within WIC: Evaluation of a Policy, Systems, and Environmental Change Approach

Abstract

Background: Bottle-fed infants are at greater risk for overfeeding and rapid weight gain (RWG); evidence-based strategies for promoting healthy bottle-feeding practices are needed.

Objective: Our aim was to assess whether policy, systems, and environmental (PSE) strategies for promoting responsive bottle-feeding practices within the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were associated with lower risk for RWG.

Design: We conducted a matched-pair cluster randomized trial. PSE strategies were implemented at 3 WIC clinics in Los Angeles County. PSE clinics were compared with 3 matched control clinics. Mothers and infants were assessed when infants were newborn and 3 months and 6 months of age.

Participants/setting: Participants were mothers (n = 246) who enrolled their newborn infants (younger than 60 days) into WIC between May and August 2019.

Main outcome measures: Infant weight was assessed and standardized to sex- and age-specific z scores. RWG was defined as weight-for-age z score change > 0.67. Mothers completed questionnaires assessing responsive and pressuring feeding styles, breast- and bottle-feeding patterns, and perceptions of WIC experiences.

Statistical analyses performed: Logistic regression with estimation via generalized estimating equations and linear mixed models with repeated measures assessed effects of PSE strategies on categorical and continuous outcomes, respectively.

Results: Infants in PSE clinics had significantly lower likelihood of exhibiting RWG (P = .014) than infants in control clinics. Mothers in PSE and control clinics reported similar levels of responsive and pressuring feeding style and similar prevalence of breastfeeding and bottle-feeding. Mothers in PSE clinics trended toward feeling better supported with respect to their decision to bottle-feed (P = .098) and had more stable intentions to stay in the WIC program (P = .002) compared with mothers in control clinics.

Conclusions: PSE strategies focused on promoting more inclusive assessment of infant feeding, tailored bottle-feeding counseling, and increased education and support for responsive bottle-feeding were associated with lower risk for RWG among WIC infants.

Keywords: Bottle-feeding; Infants; PSE; Responsive feeding; Special Supplemental Program for Women; WIC; and Children; and environmental change approach; policy; systems.