Introduction
Breastfeeding is associated with important health benefits for both mother and child. The American Academy of Pediatrics (AAP) [
1] and the World Health Organization [
2] recommend exclusive breastfeeding for the first six months of life and continued breastfeeding through at least one year of age. There are a number of factors that influence breastfeeding, including child care environments, where large numbers of infants are cared for in early life [
3]. In the United States (US), nearly two thirds of infants spend time in non-parental care, including child care centers and family child care homes [
3]. However, child care providers often receive little guidance on infant feeding. A recent study of providers found that most reported insufficient knowledge of appropriate infant feeding practices, including breastfeeding [
4].
The AAP recently put forth recommendations for feeding infants in child care. The report, entitled
Caring for Our Children: National Health and Safety Performance Standards;
Guidelines for Early Care and Education Programs, 3
rd
Edition (Caring for our Children) [
5] sets standards for health promotion in child care settings, including recommendations to support breastfeeding. These standards are voluntary unless mandated through state regulation. Regulations for child care facilities are enacted separately by each state. While many states use
Caring for our Children standards as the basis for their regulations, previous studies have found substantial variation between these standards and state regulations [
6‐
10].
A handful of studies have examined geographic differences in regulations, with mixed results. One study found that southeastern states had more regulations governing infant feeding in child care [
7]. A second study examined five breastfeeding laws and found that states in the northeast had the greatest number, whereas those in the midwest had the fewest [
11]. Thus, some overall geographic patterning of state level policies was evident. The extent to which regulations vary by state is not well understood, but is of policy relevance. In the absence of federal oversight, uniform policies across states provide a consistent message that mothers are supported in their decision to breastfeed their infants. Additionally, understanding geographic differences across states may help guide national efforts to promote breastfeeding. Geographic analyses can help identify areas of the country with relatively weak breastfeeding policies and target them for intervention. The purpose of this study was threefold: (1) to review current state regulations mandating support for breastfeeding in child care; (2) to compare these regulations to national breastfeeding standards; and (3) to examine spatial patterns in breastfeeding regulations across the US.
Discussion
This review of breastfeeding regulations revealed variation among states. Overall, the mean score for each of the four standards was <1.0 for both centers and homes, below the possible score of 2.0 if the standard was met fully, meaning most states did not have a regulation or if they did, it only partially met the standard. The majority of states had regulations addressing the standard prohibiting the introduction of solid foods to infants <four months of age, as well as regulations requiring parental permission to give formula to breastfed infants. Regulations supporting breastfeeding in general or requiring a designated place for mothers to breastfeed their infants at the child care facility were less common.
Although previous studies have compared child care regulations to national standards [
6‐
10], this is the first to examine the spatial patterning among US states, allowing for a nationwide overview of state level breastfeeding regulations for the first time. We identified a number of states that belonged to spatial clusters of high regulations (New York, Pennsylvania), clusters of low regulations (Colorado, Utah, Wyoming), and others that constituted spatial outliers, such as Texas, which had stronger regulations than its surrounding states. This information bears relevance to both future research and breastfeeding policy, an important aspect of maternal and child health. This analysis should serve to generate hypotheses and guide future, perhaps qualitative research, seeking to derive explanations for these patterns. For instance, where a state with a strong regulation forms part of a cluster, surrounded by other states with strong regulations, researchers and policymakers could seek to understand the mechanisms through which these regulations were proposed and adopted. This information could be applied elsewhere, perhaps in regions where one state outperforms its neighboring states. In addition, as previously stated, geographic analyses can help identify areas of the country with relatively weak breastfeeding policies and target them for intervention. This review may also serve as a baseline study, from which to assess changes in state level breastfeeding policies through time in future research. From a policy perspective, national efforts to promote breastfeeding may also benefit from this identification of breastfeeding regulation clusters and outliers. For example, encouragement of stronger regulatory uptake could be focused toward clusters of states with low levels of breastfeeding regulation, potentially yielding important health benefits for infants in child care in these regions. Consequently, this study builds on and extends previous research on state-level breastfeeding policy and points to several targets for improving breastfeeding policy and therefore improving maternal and child health.
We identified a few states that belonged to spatial clusters of high regulations (such as New York and especially Pennsylvania), while others were associated with clusters of low regulations (for example, Colorado, Utah, and Wyoming). Other states constituted spatial outliers, such as Texas, which had stronger regulations relative to its surrounding states. Identifying these specific clusters of regulations is of policy importance. Targeting these areas for improvement may have important health implications for infants in child care if breastfeeding is more supported through stronger regulation.
Previous research has documented variation in breastfeeding laws among states. The Centers for Disease Control and Prevention (CDC) Breastfeeding Report Card [
16] noted that six of the 50 US states (Arizona, California, Delaware, Mississippi, North Carolina, and Vermont) had center breastfeeding regulations ranked as “optimal”, which was similar to our findings. We found five states with regulations that addressed all four standards for centers—at least partially— in our review. Those states included Delaware, Georgia, Michigan, Mississippi, and Texas. For homes, two states (Delaware and Mississippi) included regulations consistent with all four standards. The CDC Report Card included one standard for evaluating state regulations, which was to “encourage and support breastfeeding and feeding of breast milk by making arrangements for mothers to feed their children comfortably on-site”. Thus, our findings are unique in that we assessed four standards supporting breastfeeding in child care.
One study found that infants living in states without breastfeeding promotion legislation (not necessarily specific to child care) had 63 % higher odds of not being breastfed after birth and 45 % higher odds of not being breastfed for at least six months, compared to states with multiple laws [
17]. Another study examining organizational policies on worksite lactation support found significant correlation between state laws and rates of exclusive breastfeeding [
18]. However, they did not consider regulations targeting child care facilities, where mandated support for breastfeeding mothers may be critical. A third study examined five laws supporting breastfeeding and found that states in the northeast had the most and states in the midwest had the fewest [
11]. We observed that states in the northeast and southeast were more likely to have regulations supporting breastfeeding in general, but not for the other standards.
Few studies have prospectively evaluated the effects of breastfeeding laws. One cross-sectional study found that breastfeeding initiation rates were higher in states requiring break time and private space for employees [
19]. Laws supporting breastfeeding appeared to impact Hispanic and black women, and women with lower educational levels more than other women. The authors suggest that breastfeeding laws may help reduce racial, ethnic, and socio-economic disparities in breastfeeding [
19]. Although previous studies have compared existing child care regulations to national standards [
6‐
10], this is the first study to examine spatial patterns among states, which is a meaningful contribution to the literature.
In this regulatory review, we also identified a few states with regulations that may negatively impact breastfeeding, as some states require child care providers to use universal precautions when handling human milk. For example, homes in Utah must wear waterproof gloves when handling human milk, sanitize any surfaces exposed to human milk, and dispose of human milk in leak-proof plastic bags. Centers in Iowa consider human milk a “bodily excrement”, and thus, providers must use universal precautions. In contrast, Mississippi, Ohio, Texas, and West Virginia (for centers only) state explicitly that universal precautions are not required when handling human milk. Mississippi regulations, for example, require human milk to be handled and stored in accordance to AAP [
5] and Centers for Disease Control and Prevention (CDC) [
20] guidelines, which state specifically that universal precautions are not necessary.
The presence of regulations supporting breastfeeding is not necessarily related to rates of breastfeeding within the state. In our study, we found that five states had regulations that partially or fully addressed all four breastfeeding standards for centers, including Delaware, Georgia, Michigan, Mississippi, and Texas. For homes, Delaware and Mississippi included regulations consistent, either partially or fully, with the four standards. However, based on the 2012 CDC Report Card (the year of our regulatory review), rates of breastfeeding at six months were highest in Oregon, Utah, Vermont, New Hampshire, and Idaho [
17]—five states with relatively few regulations in our policy review. Thus, while this review assesses the presence of regulations, this may not reflect actual practice. Future studies could explore the association between the quality of regulations and practices within child care settings.
At any given time, some states are updating their regulations. Therefore, this research reflects regulations at the time of the review in early 2012. Additionally, state regulations were assessed to see if they had been updated since the revised Caring for our Children standards were released in mid-2011. Since regulatory change takes time, states that made recent improvements may not have considered the revised Caring for our Children standards before they began their updates. Thus, this review could serve as a baseline to evaluate changes states make in response to the standards. Researchers can help document and evaluate these efforts, but further research is also required to better understand the local patterns of spatial correlation identified in this work.