Setting the PAMS Agenda (Week 5)

Per Longest (2010), creation of policy happens in two distinct phases:

1. Generation of policy

2. Implementation of policy

Policy generation begins with detailing ideas for policy, setting agendas for translating those ideas into legislation, drafting said legislation, and ushering draft(s) through the House and Senate in order to have them enacted. Once a law has been enacted, implementation is undertaken in it specifics by various actors in the executive branch. These actors may include health agencies, law enforcement agencies, and social workers, among others. Policy is also set within organizations, such as these actors, following a similar process.

Setting the Agenda

The ultimate goal of this blog and of related academic activities is to generate a draft policy statement for review by the Breastfeeding Committee of the American Academy of Nursing. My fledgling efforts and processes are briefly described.

1. Choosing a problem

Using the six criteria of problem choice, compassion is the most appropriate in addressing the agenda nature of PAMS such that – Current institutional means of allocating human milk and the present infant feeding options accepted by the health establishment do not meet the needs of a growing number of families. The result has been to turn to the practice of PAMS. The recommendations of PAMS networks involve appropriate healthcare professionals in individual PAMS practice. Nurses have the greatest contact and so the greatest ability to interact with PAMS participants. There is no current policy for guidance for nurses to engaging PAMS participants in discussions of specific benefits and risks.

2. Identify the needed alteration or addition to organizational policy

Based on the “general issues” identified by Wieck (1992), PAMS agenda is a matter of needing to understand with more clarity the practice and perceived need for PAMS leveraging greater imagination and commitment to the means already available. This is in direct opposition to the alternative situation within this general issue where a new concept would be needed to meet the needs of PAMS participants.

3. Determine the nature of representation within the agenda organization

The American Academy of Nursing defines itself in its mission statement as “[serving] public and nursing profession by advancing health policy and practice through the generation, synthesis, and dissemination of nursing knowledge.” The driving force of policy generation coming from and dedicated to serving directly the needs of the public are indicative of dynamic representation (Bevan & Jennings, 2014). Generation of policy within this structure fits a variation of Model 2 of Brosius & Weimann’s (1996) two-step agenda-setting flow such that –

Public Agenda (PAMS Guidance) -> Early Recognizers (AAN Breastfeeding Committee) -> Organization Agenda (AAN Policy Statement)

Having a grasp of this representation process is essential information for those proposing items to add to organizational agendas. Understanding where the problems or theories which generate agenda items and to whom agenda items are appropriately addressed is the critical first step in generating policy.

4. Identify likely challenges to setting agenda items

Institutional friction, simply put, is the resistance to change from the current operation within an organization (Bevan & Jennings, 2014). In the case of PAMS, this friction is likely to come from the current recognition of acceptable infant feeding options by the American Academy of Pediatrics as (1) milk from biological/birth parent, (2) milk from a human milk bank, (3) commercial infant formula (Eidelman et al., 2012).

Attention Scarcity results from the “finite nature of attention” necessitating prioritizing decision making and responsiveness within an organization. Impact of attention scarcity depends on the hierarchical relationship of the current problem to the “most important problem” that the organization seeks to engage with. Participation in PAMS is still relatively novel and practiced by a growing, but significant minority of families in the United States. The recency of the practice leaves many questions regarding the potential public health impact of PAMS as currently practiced unanswered at this time.

5. Critically evaluate the viability of moving forward with the proposed agenda item

Goodness of fit – Goal 1 of the AAN strategic plan (2014-2017) is to “[i]nfluence the implementation of healthcare reform with the goal of achieving the Triple Aim of improving the patient experience of care, improving the health of populations; and reducing the per capita cost of health care.” The patients in this instance are PAMS participants seeking recognition and facilitation of feasibility regarding their needs and wants in caring for their infants. Ip and colleagues (2007) detail the additional health burden on families resulting from suboptimal breastfeeding including (but not limited to) otitis media, childhood leukemia, asthma, diabetes, and gastrointestinal infection. Bartick & Reinhold (2010) indicate that the annual cost in the US of this same suboptimal breastfeeding is $3.6 billion dollars (or more) realized in large part by increased rates of the aforementioned chronic and acute illnesses.

Ability to overcome challenges – Institutional friction can likely be reduced with reliance on the variance of international human milk allocation models (Bond unpublished, 2013) and the broader WHO (2003) guidelines regarding infant feeding which includes well screened donors/wet-nurses as acceptable options in infant feeding. Attention scarcity is not as easily determined. It is my belief that because this agenda item was solicited, and that it is supported by experienced members of the AAN Breastfeeding Committee, that this obstacle can be overcome with their guidance.

All things being considered, this agenda item is reasonable and likely viable to move forward in the next steps of becoming a policy! On to drafting these ideas into a cohesive statement and actionable items for review and enactment.


Bartick, M., & Reinhold, A. (2010). The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics, 125(5), e1048-e1056.

Bevan, S., & Jennings, W. (2014). Representation, agendas and institutions. European Journal of Political Research, 53(1), 37-56. doi:10.1111/1475-6765.12023.

Bond, AB. (2013). Comparison of screening methods of donors and human milk in human milk banking models. Unpublished.

Brosius, H., & Weimann, G. (1996). Who sets the agenda?: Agenda-setting as a two-step flow. ( No. 23). 23(5), 561-580. doi:10.1177/009365096023005002.

Eidelman, A. I., Schanler, R. J., Johnston, M., Landers, S., Noble, L., Szucs, K., & Viehmann, L. (2012). Breastfeeding and the use of human milk. Pediatrics, 129(3), e827-e841.
Ip, S., Chung, M., Raman, G., Chew, P., Magula, N., DeVine, D., … & Lau, J. (2007). Breastfeeding and maternal and infant health outcomes in developed countries. Evidence report/technology assessment, (153), 1.
Weick, K. E. (1992). Agenda setting in organizational behavior: A theory-focused approach. Journal of Management Inquiry, 1(3), 171-182. doi:10.1177/105649269213001.
World Health Organization, & UNICEF. (2003). Global strategy for infant and young child feeding. World Health Organization.

6 thoughts on “Setting the PAMS Agenda (Week 5)

  1. Kudos for getting your foot in the proverbial door with AAN!
    One respectable group addressing the issue will surely cause others to take note. Longest (2010) comments that a problem can be highlighted by a sharply focused impact on a small but powerful group whose members are directly affected (he used medical education as an example but PAMS clients would work as well). I propose that after you get your policy published by AAN, you address the National WIC Association since over 50% of the babies born in the U.S. are enrolled on WIC (In California, it is >60%). WIC advocates breast milk feeding and milk banks can’t meet the demand of mothers with low-risk infants who are unable to meet their babies’ needs.

    • WIC may not be the next logical target, based on participation in PAMS. Obviously I can’t give spoilers for the ILCA conference presentation (you might not come then!), but the work as it stands approaching completion for the presentation indicates that in both the donor and recipient subgroups of PAMS, there isn’t significant overlap with WIC. I certainly see the value in getting policy in place for WIC, it might open up opportunities for babies who are not tolerating formula well, I am just not sure yet that they will be the best next step. Hopefully, by the time I get there, a more robust body of evidence will be available to tailor recommendations for WIC!

    • I completely agree. My perception is that there will be significantly more push-back from WIC in putting a policy in place this early. It is my sincere hope that AAN, and potentially from there ILCA or one of the RD organizations could be included. Once there are a few statements and more data available, I feel like it would make the efforts with WIC more effective and expedient, if that makes sense?

      • That’s the one! I knew it had changed names and could not for the life of me remember what to. I think WIC would be a great place to at least get in a pre-made brief unit on discussing and referring for PAMS in the PC and Promotora education classes and/or CE.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s