NUTRITION/BREASTFEEDING EDUCATION TABLE OF CONTENTS SECTION: SUBJECTS: 5.00 Overview of Nutrition Education 5.01 Primary Nutrition Education Contact 5.02 Secondary Nutrition Education Contact 5.02A Techniques that Work 5.02B Facilitated Group Discussion 5.02C Visual Aids/Exhibit Boards 5.02D Evaluation 5.02E Techniques for Telephone Counseling 5.03 Participants at High Nutritional Risk/ Care Plan Development 5.03A has been removed 5.04 Exit Counseling 5.05 Policy was replaced by policy 2.39 5.06 Annual Nutrition Services Plan 5.06A Nutrition and Breastfeeding Services Plan 5.06B Local Agency Nutrition Education Providers 5.06C Nutrition and Breastfeeding Education for Participants 5.06D Breastfeeding Support Roles 5.06E Breastfeeding Month Activity Plan 5.06F 5.06G Locally Developed Nutrition Education and Breastfeeding Support Materials Guidelines for Developing the Annual Nutrition Services Plan 5.07 This policy has been removed 5.08 Development or Procurement of Written Materials and Audiovisual Aids 5.08A Written Materials 5.09 Breastfeeding Promotion and Support 5.09A Staff Roles in Breastfeeding and Staff Support EFFECTIVE DATE: October 1, 1995 October 1, 2003 October 1, 1995 February 5, 2019 July 1, 1994 October 1, 1995 August 8, 2023 July 1, 1995 October 1, 2013 October 1, 2013 October 1, 2013 October 1, 2013 October 1, 2013 October 1, 2015 October 1, 2013 July 1, 1992 November 19, 2025 October 1, 2009

SECTION: SUBJECTS: EFFECTIVE DATE:

5.10 Breastfeeding Precautions and Contraindications October 1, 1999 5.11 Provision of Breast Pumps October 1, 1999

5.11A Breast Pump Release of Liability

5.11B Breast Pump Log

5.11C Breast Pump Tracking Form

5.11D Electric Breast Pump Loaner Agreement and Release of Liability (Eng/Spa) October 1, 2007 5.12 Provision of Breastfeeding Aids (Excluding Breast Pumps) October 1, 1999

5.12A Breastfeeding Aid Release of Liability

5.12B Guidelines for Issuing Breastfeeding Aids

5.13 Breastfeeding Peer Counseling Programs October 1, 2004

5.13A WIC Breastfeeding Peer Counselor Referral Form (Eng/Spa)

5.13B Breastfeeding Peer Counselor Confidentiality Statement

5.13C Breastfeeding Peer Counselor Contact Form

5.14 This policy has been removed

5.15 Staff Breastfeeding Support Roles October 1, 2012

5.15A Breastfeeding Support Roles

Policy and Procedure 5.00 Page 1 of 3

MARYLAND DEPARTMENT OF HEALTH WIC PROGRAM POLICY AND PROCEDURE MANUAL

Policy and Procedure Number: 5.00 Effective Date: October 1, 1995 Revised Date: November 18, 2019 SECTION: NUTRITION EDUCATION SUBJECT: Overview of Nutrition Education

A. Policy

Nutrition education1 is a Program benefit to be made available to each adult participant and the parent, caregiver, or designee of an infant or child participant. The goal of nutrition education is to assist the WIC participant in following nutrition, physical activity, and other lifestyle practices associated with good health.

Nutrition education provided to participants shall be designed to improve health status and achieve positive changes in dietary and physical activity habits and emphasize the relationship between nutrition, physical activity, and health. The method used to deliver nutrition education shall consider the participant’s category, age, nutritional need, personal and cultural preferences, language, and literacy level. Nutrition education shall be integrated into participant health care plans, the issuance of supplemental foods and other Program operations.

B. Procedure

1. The local agency shall ensure that:

a. Participants are offered nutrition contacts at a quarterly rate during each certification period where:

i. The first (primary) contact is offered at the time of certification; and

ii. The subsequent contacts are offered within the certification period, usually in conjunction with benefits issuance, such as at class/individual pickup (CPU) appointments and mid-certification visits (MCVs) at which the participant shall be present (See Policy 2.10)

1Nutrition education is defined as the provision of information about nutrition and physical activity to a participant, using methods, materials, and tools that enhance understanding of their relationship to good health and promote or reinforce desirable changes in behavior.

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b. Contacts are made available as individual or family counseling or as group education sessions.

c. An explanation of the purpose and long-term benefits of nutrition education and encouragement to participate in nutrition education activities are provided to the participant or the participant’s parent, caregiver, or designee.

d. Each pregnant participant is provided with information verbally and in writing, about the benefits of and contraindications to breastfeeding.

e. Information about the dangers of drug, alcohol, tobacco and other harmful substance abuse during pregnancy and lactation is provided to each pregnant, postpartum, or breastfeeding woman and to the parent, caregiver, or designee of each infant or child participant and a list of community agencies that provide substance abuse counseling and treatment is provided to each woman participant.

f. Exit counseling information is provided to each woman participant who is to “graduate” from the WIC Program.

g. A participant identified as at high nutritional risk (Nutrition Care) receives an appropriate plan of care, including the development of an individual care plan. (see Policy 5.03).

h. An individual care plan is developed for a participant or caregiver who requests it.

i. Nutrition education contacts are documented in each participant’s WOW record.

j. WIC foods or other Program benefits are not denied to a participant who fails to attend or participate in nutrition education activities, but refusals are documented in the participant’s WOW record.

k. Nutrition education is provided without cost to the participant.

2. The local agency shall prepare and submit to the State WIC Agency an annual Local Agency Nutrition Services Plan that describes how it intends to carry out nutrition education and breastfeeding activities.

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References: 1. 7 CFR 246.11 2. COMAR 10.54.01.18 3. SFP 04-109 4. WIC Nutrition Services Standards, Standard 8 5. SFP 06-032, WIC Nutrition Education Guidance 6. USDA Guidance for Providing Quality WIC Nutrition Services during Extended Certification Periods 8/29/2011. 7. 7 CFR 246.11 (1-1-12 edition)(e)(3)

Revisions: 10/12 Changed Procedure 1. to reflect changes required for extended certification periods.

10/15 Removed “when deemed necessary by the Competent Professional Authority” in B.1.g. and referenced Policy 5.03. Adjusted policy reference wording.

6/17 In B. a. ii. Changed check issuance to benefits issuance, and check pick up (CPU) to Class/individual Pick Up (CPU).

11/19 Policy reference updated in B.1.a.ii. to 2.10.

Policy and Procedure 5.01

Page 1 of 2 MARYLAND DEPARTMENT OF HEALTH WIC PROGRAM POLICY AND PROCEDURE MANUAL

Policy and Procedure Number: 5.01 Effective Date: October 1, 2003 Revised Date: October 1, 2014 SECTION: NUTRITION EDUCATION SUBJECT: Primary Nutrition Education Contact

A. Policy

The first (or primary) nutrition education contact shall be provided at the time of certification to each WIC participant or the parent, caregiver, or designee of an infant or child participant. The goal of the primary contact is to provide assistance to the participant or caregiver that promotes the practice of nutrition, physical activity, and other lifestyle behaviors associated with optimal health and well-being.

B. Procedure

1. The content of the primary nutrition education contact shall:

a. Be based upon information collected about the participant during the nutrition assessment.

b. Consider the participant’s identified risk factors, needs, interests, and circumstances such as household situation, cultural and personal preferences, spoken language, and literacy level.

c. Include anticipatory guidance appropriate for the participant’s category, age, and developmental stage.

d. Be presented verbally as simple, positive, practical, advice that builds upon the participant’s own knowledge and skills.

e. For a pregnant woman, include verbal and written information about the benefits of and contraindications to breastfeeding.

f. For a breastfeeding infant or child, include discussion and documentation of the amount of breastfeeding.

g. For a newly certified child who has not yet had a blood lead test to screen for lead poisoning, include information about the dangers of lead poisoning and the recommendation to discuss the issue with the

Policy and Procedure 5.01

Page 2 of 2 child’s health care provider.

h. Include referral(s) to health, social, and other community services, as appropriate.

2. The primary contact shall be documented in the participant’s WOW record in the Nutrition Education screen. Referrals made shall be documented in the Client Referrals screen. Refer to WOW Help screen for the specific procedure.

References: 1. 7 CFR 246.11 2. SFP 01-032 3. SFP 04-109 4. WIC Nutrition Services Standards, Standards 8 and 9.

Revisions: 10/2013 Removed 1.3. Modules no longer in use

10/2014 In B. inserted new f. For a breastfeeding infant or child, include discussion and documentation of the amount of breastfeeding, and renumbered original f. as g., and original g. as h.

Policy and Procedure 5.02

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MARYLAND DEPARTMENT OF HEALTH WIC PROGRAM POLICY AND PROCEDURE MANUAL

Policy and Procedure Number: 5.02 Effective Date: October 1, 1995 Revised Date: August 20, 2020 SECTION: NUTRITION EDUCATION SUBJECT: Secondary Nutrition Education Contact

A. Policy

A subsequent (or secondary) nutrition education contact(s) shall be offered to each WIC participant or the parent, caregiver, or designee of an infant or child participant at a time other than the certification appointment. The goal of secondary contact(s) is to assist the participant or caregiver in acquiring additional knowledge and skills about nutrition, physical activity, and other lifestyle practices associated with optimal health and well-being.

B. Procedure

The local agency shall:

1. Offer nutrition education in conjunction with class and individual benefit issuance.

2. Provide the secondary nutrition education contact as an individual or group session.

3. For a breastfeeding infant or child, update the amount of breastfeeding in the participant’s record, even if the same as previous visit.

4. Document the secondary nutrition education contact in the participant’s nutrition education screen in the management information system.

5. For participant’s certified for a period in excess of six months, offer nutrition education during a mid-certification visit that emphasizes:

i. For infants, the nutritional and developmental needs of an infant between 6 and 12 months of age.

ii. For breastfeeding women or child participants certified for more than six months, knowledge and skills related to food selection, purchase, storage, and preparation, infant or child feeding, and/or the adoption of physical activity and other healthful lifestyle

Policy and Procedure 5.02

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practices, giving consideration to the language and personal and cultural preferences of the individual.

6. Provide and document a secondary contact for a participant who is issued WIC food benefits during a certification appointment for another family member. This contact may be provided in the format of a “family counseling” session.

7. Document refusal of a participant or a participant’s parent, caregiver, or designee to attend or participate in nutrition education in the participant's management information system record.

8. At least annually, conduct an assessment of participant views concerning the effectiveness of secondary nutrition education.

2. Acceptable formats for delivering the secondary contact include:

i. individual counseling; ii. facilitated group discussion or support groups; iii. DVDs, exhibit or display boards, and printed materials such as newsletters, as long as authorized WIC staff providing the nutrition education, at a minimum, introduces or explains the topic and format, provides assistance when needed, and is present to answer questions during and following the session. iv. online nutrition education may be offered to participants. It is at the local agency’s discretion to not offer online nutrition education to high risk participants or if any family member is identified as high risk, pregnant women, or participants issued breast pumps who need one month follow up based on need for monitoring of condition or progress. v. phone counseling can be completed by a staff member who provides secondary nutrition education as designated by the Local Agency Coordinator, if a family is unable to come to clinic or unable to complete online education. Documentation shall be recorded in the Nutrition Education screen.

3. Attachments 5.02 A, B, C, D, and E offer guidelines for design and delivery of secondary nutrition education contact(s).

Attachments: 5.02 A Techniques that Work 5.02 B Facilitated Group Discussion 5.02 C Visual Aids/Exhibit Boards 5.02 D Evaluation 5.02 E Techniques for Telephone Counseling

Policy and Procedure 5.02

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References: 1. 7 CFR 346.11 2. COMAR 10.54.01.18 3. SFP 04-109 4. WIC Nutrition Services Standards, Standard 8 5. SFP -6-032, WIC Nutrition Education Guidance

Revisions:

10/12 Added B.1.e. to require the provision of quality nutrition education during a mid- certification visit for breastfeeding women and child participants certified for more than six months.

10/14 In B.1. Inserted a new c. For a breastfeeding infant or child, update the amount of breastfeeding in the participant’s record, even if the same as previous visit. Renumbered previous c. through i. as d. through j. In B.2. replaced videotapes with DVDs. In Attachment 5.02C, replaced overhead transparencies with internet downloads and videotapes with DVDs.

10/15 In B.2. Removed lecture as an acceptable form of secondary contact. Adjusted punctuation.

01/17 In B. 1. a, changed checks to benefits. InB.1.g. Changed checks to food

benefits.

06/17 Updated policy with eWIC terminology.

02/19 Added language related to online education and telephone counseling. 5.02E Techniques for Telephone Counseling added to policy.

08/20 Adjusted language to include offering online nutrition education to all participants

with the option at the discretion of the local agency not to offer to pregnant

women, high risk participants, or participants issued breast pumps who need one

month follow up based on need for monitoring of condition or progress.

Attachment 5.02 A Attachment 5.02A

1 of 9 Techniques that Work!

…The purpose of any training session is to assist the participants in developing their own answers. (1)

You have a goal, to provide nutrition education to WIC participants that have been identified as at nutritional risk. You hope to convince them to change certain behaviors that could lead to short- or long-term health problems. However, as one nutritionist stated, participants may view nutrition education as a “hurdle” to overcome in order to get their WIC checks. This “gap” is a major cause of frustration for nutrition educators who feel that participants are simply not interested or motivated.

Are participants not motivated or interested? Some may not be, but most are interested. And, they are motivated. (1)

Much research has been conducted and theories generated on how to sell goods, services, and ideas to all types of consumers (marketing and advertising research), how to reach an audience with a message (communication theory), and how to effectively train adults (adult learning theory). By applying the findings of research, nutrition educators may be able to bridge the gap that exists between their goals and the goals of their audience.

Let’s explore some of these theories to see how they can be applied to nutrition education in the WIC setting.

Marketing Research: Know your audience.

Who is your audience? Mostly women, but also, children, fathers, and other relatives. Our audience may be quite diverse, teens, grandmothers, “native” born, or recent arrivals from another country.

Ideally, we should segment our audience into homogeneous groups and tailor our activities to their specific needs. But, that is not always feasible. However, even a diverse WIC audience has one thing in common – their children. Perhaps the best approach if your agency has a diverse caseload, is to develop all of your programming around the children. You can use children as a central theme when you deliver activities to adults or you can offer activities directly to their children.

Design sessions around children.

Attachment 5.02 A Attachment 5.02A

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Involve participants before, during, and after your sessions.

Treat participants as a company does its customers. Market researchers go directly to customers (or potential ones) to find out what they want and need. Make participants the focus of nutrition education, not the topics. In the planning phase, find out what nutrition and health topics participants are interested in and how they want to learn the information. Survey them. Pay attention to what they say. Talk to your co- workers, as well. Finding out what interests your customers will help you design sessions that they will be receptive to. Let them know that the sessions were planned “by them.”

As you carry out your nutrition education activities, involve participants. Start the session by finding out what they already know or how they feel about the topic. You can do this by asking an open-ended question. For example:

♥ Ask participants to share the names and ages of their children. This will give you an idea of the numbers of new and experienced mothers in the group.

♥ Ask participants why they think people don’t like to eat vegetables. The responses may give you an idea of how they feel about eating vegetables.

♥ Ask participants to share the types of breakfast that they eat. This will give you an idea of who eats breakfast.

♥ Ask participants to name their favorite bean dish. This may give you an idea of who knows how to prepare dry beans.

Ask participants to share their ideas, experiences, and solutions. Breastfeeding moms are great resources for promoting breastfeeding to pregnant participants. Ask for volunteers to help when you are doing a food demonstration.

The third time you involve your participants is at the end of the session when you invite them to evaluate the effectiveness of the session.

Participants want to feel important (1). Involving them throughout the process of planning, conducting, and evaluating nutrition education activities sends a strong message to them that you value them and appreciate their input. They are likely to respond in a positive way.

Train your sales force.

When participants are certified, are they informed about the nutrition education activities by staff? Are they told they will have to attend a “class” when they pick up their checks? Brainstorm with staff how to “sell” nutrition education activities. Get them excited about it. Give them a “bonus” for coming up with a unique approach to excite the participants they certify.

Attachment 5.02 A Attachment 5.02A

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Communication Theory: What did you say?

There are many communication theories, but the common thread among them is:

Message

As we know, there are many factors that interfere with the reception of the message by the receiver. We must recognize that receivers: (4)

• Pay attention to a message that meets a need or interest. • Shape (or distort) the message according to their circumstances or point of view. • Are more likely to accept messages when there is interaction with the sender or with other members of the audience. • Will accept or reject the message intellectually, emotionally or behaviorally.

Adult Learning Theory: Adults want to solve their own problems, (thank you!)

According to Pike (1), the most effective training allows participants to discover and to participate. He also says that learning does not take place unless the participant uses the information you have imparted.

Adults have accumulated a lifetime of knowledge and experiences, including eating and child feeding practices. Their eating and feeding practices are shaped by culture, taste, resources (time, money, and skills), beliefs, status, and the influential people in their lives. While health concerns may be a factor in food practices, taste, convenience, status, and emotions likely play a greater role. Young age and generational poverty may shape an attitude of “live for today,” not tomorrow, so messages about the future, such as saving money or preventing chronic disease may not be heard. They may, however, listen to messages that offer immediate results (5).

Adults want “hands on” experiences. They want to solve their own problems on their own terms. You can give them a list of ideas, but they need to come up with their own. If you tell them something, they may accept it. But, if they say it, they believe it. (1) Pike says to consider adult learning as a “do-it-yourself project” where insights, discoveries, and decisions are theirs, not yours. The best role for the educator is not to be a lecturer, but to be “a facilitator of insight, change, and growth who teaches that the answers come from within.” (1) Be “patient, understanding, and positive” even when participants are uncooperative.

Social Cognitive Theory, established by Albert Bandura states that “there is a dynamic, reciprocal relationship among the individual, her environment, and behavior.” (4) A change in one of the three will affect the other two. In order for behavior to change, the individual must believe that she can overcome any Sender Receiver

Attachment 5.02 A Attachment 5.02A

4 of 9 environmental obstacles to the change. These obstacles may be internal (I can’t do this) or external (“X” prevents me from making this change).

The individual must develop a sense of self-efficacy, a belief that she can overcome her perceived or real obstacles, in order to change. Of course, the individual must first decide that the behavior change is desirable (her perception of a “health value”). The level of self-efficacy the individual has will influence the degree of effort expended or the desire to “hang in there” if it becomes difficult to “stick with” the new behavior. A high level of self-efficacy will enable the individual to continue with the new behavior while a low level will likely lead to abandonment of the behavior. A participant who does not believe in her ability to breastfeed may be at risk of giving it up if she perceives problems, especially if family members are openly or covertly unsupportive. The participant’s perception of internal (herself) versus external control (other persons or circumstances) over her behavior has relevance for approaches to build self-efficacy. She may be more likely to change a behavior she has control over. If she perceives that outside influences exert more control, she may not make a behavior change. For example, she may want to breastfeed, but must return to work and thinks that the two are incompatible.

A third aspect of Bandura’s theory is the perception of expected outcome. A participant who perceives a high level of benefit is more likely to change a behavior than one who perceives a low level of benefit. If she does not like vegetables and does not see a tangible reason to eat them other than for “health” reasons, she will not change her habits. She may rationalize, “Sure they are good for me, but I smoke. That cancels out the health benefit.”

How can nutrition educators help participants achieve a high degree of self-efficacy?

♥ Impart more than knowledge. Knowledge, as we know, does not lead to behavior. Offer opportunities for participants to develop skills. Enable them to believe that they can breastfeed.

♥ Give them tools to cope with threats to the new behavior. For a weight loss group, let them role play how to eat at a party or how to respond to unsupportive family or friends.

♥ Enable participants to solve their problems. Let them figure out how to get an extra serving of vegetables at lunch time when they are at work.

♥ Offer positive feedback, especially when they have made small changes. Help them obtain positive feedback from others.

♥ Encourage participants to make changes in small “bites.” They can have a series of small successes to boost their belief in their ability.

IthinkIcan,IthinkIcan,IthinkIcan,IthinkIcan,IknowIcan,IknowIcan,IknowIcanIknowIcan.Whoo,Whooooo.

Attachment 5.02 A Attachment 5.02A

5 of 9 “Structure (the learning experience) to apply content to life.” (1)

Adults are busy people who are pressed for time. They want practical information - time savers, quick tips, and simple facts. Present more “need-to-know” and less “nice- to-know” information. Focus on food, not nutrients. Let participants walk out of your session with information that they can use.

Offer recipes that are simple to prepare, inexpensive, require few ingredients and do not require special appliances or equipment. Demonstrate how easy the recipe is to prepare. And, be sure to use props like real foods and their containers, food models, utensils, etc.

We remember: (1)

10% of what we read. 20% of what we hear. 30% of what we see. 50% of what we see and hear. 70% of what we say. 90% of what we say as we do it.

Limit the amount of information provided in the session.

Limit the topic to one small one. Trying to cover a broad topic such as “Weight Management,” Infant Feeding,” or “Dietary Guidelines for Americans” is too much for one session. Break up a large topic into very small segments and cover only one of them. For example, talk about how to reduce fat when eating out or when cooking foods, but not both at the same session.

The average adult cannot retain more than about 3 new pieces of information over a 20 minute period. Plan to discuss no more than 3 key concepts with 1 or 2 supporting or explanatory facts. The 3 concepts should flow in a logical sequence. For example, you want to discuss infant feeding. Select 3 key concepts, such as:

 Learn your baby’s cues for hunger and fullness.  Hold your baby when you feed her.  Keep your baby on breast milk or formula for the entire first year.

Add 1 or 2 supporting statements to each of these 3 concepts:

• Learn your baby’s cues for hunger and fullness. Key Concept - Your baby will … when she is hungry. Supporting Statement - Your baby will … when she is full. Supporting Statement • Hold your baby when you feed her. Key Concept - Burp your baby once or twice during the feeding. Supporting Statement • Keep your baby on breast milk or formula for the entire first year. Key Concept - Breast milk or formula has what your baby needs to grow. Supporting Statement - Nothing else should be added to baby’s bottle. Supporting Statement

Attachment 5.02 A Attachment 5.02A

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Now, decide what you will use to illustrate and reinforce these concepts and supporting statements. That is, what props and other visual aids will you use? What open-ended questions will you ask the group? How can group members help reinforce the concepts?

Most adults remember information given at the beginning and at the end of a session. They may not remember what comes in the middle. So, deliver the most important message at the beginning of the session. Reinforce it at the end. Use the middle to illustrate and clarify the message and teach participants skills that they can use to apply the message.

Advertising Research: If you don’t grab them in 6 seconds, you’ve lost them. (1)

You have a short time with participants. You must make an impression quickly in order to gain their attention. Some ways to do this are:

♥ Tell participants a funny story about your own kids (or nieces or nephews). ♥ Ask, “Why do kids stop drinking milk?” or, “Why do kids stop eating vegetables?” ♥ Use a Halloween mask of a beautiful woman to illustrate that women take care of the outside but neglect the inside. Then, ask for a show of hands for how many agree with that statement? ♥ Show an unusual vegetable and ask if anyone knows what it is.

Try to use opening statements and icebreaker exercises that relate to the topic to help get the audience focused and ready for the next part of the discussion. Once you get Describe an incident (tell a story). Ask for a show of hands. Ask a question. Get them laughing. Cite an unusual statistic. Use a visual aid or prop.

Attachment 5.02 A Attachment 5.02A

7 of 9 their attention, you must keep them interested as the content of the topic is presented. Try the techniques used by training experts.

Use a variety of teaching methods (even in the same session).

Different methods reach different participants. Some learners enjoy the traditional lecture format, while others prefer walking through exhibits. It is best to vary your approaches. Use demonstrations, games, puppet shows, exercise sessions, and support groups. Don’t be afraid to try something new. You may be pleasantly surprised by what you discover. Don’t let fear of failure stop you from experimenting with a new idea or approach to nutrition education. If the idea does not work, consider it a learning experience. Doing things the “same old way” makes us stale and leads to burnout. Trying new things makes us feel creative and energized.

Be creative. Maintain eye contact. Don’t tell participants everything. Feed them a little information. Then, let them talk and react. Be flexible. Parents are motivated by their children. If you feel they are not interested in what you are saying, think of a way to relate the topic to their children. Ask the group how they approach the topic as it relates to their children. You send a message that their concerns and experiences are important. Give positive feedback to their comments and ideas. Relate information you provide to a motivator – the WIC checks. Show them creative ways to use their WIC foods. Use food demonstrations or have foods in partial stages of preparation. Take a high-fat fast food apart to talk about each component. Have the group “rebuild” a healthier alternative. Instead of telling the group, “Let’s plan a menu,” say, “Let’s plan a special birthday or anniversary dinner.” Or, “You’re planning a picnic. What can go into the basket?”

Give participants a choice. Give them 3 topics that the group can talk about and let them pick one. Or, add an element of surprise. Fill 2 grocery bags, each with different food items. Tell them that one grocery bag contains “must haves” for quick meals and the other is a mystery “grab bag.” Let the group choose which bag of items you will use for the session.

Use lots of props. Check out the “dollar store” for items that you can use in your presentations. Try an unconventional prop. Hand out “blue ribbons” and paper corsages.

Use a positive approach.

Open the session with enthusiasm. If you aren’t enthusiastic, don’t expect your participants to get excited, either. Barbara Mayfield says she always wears a smile on her face, even when she doesn’t feel like smiling. People smile back and pretty soon, she does feel like smiling!

Make the room as pleasant and comfortable as you can. Have fun and enjoy yourself.

Present information in a positive way. Emphasize what participants can eat, not what they shouldn’t. Refrain from using “instead of these, eat…” lists.

You can’t motivate people but you can create a motivating environment. (1)

Attachment 5.02 A Attachment 5.02A

8 of 9 For fast foods, show a list of healthier food choices. “When you eat out, choose these foods most of the time….”

For snack foods, show a list of healthy snacks. “When you want a snack, choose these most of the time….”

Have fun. Get the participants laughing. Humor can help participants relax so they will be in a good mood to learn. (1)

Move beyond the basic health messages.

Most adults know basic health messages – they know that vegetables are “good for you.” They tire of hearing this message, even if they do not eat the recommended numbers of servings. Help move participants beyond the basic message by teaching them a specific skill. Demonstrate how to make a simple main dish salad or soup containing seasonal vegetables. Show them how to make a fruit and yogurt parfait.

Present concepts clearly and simply.

Keep the message simple, present it clearly, but do not be condescending. Use “easy” words and explain technical terms (like hemoglobin) if they are necessary to use. Avoid jargon. Give examples. Do not use scare tactics.

Have a strong ending.

Think of a strong ending. Recite a poem. Read a verse from a Mother’s Day or Thank You card. Play a song. Recap the main point(s) of the session. Ask participants what they think the most important points are, or how they think them might use the tips and ideas that have been shared. Ask them to share with each other. Ask them what they might tell a friend.

Three final notes.

 Lesson Plans

“It is difficult to plan so far in advance.”

A lesson plan is a road map to keep you on course so that you reach your destination. It is a structured way to keep you mindful of the tasks that must be completed so that you can organize your time. It can also help you plan for purchases of supporting materials or supplies that you will need during the year.

Without a lesson plan, you may find yourself in a state of panic the day of the session because you are not ready. And, participants will be able to sense the lack of preparation.(1) For consistency, it is important to write down the key messages and supporting statements, especially when other staff provides the nutrition education, to ensure that the basic information is addressed.

Attachment 5.02 A Attachment 5.02A

9 of 9  Nutrition Education for Children (6)

By ages 3 and 4, children become more aware of food and begin to acquire habits that may be lifelong. You can provide experiences that parents can use at home to help their children develop physically, mentally, and emotionally. Offer activities that allow children to explore and experiment. Some activities include:

♥ Reading books or telling stories about food. ♥ Letting children explore unfamiliar foods and learn their smell, taste, feel, and sound. ♥ Letting children engage in “pretend” play where they play store or prepare a meal. ♥ Playing music and letting children dance or be active. ♥ Pretending to be animals or a growing plant. ♥ Having a puppet show or a game.

Each local agency should have a copy of the Kids Club, Food & Me, and Tickle Your Appetite curricula. These excellent resources contain lesson plans, activities, songs, games, take-home sheets, and recipes.

 Seeking Help

Providing nutrition education is a big job. Who can help you? Can you train paraprofessionals? Can you get help from “outside” sources, such as Health Department staff with expertise in dental health, lead risk reduction, or substance abuse counseling? Can you work with the local Family and Consumer Science Extension Educator to offer some sessions? Are there any retired, qualified staff who might be willing to be trained and volunteer some time?

Use your participants. They can share their experiences with other “novice” participants. Moms who have breastfed their infants can influence other mothers to breastfeed their infants. These moms have overcome obstacles to breastfeeding and can send the message, “if I can do it, so can you!”

References

1. Creative Training Techniques Handbook, Robert W. Pike, CSP, Lakewood Books, 1994.

2. Ten Keys to Success: What Works with Hard-to-Reach Audiences, Ellen Schuster, PhD, Oregon State University Extension Family & Community Development.

3. Facilitative/Experiential Teaching Ideas, Ellen Schuster, PhD, Oregon State University Extension Family & Community Development.

4. Nutrition Education Ideas Resource Manual, The Pennsylvania State University, October 2000.

5. The Learn Together Approach, Facilitated Discussion Train-the-Trainer Guide, Michigan Department of Community Health WIC Division, October 2001

6. United States Department of Agriculture. The Idea Book: Sharing Nutrition Education Experiences, 1981.

Attachment 5.02 B Attachment 5.02B Page 1 of 3

Faciliated Group Discussion

Listen, Share, Support. (1)

Facilitated discussion is a nutrition education technique that can be used for individual counseling or group discussion. The WIC staff person serves as a facilitator who moderates the discussion. When used for groups, chairs are arranged in a circle so that participants can see one another, and everyone is “equal.” Communication occurs in all directions:

Learning is active, not passive. WIC participants share their experiences and ideas with the rest of the group. They learn from one another as well as from the facilitator. And, they are more likely to learn since they are actively involved in the discussion, discovering new information and solving problems.

Each group session is unique in content and style, as it is shaped by the circumstances, interests, and experiences of the participants.

The facilitator gets the group going by explaining what the session will be about, that it will flow according to the interests of the group. “We surveyed participants to find out the kinds of information they were interested in. The topic today was number one on the survey.”

Ground rules are set as needed, at the beginning of the session. Set the time and agenda for the session. “We are going to spend the next 15 minutes talking about how to have a healthy baby. I will start with a question.”

The facilitator may remind the group to respect each member’s views, even if they do not agree with their views, that all members of the group should feel free to participate and share ideas. “Each of you has ideas and experiences that you can share with other members of the group. I do ask that everyone listen and respect one another’s ideas.”

Display a poster:

Thank you for:

• Sharing your ideas. • Listening to the ideas of others.

Attachment 5.02 B Attachment 5.02B Page 2 of 3

Icebreakers are used to get each member of the group to say something, to encourage them to participate. Examples of icebreakers include asking each participant to tell something about themselves, such as their favorite baby name, favorite color, fruit, or TV show. If you are worried about the time involved in an icebreaker activity, at the very least ask participants to turn to the person sitting on either side and say “Hello” or “Good Morning/Afternoon.” This can relax everyone in the room!

Ask the first question. Make it simple and non-threatening. Expect silence, at first. Give everyone a moment to think about a response. Find someone who appears to be comfortable in answering. You might try the question another way.

“What advice would you give your best friend (or daughter) to have a healthy baby?” Or, “How does the food you eat affect the health of your baby?”

Sometimes, giving the first person to respond a small reward, such as a magnet, can be an incentive for others to contribute ideas.

Open-ended questions are the best questions to use throughout the discussion.

Asking closed-ended questions where a “yes” or “no” is the only response, should be limited. They can be appropriate. “Do you think it is important to eat healthy during pregnancy?” Ask for a show of hands. Then, follow it up with “What does it mean to “eat healthy?” to continue the discussion.

The facilitator guides the discussion, keeping the session focused, encouraging all members to participate, clarifying and asking for more detail on comments or ideas offered, gently correcting misinformation if stated by a group member, and bringing the session to a close. The facilitator must not allow members to interrupt another member who is speaking and must discourage “side” conversations.

The facilitator must use active listening, acting like a talk show host! “That is a good point that you made about not having enough time to cook a meal. Let’s explore some ideas for eating on the run. Do you think you can eat healthy at a fast food restaurant?”

The facilitator must learn to deal with disagreement in the group and members who monopolize. “You have much to share on this topic, but we have some other issues we need to discuss. Could we talk for a few minutes after this session is over?” Or, “We respect how you feel about this issue, but not everyone agrees with your opinion. Let’s move on with the discussion. I would be happy to talk with you after this session is over.”

Make sure that the comments of group members can be heard by all. You may need to repeat the comment to the group. Respond positively to the information Display a poster with key words that “outline” the discussion to keep things on track.

Attachment 5.02 B Attachment 5.02B Page 3 of 3

group members offer. “That’s a good way to remember to take your prenatal vitamin.” “What are some other ways to help you remember? Pay attention to all members, watching for signs that they want to say something, or that they have lost interest (to draw them back into the group).

Close the session by thanking the group for sharing their ideas and experiences. Offer sources of additional information, such as pamphlets, fact sheets, and referral information.

Attached to this section is an example of a lesson plan for facilitated discussion developed by the Michigan WIC Program.

References

1. Listen, Share, Support, Facilitator’s Guide for Nutrition Education, New Mexico WIC Program.

2. Facilitative/Experiential Teaching Ideas, Ellen Schuster, PhD, Oregon State University Extension Family & Community Development.

Attachment 5.02 C Attachment 5.02C 10/1/2014 1 of 3 Visual Aids/Exhibit Boards

What I hear, I forget. What I see, I remember. What I do, I understand. - Confucius, 451 B.C.

Visual aids should enhance your presentation/group discussion. When used as an interactive exhibit, it may provide the bulk of your presentation with someone present to explain what the exhibit is all about and how to navigate it.

Visual aids can keep participants tied to an oral presentation and prevent their minds from wandering. (2) They can reinforce key concepts and prevent misunderstanding. Used with a group discussion, they can help keep the group on track. Like a road map, they help us reach a destination. (2)

Visual aids can be:

• Projected, such as internet downloads, Power Point presentations, or DVDs; or

• Non-projected, such as posters; flannel, exhibit, or bulletin boards; chalk or magnetic boards; charts; flip charts; models; and objects.

Be sure that participants can see and read visual aids such as internet downloads, DVDs, posters, or flip charts. Test them by sitting in the back of the room before your presentation.

Tips for developing visual aids (1, 2)

♥ Start with an attention-getter, perhaps a catchy title, especially for an exhibit board that you want to draw the participant to.

♥ Use bold, bright colors.

♥ Keep it as simple as possible, avoiding too many words and illustrations.

♥ Use 1 simple font, in a size that people can read. For an exhibit board, walk to the room entrance and see if you can read the title and subtitles.

♥ Use upper and lower case letters.

♥ Use illustrations to clarify the printed message. Participants may prefer photographs of foods that are affordable, “served in dishes they might use at home.” (2) Photographs of people in action, such as children eating a snack, can suggest “doable” behaviors, especially if the subjects are people the participants can identify with culturally and ethnically. Photographs should also be

Attachment 5.02 C Attachment 5.02C 10/1/2014 2 of 3 uncluttered. If photographs are not available, clearly drawn illustrations should be used. Use contemporary photographs and illustrations.

♥ Statements should read from left to right.

♥ Present the information in a logical order, using an active voice. For an exhibit board, organize the statements so that they tell a story.

♥ Use bullets to set off key words or phrases and numbers for steps to be performed in a sequence.

♥ Consider using peer language. Peer language may “increase personal identification, improve readability, and optimize the tone of communication.” (2) Less skilled readers react more positively to peer statements.

♥ For a self-paced exhibit board, include one or two activities.

♥ Let someone else check over a draft of your visual to check for errors in spelling and grammar.

♥ Don’t overdo. A rule of thumb is 1 visual for every 2 to 4 minutes of presentation.

♥ Display only one key point at a time as you make your presentation. Cover up the other information until you are ready to talk about it.

A checklist for evaluating your visual aids is found on page 3.

Tips for using a flip chart. (2)

♥ Prepare at least some of the charts in advance. Tape or “Velcro” strips of paper over statements that can be removed as each point is made during the session.

♥ Use a variety of colors, preferably something other than the standard red, blue, or black. Check out an art or office supply store for red-violet or blue-green.

♥ Write on only the top third of the flip chart to ensure that the text can be seen by everyone in the room.

♥ Add some simple illustrations.

♥ Use graph type paper if you want to write during the session, to keep your writing level.

♥ As you present, point to the information on the flip chart. Don’t assume everyone sees the information. Then, step to the side of the flip chart.

Attachment 5.02 C Attachment 5.02C 10/1/2014 3 of 3 Recommendations for using color (3)

♥ Black and blue: Should be the primary print color since they provide contrast. ♥ White: The best background color. ♥ Red and green: Good accent colors, but should not be used for words. ♥ Yellow: An accent color only. It is hard on the eyes in large doses. ♥ Brown: Has a negative connotation related to dirt. Avoid using.

Remember that color preferences do go in and out of fashion.

Checklist for Visual Aids (2)  My visual aids:

Are clear and simple.

Are readable, even in the back of the room.

Convey a single idea.

Correspond to my presentation.

Are interesting and attractive.

References

1. Creative Training Techniques Handbook, Robert W. Pike, CSP, Lakewood Books, 1994.

2. Nitzke, Susan, et al. Writing for Reading. Guide for Developing Print Materials in Nutrition for Low Literacy Adults, University of Wisconsin Extension, 1986.

3. Nutrition Education Ideas Resource Manual, The Pennsylvania State University, October 2000.

Attachment 5.02 D Attachment 5.02D

1 of 4 Evaluation

So, how did it go?

Evaluation is the process of measuring the effectiveness and appropriateness of an activity or intervention.(1) Evaluating nutrition education activities helps you to make changes or improvements when needed and can provide satisfaction that your activity has had a positive impact. Evaluation is also important for program accountability.

There are two types of evaluations, process and outcome.

• A process evaluation measures how well the activity was conducted.

• An outcome evaluation measures the extent to which the anticipated outcome was achieved.

You can evaluate changes in knowledge, attitude, beliefs, and behaviors.

Evaluation starts with a written objective.

Ask yourself, what it is that you would like for the participant to know, do, or feel as a result of your nutrition education activity? Write down what you hope to accomplish in the form of an objective. To write an objective:

1. Identify the audience, such as WIC participants. 2. Specify what you want them to do, such as, state one way to prepare a green vegetable. 3. Use an action verb, something specific, like list, name, select, etc. 4. Include a measurement criterion, such as, 80 percent of a 10 percent sample of participants will list 3 vegetables that are high in vitamin A.

Write only one or two objectives for each activity.

Types of Evaluation Methods

Traditional Methods:

1. Paper and pencil test. This format is the most familiar one and is usually used to measure change in knowledge. Tests may use singly or in combination, true-false, multiple choice, and fill-in-the blank questions.

2. Surveys. Surveys may contain open-ended questions or a Likert scale format (shown below). Surveys may measure change in attitude or may be used for process evaluation, to evaluate how well the program is performing.

Attachment 5.02 D Attachment 5.02D

2 of 4 Examples of Likert-scale questions:

How likely are you to eat 2 servings of fruit every day? 1

3

5 Very likely

Somewhat likely

Not likely

Or,

How much did you learn today? 



 A lot

A little

Nothing

Tests and surveys, especially those without “open” responses, are quick to score and summarize. The disadvantage is that they give one the feeling of being in “school,” which adult learners do not like. Participants who cannot read well may not answer the test questions correctly. You will not know if they did not understand the information or the test question. Furthermore, unless a pretest is administered, you never know if the participant knew the information prior to your session.

Some tips for writing test questions (2):

1. Write simple, clear instructions for completing the test.

2. Write the test questions very simply.

3. Write positive test questions instead of negative ones (which of these is …. rather than which of these is not….)

4. For multiple choice questions, limit the number of choices to 3. Make the choices simple words or phrases. Avoid choices of “all of the above” or “none of the above.”

5. Pretest your test questions to make sure they are clear.

Attachment 5.02 D Attachment 5.02D

3 of 4 Non-Traditional Methods:

1. Use a ruler to “measure” intent to change a behavior.

Show participants a ruler. Ask them to indicate their intent to make a behavior change (such as adding an extra daily serving of a fruit or vegetable or adding a specific physical activity to their day) by writing a number (1, 6, or 12) on a piece of paper.

Tell them to write 1 if they plan no changes, 6 if they will think about making a change, and 12 if they plan to make a change.

2. Use a piece of paper divided in two, to gauge self-efficacy, before and after the session.

Ask participants to write down the number 1, 2, or 3, to signify how easy it would be to perform a specific activity, such as eating one more serving of a fruit or vegetable or adding 10 minutes of physical activity to their day. The number 1 means not easy at all, 2 means somewhat easy, and 3 means very easy. They fill in the left side before the session, and the right side, after the session.

I can eat one more serving of a fruit or vegetable every day:

I can eat one more serving of a fruit or vegetable every day:

3. Use a “Post-It” note to indicate one new idea learned.

Distribute a “Post-It” to each participant. Ask them to write down one new idea learned from the session. Permit them to write “none” or to offer an idea for a future session.

4. Use a show of hands to indicate change in knowledge or intent to change a behavior.

Attachment 5.02 D Attachment 5.02D

4 of 4

Keep a record of participants’ responses when you use an alternative method such as a show of hands. This will allow you to summarize the responses later on. A sample form is shown below.

Class/Topic: Incredible, Edible Beans! Objective: Participants will state their intention to prepare WIC beans. Evaluation Method: Show of Hands Class # Number in Class Number indicating intention to prepare a bean recipe.

References

1. United States Department of Agriculture. The Idea Book: Sharing Nutrition Education Experiences, 1981.

2. How to Write Training Materials, Linda Stoneall, Jossey-Bass-Peiffer, 1991.

Attachment 5.02E Page 1 of 2 Attachment 5.02E Techniques for Telephone Counseling

Providing nutrition education by telephone can be an important method to continue food benefits and improve retention in WIC programs. When a participant is unable to get to the WIC clinic to complete secondary nutrition education or is unable to complete online nutrition education, telephone counseling can be the answer. In other cases, the only way for a CPA to provide high risk nutrition education is to contact the participant by phone. In such situations, participants shall receive nutrition education equal in quality to what they would receive in the WIC clinic and receive their food benefits in a timely manner. Following are guidelines for providing comprehensive nutrition education by telephone. Be Prepared: Review the participant’s record thoroughly before making the call. Connect with Body Language: Let your participant hear your smile and feel your body language and interest. Be Participant Focused: Ask if this is a good time for the participant to talk. If the participant says no, don’t be offended. Offer the participant options for different times for you to call back. If the participant says yes, involve the participant in the conversation. 1. If the participant has not completed online nutrition education: a. Ask if the participant has had difficulty using online nutrition education. b. If so, ask what is causing the difficulty. c. Ask if the participant would like you to walk them through the steps to access online nutrition education. d. If the participant agrees, follow up with assistance as needed. 2. If the participant has not kept an appointment, does not want assistance with online nutrition education, or otherwise needs secondary nutrition education, or is receiving high risk counseling from a CPA: a. Follow up on any prior goal the participant set. b. Offer to discuss any information or questions remaining from prior education. c. Invite the participant to share health or food concerns related to her risks. d. Ask the participant to share her ideas for moving forward. e. If needed, ask if you can share information and/or suggestions for a small next step. f. Ask the participant which of the options she thinks will work for her.

Attachment 5.02E Page 2 of 2 Attachment 5.02E g. Help the participant make the step. The step should be specific, measurable, attainable, realistic, and timely. h. Record any goal the participant sets. i. Record the education topic in the participant’s Nutrition Education screen. j. If this is a high risk contact, complete a Care Plan in NoteMaster. Plan for the next appointment: 1. Verify the participant’s address. 2. Remind the participant of the next appointment date and time, or 3. Set the next appointment. Wrap up the call: 1. Summarize the discussion. 2. Ask if the participant has any other questions or concerns. 3. Thank the participant for her time.

Policy and Procedure 5.03

Page 1 of 3 MARYLAND DEPARTMENT OF HEALTH WIC PROGRAM POLICY AND PROCEDURE MANUAL

Policy and Procedure Number: 5.03 Effective Date: July 1, 1994 Revised Date: May 20, 2020 SECTION: NUTRITION EDUCATION SUBJECT: Participants at High Nutritional Risk/Care Plan Development

A. Policy

A Care Plan shall be developed by a Competent Professional Authority (CPA) and documented in the WOW record for a participant who is identified as at high nutritional risk. A Care Plan shall also be developed by a CPA for a participant who requests one.

Initial contact1 between the CPA and the participant shall be as follows: Best Practice: speak with the participant and develop the care plan at the time of certification, or, if delayed, within ten business days by appointment, phone, or letter. At the latest, the initial contact and Care Plan shall be completed within one calendar month.

A participant with one or more of the criteria identified as high risk in Attachment 2.31A Nutrition Risk Criteria: Guidelines for Interpretation shall be considered at high nutritional risk. Local agencies may expand the high-risk designation to other at-risk cohorts such as obese or overweight children or pregnant adolescents.

High risk services shall be performed by a qualified Competent Professional Authority, preferably a licensed dietitian/nutritionist.

B. Procedure

1. The local agency shall:

a. Designate qualified staff to perform high risk services and grant them access to the Care Plan screens and High-Risk Report in WOW.

b. Develop a written procedure to ensure that participants identified as “at high nutritional risk” receive a Care Plan within a time frame consistent with section A above. Counseling should be consistent with guidance provided by the following resources: i. Attachment 2.31A Nutritional Risk Criteria: Guidelines for Interpretation

1 Initial Contact: Actual contact in clinic/actual or attempted contact by phone or letter by CPA after risk is assigned. Contact shall occur at every Cert/Recert and MCV, upon risk assessment.

Policy and Procedure 5.03

Page 2 of 3 ii. The Nutrition Care Manual and the Pediatric Nutrition Care Manual (Academy of Nutrition and Dietetics) https://www.nutritioncaremanual.org

c. Establish a process for routinely monitoring the status of high-risk participants, such as using the High Risk Report available in WOW.

2. Counseling performed by the WIC CPA, including the initial Care Plan, follow up, contacts, and refusals shall be documented by the CPA in the participant’s Care Plan, and on the Nutrition Education screen as “Nutrition Care Counseling.”

3. The Care Plan shall document in the participant’s WOW record, at minimum, the following information: a. At least one attempt by the CPA to contact the participant by telephone, mail, or email if unable to provide the high-risk service at the time of certification; b. A participant or caregiver’s refusal to the CPA of high-risk services, if refused; and c. A written statement by the CPA in the Care Plan section of NoteMaster describing the manner in which high risk status is resolved2. d. Rationale to allow children ages two through four with a well-maintained high-risk condition to be designated as low risk and allowed to complete secondary nutrition education through online nutrition education. The child’s risk status shall be reassessed at the next mid-certification or recertification visit.

4. The WOW Client Referrals screen may be used to refer participants to WIC staff designated to perform high risk services. For manual certifications only, the referral section of Attachment 2.02A, shall be used.

5. The WIC CPA shall review the record of the participant to determine the type and frequency of counseling that is required. The service may include one of the following: • A Nutrition Care (NC) appointment for individual counseling. • Nutrition Care counseling by telephone. • Further probing that establishes that the participant is currently receiving appropriate Nutrition Care from another provider. • Referral to a qualified provider outside of the local agency if the participant will not be charged a fee for the service.

2 Risk Resolved: Risk is no longer a risk because the condition is no longer present.

Policy and Procedure 5.03

Page 3 of 3 References: 1. CFR 246.11 2. WIC Nutrition Services Standards

Revisions:

10/10 Added Best Practice time frame for care plan development. Changed instructions for documenting care plans. Added new high-risk criteria to policy as follows: Women: History of gestational diabetes; History of preeclampsia; Hypertension/prehypertension; Post bariatric surgery; and Vegan or fasting diet, Children: Hypertension/prehypertension. Added new risks to Attachment 5.03A.

10/11 B.2. Changed “High Risk” Counseling to “Nutrition Care” Counseling.

10/15 Extended Best Practice time frame to ten days. Set one month limit for Care Plan completion. Defined initial contact.

Corrected definition of Prematurity.

Added three counseling resources.

In Procedures 2 and 3: clarified duties to be performed by the CPA

Added the definition of “risk resolved”. Converted the original Att 5.03A to Att 2.02A, to be used only for manual certifications. In B. 5., deleted Group Counseling for High Risk conditions. Changed “appropriate care” to appropriate “Nutrition Care”. Removed WOW help references. Formatting changes.

10/16 Changed the high risk blood lead level to 5 micrograms/dl for both women and children. Added Breastfeeding Complications or Potential Complications to pregnant woman high risk list and Breastfeeding Mother of Infant at Nutritional Risk to both pregnant woman and breastfeeding woman high risk lists. Removed Inadequate Growth risk from both infants and children.

11/17 Updated 2.31A Nutritional Risk Criteria.

02/19 Added B.3.d. Rationale to allow children ages two through four with a well maintained high risk condition to be designated as low risk for the time frame to complete secondary nutrition education through online nutrition education.

Removed resource Maryland WIC Nutrition Care Counseling Guidelines from B.1.b.

05/20 Removed section listing specific criteria for participants at high nutritional risk. Added reference to Attachment 2.31A Nutrition Risk Criteria: Guidelines for Interpretation for guidance related to participants considered at high nutritional risk.

October 2013

Policy and Procedure 5.03A has been removed.

Policy and Procedure 5.04 Page 1 of 2 MARYLAND DEPARTMENT OF HEALTH WIC PROGRAM POLICY AND PROCEDURE MANUAL

Policy and Procedure Number: 5.04 Effective Date: October 1, 1995 Revised Date: March 4, 2025 SECTION: NUTRITION EDUCATION SUBJECT: Exit Counseling

A. Policy

Postpartum participants shall receive information referred to as “exit counseling.” The purpose of this information is to reinforce five important messages designed to improve the health of postpartum participants (WPP, BE, and BP) and their families:

 Make healthy food choices and be physically active;  Consume adequate folic acid;  Consider breastfeeding as the preferred method of infant feeding;  Follow the recommended schedule for immunizations and  Know the health risks associated with alcohol, tobacco and drug use.

B. Procedure

1. WIC staff shall provide exit counseling information to postpartum participants at the most appropriate time; best practice is at the postpartum recertification appointment.

2. Following a complete WIC nutrition assessment, staff shall decide the most relevant information to discuss, based on the participant’s identified risk factors, needs, interests, and circumstances.

3. Topics discussed shall be documented in the management information system Nutrition Education screen. Referrals made shall be documented in the Client Referrals screen.

Policy and Procedure 5.04 Page 2 of 2

4. The booklet Maryland WIC Guide for a Healthy New Mom contains exit counseling information and shall be provided to postpartum participants. When this booklet is given, the Exit Counseling topic shall be checked in the Nutrition Education Screen. Local agencies may substitute other materials that provide exit counseling information, with prior approval from the State Nutrition Education specialist.

References: 1. SFP 94-142, Provision of Exit Counseling 2. WIC Nutrition Services Standards, Standard 8 3. SFP 06-032, WIC Nutrition Education Guidance

Revisions: 10/2010 Changed B.4 to order from the Maryland WIC Distribution Center using Attachment 7.65C.

10/2013 Removed B.5. Modules no longer available.

10/2015 Changed Health Tips for New Moms to Maryland WIC Guide for a Healthy New Mom. Removed reference to Distribution Center.

3/2025 Updated B.1. Replaced “for example, at the postpartum recertification appointment. with “…best practice is at the postpartum recertification visit.”

Added to B.4. “When this booklet is given, the Exit Counseling topic shall be checked in the Nutrition Education Screen.”

Changed ‘women’ to ‘postpartum participants’ throughout policy

October 2013

Policy and Procedure 5.05 has been replaced by policy 2.39.

MARYLAND DEPARTMENT OF HEALTH WIC PROGRAM POLICY AND PROCEDURE MANUAL Policy and Procedure Number: 5.06 Effective Date: October 1, 1995 Revised Date: April 18, 2024 SECTION: NUTRITION EDUCATION SUBJECT:

Annual Nutrition/Breastfeeding Services Plan

A. Policy Local agencies shall develop an annual Nutrition/Breastfeeding Services Plan1. The Plan shall contain at a minimum: ∙ A description of the local agency’s procedures for providing nutrition education and breastfeeding promotion and support to participants ∙ A description of planned nutrition education and breastfeeding promotion and support activities and staff training for the next federal fiscal year; and ∙ An evaluation of completed nutrition education and breastfeeding promotion and support activities and staff training for the current fiscal year.

B. Procedure

1. The local agency shall:

a. Develop the Plan using Attachments 5.06A-G, following the guidelines found in Attachment 5.06G.

b. Submit the Plan by July 31 of the current federal fiscal year to the State Nutrition Services Unit.

c. After review by the State Nutrition Services Unit, submit modifications as needed.

d. After final approval, implement the Plan beginning October 1, of the next federal fiscal year.

1 Nutrition services is defined as “the full range of activities performed by a variety of staff to operate a WIC Program, such as participant assessment and screening, nutrition education, nutrition, breastfeeding, and health promotion, food package prescriptions, and health care referrals. WIC nutrition services encompass not only what WIC offers to participants, but how WIC offers its services. At all levels this includes taking a fresh look at clinic environment, staff attitude, training and proficiency, materials and tools used, strategies for assessment, and nutrition education/counseling techniques.” WIC Nutrition Services Standards, August 2013.

Policy and Procedure 5.06 Page 1 of 4

e. Submit any changes to the Plan in writing to the State Nutrition Services Unit for approval.

f. Maintain a current version of the Plan at its administrative office and make it available for review by staff conducting a management evaluation.

2. The local agency shall receive a reminder notice from the State, two months prior to the Plan’s submission date that contains additional guidance as well as an electronic version of Attachments 5.06 A-G.

Attachments: 5.06A Nutrition/Breastfeeding Services Plan 5.06B Local Agency Nutrition Education Providers 5.06C Nutrition/Breastfeeding Education for Participants Worksheet 5.06D Breastfeeding Support Roles 5.06E Breastfeeding Month Activity Plan 5.06F Local Agency Developed, Procured, or Downloaded Nutrition Education and Breastfeeding Materials 5.06G Guidelines for Developing the Annual Nutrition/Breastfeeding Services Plan

References: 1. 7 CFR 246.11 2. WIC Nutrition Services Standards, Standard 8

Revisions: 10/10 Revised Attachment 5.06A, Part 1, #6 to include a wider array of professional credentials to include RD, LDN, RN, IBCLC, and PC.

10/11 Revised Attachment 5.06A as follows: Added Participant Focused Contact. Rearranged several questions in more logical order. #4, Added “alcohol” and “lactation.” #5. Changed to describe how this agency refers and documents. #6. Asked more specifically about coordinating agencies. #8. Added Hearing impaired. #9. Added question regarding which cultures are being served and how their needs are met. #11. Added attach list with State approval date if known. #13. Added three questions. 14. Added specific requirements and procedures. #15. Requested prior year Participant Focused and BF topics. #16. Deleted resubmission of entire Lesson Plans and handouts from prior year. #17. Required submission of completed Lesson Plan for each quarterly activity. #19. Requested copy of written information. #22. Refers to new BF Month Activity form. Added check box to delay submission of BF Month Plan. Added Part 5: FY 2012 BF Month Activity form. Added requirement for complete Lesson Plans, handouts, and descriptions of props. Incorporated Attachment 5.06B into 5.06A, Part 4.

10/12 Updated 5.06A, Parts 1-4, as follows: #4 added Exit Counseling. #8 now includes Hearing Impaired. #9 asks for cultures, non-English speaking groups served. #11 asks to attach list with dates approved. #13 asks if annual participant survey is done, how done, and how used. #14 asks for specific topics and how to report. #15 asks for specific topics. #16 asks for completed evaluation of topic. #17 asks for a lesson plan for each topic. #18 Inserted: List current local agency employees and identify BF support roles. #20 added two categories. #23 added Part 5, and deferred submission of Breastfeeding Month Plan.

10/13 Updated 5.06A as follows: In #2, changed the number of required nutrition education contacts to at least 4 for all participants. Removed and renamed #7 as 5.06B, #18 as 5.06E, Part 4 as 5.06C and 5.06D, Part 5 as 5.06F. Renumbered items as needed. Renamed 5.06B as 5.06G. New #11 includes only allowed incentives and requires a nutrition message for each incentive. New 5.06B: Changed “HR” (High Risk) to “NC” (Nutrition Care). New 5.06 C: Revised format for Lesson Plans. Updated the Attachments list at end of 5.06.

10/14 Updated 5.06 as follows: In B1.a., changed 5.06A to 5.06A-F and changed 5.06B to 5.06G. In B.2., changed three months to two months and 5.06A and 5.06B to 5.06A-G. Updated 5.06A as follows: In #11, changed CPU education topics and incentives for current year. Renamed Part 3 as Nutrition Education Activities Summary, and included #s 15-17. Changed #17 to require a list as well as attaching copies. Renamed Part 4 as Breastfeeding Promotion & Support, including #s 18-26. Changed #s 20 & 21 to include names of new Maryland WIC Pregnancy & Postpartum Guides and requested list and copies of any other materials. Updated 5.06C as follows: In Methods, deleted Lecture, Health Fair, Overheads, and Video. Added Handouts/Brochures. Moved entire section to begin after questions #1-10. In Evaluation-Describe Results, changed “failures” to “challenges”. Updated 5.06D as follows: Deleted Health Fair, Overheads, and Video. Added Handout/Brochure. In

Evaluation-Describe Results, changed “failures” to “challenges.”

Updated 5.06 F as follows: In Methods, deleted Lecture, Overheads, and Video. Added Handouts/Brochures and Internet Download. Moved entire section to begin after Description of Activity.

10/15 Added Attachments 5.06H and I. Format revisions made to 5.06A, 5.06C and 5.06F.

07/16 Changed Subject Nutrition Services to Nutrition/Breastfeeding Services Updated 5.06 A as follows: In #11, updated category incentives. Eliminated Quarterly incentives. In #15, inserted b. Please attach a copy of the form you use to assess participant views of the effectiveness of the education.

Updated 5.06 C as follows: Removed questions 7 and 8. In Staff Engagement, added #10: How will you check their knowledge? Updated 5.06 D as follows: Removed questions 4 and 5. In Staff Engagement, added #6: How will you check their knowledge?

Updated 5.06 F as follows: Added “Local Agency” information in the title.

Updated 5.06 G as follows: In section 3, removed bullet point about incentives. In 3.b. removed “lectures”.

07/20 Added additional questions related to evaluation of online nutrition education by participants.

05/22

In B.1.a. and B.2. Changed Attachments A-I to A-G.

In 5.06.A., Q.15.A., replaced questions a. through k. with Question 1-10 using check boxes to simplify responses. In Q.11. requested copy of assessment form. In Q.12. requested a summary of collected data. In 5.06A, Q. 15.B. questions a-d were replaced by Q 1-4, requesting information on who was assigned online education, when follow up occurred, how goals and changes were addressed, and participant feedback about online nutrition education.

In 5.06.A., Q.19-23 were replaced by direction to update attachment 5.06D. Q.20 inserted a chart to identify overall breastfeeding goals and objectives for coming year, check box questions on providing information on benefits and contraindications of breastfeeding, written materials provided, and a series of

questions to evaluate previous year’s breastfeeding support activities. Added Q 24 regarding changes to coming year’s plan, and Q. 25. Requesting completed forms 5.06.C for ongoing breastfeeding classes or support groups.

Removed prior 5.06C and 5.06D. Replaced with revised 5.06C. Combined 5.06H & 5.06I. Renumbered attachments accordingly.

10/23 In 5.06A, #11. Added link for recipe cards.

In 5.06A, #16, removed “or D” for discontinued attachment. In 5.06A, #17, added to submission instructions, to include PowerPoints and bulletin board drawings.

In 5.06D Added question regarding how to ask permission to share information

4/24 Updates to attachments A, B, and C to streamline the process. 5.06A Removed Market to Mealtime as options for lessons; deleted question 6 and made edits to question 17. 5.06B Added DBE and BFPC classifications; assume all staff conduct primary and secondary education so removed columns; added columns for high risk nutrition and high risk breastfeeding education. 5.06C minor edits and updated year.

Attachment 5.06A

Attachment 5.06A 4/18/2024

Page 1 of 11

FY 20xx_ Nutrition/Breastfeeding Services Plan for ________________________________________

Name(s) of ALL person(s) who developed this plan: Click or tap here to enter text.

☐ Nutrition Education ☐ Breastfeeding ☐ Participant Focused Counseling Click or tap here to enter text.

☐ Nutrition Education ☐ Breastfeeding ☐ Participant Focused Counseling Click or tap here to enter text.

☐ Nutrition Education ☐ Breastfeeding ☐ Participant Focused Counseling

Part 1: Program Description 1. Print out, review, and attach the WOW report, Participant Risk Factors (condensed version) for your agency. Describe your local agency’s goal for nutrition education for this fiscal year. Indicate any nutrition priority that you plan to address based on participant risk factors, national trends, or local agency needs. (See examples in staff portal)

2. This agency ensures that each participant is offered at least 4 nutrition/breastfeeding education contacts during the certification period through: ☐ Individual counseling at certification

☐ Individual secondary contacts ☐ Group nutrition education at class pick up

☐ Online Nutrition Education ☐ Mid-certification visits

☐ Phone counseling

3. This agency handles “no-shows” and refusals of nutrition education by: No Shows: Refusals:

4. This agency provides information about the dangers of substance abuse to all adult participants and caregivers of infant and child participants through: ☐ Advice given at time of certification

☐ Local agency developed/procured materials (copy attached) ☐ Group classes

☐ Posters displayed in the clinic ☐ State-developed written materials

☐ Videos shown in the clinic ☐ Exit counseling

☐

Attachment 5.06A

Attachment 5.06A 4/18/2024

Page 2 of 11

5. Describe how this agency refers and documents the referral of participants in need of high risk (Nutrition Care) counseling, or those who request counseling. Describe how CPA receives referral. Include expected CPA response time. Local Agency Nutrition Care procedures and protocols must comply with Policy & Procedure 5.03.

6. This question has been deleted.

7. List current local agency employees who provide nutrition/breastfeeding education: Use Attachment 5.06B.

8. Explain how you accommodate special needs participants with food package tailoring, Limited English Proficiency (LEP), American Sign Language (ASL) and others. ☐ Homeless ☐ Migrant farmworker ☐ Hearing impaired ☐ ☐ ☐ Not applicable

9. List the dominant cultures served by your agency. Describe how you meet their needs for translation, handouts, focus on cultural foods, interpreters. ☐ ☐ ☐ ☐ ☐

10. Describe challenges to carrying out nutrition/breastfeeding education activities and how you address them: ☐ Space limitations ☐ Lack of staff ☐ ☐ Not applicable

Attachment 5.06A

Attachment 5.06A 4/18/2024

Page 3 of 11

11. In the list of incentives below, explain how you link each incentive with a nutrition message. State nutrition/breastfeeding messages as if speaking to participant. (See examples in the staff portal)

Category Appt Type Incentive Related Nutrition Message Infant Cert Mouth swab

MCV Infant spoon OR

Open cup

C1 Recert Snack Buddy

MCV Time to Eat English/Spanish

C2 Recert MyPlate Plate

C2 MCV Beach Ball

C3 Recert Apron

C3 MCV Water Bottle

C4 Recert Berenstain Bears Bike Book

Last Appt Insulated lunch bag

All Children As needed Toothbrush

Pregnant Cert Chico bag

Attachment 5.06A

Attachment 5.06A 4/18/2024

Page 4 of 11

Postpartum Recert Everyday Healthy Meals cookbook

BE, BP Cert/MCV BF or other water bottle BE, BP As needed.

Deluxe 6-pack purple cooler/ice pack

C 1-4 As needed My Mom Is Breastfeeding book

Others

Part 2: Staff Training 12. Describe trainings provided to local agency staff during the past fiscal year. ☐ Annual bloodborne pathogens refresher ☐ Civil Rights ☐ Internet Security ☐ Participant focused education staff training: Name the four topics you provided

☐ Breastfeeding staff training is required for all staff. Go to Section 4: Breastfeeding to complete the list.

☐ Other training

Attachment 5.06A

Attachment 5.06A 4/18/2024

Page 5 of 11

13. Describe trainings planned for local agency staff during the coming fiscal year. See WOW staff portal for handouts and recorded trainings or call Nutrition and Breastfeeding Unit for information. ☐ Annual bloodborne pathogens refresher ☐ Civil Rights ☐ Internet Security ☐ Participant focused education staff training must be conducted a minimum of 4 times per year. Submit Activity Sheet, S ign in sheets, and staff evaluations to the State Nutrition and Breastfeeding Services Unit upon completion. Name four topics currently planned for the coming year.

☐ Breastfeeding staff training is required for all staff. Go to Section 4: Breastfeeding to complete this list.

☐ Other training

14. Describe any specific needs not already available for State assistance/support in the coming year.

TOPIC AREA NEEDS Participant Nutrition Education Materials

Staff Nutrition Education Training

Breastfeeding Education

Breastfeeding Materials

Nutrition Care Training

Nutrition Care Materials

Incentives

Others (list and explain)

Attachment 5.06A

Attachment 5.06A 4/18/2024

Page 6 of 11

Part 3: Nutrition Education Activities Summary 15.A . Federal Regulations require each local agency to assess participant views on the overall effectiveness of nutrition/breastfeeding education at least once each year. Tell us how you assessed participant views on the effectiveness of nutrition/breastfeeding education this past year. For examples of questions for Nutrition or Breastfeeding change, see the Staff Portal.

1. How did you conduct assessments on the effectiveness of your nutrition/breastfeeding education this past FY? (select all that apply)

☐ in-person ☐ phone ☐ video conference ☐ text ☐ website ☐ other (specify) Click or tap here to enter text.

2. When did you conduct assessments on the effectiveness of your nutrition and breastfeeding education this past FY? (select all that apply) ☐ Certification ☐ Recertification ☐ MCV ☐ IND ☐ CPU ☐ ONE ☐ NC ☐Other (please specify) Click or tap here to enter text. 3. How were the assessments provided and collected from the participants? (select all that apply) ☐ Link to an electronic survey (e.g., survey monkey, google survey, etc.) ☐ Sent and received questionnaire vial mail, text, email ☐ Reviewed questionnaire by phone ☐ Reviewed questionnaire by video conference ☐ Gave out questionnaire during in-person visit ☐ Other (specify) Click or tap here to enter text.

4. Who received the assessments/surveys? (Select all that apply) ☐ Pregnant participants ☐ Breastfeeding participants ☐ Non-breastfeeding participants ☐ Parents/caregivers of infants and children

5. How did you explain the purpose of the assessments to your participants? Click or tap here to enter text.

Attachment 5.06A

Attachment 5.06A 4/18/2024

Page 7 of 11

6. What method did you use to compile the participant responses? ☐ Check boxes ☐ Count & Tally ☐ Survey Monkey ☐ Graphs ☐ Written comments ☐ QR codes

☐ Hashmarks by hand ☐ Statistical program ☐ Other: Please describe. Click or tap here to enter text.

7. What was your biggest surprise/insight from the participant responses? Click or tap here to enter text.

8. What conclusions did you draw about the effectiveness of your nutrition and breastfeeding education? Click or tap here to enter text.

9. What, if any, changes do you plan to make in providing nutrition education as a result of the responses you received, including changes to your assessment tool? Click or tap here to enter text.

10. Please attach a copy of the form you used to assess participant views of the effectiveness of nutrition and breastfeeding education. 11. Please include tabulated results of your collected data.

15.B. Tell us how you assess participant views of the effectiveness of nutrition/breastfeeding online education (ONE).

1. Who is assigned online nutrition education in your clinic? (Check all that apply.) ☐ Pregnant participants ☐ Breastfeeding participants ☐ Postpartum participants ☐ Infants ☐ Children ☐ High risk participants

2. When did you follow up with participants who took online nutrition education (ONE)? Click or tap here to enter text.

3. How did you address their goals and the changes they make after completing the online nutrition education (ONE)? Click or tap here to enter text.

Attachment 5.06A

Attachment 5.06A 4/18/2024

Page 8 of 11

4. Please provide any feedback from participants about doing online nutrition education (ONE). a. Likes: Click or tap here to enter text. b. Dislikes: Click or tap here to enter text. c. Suggestions: Click or tap here to enter text.

16. Summarize completed nutrition activities for last year by resubmitting Section 4 of Attachment 5.06C for each activity with the evaluation completed. Do not resubmit your handouts or other materials. Submit the evaluation from the 4th quarter of the prior year, and the first 3 quarters from the current year.

17. Use Attachment 5.06C. Complete one form for each activity planned for the coming year. Submit the form, handouts, and all other materials with this plan.

Name the type of Secondary Nutrition Education that you will offer with their titles:

☐ Online Nutrition Education (No title needed) ☐ One on One Individual Learning Centered Education on a specific topic. Click or tap here to enter text. ☐ One on One Individual Learning Centered Education Participant’s choice (No title needed) ☐ Group Classes Click or tap here to enter text. ☐ Standard Classes (Classes you offer repeatedly to a specific group of participants, e.g. Infant Feeding, Breastfeeding, Pregnancy) Click or tap here to enter text.

18. This agency provides educational materials to participants that are: ☐ State developed

☐ Local agency developed, procured, or downloaded materials. Complete Attachment 5.06F and attach one copy of each.

Attachment 5.06A

Attachment 5.06A 4/18/2024

Page 9 of 11

Part 4: Breastfeeding Promotion & Support

19. Update attachment 5.06D, preferably using the version shared via Google Drive, to list all current local agency employees and identify each person’s breastfeeding support role(s). Be sure to use last year’s (5. 06D) completed document and revise it to reflect any changes since last year’s submission. If you would prefer, contact one of the Breastfeeding Services Unit staff to virtually meet with you to update the Google Drive document.

20. Please evaluate your agency’s breastfeeding promotion and support activities from last year. When answering this question, refer to activities other than Breastfeeding Month:

a. Did you accomplish your overall goal/objective? ☐ yes ☐ no

b. What worked best? Click or tap here to enter text.

c. What surprised you? Click or tap here to enter text.

d. What would you do differently and why? Click or tap here to enter text.

e. What feedback did you get from staff and/or participants? Click or tap here to enter text.

21. Comment on how your Breastfeeding Month (August 20xx) activity worked out. Please tell us about the success and/or challenges that you encountered, as well as feedback from staff and/or participants. Click or tap here to enter text.

22. List the Breastfeeding trainings/topics provided to local agency staff during the past fiscal year:

a. ___ b. ___ c. ___ d. ___

Attachment 5.06A

Attachment 5.06A 4/18/2024

Page 10 of 11

23. A minimum of 4 breastfeeding trainings should be provided to all staff over the upcoming fiscal year. List the Breastfeeding trainings/topics planned for staff during the upcoming fiscal year.

a. ___ b. ___ c. ___ d. ___

24. Go to Part 2, question 14 to complete any additional breastfeeding resources needed for your local agency.

☐ Breastfeeding resource request(s) added to question 14 ☐ No additional breastfeeding resources needed

25. Complete the chart to identify your agency’s overall breastfeeding goal(s)/objective(s) for the coming year and strategies (or steps) to accomplish these outcomes. (At least one overall goal and accompanying strategies should be identified for the upcoming fiscal year).

26. How does staff provide information to all pregnant women about the benefits of and contraindications to breastfeeding? ☐ Verbal information ☐ MD WIC Guide to a Healthy Pregnancy ☐ Other ________________________________ OVERALL GOAL/OBJECTIVE(S): STRATEGIES/STEPS TO ACCOMPLISH GOAL: 1.Click or tap here to enter text. 1. Click or tap here to enter text.

2. Click or tap here to enter text.

3. Click or tap here to enter text.

2.Click or tap here to enter text. 1. Click or tap here to enter text.

2. Click or tap here to enter text.

3. Click or tap here to enter text.

Attachment 5.06A

Attachment 5.06A 4/18/2024

Page 11 of 11

27. What educational materials are provided to participants to promote and support breastfeeding? ☐ State developed handouts

☐ State developed infographics

☐ MD WIC Guide to a Healthy Pregnancy

☐ MD WIC Guide to a Healthy New Mom ☐ Local agency developed, procured, or downloaded materials. In coordination with local agency nutrition staff, complete Attachment 5.06F and attach one copy of each.

28. Go to Part 1, question 11 to complete the breastfeeding messages your staff give when breastfeeding incentives are provided. ☐ Breastfeeding incentive messages completed ☐ No breastfeeding incentives are provided

29. What aspect(s) of the new fiscal year’s breastfeeding services plan is (are) different from what your agency did last year? Click or tap here to enter text.

30 . Complete one form for each ongoing breastfeeding class or support group. Use Attachment 5.06C. ☐ __Click or tap here to enter text. (#) completed forms attached. ☐ Our agency does not have breastfeeding classes/support groups.

Plans for Breastfeeding Month need be submitted between February 1 and April 30 of the fiscal year, using form 5.06E. A reminder email will be sent during that time. Breastfeeding Month Plans will be reviewed and approved during the second quarter of the calendar year.

Attachment 5.06B 1 | P a g e Attachment 5.06B 4/18/24

List current local agency employees who provide Nutrition Education. Please indicate staff who provide High Risk Nutrition Counseling and complete the Nutrition Care Plan, those who provide High Risk Breastfeeding Counseling and document under Breastfeeding Notes, and those who provide both HR Nutrition Counseling and HR breastfeeding counseling. Please check all that apply.

Classification

Credentials

Type of NE Name CPA CPPA BFPC DBE RDN LDN DTR RN IBCLC HR - NC HR - BF

Attachment 5.06B 2 | P a g e Attachment 5.06B 4/18/24

Attachment 5.06C

Page 1 of 8 Attachment 5.06C 4/18/24

FY 202_ Nutrition/Breastfeeding Education Activity for Participants Worksheet Local Agency: Click or tap here to enter text. Quarter: Click or tap here to enter text. Title of Lesson: Click or tap here to enter text.

1. Quarterly Nutrition/Breastfeeding Education – WORKSHEET

1. Learning Objectives: What Will the Participants Learn? Answer those that apply. By the end of this lesson, the participant will ☐ Gain the following KNOWLEDGE: Click or tap here to enter text. ☐Acquire the following SKILL: Click or tap here to enter text. ☐Change a specific BEHAVIOR: Click or tap here to enter text. ☐Change an important ATTITUDE: Click or tap here to enter text.

2. Three Key Messages and 3 Supporting Statements for each a. Click or tap here to enter text. • Click or tap here to enter text. • Click or tap here to enter text. • Click or tap here to enter text.

Attachment 5.06C

Page 2 of 8 Attachment 5.06C 4/18/24

b. Click or tap here to enter text. • Click or tap here to enter text. • Click or tap here to enter text. • Click or tap here to enter text. c. Click or tap here to enter text. • Click or tap here to enter text. • Click or tap here to enter text. • Click or tap here to enter text. 3. Choose One: ☐Facilitated Group Discussion ☐Individual Learner Centered Education

4. How will you provide the factual information? ☐ PowerPoint: Title: Click or tap here to enter text. Number of slides: Click or tap here to enter text.

☐ Handout (limit one): ☐ State Developed Handout Do NOT submit Name of handout Click or tap here to enter text. ☐ Prior Approved Developed, Downloaded, or Acquired Handout Name of handout Click or tap here to enter text. Submit eCopy or Link Click or tap here to enter text. ☐ NEW Developed, Downloaded, or Acquired Handout

Attachment 5.06C

Page 3 of 8 Attachment 5.06C 4/18/24

Name of handout Click or tap here to enter text. Submit Nutrition Education Assessment Tool and an eCopy or a link Click or tap here to enter text.

☐ Downloaded Media ☐ YouTube Video. Title: Click or tap here to enter text. Link: Click or tap here to enter text. ☐Video Download Title: Click or tap here to enter text. Link: Click or tap here to enter text. ☐ Podcast Title: Click or tap here to enter text. Link: Click or tap here to enter text. ☐ Bulletin Board Title/Topic: Click or tap here to enter text. How will you use this Bulletin Board? Click or tap here to enter text.

☐ Table Display Title/Topic: Click or tap here to enter text. What will be in the display? Click or tap here to enter text. How will the display be used in this discussion?Click or tap here to enter text.

Attachment 5.06C

Page 4 of 8 Attachment 5.06C 4/18/24

☐ Flip Chart Title/Topic: Click or tap here to enter text. How will you use the Flip Chart? Click or tap here to enter text.

☐ Other Props/Visual Aids/Food Will any other props/visual aids/food be used in this presentation? Name the props Click or tap here to enter text. How will they be used? Click or tap here to enter text.

☐ Game Title/Topic Click or tap here to enter text.

What materials will you use to play this game? Click or tap here to enter text. Attach any components of the game

Link to Game: Click or tap here to enter text.

5. Now that you have decided on your topic and method of presentation of your factual materials, decide on some Open-Ended Questions to have ready to help you engage your participants in discussion. These questions should have no right or wrong answers. Open Ended Questions: Questions that have no right or wrong answers. Use for Facilitated Discussion: 1. Click or tap here to enter text. 2. Click or tap here to enter text. 3. Click or tap here to enter text. 4. Click or tap here to enter text.

Attachment 5.06C

Page 5 of 8 Attachment 5.06C 4/18/24

6. How will you ask permission to share information with the participant, including suggestions for new ideas to try? Click or tap here to enter text.

7. Returning to your Learning Objectives in #1, describe how you will evaluate whether or not you met your objectives? 1. KNOWLEDGE Click or tap here to enter text. 2. SKILL Click or tap here to enter text. 3. BEHAVIOR Click or tap here to enter text. 4. ATTITUDE Click or tap here to enter text.

Attachment 5.06C

Page 6 of 8 Attachment 5.06C 4/18/24

2. Quarterly Nutrition/Breastfeeding Education Lesson Plan Title: Click or tap here to enter text.

3 Main Points

What are the 3 main points, with their supporting statements, that you will cover in today’s lesson. Click or tap here to enter text. Open Ended Questions

List 4 or 5 questions that have no right or wrong answers. Use them to engage your participants in the lesson. Click or tap here to enter text. Introduction and Overview

Welcome your participants and tell them about today’s topic: Today we will discuss/learn about/learn how to Click or tap here to enter text. Description of Activity

Describe how you plan to conduct the Lesson step by step. Click or tap here to enter text. Concluding Statement

Today we talked about Click or tap here to enter text.

Evaluation How will you evaluate what the participants learned from this lesson? Click or tap here to enter text.

Attachment 5.06C

Page 7 of 8 Attachment 5.06C 4/18/24

3. Nutrition Education/Breastfeeding Staff Training Description 1. Which staff will provide the Nutrition Education to WIC participants? ☐ CPA ☐ CPPA ☐ IBCLC ☐ BFPC ☐ Other Click or tap here to enter text.__________________ 2. Who will train the staff to provide the nutrition education? Click or tap here to enter text. 3. Describe how, when, and where you will train staff to present this information How? Click or tap here to enter text. When? Click or tap here to enter text. Where? Click or tap here to enter text. 4. How will you assess the staff’s competence to educate WIC participants on this topic? ☐ Exam/Quiz ☐ Observation ☐ Role Play ☐ Other Click or tap here to enter text.

Describe the training Click or tap here to enter text.

Attachment 5.06C

Page 8 of 8 Attachment 5.06C 4/18/24

4. Staff Evaluation of FY 20xx Nutrition/Breastfeeding Education To be submitted with your FY 20xx Plan Local Agency: Click or tap here to enter text. Quarter: Click or tap here to enter text. Title of Lesson: Click or tap here to enter text.

How did the staff who provided the FY 20xx Nutrition/Breastfeeding Education evaluate the success/failure of this Lesson? What were your Learning Objective(s) for the participants? ☐ Knowledge ☐ Skill ☐ Behavior ☐ Attitude Describe how this lesson did/did not deliver its Key Messages and meet its Learning Objectives. Click or tap here to enter text. What did staff find were the greatest successes of this lesson? Click or tap here to enter text. What were the biggest challenges staff faced in presenting this information? Click or tap here to enter text. What surprised you/your staff about this lesson and/or how participants responded? Click or tap here to enter text. What would staff do differently if they were going to do this lesson again? Click or tap here to enter text.

Attachment 5.06D 05/25/2022 Page 1 of 2 Access Pre-Filled Form and Complete in Google Drive Local agency breastfeeding support roles Local Agency Name: _____________

Name Breastfeeding Roles Date roles agreed upon Progressing to knowledge level Date meets knowledge level Not yet initiated 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Attachment 5.06D 05/25/2022 Page 2 of 2

Name Breastfeeding Roles Date roles agreed upon Progressing to knowledge level Date meets knowledge leve Not yet initiated 11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

Attachment 5.06E 05/25/2022 Page 1 of 1 Part 5: FY 20 Breastfeeding Month Activity Plan Local Agency: Click here to enter text. Due April 30

Staff Completing Form: Click here to enter text. Please be specific. Describe overall idea, and submit components (i.e., handouts, powerpoints, bulletin board mock-ups) as part of this plan. Title/Subject of Activity: Date(s) for Activity:

Objective of Activity: Description of Activity:

Please indicate all of the following that will be included: Method Check if included Additional Material to Submit

Method Check if included Additional Material to Submit Facilitated Discussion, Class, and/or Support Group

Submit completed lesson plan (5.06C) Handout(s)/Brochure(s)/ Internet Download(s)

Submit. Include handout approval form if not already on approved list PowerPoint

Submit PowerPoint DVD

Submit name of DVD Tabletop Display

Submit mock-up Game

Submit Newsletter

Submit newsletter Social Media Post

Submit Bulletin Board

Submit mock-up Children’s Activity

Indicate activity Demonstration

---------- Learner Self-paced

---------- Guest Speaker

---------- Flip Chart

---------- Health Fair

---------- Props

---------- Other: _______________

Will incentive items be provided? No

Yes* List items and submit pictures: Click here to enter text.

Will food be provided: No

Yes Indicate funding source: Click here to enter text.

Attachment 5.06F 05/25/2022 Page 1 of 1

Attachment 5.06G 05/25/2022 1 of 2 Guidelines for Developing the: Annual Nutrition/Breastfeeding Services Plan

1. Summarize your accomplishments for the current fiscal year.

a. Complete the Actual Evaluation sections of the Plan for activities completed during the current fiscal year.

b. Compile all outlines, factsheets, pamphlets, and other materials used to carry out and support your activities.

Start the process by evaluating the results of your activities this year. What worked well? Did anything not work well? What would you do differently? If you did not achieve the objective(s) you set for any activities, is it important to try to reach the objective in the next year?

Are there any barriers that get in the way of effective nutrition education? Is there anything that you can do about them? Who might help you?

2. a. Using Attachments 5.06 A-F, describe your local agency regarding:

• How nutrition education is offered to participants and their caregivers and documented in the participant’s record. • Staff and others who provide nutrition education, participant focused staff training, and breastfeeding promotion and support. • Barriers to providing nutrition education and suggestions to alleviate them. • How high risk nutrition services are provided to participants at high nutritional risk. • How information on the dangers of substance abuse during pregnancy and lactation is provided to all adult participants and the caregivers of infant and child participants. • How the educational needs of special populations are met. • How the local agency assesses the effectiveness of its nutrition education activities and how this information is used to improve services and reduce refusals for nutrition education. • Plans for staff training.

b. Print out and review the WOW Risk Factor Report for your agency.

3. Develop specific plans for nutrition education activities for participants and for staff training.

Think about your potential audience for nutrition and breastfeeding activities. What do participants want to learn more about? Have you surveyed them? Is there a need to in-service our “partners” in the community so that we provide participants with the same messages? Are there any special programs within your local health department that you wish to partner with? What are your staff training needs?

Attachment 5.06G 05/25/2022 2 of 2 Develop your plans for nutrition education and breastfeeding activities. Develop a lesson plan for each activity. “A lesson plan is a working document that helps you organize, order, and approach all of the tasks involved in teaching.” (1)

A lesson plan should include:

• One or two measurable learning objectives; • 2 or 3 Key messages to be covered • Educational activities: experience-based open-ended questions, activities, props, visual aids and/or handouts to be used to engage participants in the learning experience • A description of the process you will use to educate staff who will provide this information • Resources to be used; and • An evaluation plan.

a. Write one or two learning objectives that are desirable outcomes of your activity. An objective is a statement that describes an expected change in knowledge, behavior, beliefs, or attitudes of participants. Put more simply, what is it that you want participants to “know, do, or feel” as a result of the activity? (1)

Objectives should be simple, specific, and measurable. For example:

Eighty percent of participants from a ten percent sample will correctly state one health benefit associated with eating five or more servings of vegetables and fruit daily.

Eighty percent of participants from a ten percent sample will name one vegetable or fruit serving that they are willing to try.

Decide upon the tool that you will use to measure your objectives. Examples include post tests, a show of hands, verbal responses, and written or verbal goals.

b. Plan the type of activity that best meets the needs and learning styles of your audience. Examples of activities include facilitated discussion groups, support groups, interactive learning displays, health fairs, and videotape/discussion sessions. (Remember that active learning is more effective than passive learning!)

Provide as much detail in your plan as possible, including an outline of what you intend to say, resources to be used, handouts, and speakers. Indicate the evaluation format that you intend to use.

4. Send the completed Nutrition Services Plan (1 – 3 above) to the State Nutrition Services Unit by July 31 of the current fiscal year. You may request technical assistance from the Unit for developing your plan.

References

1. Creative Training Techniques Handbook, Robert W. Pike, CSP, Lakewood Books, 1994. 2. California WIC Program Recipe for Successful Group Education

Policy and Procedure 5.07 is deleted as of 10/01/2013

Policy and Procedure 5.08

Page 1 of 2 MARYLAND DEPARTMENT OF HEALTH WIC PROGRAM POLICY AND PROCEDURE MANUAL

Policy and Procedure Number: 5.08 Effective Date: July 1, 1992 Revised Date: July 1, 2016 SECTION: NUTRITION BREASTFEEDING EDUCATION SUBJECT: Development or Procurement of Written Materials and Audiovisual Aids

A. Policy

Nutrition education or breastfeeding materials used with WIC participants should be appropriate and consistent with federal and State WIC nutrition/breastfeeding education policies.

B. Procedure

1. A local agency considering the development or procurement of an item for use with WIC participants, such as a pamphlet, brochure, flip chart, or DVD shall contact the Nutrition Education Specialist (if nutrition education) or the Breastfeeding Coordinator (if breastfeeding promotion or support) to discuss the item prior to incurring costs.

2. Local agency-developed or purchased materials shall be written at a level suitable for low-literacy readers and shall be translated as needed into language(s) appropriate for the population it serves.

The USDA nondiscrimination statement in Policy and Procedure 7.00 shall be used on all developed publications, handouts, leaflets, and brochures that identify or describe the WIC Program.

3. Nutrition education materials that advertise or provide coupons for specific product brands shall not be provided to WIC participants or made available in WIC waiting areas.

4. Attachment 5.08A contains additional guidance for the development and evaluation of written materials.

5. Copies of approved nutrition education or breastfeeding promotion and support materials developed by local WIC agencies shall be submitted with the Annual Nutrition/Breastfeeding Services Plan. The State WIC Agency will maintain a list of the approved items in SharePoint for sharing with other local agencies.

Policy and Procedure 5.08

Page 2 of 2 Attachment:

5.08A Written Materials

References: 1. 7 CFR 246.11 2. 7 CFR 246.8 3. WIC Nutrition Services Standards, Standard 9

Revisions: 01/2012 Revised B.3. Nondiscrimination statement as per STAR 2011 Civil Rights review. 10/2013 Revised B.3. Nondiscrimination statement per USDA 5/24/13. 10/2014 In B.1, replaced video with DVD. Inserted B.4. Directed that nutrition education materials or coupons for specific branded products not be given to WIC participants or made available in WIC waiting areas. In B.6. (previously B.5) replaced “placed in the State WIC Office Nutrition Education Resource Center” with submitted with the Annual Nutrition/Breastfeeding Services Plan. The State WIC Agency will maintain a list of the approved items in SharePoint.” Deleted previous B.6 as equipment is covered in Policy and Procedure 6.06; deleted ‘Equipment’ from title of policy. 07/2016 Referenced Policy and Procedure 7.00, changed Nutrition education to Nutrition/Breastfeeding education, changed Breastfeeding Promotion Coordinator to Breastfeeding Coordinator.

Attachment 5.08 A Revised 10/1/2007 1 of 3 Written Materials

Get to the point, FAST! - Joe Marks, University of Missouri

Develop written materials that will be read.

Written materials, such as factsheets, brochures, questionnaires, bookmarks, and newsletters, reinforce information provided verbally or provide supplemental information. To be effective, the written material must be read and its content understood. The material must gain the attention of the learner and sufficiently motivate her/him to read it. The material should be attractive and engaging. What can you do to “catch her eye?” Andy Goodman (1) says, “Capture the reader’s attention like a stop sign and direct it like a road map.”

Once you get the reader’s attention, the written material should engage her to continue to read. Use catchy sub-headings. Use illustrations that the reader can relate to and that reinforce the written information. The text should be readable and flow in a logical order. The information should be clearly conveyed so that it will be comprehended. Ideally, the reader will retain and use the information.

Allow the reader to “take ownership” of the material. Include space on the handout for participants to write their own ideas. For a brochure, create lines for writing down information about the participant.

Evaluate your materials. Ask participants to give you feedback. For a newsletter, make an offer of a small incentive, such as a magnet, that you will send to participants who call the office with feedback.

Follow the “golden rules” for written materials.

♥ Use a font size and type that is readable.

Use one font style, preferably a serif font (such as Times New Roman.)

A non-serif font looks like this, without the little lines or tags.

The font size should be 12 to 14. Margins should be left-justified (not fully justified where the page of text looks like a block with the right edges of text all lined up). Use upper and lower case, not all-capital letters.

WRITING LARGE SECTIONS OF TEXT USING ALL-CAPITAL LETTERS IS NOT RECOMMENDED BECAUSE IT IS TOO DIFFICULT TO READ.

I know my baby is full when

Attachment 5.08 A Revised 10/1/2007 2 of 3 Write text so it is read in a left-to-right direction. This is how readers have been taught to read. Keep paragraphs short. Use “mini-paragraphs of no more than 2 to 4 short sentences.

♥ Use a simple, organized layout.

Use plenty of “white space.” Use “subheadings” that give the reader some idea of what the next section is about. Use illustrations that help explain or clarify text. Avoid placing text over illustrations or watermarks. It is difficult to read. Use bullets or numbering to guide the reader through a series of steps. If the budget permits, use a higher weight paper so that when you have double-sided print, the text on the back side does not show on the face side.

♥ Write simply and directly.

Use simple words instead of technical, multi-syllable ones. Use positive, not negative statements. Keep the sentence length short. Use the active (not passive) voice. Use specific words, not idioms. Say soda and chips instead of junk foods, and vegetables instead of veggies. Avoid abstract statements like, “get your veggies on the go.” Specific words are clearer than general terms.

♥ Evaluate readability and comprehension.

Test a draft of your written materials before you print them. Test the reading level of the text with a tool such as the Fry Graph Reading Level Index or Smog Readability Formula. (4) A 5th grade reading level is recommended. Let participants and coworkers read what you have written and provide feedback regarding its clarity. If your written materials are translated into other languages, get someone to read the translated version against the English version to make sure that the content is correct.

Poor readers tend to: • Read slowly, often one word at a time. • Skip over words that are unfamiliar. • Tire quickly. • Miss the meaning or context of the sentence.

Last but not least: check your spelling! Keep these golden rules in mind as you purchase, develop, or reproduce written materials. A checklist for evaluating written materials follows.

If you plan to photocopy a written material, remember that copyrighted publications (designated with the symbol © or ® should not be photocopied in large quantities (after all the companies want you to purchase them!). Public domain (non- copyrighted) publications can be photocopied or reprinted, but the source should be acknowledged.

Attachment 5.08 A Revised 10/1/2007 3 of 3 You can use the simple checklist below to evaluate written materials. Many other checklists are available.

Checklist for Written Materials (2,5)  My written materials:

Are attractive.

Contain no more than 5 to 7 key points.

Contain practical information.

Use simple words and short sentences.

Use illustrations that reinforce the text and that are relevant to my audience.

Are uncluttered.

Contain information organized in a logical sequence.

Read at no higher than a 5th grade reading level (as checked by a readability formula)

Are respectful of all of our participants.

The USDA National Agricultural Library Food and Nutrition Information Center (FNIC) has developed a Health Literacy Resource List for Educators. This guide contains additional information about developing educational materials and is available from:

http://fnic.nal.usda.gov

References:

1. Goodman, Andy. Why Bad Ads Happen to Good Causes. Cause Communications, 2002.

2. United States Department of Agriculture. The Idea Book: Sharing Nutrition Education Experiences, 1981.

3. Nitzke, Susan, et al. Writing for Reading. Guide for Developing Print Materials in Nutrition for Low Literacy Adults, University of Wisconsin Extension, 1986.

4. Writing and Designing Print Materials for Beneficiaries: A Guide for State Medicaid Agencies, U.S. Department of Health and Human Services, 1999.

5. Facilitative/Experiential Teaching Ideas, Ellen Schuster, PhD, Oregon State University Extension Family & Community Development..

Policy and Procedure 5.09

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MARYLAND DEPARTMENT OF HEALTH WIC PROGRAM POLICY AND PROCEDURE MANUAL

Policy and Procedure Number: 5.09 Effective Date: October 1, 1995 Revised Date: November 19,2025 SECTION: NUTRITION EDUCATION SUBJECT: Breastfeeding Promotion and Support

A. Policy

Overview:

The Maryland WIC Program strongly endorses exclusive breastfeeding as the optimal method of infant feeding unless medically contraindicated (see Policy and Procedure 5.10) and expects local agencies to promote breastfeeding and support those who choose to breastfeed. In order to best establish breastfeeding, exclusively breastfed infants receive the benefit of frequent breastfeeding support during the first month of life.

The Maryland WIC Program’s philosophy is to position breastfeeding as the normal way to feed babies and assume all participants are breastfeeding or planning to breastfeed. All staff are responsible for breastfeeding promotion and support. Attachment 5.09A identifies those responsibilities within each staff person’s role.

Maryland WIC Staff Breastfeeding Training is required for all new WIC staff except peer counselors. Peer Counselors receive the Learn Together, Grow Together with Peer Counseling training that encompasses both the USDA WIC Breastfeeding Curriculum for peer counselors and WIC on the Web (WOW) training on the use of the areas peer counselors access. The Maryland WIC Program Breastfeeding Kardex and Breastfeeding Protocols contain accurate, up-to-date information for staff who have received breastfeeding training to use as resources when responding to breastfeeding related questions.

The Maryland WIC Program respects the breastfeeding goals set by participants and works to support each respective family’s goals. Maryland WIC also recognizes that early breastfeeding practices set families up to succeed in their respective goals. While supplementary formula from birth can be provided to breastfeeding families, Maryland WIC staff shall strongly encourage all breastfeeding families to breastfeed exclusively in the first month of life, to most effectively establish breastmilk supply and breastfeeding

Policy and Procedure 5.09

Page 2 of 10 skills, leading to effective milk transfer.

Families experiencing early breastfeeding complications that inhibit the ability to exclusively breastfeed initially should be provided with a tailored amount of supplementation to help provide nutrition while establishing breastfeeding, and a referral to the International Board-Certified Lactation Consultant (IBCLC)/Designated Breastfeeding Expert (DBE). These early breastfeeding complications may include:

1. A breastfeeding parent with underdeveloped glandular breast tissue or breast surgery with incisions near the nipple. 2. A premature infant receiving breastmilk mixed with formula powder to increase calories 3. An infant with an inborn error of metabolism requiring a limitation in the daily amount of breastfeeding – see Policy and Procedure 3.06: Medicaid Payment for Exempt (“Special”) Infant Formula and Medical Foods 4. An infant with a significantly weak or ineffective suck 5. An infant with difficulty latching onto the breast beyond what is normal for a newborn 6. An infant with Down syndrome or other neurological disorder that affects breastfeeding 7. An infant with cleft lip/palate or other congenital condition that affects breastfeeding

With the passage of the Child Nutrition and WIC Reauthorization Act of 1989 (Public Law 101-147), Congress added special emphasis to WIC's responsibility to encourage breastfeeding. The Act specified that a minimum amount of the national WIC funding for states' nutrition services and administrative grants (above the amount specified for nutrition education) be spent annually for breastfeeding promotion and support programs. Public Law 103-448 increased this minimum.

In accordance with Public Law 101-147, the Maryland WIC Program has established the following infrastructure to facilitate breastfeeding promotion and support efforts:

1. Adoption of the USDA definition of breastfeeding: For categorical purposes, the Maryland WIC Program has adopted the USDA, Food and Nutrition Service definition of breastfeeding: "the practice of feeding a mother's breastmilk to her infant(s) on the average of at least once a day."

A non-birth mother who is breastfeeding an infant she is legally responsible for may be certified as a breastfeeding mother if all the following criteria are met: ● The non-birth mother meets the eligibility requirements of residency, income, and nutritional risk. She may qualify for a nutritional risk if the

Policy and Procedure 5.09

Page 3 of 10 infant she is breastfeeding is found to be at nutritional risk. ● The non-birth mother provides breastmilk to the infant on the average of at least once per day. ● The infant being breastfed is currently certified on WIC. ● The birth mother of this infant is not certified on WIC as a breastfeeding mother of this infant.

The non-birth mother’s certification on WIC ends when she discontinues breastfeeding the infant at least once a day or the infant turns one year old, whichever comes first. Since this mother did not give birth to the infant, she cannot be changed to a postpartum category participant.

2. Designation of a State Breastfeeding Coordinator: The Maryland State WIC Breastfeeding Coordinator oversees WIC breastfeeding promotion and support efforts statewide, serves as chairperson for the Maryland WIC Breastfeeding Planning Committee, provides local agencies with technical assistance in breastfeeding education, promotion and support, and evaluates the breastfeeding component of local agency annual Nutrition and Breastfeeding Services Plans.

3. Provision of breastfeeding aids: Breast pumps, nursing pads, breast shells, nipple shields, feeding tube devices (i.e. supplemental nursing systems), and nursing bras are available through various local agencies within the Maryland WIC Program. (For more information about breastfeeding aids, see Policy and Procedure 5.11 and 5.12).

4. Training local staff to promote and support breastfeeding: The Maryland WIC State Agency provides a multi-tiered breastfeeding training for all staff who interact with WIC participants. Breastfeeding information is included as part of new employee trainings (see Policy and Procedure 7.66). These trainings must be attended in sequential order. The trainings are designed to encourage positive attitudes toward breastfeeding, motivate staff to maintain breastfeeding friendly clinic environments, provide staff with ways to recognize when breastfeeding may or may not be done correctly and an understanding of what staff can do to assist breastfeeding dyads, including making appropriate referrals when needed. a. Level 1 focuses on attitude, why breastfeeding is important, policies, and basic information all staff need to know, including appropriate referrals. Level 1 breastfeeding training is taught in the new employee WIC Wise 1 training.

b. Level 2 adds depth to what has been already presented, encompassing normal breastfeeding issues. Topics highlighted include exclusivity of breastfeeding, simple anatomy and physiology of breastfeeding, basics of breastfeeding, baby behavior, counseling skills specific to breastfeeding topics, position and latch, common

Policy and Procedure 5.09

Page 4 of 10 challenges that are easily overcome, and equipment/breastfeeding aids commonly used by nursing parents. Level 2 breastfeeding training is taught in the new employee WIC Wise 2 training.

c. Level 3 further adds depth for WIC professionals, highlighting prenatal breastfeeding assessment, breastfeeding policies, breastfeeding risk codes and ways to assist participants with overcoming those that are less complicated, and details on interpreting the Medications and Mothers’ Milk reference when researching medication questions. Level 3 breastfeeding training is taught in the CPA new employee training.

d. Level 4 provides advanced training for staff with greater responsibility for breastfeeding promotion and support, focusing on overcoming complicated breastfeeding challenges, breastfeeding aids used with more complicated challenges, and case study discussion. Ongoing updates over time, as new information is revealed, are included via IBCLC/DBE meetings.

5. Evaluation of breastfeeding promotion efforts: A breastfeeding surveillance system provides quarterly reports on breastfeeding incidence, prevalence, duration and exclusivity for evaluation of WIC breastfeeding promotion and support efforts statewide and by each individual local agency. The Maryland WIC State Breastfeeding Coordinator reviews evaluation results with the local agencies and assists as needed to improve outcomes.

6. Education about breastfeeding precautions and contraindications: Guidelines related to breastfeeding precautions and contraindications are found in Policy and Procedure 5.10.

B. Procedure

The local agency shall foster an environment and deliver WIC services in a manner that endorses breastfeeding as the preferred method of infant feeding by:

1. Encouraging all prenatal participants to breastfeed (unless medically contraindicated). All prenatal participants, at the time of certification, shall be given the brochure Guide to a Healthy Pregnancy, which describes both the importance of breastfeeding and breastfeeding precautions and contraindications. For more information related to breastfeeding precautions and contraindications, see Policy and Procedure 5.10.

2. Promoting and supporting breastfeeding using printed, audiovisual, and display materials.

3. Creating and maintaining a breastfeeding friendly environment by:

Policy and Procedure 5.09

Page 5 of 10

a. Using educational materials, social media posts, and office supplies (including coffee mugs, pens, posters and note pads) that are free of bottle feeding (except for nursing bottle caries, baby-paced bottle feeding materials, and bottles shown to collect expressed milk in breast pump materials), and formula advertisements. b. Storing infant formula out of view of participants. c. Assuming participants are breastfeeding or planning to breastfeed. d. Exhibiting positive staff attitudes towards breastfeeding at each participant contact, including telephone, texting, and email contacts.

4. Supporting breastfeeding by: a. Answering questions the participant/family has related to breastfeeding. b. Using the Maryland WIC Program Breastfeeding Kardex and Breastfeeding Protocols as the designated resources when responding to breastfeeding related questions. c. Offering and providing assistance with positioning and latch. d. Providing breastfeeding anticipatory guidance appropriate for each participant’s age. e. Following up with breastfeeding participants to check on progress or breastfeeding status, provide additional information as needed, update the management information system, and schedule follow-up breastfeeding support appointments, as appropriate. f. Providing breastfeeding aids such as breast pumps, nursing bras, breast shells, and supplemental nursing systems as appropriate. g. Providing referrals to other sources of breastfeeding support within WIC and the community as appropriate.

5. Having a Local Agency Breastfeeding Coordinator. The Local Agency Breastfeeding Coordinator shall be a DBE or a CPA with breastfeeding expertise (unless an exception is granted in writing from the State WIC Director), and performs the roles and responsibilities of a DBE or CPA, on a regular basis. Ideally the same person should remain as Breastfeeding Coordinator for the fiscal year. The Local Agency Breastfeeding Coordinator will be responsible for:

a. Attending quarterly Breastfeeding Coordinator Meetings. b. Disseminating breastfeeding promotion and support information to and from the State Agency Breastfeeding Services staff. c. Assisting with training in breastfeeding promotion and support for local agency and local health department staff. d. Developing and implementing the breastfeeding component of the local agency’s annual Nutrition and Breastfeeding Services Plan and attending the Nutrition and Breastfeeding Services Plan Workshop. e. Establishing and utilizing a referral system within WIC, and with other health professionals within the health department and community to provide support to breastfeeding women.

Policy and Procedure 5.09

Page 6 of 10 f. Recommending breastfeeding aids that are appropriate for the local agency’s participants. If the Local Agency Breastfeeding Coordinator is not a DBE, this recommendation shall be determined by consulting a DBE.

The Local Agency Breastfeeding Coordinator shall be given at least 2 hours per week to fulfill Local Agency Breastfeeding Coordinator administrative duties.

6. Assuring that the local agency employs at least one designated breastfeeding expert (DBE). Local agencies with larger caseloads are encouraged to employ more DBEs. As a best practice, it is recommended that the DBE be an IBCLC. Those fulfilling the DBE role shall: a. Have a minimum of one year experience in routinely counseling mother/infant dyads beyond normal breastfeeding issues. b. Have one of the following credentials or educational background: i. An International Board Certified Lactation Consultant (IBCLC), or ii. A Registered Nurse (RN), or iii. A Registered Dietitian (RD), or iv. Have a Master’s or Bachelor’s degree in Nutritional Sciences, Community Nutrition, Clinical Nutrition, Dietetics, Public Health Nutrition, or Home Economics with an emphasis in nutrition, or v. Have completed a minimum of 8 college courses from an accredited institution in health sciences to include at least some of the following areas: Human Anatomy, Human Physiology, Biology, Infant Growth and Development, Nutrition, Counseling Skills, Sociology, and Clinical Research. c. Successfully complete all four levels of the WIC Breastfeeding Training Curriculum provided by the State WIC Agency, as well as successfully complete any post-test and competency checklists that are available for this position. IBCLC’s are considered DBEs prior to completion of this training and shall complete this training and evaluation component within 6 months of hire. d. Acquire at least 3 hours of ongoing lactation continuing education annually. It is expected that the DBE will attend continuing education outside of WIC offerings. e. Assist WIC participants with complex breastfeeding challenges, as needed, and at least monthly. f. Participate in State-WIC DBE meetings and communications. g. Serve as a resource to whom local agency staff yield when breastfeeding issues and recommendations are beyond their scope of practice.

DBEs may fulfill other roles within WIC but must be allotted reasonable time to attend to participants’ complex breastfeeding issues, as they arise. If performing administrative breastfeeding duties, including staff training, preparation time outside of attending to participants shall be allotted.

Policy and Procedure 5.09

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7. Sending all staff to new employee training as indicated in Policy and Procedure 7.66. Staff shall be registered for each of these trainings at the first opportunity after each staff person’s hire date.

8. Food packages of breastfeeding dyads shall be prescribed in coordination with one another. Infant formula supplements are discouraged for breastfed infants, especially during the first month of life when establishment of breastfeeding should take precedence. Powdered formula shall be provided to breastfed infant participants who receive supplementation, since it can be prepared in small quantities, as needed, and has a longer shelf life once opened. Food packages shall also be tailored limiting the amount of formula provided to a volume that most closely matches the formula volume being consumed (see Policies and Procedures 3.01A and 3.02).

9. When a lactating participant expects to be separated from their infant for more than two hours, they should be encouraged to express their breastmilk for supplementary feeding. Those wishing to do so should be assisted to obtain a breast pump through their insurance, when possible, and may be given a breast pump when unable to acquire an appropriate pump through insurance (see Policy and Procedure 5.11).

Attachments: 5.09A Maryland WIC Staff Roles in Breastfeeding Promotion and Support

References: WIC Final Policy Memorandum #96-001: Non-Birth Mothers Certified as Breastfeeding Women, October 4, 1995.

Revisions:

10/2009 Added language to reflect USDA food package changes effective 10/09; Added breastfeeding support requirements, philosophy of assuming participants are breastfeeding/planning to breasted, and updated food package prescription guidance for breastfed babies and lactating mothers. Added information regarding situations when one can of powdered formula could be provided for infants during the first month of life. Added Attachments 5.09A and 5.09B. 10/2010 Corrected reference attachment 5.09A in paragraph 2 of this policy. Clarified section on providing one can of powdered formula for an exclusively breastfeed infant less than 1 month old. Only a CPA can assign a P3 food package with documentation of a specific breastfeeding complication, as previously defined in this policy, from a physician or IBCLC. Updated section on training of local staff to promote breastfeeding. 10/2011 Added reference to Breastfeeding Protocols in page 1 paragraph 2. Added bullet point, ‘Mother has underdeveloped glandular breast tissue or breast surgery with incisions near the nipple,’ on

Policy and Procedure 5.09

Page 8 of 10 page 1. Reworded and bulleted description of training of local agency staff to page 3 number 4. Added prevalence and exclusivity to page 3 number 5. Changed formula product names to bottle feeding and formula advertisements to page 4 number 3. Added, ‘and Breastfeeding Protocols,’ to page 4 number 4.Appendix 5.09A: changed The State WIC Breastfeeding Promotion Coordinator in conjunction with the Chief of Breastfeeding Services to The State WIC Breastfeeding Coordinator/Chief of Breastfeeding Services on page 1. Appendix 5.09B: Added when baby >4 wks. old to table for Mostly, Food Package, Baby and Mother on page 1. Added bullet point, ‘Mother has underdeveloped glandular breast tissue or breast surgery with incisions near the nipple,’ to page 1. Added, ‘unless medical exception met (see page1),’ on page 2. 10/2012 Added training requirement (completion of WIC WISE 1, WIC WISE 2, and Grow and Glow (parts 1 and 2) as part of new employee breastfeeding training. Added information regarding food package prescription changes during the first 4 weeks of life for exclusively breastfed infant/mother dyads 10/2013 Changed State Breastfeeding Promotion Coordinator to State Breastfeeding Coordinator. Added nursing bras within list of breastfeeding aids provided. Changed Local Agency Coordinator will designate a Local Agency Breastfeeding Coordinator who is a CPA with breastfeeding expertise. Added attendance at Breastfeeding Coordinator Meetings as part of Local Agency Breastfeeding Coordinator’s role. Appendix 5.09A Changed Breastfeeding Promotion Coordinator to Breastfeeding Coordinator. Added referrals to WIC Support Staff breastfeeding mothers of multiples is a BE category and her food package is BEM. 10/2014 Clarified that follow-up for breastfed infants in the first month of life who receive the P-3 exception package must be with an IBCLC. Clarified that breastfeeding information within this policy refers to both breastfeeding promotion and support. Added New CPA Training as a new employee training that contains breastfeeding information. Updated name of handout for pregnant women to Guide to a Healthy Pregnancy. Clarified that nursing bottle caries and breast pump information are the only educational material that can include bottle feeding or bottles. Clarified that Local Agency Breastfeeding Coordinator is expected to attend Nutrition Services Plan Training. Clarified in Attachment 5.09B that formula given to mostly breastfed infant in first month of life must be limited to a P-3 package. 10/2015 Deleted reference to specific breastfeeding complication requiring formula supplementation, as that would disqualify the infant from being exclusively or fully breastfed. Clarified training requirement for WIC staff vs. WIC peer counselors. Added breastfeeding risk codes as part of CPA training. Added requirement to check

Policy and Procedure 5.09

Page 9 of 10 breastfeeding status and document in the management information system. Clarified that a breastfeeding woman who is also pregnant receives the equivalent of a BE food package. Clarified role of State Breastfeeding Peer Counselor Program Coordinator in Attachment 5.09A. Added table in attachment 5.09B showing food packages for women who are pregnant and also breastfeeding an infant 06/2017 Changed references for WIC checks to WIC food benefits. Changed Breastfeeding Promotion Committee to Breastfeeding Planning Committee. Added Paced Bottle Feeding materials as an exception when bottles are pictured/shown in the WIC clinic. Edited description of WIC Wise 2 to include baby behavior. Moved tailoring of food packages to the description of WIC Wise 1. 11/2017 Attachment 5.09B edited to remove P3 reference and replaced with reconstituting to < 104 oz. Minor format changes. 07/2018 Edited to clarify that one can of formula in the first month of life can only be provided when one of the situations listed exists. Corrected referral of WIC definition of breastfeeding to reflect this is a USDA definition. Clarified food package changes and tailoring to be consistent with eWIC terminology and procedure. Edited 5.09B to update food package terminology to be consistent with current terminology. 11/2019 Edited that when infants previously IBE are no longer breastfeeding in the first month, benefits can only be reissued if the mother has not used her benefits or when the benefits spent combined with those reissued do not exceed what she would otherwise be allowed to eta as a WPP. Added information about the requirement for at least one DBE including background and expectations of that individual. Added that BF Coordinator must consult with DEB on BF Aids needed if BF Coordinator is not a DBE. roles. Appendix 5.09B Added best practice is to follow-up during the first month of life. Changed should to shall for tailoring formula supplement. Changed Table 2 to reflect that exclusive 07/2023 Added information of allowing non-birth mothers who are breastfeeding infants they are legally responsible for to be certified onto the Program as breastfeeding women. Edited the name of the peer counselor program training to include the current WIC breastfeeding campaign. Moved information on food packages to 3.01 and 3.01A. 11/2025 Edited breastfeeding in the first month section to align with the current NASEM food package changes for breastfeeding infants allowing all to receive supplementary infant formula in the first month of life to meet individual participant goals. Included recommendation for staff to strongly encourage exclusive breastfeeding in the first month to prevent early formula supplementation from interfering with breastfeeding establishment and later success. Revised list of early complications and added recommendation that participants identified with these issues be

Policy and Procedure 5.09

Page 10 of 10 referred to the IBCLC/DBE. Revised descriptions of training to conform to four levels of training per USDA breastfeeding platform.

Attachment 5.09A Attachment 5.09A 11/18/2019 Page 1 of 2 Maryland WIC Staff Roles in Breastfeeding Promotion and Support The State WIC Director - Articulates the Vision • Articulates the vision of breastfeeding in WIC to staff at all levels • Empowers staff through training and policies and procedures that support the vision • Allocates funding and resources for breastfeeding promotion and support The State WIC Breastfeeding Coordinator – State WIC Peer Counselor Program Coordinator-- Implements the Vision • Coordinates State breastfeeding efforts • Provides breastfeeding training and support, technical assistance and consultation to State and local staff and participants as necessary • Identifies breastfeeding promotion methods for local agencies • Develops State breastfeeding standards • Monitors State breastfeeding rates and local agency activities • Evaluates State breastfeeding activities • Coordinates with other agencies for breastfeeding promotion and support The Local Agency Coordinator - Sets the Tone • Supports breastfeeding activities • Maintains a breastfeeding-friendly clinic • Allocates funding and resources for breastfeeding promotion and support The Local Agency Breastfeeding Coordinator - Mentors Staff and Coordinates Activities • Oversees planning, implementation, evaluation, and training of breastfeeding activities • Keeps current with breastfeeding knowledge • Identifies, coordinates and collaborates with community breastfeeding resources • Monitors local breastfeeding rates WIC Certifier (CPA/CPPA) - Gives Appropriate Advice • Conducts a complete WIC breastfeeding assessment using participant-centered principles and techniques • Provides appropriate education, assistance, referrals

Attachment 5.09A Attachment 5.09A 11/18/2019 Page 2 of 2 • Provides appropriate food package to mothers and infants to encourage exclusive breastfeeding and, when exclusive breastfeeding is not possible, breastfeeding with minimal supplementation WIC Breastfeeding Peer Counselor - Gives Mother-to-Mother Support • Serve as a model for breastfeeding behaviors • Scope of practice is normal breastfeeding issues • Supplements the WIC breastfeeding team • Available to mothers outside of the usual clinic hours or environment • Fills the gap in services after hospital discharge for seamless continuity of care WIC Staff with Advanced Breastfeeding Training (Designated Breastfeeding Experts (DBEs) including Certifiers, IBCLCs, Breastfeeding Peer Counselor Coordinators) - Provides Hands-On Support and Gives Appropriate Advice • Conducts complete breastfeeding assessments using participant-centered principles and techniques • Provides appropriate education, technical assistance, and takes referrals • Gives hands-on support as needed WIC Support Staff Answering the Phone and Greeting Participant - Provides Front Line Support • Uses breastfeeding-friendly language • Knows agency’s breastfeeding policies • Makes appropriate appointments and referrals for breastfeeding mothers for support and follow-up Adapted from USDA Breastfeeding Guidance, Attachment 3: WIC Staff Roles in Breastfeeding Promotion and Support (6/2009)

Policy and Procedure 5.10 Page 1 of 4 MARYLAND DEPARTMENT OF HEALTH WIC PROGRAM POLICY AND PROCEDURE MANUAL Policy and Procedure Number: 5.10 Effective Date: October 1, 1999 Revised Date: July 31, 2023 SECTION: NUTRITION EDUCATION SUBJECT: Breastfeeding Precautions and Contraindications A. Policy The Maryland WIC Program strongly supports breastfeeding as the normal method of infant feeding and optimal infant nutrition, unless medically contraindicated. Breastfeeding is contraindicated if: • the mother uses street drugs; • the mother uses marijuana (even if medically prescribed) • the mother is taking a medication that is incompatible with breastfeeding; • the mother has active, untreated tuberculosis. Certain other medical conditions may also require that the mother not breastfeed, temporarily interrupt breastfeeding, or take precautionary measures prior to or during breastfeeding. The Centers for Disease Control recommends that mothers living with HIV or AIDS be provided client-centered counseling using evidence-based information, allowing them to participate in shared decision making regarding infant feeding decisions. Use of pasteurized donor human milk from a milk bank or infant formula eliminates the risk of transmitting HIV to the infant postnatally. While the HIV virus passes to infants through breastmilk, achieving and maintaining viral suppression through antiretroviral therapy (ART) decreases the risk of transmission to less than 1%. It is important that breastfeeding parents living with HIV are monitored to assure they maintain suppressed levels. Breastfeeding parents who acquire the HIV virus during the period when they are lactating are at greater risk for infecting their breastfed infants. Thus, mothers whose partners are living with HIV should be included in the client-centered decision making and information regarding infant feeding and the impact and importance of viral suppression through ART for their partners.

Policy and Procedure 5.10

Page 2 of 4 Individuals living with HIV who are not on ART and those who do not have undetectable or suppressed viral loads are encouraged to feed using pasteurized donor human milk from a milk bank, when possible, or infant formula.

Those living with HIV who choose to breastfeed should not be referred to Childrens Protective Services as a result of that decision.

Guidelines related to breastfeeding precautions and contraindications are found in The Maryland WIC Program Breastfeeding Kardex This reference provides precautionary guidelines related to topics including cigarettes, caffeine, alcohol, and non-prescription and prescription medication while breastfeeding, as well as contraindications for breastfeeding.

B. Procedure

When promoting breastfeeding, WIC staff shall:

1. Provide all prenatal participants with both written (Guide to a Healthy Pregnancy pamphlet) and verbal information about breastfeeding contraindications.

2. Verbalize the following information to prenatal participants: • Breastfeeding is the normal way to feed most babies; however, a mother should not breastfeed if she is using street drugs or marijuana. • Breastfeeding parents living with HIV, who are on antiretroviral therapy and maintain undetectable or suppressed viral loads have a less than a 1% risk of passing the virus to their babies through breastfeeding. Using infant formula eliminates the risk. • Individuals who are living with HIV and either are not on antiretroviral therapy or do not have suppressed viral loads are encouraged to feed with infant formula. • Breastfeeding parents whose partners are living with HIV should be aware of the importance of partners being on antiretroviral therapy and sustaining undetectable or suppressed viral loads.

3. Encourage all adult participants who are unaware of their HIV status to be tested.

4. Research questions from participants and health care providers regarding the compatibility of breastfeeding while taking specific medications. All CPAs are trained in the use of Hale’s Medications and Mother’s Milk reference. The State Breastfeeding Services staff are available to provide technical assistance, as needed, using reference materials, online sources, and hot-lines specific to medications and lactation. When

Policy and Procedure 5.10

Page 3 of 4 possible, staff shall provide written material to the person seeking information.

5. Use the 2015 Maryland WIC Program Breastfeeding Kardex as a resource for information related to breastfeeding precautions and contraindications.

6. If a participant who continues to use marijuana chooses to breastfeed despite being advised not to do so, staff shall provide her breastfeeding assistance and support after:

a. Advising the participant to speak with her doctor regarding use of marijuana while breastfeeding.

b. Documenting in the management information system that the participant was advised not to breastfeed, made the choice to breastfeed, was provided breastfeeding support, and was advised to speak with her doctor about her decision to breastfeed while continuing to use marijuana.

c. Provide the participant the “Weed to Know” rack card with information about breastfeeding and marijuana. Document in the management information system that this handout was provided.

References:

The Maryland WIC Program Breastfeeding Kardex, Revised 2015.

Medications and Mothers’ Milk 2023, by Thomas W. Hale, R.Ph,, PhD and Kaytlin Krutsch, PharmD, MBA, BCPS, © 2023.

CDC: Recommendations for Counseling Mothers With HIV About Feeding Their Infants (February 2, 2023), https://www.cdc.gov/breastfeeding/breastfeeding-special- circumstances/maternal-or-infant-illnesses/hiv.html

Revisions: 10/06 Changed NAWD to NWA to be consistent with current terminology.

10/13 Changed State Breastfeeding Promotion Coordinator to State Breastfeeding Coordinator.

10/14 Updated name of prenatal handout, Guide to a Healthy Pregnancy.

Policy and Procedure 5.10

Page 4 of 4

10/15 Updated date of printing of Breastfeeding Kardex to 2015 revision.

11/19 Added marijuana as a contraindication to breastfeeding (rather than having it considered a ‘street drug’; Changed statement to verbalize to include breastfeeding as the normal way to feed (rather than best) to be consistent with teaching philosophy; Added State Peer Counselor Program Coordinator as a technical resource people for local agency staff; Added Hale’s Medications and Mothers’ Milk as a reference for this material.

07/21 Added information regarding how to proceed when a participant has been advised not to breastfeed due to use of marijuana yet chooses to breastfeed.

07/23 Removed living with HIV as a contraindication to breastfeeding. Added information consistent with CDC regarding having client-centered conversations about breastfeeding and living with HIV so that participants can make the best decision for their situations. Added that all CPAs are trained in the use of Medications and Mother’s Milk reference. Updated references and removed Ruth Lawrence (old) reference.

Policy and Procedure 5.11 Page 1 of 6 MARYLAND DEPARTMENT OF HEALTH WIC PROGRAM POLICY AND PROCEDURE MANUAL

Policy and Procedure Number: 5.11 Effective Date: October 1, 1999 Revised Date: February 12, 2025 SECTION: NUTRITION EDUCATION SUBJECT: Provision of Breast Pumps

A. Policy Breast pumps shall be offered to participants based on established need at no cost to the participant. They may not be provided to all breastfeeding women or provided solely as an inducement to consider or continue breastfeeding. Reasons breast pumps may be provided include, but are not limited to, the following: 1. to assist with expressing milk when mothers are separated from their infants due to school, work, or maternal/infant illness or hospitalization 2. to help relieve recurrent engorgement 3. to assist with everting flat or inverted nipples 4. to help maintain milk supply while the mother is taking a medication that is incompatible with breastfeeding 5. to help build up a mother’s milk supply while she is breastfeeding; and 6. to assist with severe feeding difficulties such as cleft lip or palate or inability to suck. WIC administrative and food funds may be used to purchase both manual and electric breast pumps and electric breast pump collection kits. Food funds may not be used to purchase breast pump carrying cases, videos, and similar accessories, although administrative funds may be used for these purchases. A selection of manual and electric breast pumps shall be available through the Maryland WIC Distribution Center. To minimize storage requirements and the potential for damage or theft, breast pump inventory shall not exceed the amount that the agency projects it will provide to participants during a 90-day period. Local agencies that are authorized by both the State Breastfeeding

Policy and Procedure 5.11 Page 2 of 6 Section and Fiscal Unit to purchase their own supply of breast pumps shall refer to policy 6.03 Allowable Costs for Program Support Materials and policy 6.08 Procurement. B. Procedure

1. Staff may recommend participants acquire breast pumps through their respective insurance providers, when available, before providing pumps through WIC. When the type of breast pump needed is not available through insurance or when a delay in insurance provision affects ability to maintain breastmilk supply, WIC breast pumps shall be provided using the following guidance in determining which breast pump to provide to a participant:

Manual breast pumps: A manual pump is appropriate for lactating parents who need to use a breast pump occasionally. For example, a parent may wish to supplement breastfeeding with an occasional bottle. Or they may need relief from engorgement or assistance with getting the infant latched onto the breast. Those who exclusively breastfeed may be given a manual pump when their infants begin taking infant cereal so that breastmilk can be expressed and used to prepare the cereal.

A/C Adapter Electric breast pumps: An A/C Adapter Electric breast pump is appropriate for lactating participants who need to use it on a more regular basis. For example, a parent may be having difficulty maintaining milk supply (documented by poor infant weight gain). The parent may be separated from the infant for periods of at least 4 hours per day, 3 times per week. The breastfeeding parent may be taking medication that is incompatible with breastfeeding, requiring them to pump and discard the expressed breastmilk. Or the infant may be having difficulty obtaining adequate nourishment at the breast (documented by poor weight gain or medical condition). The Hygeia Enjoye breast pump must be returned to the WIC Program by the participant when it is no longer being used, or when requested by the local agency. Lactating participants receiving full formula packages for their infants may not receive an electric breast pump from WIC unless they need to temporarily discard expressed milk due to a medication or an exception is given by the State Breastfeeding Services section.

Hospital Grade Electric breast pumps: A hospital grade electric breast pump is appropriate for breastfeeding parents who have an infant in the neonatal intensive care unit, do not yet have a fully established milk supply or have a need to pump when the infant is less than four weeks old. These pumps are the most powerful and most expensive of the pumps WIC has to offer. They should be reserved for high-risk infants

Policy and Procedure 5.11 Page 3 of 6 and, once the issue resolves or improves, these pumps must be returned by the participant to the WIC Program and replaced with A/C Adapter Electric breast pumps as needed. Lactating participants receiving full formula packages for their infants may not receive an electric breast pump from WIC unless they need to temporarily discard expressed milk due to a medication or an exception is given by the State Breastfeeding Services section.

2. Local agencies shall designate and ensure that staff members who issue breast pumps are trained in the use of the pumps and are able to provide appropriate education to participants. Staff members providing breast pumps shall explain to participants when to use the breast pump, how to use it effectively and safely, and how to clean it. They shall explain where to call for assistance and provide a written phone number. They shall also demonstrate assembly and disassembly and then ask the participant to demonstrate assembly and disassembly of the pump. Staff training may be obtained through the local agency or through attendance at the state agency’s level 3 breastfeeding training.

Best practice is that participants receiving hospital grade electric breast pumps receive consultation from an International Board Certified Lactation Consultant (preferably) or Designated Breastfeeding Expert.

3. Additional nutrition education shall be provided and include the following, as appropriate:

a. Inform the parent of possible nipple confusion if a bottle nipple is introduced before 3-4 weeks of age.

b. Discuss options for feeding expressed breastmilk and review selection of artificial nipples if bottles are chosen.

c. Discuss proper hygiene, pumping time, and milk storage.

d. Discuss ways to maximize milk production and volume expressed, including frequent pumping, hands-on pumping, and expressing from one breast while nursing on the other.

e. Provide the handout, Planning for Breastfeeding When Away from Your Baby, which includes information on milk storage, breastfeeding and returning to work, and expressing breastmilk.

. 4. Participants shall be given written instructions/literature provided by the product manufacturer, as applicable.

5. Education on the use of breast pumps shall be given directly to the

Policy and Procedure 5.11 Page 4 of 6 participant using the breast pump. Participants shall sign the Breast Pump Release of Liability form (Attachment 5.11A) prior to receiving manual and Personal Use Electric breast pumps. Participants shall sign the Electric Breast Pump Loaner Agreement and Release of Liability Form (Attachment 5.11D) prior to receiving Enjoye, Nurture III, and Hospital-Grade Electric Breast Pumps. Staff shall retain the signed form on file at the local WIC agency following the retention schedule in policy and procedure 6.00.

When, due to medical reasons, the user of the pump is unable to come to clinic to be issued a breast pump, her proxy may pick up the pump for her. In these cases, the participant must first sign the appropriate release of liability form (Attachment 5.11 A or 5.11 D) prior to her proxy receiving the pump. The proxy must receive instruction on the pump and also sign the appropriate release of liability form. The WIC staff must follow up with the participant via phone, within two business days, to provide additional instruction and answer any questions.

6. Staff issuing breast pumps shall document each issuance on the breastfeeding screen, BF Support. In addition, the paper breast pump log (Attachment 5.11B) may be used, if desired. Enjoye, Nurture III, and Hospital- Grade Electric Breast Pumps may be signed out on the Electric Breast Pump Tracking Form (Attachment 5.11 C) in addition to the BF Support screen.

7. Hospital-Grade Electric Breast Pumps shall be issued for 1-month increments and must be returned to the WIC Program. Multi-user pumps that are not considered Hospital-Grade Electric should also be returned when no longer needed. If the participant does not return the pump or call to request an extension, staff shall phone the participant to determine if the breast pump can be returned or the lending period should be extended, if applicable. This information shall be documented on the Electric Breast Pump Tracking Form (Attachment 5.11 C) or similar tracking form.

Staff shall place an alert in the participant’s management information system record and also make at least three attempts to reach participants by phone (if a participant has a working phone) to retrieve Hospital-Grade Electric and other multi-user breast pumps. These attempts shall be documented in the management information system and, if desired, on the Electric Breast Pump Tracking Form (Attachment 5.11 C), or a similar tracking form. If all phone attempts are unsuccessful, a certified letter shall be sent to the participant, requesting return of the breast pump and explaining potential sanctions. Staff should consider providing monthly WIC benefits to a participant who has an outstanding breast pump, as a way to encourage the participant to return the pump.

8. Staff receiving returned multi-user breast pump motors (AC Adapter Electric, when appropriate, and Hospital-Grade Electric) shall log the pump in on the management information system, and if desired, the Electric Breast Pump Tracking Form (Attachment 5.11 C) or similar tracking form.

Policy and Procedure 5.11 Page 5 of 6

9. The outer casing of returned breast pump motors shall be cleaned each time the pump motor is returned and prior to storing, using a 1:10 bleach solution, a Cavicide ® solution, or household disinfectant (e.g. Lysol ®, Clorox ®). A soft cloth should be used to apply the cleaning solution. Staff shall pay particular attention to clean the pivot arm and guide slot for the cylinder holder if loaning the Medela ® Lactina breast pump. The plastic casing should be dried and buffed using a dry, soft cloth or absorbent paper towel. Staff shall also check the pump casing, electric cord, and plug to assure there are no visual defects. Each hospital-grade electric breast pump must be checked at least every six months to assure its satisfactory working condition by connecting the appropriate hook-up kit and using a vacuum gauge to assure pressures of 240 mm Hg at the maximum setting.

Attachments:

5.11A Breast Pump Release of Liability 5.11B Breast Pump Log 5.11C

Electric Breast Pump Tracking Form 5.11D Electric Breast Pump Loaner Agreement and Release of Liability

References:

WIC Final Policy Memorandum #00-013: Clarification of SFP99-145: Breast Pumps as a Food Cost, October 28, 1999.

WIC Final Policy Memorandum #99-145: Breast Pumps as a Food Cost, August 3, 1999.

WIC Final Policy Memorandum #95-18: Providing Breast Pumps to WIC Participants, June 22, 1995

Revisions: 10/10 Removed State Agency will distribute breast pumps. Added breast pumps shall be ordered by Local Agencies through the Maryland WIC Distribution Center. Added local agencies shall designate staff members who issue breast pumps. Changed Lactation Education for WIC Professionals conference to Grow and Glow 2 day training. Changed screen name from BF Aids to new screen name BF Support. Changed similar tracking form to on the BF Support screen.

10/13 Added Appendix 5.11A Spanish Breast Pump Release of Liability.

10/14 Clarified that staff choose between more than a manual and a/c adapter breast pump when issuing pumps. Clarified that documentation of breast pumps, including notes, should always occur in the management information system. Other tracking forms can be used, but must be used in addition to the management information system. Added that hospital-grade electric breast pumps must be tested using a

Policy and Procedure 5.11 Page 6 of 6 pressure gauge at least every 6 months. Revised Breast Pump Tracking Form (Attachment 5.11 C) to include place to document pressure testing of pumps.

02/19 Adapted to include Hygeia Enjoye breast pumps and require return of all multi-user pumps. Edited attachment 5.11D to be appropriate for all multi-user pumps and indicated with which pumps 5.11A and 5.11D would each be used. Added if applicable to 5.11B.

11/19 Clarified that an electric breast pump can be given to a participant receiving a full food package if the participant needs to temporarily pump and dump due to a medication taken. Added instruction to maximize milk removal as one of the suggested nutrition education topics to discuss.

08/21 Changing breastfeeding women to lactating women; Referring to DBE rather than breastfeeding specialist. Updated 5.11A and 5.11D (English and Spanish) by removing breast tag number and on loan and added by for consistency between the English and Spanish versions. Added Mya Joy Pump to 5.11A.

02/25 Indicated that staff should work with participants to get breast pumps through the participants’ insurance, when available prior to providing pumps through WIC. Added that local agencies need approval to purchase breast pumps.

Attachment 5.11A 08/05/2021 Page 1 of 1 For use when providing Harmony, Pump In Style, and Mya Joy Breast Pumps Maryland WIC Program Breast Pump Release of Liability DATE: _____________________________ WIC ID #: _________________________________ NAME: _____________________________________PHONE NUMBER: ___________________ ADDRESS: ____________________________________________________________________ ____________________________________________________________________ REASON FOR REQUESTING BREAST PUMP: _____________________________________________________________________________ BABY’S DOB: ______________________ Initial: _____ I acknowledge that I have received, a ____________________ breast pump, from the ____________________WIC Program. The operation, use, and care of this breast pump have been explained to me and I have received written instructions. I have also been given information on proper storage of breast milk and monitoring of the breastfed infant. I understand that I am under no obligation to use this breast pump, that I may discontinue its use at any time, and that I should discontinue its use if it causes discomfort. I release the State of Maryland, MDH, Maryland WIC Program State and Local Agencies and their officers, servants, agents, and employees from any liability for any loss regarding the use, operation, or care of this breast pump or the storage of breast milk and monitoring of the breastfed infant. Initial: _____ I understand that this breast pump is being given to me for my sole use. I will not sell this breast pump or share it with anyone else I have had an opportunity to ask questions on the operation, use, and care of the breast pump, as well as proper storage of breast milk and monitoring of the breastfed infant. I understand all instructions and agree to follow them. I am aware of the risks connected with use, operation, and care of the breast pump and I voluntarily assume full responsibility for all known and unknown foreseen and unforeseen risks of loss, property loss or personal injury, resulting from the use, operation, and care of the breast pump. I have no physical conditions or restrictions which would prohibit my safe carrying, use, or operation of this breast pump. It is my express intent that the release of liability, indemnification agreement, and waiver contained in this agreement shall bind my heirs, assigns, and personal representatives. BY SIGNING BELOW, I ACKNOWLEDGE AND REPRESENT THAT I have read this Agreement, I understand it, I agree to its terms, and I sign it voluntarily; no oral representations, statements or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age or an emancipated minor and fully competent; and I have the legal capacity to enter into this Agreement. This Agreement shall be construed in accordance with the laws of the State of Maryland and does not operate to waive sovereign immunity or any other immunity held by the State, MDH, or the Maryland WIC Program State and Local Agencies. SIGNATURE: ______________________________________ DATE: ______________________ WITNESS: _________________________________________ DATE: ______________________ DATE RETURNED: ______________STAFF SIGNATURE: ______________________________ This institution is an equal opportunity provider.

Attachment 5.11A 08/05/2021 Pagina 1 de 1

Uso para cuando se provéen

Extractores de leche Harmony y Pump In Style y Mya Joy

Liberación de responsabilidad del extractor de leche del Programa WIC de Maryland

FECHA: _____________________________ # ID WIC: _________________________________

NOMBRE: _________________________________ NÚMERO DE TELÉFONO: ______________

DIRECCIÓN: ___________________________________________________________________

____________________________________________________________________

RAZONES PARA SOLICITAR UN EXTRACTOR DE LECHE:

_____________________________________________________________________________

Fec. de Nac. DEL BEBÉ: _________

Iniciales: _____ Confirmo que recibí, un extractor de leche ____________________, del Programa WIC ____________________. Me explicaron la operación, uso y cuidado de este extractor de leche y recibí las instrucciones por escrito. También me dieron información sobre cómo guardar la leche materna de forma adecuada y monitorear al bebé lactante. Entiendo que no tengo obligación de usar este extractor, que puedo dejar de usarlo en cualquier momento y que debo dejarlo de usar si me provoca molestias. Libero al Estado de Maryland, MDH, al Programa WIC del Estado de Maryland y a las Agencias Locales, a sus oficiales, sirvientes, agentes y empleados de cualquier responsabilidad por cualquier pérdida en cuanto al uso, operación ó cuidado de este extractor de leche ó del almacenamiento de la leche materna y el monitoreo de un bebé lactante. Iniciales: _____ Entiendo que me dieron este extractor de leche para mi uso exclusivo. No venderé ni compartiré con nadie este extractor de leche.

Tuve la oportunidad de hacer preguntas sobre la operación, uso y cuidado del extractor de leche, así como sobre el almacenamiento apropiado de la leche materna y el monitoreo del bebé lactante. Entiendo todas las instrucciones y estoy de acuerdo con seguirlas. Estoy consciente sobre los riesgos ligados al uso, operación y cuidado del extractor de leche y voluntariamente asumo plena responsabilidad sobre todos los riesgos conocidos y no conocidos, previstos o no previstos por pérdida, pérdida de propiedad o daños personales que se den como resultado del uso, operación y cuidado del extractor de leche. No tengo condiciones físicas o restricciones que prohíban que cargue, use ú opere este extractor de leche de forma segura. Es mi expresa intención que la liberación de responsabilidad, el acuerdo de indemnización y la exención contenida en este acuerdo obliguen a mis herederos, personas asignadas y representantes personales. AL FIRMAR ABAJO, RECONOZCO Y GARANTIZO QUE leí este Acuerdo, lo entiendo, estoy de acuerdo con sus términos y lo firmo voluntariamente; no se hicieron representaciones orales, declaraciones ó incentivos, aparte del precedente acuerdo escrito; Tengo al menos dieciocho (18) años de edad ó soy menor emancipado y plenamente capaz y tengo capacidad legal para entrar en este Acuerdo. Este Acuerdo se interpretará de acuerdo con las leyes del Estado de Maryland y no opera para eximir la inmunidad soberana o cualquier otra inmunidad en poder del Estado, MDH ó el Programa WIC del Estado de Maryland y las Agencias Locales.

FIRMA: _________________________________________ FECHA: ______________________

TESTIGO: ________________________________________ FECHA: ______________________

FECHA DE REGRESO: ______________ FIRMA DEL PERSONAL: _______________________

Este proveedor brinda igualdad de oportunidades.

Attachment 5.11B Attachment 5.11B 02/05/2019

Page 1 of 1

Local Agency:

Clinic:

BREAST PUMP LOG

Staff Initials

Date

Participant Name and Phone Number

Age of Infant

Type of Pump Given

Reason for Issuance

Pumping Frequency # times # days per day per wk

Date(s) Filters Given, if applicable

Date Pumping Stopped

Duration of Pumping

Attachment 5.11 C Attachment 5.11 C 10/01/2014

Page 1 of 1 Breast Pump Tracking Form

Local Agency: _________________________________________

Breast Pump Type and Serial Number Participant’s Name Participant’s Phone Number Participant’s WIC ID Number Date Loaned Dates Tracked Date Returned Date Cleaned Staff Initials

Pressure tested? Yes No

Pressure tested? Yes No

Pressure tested? Yes No

Pressure tested? Yes No

Pressure tested? Yes No

Pressure tested? Yes No

Pressure tested? Yes No

Pressure tested? Yes No

Pressure tested? Yes No

Attachment 5.11D 08/05/2021 Page 1 of 1

For use when providing multi-user breast pumps:

Elite, Lactina, Nurture III, and Enjoye Maryland WIC Program Electric Breast Pump Loaner Agreement and Release of Liability

DATE: _____________________________ WIC ID #: _________________________________

NAME: _____________________________________PHONE NUMBER: ___________________

ADDRESS: ____________________________________________________________________

____________________________________________________________________ REASON FOR REQUESTING BREAST PUMP:

_____________________________________________________________________________

BABY’S DOB: ______________________

Initial:

_____ I acknowledge that I have received, a ____________________ breast pump, from the ____________________WIC Program. The operation, use, and care of this breast pump have been explained to me and I have received written instructions. I have also been given information on proper storage of breast milk and monitoring of the breastfed infant. I understand that I am under no obligation to use this breast pump, that I may discontinue its use at any time, and that I should discontinue its use if it causes discomfort. I release the State of Maryland, MDH, Maryland WIC Program State and Local Agencies and their officers, servants, agents, and employees from any liability for any loss regarding the use, operation, or care of this breast pump or the storage of breast milk and monitoring of the breastfed infant. Initial: _____ I understand that this breast pump is property of the State of Maryland WIC Program. I agree to return this pump to the ______________________ WIC Program by _________________ ________. I understand that if I do not return this breast pump, I may be liable for the cost of this breast pump. I understand that if I damage this pump beyond normal wear and tear I may be responsible for the cost of repairs.

I have had an opportunity to ask questions on the operation, use, and care of the breast pump, as well as proper storage of breast milk and monitoring of the breastfed infant. I understand all instructions and agree to follow them. I am aware of the risks connected with use, operation, and care of the breast pump and I voluntarily assume full responsibility for all known and unknown foreseen and unforeseen risks of loss, property loss or personal injury, resulting from the use, operation, and care of the breast pump. I have no physical conditions or restrictions which would prohibit my safe carrying, use, or operation of this breast pump. It is my express intent that the release of liability, indemnification agreement, and waiver contained in this agreement shall bind my heirs, assigns, and personal representatives. BY SIGNING BELOW, I ACKNOWLEDGE AND REPRESENT THAT I have read this Agreement, I understand it, I agree to its terms, and I sign it voluntarily; no oral representations, statements or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age or an emancipated minor and fully competent; and I have the legal capacity to enter into this Agreement. This Agreement shall be construed in accordance with the laws of the State of Maryland and does not operate to waive sovereign immunity or any other immunity held by the State, MDH, or the Maryland WIC Program State and Local Agencies.

SIGNATURE: ______________________________________ DATE: ______________________

WITNESS: _________________________________________ DATE: ______________________

DATE RETURNED: ______________STAFF SIGNATURE: ______________________________

This institution is an equal opportunity provider.

Attachment 5.11D 08/05/2021 Página 1 de 1 Uso para cuando se proveen extractores de leche multiusuario:

Elite, Lactina, Nurture III y Enjoye Extractor eléctrico de leche del Programa WIC de Maryland Contrato de préstamo y Liberación de Responsabilidad

FECHA: _____________________________ # ID WIC: _________________________________

NOMBRE: _________________________________ NÚMERO DE TELÉFONO: ______________

DIRECCIÓN: ___________________________________________________________________

____________________________________________________________________

RAZONES PARA SOLICITAR UN EXTRACTOR DE LECHE:

_____________________________________________________________________________

Fec. de Nac. DEL BEBÉ: _________

Iniciales: _____ Confirmo que recibí, un extractor de leche ____________________, del Programa WIC ____________________. Me explicaron la operación, uso y cuidado de este extractor de leche y recibí las instrucciones por escrito. También me dieron información sobre cómo guardar la leche de forma adecuada y monitorear al bebé lactante. Entiendo que no tengo obligación de usar este extractor, que puedo dejar de usarlo en cualquier momento y que debo dejarlo de usar si me provoca molestias. Libero al Estado de Maryland, MDH, al Programa WIC del Estado de Maryland y a las agencias locales, a sus oficiales, sirvientes, agentes y empleados de cualquier responsabilidad por cualquier pérdida en cuando al uso, operación ó cuidado de este extractor de leche ó del almacenamiento de la leche materna y el monitoreo de un bebé lactante. Iniciales: _____ Entiendo que este extractor de leche es propiedad del Programa WIC del Estado de Maryland. Estoy de acuerdo en regresar este extractor al Programa WIC _____________________por ___________________. Entiendo que, si no regreso este extractor, puedo incurrir en la responsabilidad del costo del mismo. Entiendo que si este extractor se daña más que el uso normal puedo ser responsable del costo de las reparaciones.

Tuve la oportunidad de hacer preguntas sobre la operación, uso y cuidado del extractor de leche, así como sobre el almacenamiento apropiado de la leche materna y el monitoreo del bebé lactante. Entiendo todas las instrucciones y estoy de acuerdo con seguirlas. Estoy consciente sobre los riesgos ligados al uso, operación y cuidado del extractor de leche y voluntariamente asumo plena responsabilidad sobre todos los riesgos conocidos y no conocidos, previstos o no previstos por pérdida, pérdida de propiedad ó daños personales que se den como resultado del uso, operación y cuidado del extractor de leche. No tengo condiciones físicas ó restricciones que prohíban que cargue, use ú opere este extractor de leche de forma segura. Es mi expresa intención que la exención de responsabilidad, el acuerdo de indemnización y la exención contenida en este acuerdo obliguen a mis herederos, personas asignadas y representantes personales. AL FIRMAR ABAJO, RECONOZCO Y GARANTIZO QUE leí este Acuerdo, lo entiendo, estoy de acuerdo con sus términos y lo firmo voluntariamente; no se hicieron representaciones orales, declaraciones ó incentivos, aparte del precedente acuerdo escrito; tengo al menos dieciocho (18) años de edad o soy menor emancipado y plenamente capaz y tengo capacidad legal para entrar en este Acuerdo. Este Acuerdo se interpretará de acuerdo con las leyes del Estado de Maryland y no opera para eximir la inmunidad soberana ó cualquier otra inmunidad en poder del Estado, MDH ó el Programa WIC del Estado de Maryland y las agencias locales.

FIRMA: _________________________________________ FECHA: ______________________

TESTIGO: ________________________________________ FECHA: ______________________

FECHA DE REGRESO: ______________ FIRMA DEL PERSONAL: _______________________

Este proveedor brinda igualdad de oportunidades.

Policy and Procedure 5.12

Page 1 of 2 MARYLAND DEPARTMENT OF HEALTH WIC PROGRAM POLICY AND PROCEDURE MANUAL

Policy and Procedure Number: 5.12 Effective Date: October 1, 1999 Revised Date: February 12, 2025 SECTION: NUTRITION EDUCATION SUBJECT: Provision of Breastfeeding Aids (Excluding Breast Pumps)

A. Policy

WIC funds may be used to purchase aids which directly support the initiation or continuation of breastfeeding. Breastfeeding aids may not be provided to participants solely as an inducement to consider or continue breastfeeding. Breastfeeding aids should be offered to participants based on established need.

Examples of breastfeeding aids which directly support the initiation or continuation of breastfeeding are breast pumps (see Policy and Procedure 5.11), breast shells, nipple shields, nursing bras, nursing pads, and alternative feeding devices. Examples of aids that do not directly support the initiation and continuation of breastfeeding, and cannot be purchased with WIC funds, are topical creams, ointments, medicinals, foot stools, and nursing blouses.

B. Procedure

1. Local agencies shall insure that staff members who give out breastfeeding aids are trained in their appropriate use and are able to effectively educate participants on the proper use of the breastfeeding aids. Staff who provide nursing supplementers, breast shells, and/or nipple shields to participants shall be an IBCLC or have completed the state agency level 4 breastfeeding training, and have written approval from the State WIC Agency Breastfeeding section.

2. Staff members providing breastfeeding aids shall explain to participants when to use the breastfeeding aid provided (see Attachment 5.12B), how to use it, how to clean it, and if applicable, how to dissemble and reassemble it. Safe use of the breastfeeding aid shall be emphasized. Staff members shall explain where to call for assistance and provide a written phone number. Participants receiving a nursing supplementer shall view a video that explains how to properly use this device.

3. Participants shall be given instructions provided by the product manufacturer and nutrition education and handout literature, as applicable (see the Breastfeeding Kardex and Attachment 5.12B).

Policy and Procedure 5.12

Page 2 of 2

4. Staff issuing breastfeeding aids shall document each issuance under BF Aids on the Breastfeeding Support breastfeeding screen.

5. Participants shall sign the Breastfeeding Aid Release of Liability form (Attachment 5.12A) prior to receiving nursing supplementers or breast shells. Staff shall retain the signed form on file at the local WIC agency following the retention schedule in policy and procedure 6.00.

6. All participants receiving alternative feeding devices shall receive a follow- up contact to determine progress within two working days.

7. Staff shall recommend that participants inform the infant’s health care provider of the use of alternative feeding devices, and/or nipple shields, and the mother’s health care provider of the use of breast shells.

Attachments: 5.12A Breastfeeding Aid Release of Liability 5.12B Guidelines for Issuing Breastfeeding Aids

References:

7 CFR 246.14(c)(1)(ii)

7 CFR 246.4(a)(11)(ii)

Revisions: 10/2010 Changed Lactation Education for WIC Professionals conference to advanced lactation training as scheduled by the State Agency. Changed breastfeeding screen BF Aids to BF Support.

10/2011 Added, ‘with WIC funds,’ on page 1 A, second paragraph. Added, ‘under BF Aids on the BF Support breastfeeding screen,’ on page 2 number 4.

10/2014 Added nipple shields as an approved breastfeeding aid. Added staff providing nipple shields, breast shells, or nursing supplementers must be IBCLC certified or have State Agency written approval. Changed advanced lactation training to Grow and Glow Part 2. Revised Attachment 5.12 B to include recommendations for use of and nutrition education with nipple shields.

02/2025 Changed videotape to video. Made language edits for clarity and consistency with other policies.

Attachment 5.12A Attachment 5.12A

Page 1 of 1

BREASTFEEDING AID RELEASE OF LIABILITY

DATE: ________________ WIC ID #: _________________________

NAME:__________________________________________________________________

ADDRESS: _____________________________________________________________

________________________________________________________________________

PHONE NUMBER: ________________ BABY'S DOB: ________________

REASON BREASTFEEDING AID PROVIDED: ________________________________

______________________________________________________________________

I acknowledge that I have received__________________________________ from the _____________________________ WIC Program for my sole use. I have also been given information on monitoring of the breastfed baby and have been instructed to inform my doctor or the baby’s doctor

□ prior to □ that I am using this product. I have been informed that I may call the WIC office if I have questions or problems regarding the use of this product. I understand that I am under no obligation to use this product, that I may discontinue its use at any time, and that I should discontinue its use if it causes discomfort. I release the WIC Program from any liability regarding my use of this product.

SIGNATURE: ___________________________________

WITNESS: _____________________________________

Attachment 5.12 B Attachment 5.12 B 02/12/2025 Page 1 of 3

Guidelines for Issuing Breastfeeding Aids

Breast Shells

Breast shells may be provided for the following reasons:

1. To gently apply pressure to help evert flat or inverted nipples during pregnancy or lactation. (Use the ring with the smaller opening for this purpose.) Note: Participants at high risk for premature labor should not be given breast shells.

2. To promote healing of sore nipples by creating room for air circulation around and preventing friction against the nipple. (Use the ring with the larger opening for this purpose.)

Suggestions for Nutrition Education:

1. Do not wear at night.

2. Wear with the air holes on the upper half of the shell so that milk leakage does not soil clothing. Any milk that is collected in the breast shells should be emptied frequently and discarded.

3. Caution mother against wearing a tight bra to minimize the possibility of milk building up in the milk ducts.

4. Prenatally, do not begin use until at least 35 weeks gestation. Initially wear for limited periods of time (approximately 20 minutes, several times per day) and gradually build up to wearing all day.

5. During the postpartum period, wear between feedings when not sleeping.

6. Provide handouts on positioning and latch if nipples are sore.

7. Provide instruction literature that comes with breast shells.

Nursing Pads

Nursing pads may be provided to mothers who:

1. Experience leakage of breastmilk.

2. Complain of soiled clothing which may result from leakage of breastmilk.

Attachment 5.12 B 02/12/2025 Page 2 of 3

Suggestions for Nutrition Education:

1. Remove and replace nursing pads when they become damp.

2. Nursing pads can be combined (i.e. worn two at a time) to provide additional protection for mothers who experience larger amounts of leakage.

3. Review manufacturer laundering directions.

Alternative Feeding Devices

This group includes, but is not limited to, cups, orthodontic syringes, and nursing supplementers. These devices may be useful in the following situations:

1. To feed expressed breastmilk or infant formula to a breastfed infant in a way which prevents nipple confusion which could result from use of artificial nipples.

2. To feed additional breastmilk or infant formula when caloric needs are high (e.g., cardiac conditions, preterm babies).

3. To feed additional breastmilk or infant formula when an infant has a poor or uncoordinated suck and, as a result, does not take in enough on their own (e.g., a baby with Down’s Syndrome, hypo- or hypertonicity, neurological impairment, nipple confusion, cleft lip or palate).

4. To supplement an infant when maternal milk production is not adequate (e.g., breast surgery, adoptive nursing, re-lactation, too little functional breast tissue to support full milk supply).

Suggestions for Nutrition Education:

1. Demonstrate how to use the feeding device provided, using doll or baby.

2. Show a manufacturer or state agency approved video of the device being properly used, if available. Best practice is to send the URL to the video to the parent so they can reference it at home.

3. Explain and demonstrate how to secure the nursing supplementer in place. Have the parent return the demonstration.

4. Provide manufacturer’s literature for the feeding device.

Attachment 5.12 B Attachment 5.12 B 02/12/2025 Page 3 of 3

Nipple Shields

When other techniques and methods have been tried and proven ineffective, nipple shields may be provided for the reasons listed below. They should be used with caution, careful monitoring, and ongoing assessment of milk supply and infant weight gain. It is important, when providing nipple shields, that the IBCLC demonstrate how they are to be used, giving careful attention to baby’s correct latch.

1. To assist with infants having difficulty latching on.

2. To facilitate improved latch with an inverted nipple.

Suggestions for Nutrition Education:

1. Advise that nipple shield use is temporary. 2. Advise that long-term use of a nipple shield could result in lower milk supply and inadequate weight gain for the baby. 3. Invert the base of the nipple shield and demonstrate how to put it on. Have the parent provide a return demonstration. 4. Schedule a follow-up appointment for continued monitoring. 5. If appropriate at this time, discuss ways to remove the nipple shield, after initial let-down. 6. Discuss proper cleaning of the nipple shield.

Policy and Procedure 5.13

Page 1 of 5 MARYLAND DEPARTMENT OF HEALTH WIC PROGRAM POLICY AND PROCEDURE MANUAL

Policy and Procedure Number: 5.13 Effective Date: October 1, 2004 Revised Date: February 12, 2025

SECTION: NUTRITION EDUCATION SUBJECT: Breastfeeding Peer Counseling Programs

A. Policy

Combining peer counseling with the on-going breastfeeding promotion efforts in the Maryland WIC Program has the potential to positively impact breastfeeding rates among Maryland WIC participants. Peer counseling has been a significant factor in improving breastfeeding initiation and duration rates among breastfeeding parents in a variety of settings, including low income and WIC populations representing diverse cultural backgrounds and geographical locations (Best Start Social Marketing, Inc. research findings). One of the prime factors that has been attributed to this success is the ability of peer counselors to provide ongoing support and practical suggestions for breastfeeding that are modeled in their own life experiences.

It is reported in the literature that many feel overwhelmed with the various competing demands of parenting and believe breastfeeding is too great a challenge. However, having a peer counselor available for discussion and advice can make breastfeeding less intimidating and more attainable. Breastfeeding parents who have benefited from peer support report improved confidence in their ability to breastfeed (Best Start Social Marketing, Inc. research findings).

Regardless of the funding source, Peer Counseling Programs within Maryland WIC must meet both the requirements in the USDA Breastfeeding Peer Counselor guidelines and this policy. The Maryland WIC Program defines a breastfeeding peer counselor as a paraprofessional peer with personal, successful breastfeeding experience who wants to help others enjoy a positive and successful experience with breastfeeding. Ideally the peer counselor is a current or former WIC participant who shares the same ethnicity, age, language, and cultural background as the participants being counseled. The peer counselor must satisfactorily complete the peer counselor training and identify with, and relate well to, WIC participants.

Peer counselors within the Maryland WIC Program will be trained using a state agency approved protocol, and function following consistent documentation standards (defined in the Peer Counselor Management Materials [PCMM]). Local agencies will be expected to recruit, supervise peer counselors, and assist

Policy and Procedure 5.13

Page 2 of 5 with training. Peer counselors will be compensated for their work through the local agency’s pay scale.

Peer counselors are not health care professionals. They work as members of a team that may include International Board Certified Lactation Consultants (IBCLCs), WIC Designated Breastfeeding Experts (DBEs), breastfeeding specialists, nutritionists, nurses, WIC Competent Professional Authorities (CPAs), WIC Competent Paraprofessional Authorities (CPPAs), and Local and State Agency Breastfeeding Coordinators. They work under the guidance and direct supervision of the Local Agency Peer Counselor Coordinator and with additional technical support of the State Agency Peer Counselor Program Coordinator.

B. Procedure

1. Breastfeeding Peer Counseling Programs must comply with the fiscal requirements in policy and procedure 6.11 BFPC Allowable and Unallowable Expenditures. Request for purchasing materials for demonstration purposes, resources for the Breastfeeding Peer Counseling Program staff, and materials to promote the Breastfeeding Peer Counseling Program (including pamphlets and media campaigns) should be submitted for approval to both the State Breastfeeding Peer Counseling Program Coordinator and the State Fiscal Unit.

2. Each local agency with a peer counseling program will designate a Peer Counselor Coordinator. The Local Agency Peer Counselor Coordinator must be a DBE, meet the qualifications outlined in the Local Agency Peer Counselor Coordinator job description (see PCMM), and be provided designated time to administer and supervise the peer counseling program.

3. Local agencies will recruit and hire peer counselors. Job descriptions developed by the state agency and documented in the PCMM will be used as the basis for peer counselor job functions.

4. Peer counselors will complete both WIC Wise for Breastfeeding Peer Counselors and the Maryland WIC Peer Counselor Training Program prior to independent contact with WIC participants. When able, WIC Wise for Breastfeeding Peer Counselors should be completed first. The state agency will assist with training local agency peer counselors, as schedules allow. If a state agency training is not available during a new peer counselor’s training period, the local agency peer counselor coordinator is responsible for providing the full training, using the State WIC Peer Counseling presentations and materials for new peer counselors. In addition, all peer counselors who are initially trained locally shall attend the next available state agency new peer counselor training. Local Agency Peer Counselor Coordinators are expected to participate in state agency new peer counselor trainings.

5. Peer counselors will directly counsel WIC participants about normal

Policy and Procedure 5.13

Page 3 of 5 breastfeeding issues. Peer counselors will follow protocols, outlined in the PCMM, provided to them during the Maryland WIC Peer Counseling Training Program (with updates provided by the State and Local Agency Peer Counselor Coordinators) to determine frequency of contact with participants and issues to be discussed for specific concerns.

6. Peer counselors will document using the Maryland WIC Program management information system following the contact guidelines in Attachment 5.13A and document the amount of breastfeeding at each contact (even if same as previous contact) or, when not available, using a paper documentation form (Attachment 5.13C). Peer counselors will follow documentation procedures outlined in the PCMM provided to them during the Maryland WIC Peer Counselor Training Program.

7. Peer Counselors in dual roles as CPPAs will not be determining eligibility when performing peer counselor duties. Peer counselors require designated time outside the certification appointment to perform their peer counseling duties. Permission to work as a CPPA and peer counselor will be granted in limited circumstances. The local agency will contact the State Breastfeeding Coordinator and State Breastfeeding Peer Counselor Program Coordinator, who will make the determination with the approval of the State Nutrition and Breastfeeding Unit Chief, State WIC Director and FNS Regional Office.

8. Peer counselors may be expected to work outside of the local agency WIC clinic or business hours.

9. Local agencies are strongly encouraged to partner with community resources to extend breastfeeding support beyond the WIC clinic. For example, a local agency might have peer counselors facilitating breastfeeding support groups in a local hospital or physician office setting. Peer counselor programs should also network with community lactation consultants. 10.A State Agency Peer Counselor Program Coordinator will be designated to support and guide local agency peer counselor programs. This position will not be responsible for direct supervision of peer counselors and will not replace the local agency Peer Counselor Coordinator.

11. Statewide Peer Counselor Meetings will be held 2 times per year. Peer Counselor Coordinator and Peer Counselor attendance at these meetings is required. Two additional meetings for Peer Counselor Coordinators will be held each year, usually by conference call. Peer Counselor Coordinator attendance is required at these meetings.

Policy and Procedure 5.13

Page 4 of 5 Attachments: 5.13 A WIC Breastfeeding Peer Counselor Referral Form 5.13 B Breastfeeding Peer Counselor Confidentiality Statement 5.13 C Breastfeeding Peer Counselor Contact Form

References: Maryland WIC Program Peer Counselor Management Materials Revisions: 10/08 Added that Peer Counselor Coordinator attendance is required at statewide Peer Counselor Meetings.

10/10 Changed State Agency Peer Counselor Program Coordinator to State Agency Peer Counselor Program Manager. Added reference to paper documentation form Attachment 5.13C. Changed Statewide Peer Counselor Meetings will be held 1 - 2 times per year to 2 times per year.

10/12 Revised Attachment 5.13A Peer Counselor Referral and Information Release and Attachment 5.13C Breastfeeding Peer Counselor Contact Form.

10/13 Revised Attachment 5.13A Peer Counselor Referral and Information Release (English and Spanish).

10/14 Added following the contact guidelines in Attachment 5.13A and document amount of breastfeeding at each contact (even if same as previous contact) to Procedure 5.

04/15 Revised Attachment 5.13A Peer Counselor Referral and Information Release (English and Spanish).

10/15 Changed Peer Counselor/Peer Counselor Coordinator Meetings held twice per year and added that Peer Counselor Coordinator Meetings held an additional two times per year. Changed name of statewide position to Peer Counselor Coordinator.

02/19 Added Designated Breastfeeding Expert title. Updated 5.13A to align with USDA contact guidelines.

04/19 Added clarification on duties performed by a breastfeeding peer counselor who also works as a CPPA and approval process.

11/19 Added that the PC Coordinator shall be a DBE. Clarified that PCs will receive revisions to PC Protocols that they follow from the State Peer Counselor Program Coordinator and their Local Agency Peer Counselor Coordinator.

02/25 Added need to follow fiscal requirements of BFPC grant and

Policy and Procedure 5.13

Page 5 of 5 referenced fiscal policy for BFPC programs within this policy. Clarified that BFPCs must be trained locally when a State BFPC training is not readily available and that locally trained BFPCs shall attend the next available State BFPC training.

Attachment 5.13A B-41/0215 02/05/2019

Page 1 of 2

WIC Breastfeeding Peer Counselor Referral and Information Release

Name: ________________________________________ ID#:______________________ Age: ____________________

Phone Number: _________________ Best time to contact: ____________ Preferred Language: _____________________

Mother’s Race:  Asian  Black or African American  White  Other: _______________________ Mother’s Ethnicity: Hispanic or Latino?  Yes  No

Maternity Care Physician: ____________________________________ Hospital: ________________________________ Due Date: __________ First Baby?  Yes  No Pregnant with multiples:  Yes  No

Tell us about your breastfeeding experience: _____________________________________________________________ How many children have you breastfed? ____________ Are you currently nursing another child?  Yes  No How long did you breastfeed your other children? _________________________________________________________ Tell us why you stopped breastfeeding those children: ______________________________________________________ How do you feel about breastfeeding this baby?  Definitely will  Extremely interested  Somewhat interested  Not sure Who supports your decision to breastfeed? _______________________________________________________________ What are your plans for returning to work or school? _______________________________________________________ Other concerns or issues: _____________________________________________________________________________

Do you: ➢smoke cigarettes?  No  Yes Number per day? ______ ➢currently drink beer, wine, or drinks with alcohol?  No  Yes How many per day? _______ ➢take any medicines?  No  Yes Name of medication? ____________________________

➢use recreational [street] drugs?  No  Yes What type? _____________________________

After getting permission, WIC breastfeeding support staff might touch you and/or your baby as they provide breastfeeding information or supplies.

 I agree to receiving text messages from the WIC breastfeeding support staff and am aware that I can stop receiving text messages at any time by notifying the Maryland WIC Program.

 I give permission, on behalf of my baby, and myself to release the information, weights, and medical conditions contained on this form to the WIC staff, the breastfeeding support staff at the hospital where I receive services, my baby’s pediatrician(s), and my physician(s).

Signature: _____________________________________ Printed Name: ___________________________Date:_______ FOR OFFICE USE ONLY EDD: ADD:

Date of Certification: Date Referral Received: Weekly prior to EDD: 1 week after Once a year until weaned 2 months pregnant 4 weeks prior 2 weeks after 1 year 3 months pregnant 3 weeks prior 3 weeks after 2 years 4 months pregnant 2 weeks prior 4 weeks after 3 years 5 months pregnant 1 week prior 1-2 weeks before returning to work/school 4 years 6 months pregnant Around EDD 6 weeks

7 months pregnant 2-3 days after delivery 3 months

8 months pregnant 5-6 days after delivery 6 months

9 months

If your baby is already here, please complete: Delivery Date: ______________ Weeks of Gestation: _______ Baby’s Doctor: _____________________ Baby’s name: ____________________ Gender: ______ Birth weight: __________ Baby’s name: ____________________ Gender: ______ Birth weight: __________ Multiples:  Yes  No C-section:  Yes  No Premature:  Yes  No

Attachment 5.13A B-41/0215 02/05/2019

Página 1 de 2

Referencia a una Consejera de Lactancia de WIC y Liberación de Información

Nombre: _______________________________________ #ID:______________________ Edad: ___________________

Número de teléfono: _________________ Mejor hora para contactarla: ____________ Idioma preferido: _____________

Raza de la madre:  Asiática  Negra o Afroamericana  Blanca  Otro: _______________________ Origen étnico de la madre: ¿Hispana o latina?  Sí  No

Médico de atención de maternidad: ____________________________________ Hospital: _________________________ Fecha prevista: __________ ¿Primer bebé?  Sí  No Embarazo múltiple:  Sí  No

Cuéntenos sobre su experiencia con la lactancia: __________________________________________________________ ¿A cuántos niños le ha dado pecho? ____________ ¿Le está dando pecho a otro niño en este momento?  Sí  No ¿Durante cuánto tiempo le dió pecho a sus otros hijos? _____________________________________________________ Díganos por qué le dejó de dar pecho a esos niños: ________________________________________________________ ¿Cómo se siente de darle pecho a este bebé?  Definitivamente lo haré  Extremadamente interesada  Algo interesada  No estoy segura ¿Quién apoya su decisión de dar pecho? _________________________________________________________________ ¿Cuáles son sus planes para regresar a trabajar o ir a la escuela? ______________________________________________ Tiene otras preocupaciones o problemas: ________________________________________________________________

Usted: ➢¿fuma cigarrillos?  No  Sí ¿Cuántos al día? ______ ➢¿bebe cerveza, vino o bebidas alcohólicas?  No  Sí ¿Cuántas al día? _______ ➢¿toma medicamentos?  No  Sí ¿Nombre del medicamento? ____________________________

➢¿consume drogas recreativas [calle]?  No  Sí ¿De qué tipo? _____________________________ Si su bebé ya nació por favor conteste lo siguiente: Fecha de nacimiento: ______________ Semanas de gestación: _______ Pediatra: _____________________ Nombre del bebé: ____________________ Sexo: ______ Peso al nacer: __________ Nombre del bebé: ____________________ Sexo: ______ Peso al nacer: __________ Múltiples:  Sí  No Cesárea:  Sí  No Prematuro:  Sí  No Después de obtener permiso, el personal de apoyo de WIC podría tocarla a usted y/o a su bebé cuando están proporcionando información o suministros de lactancia.

 Acepto recibir mensajes de texto del personal de apoyo de WIC y sé que puedo dejar de recibir los mensajes de texto en cualquier momento al notificar al Programa WIC de Maryland.

 Doy permiso, en nombre de mi bebé y mío, para que se libere la información, los pesos y las condiciones médicas contenidas en esta forma al personal de WIC, al personal de apoyo a la lactancia en el hospital donde recibió los servicios, al pediatra de mi bebé y a mi médico(s).

Firma: _____________________________ Nombre en letra de molde: ___________________________ Fecha:_______ SÓLO PARA USO OFICIAL: Fecha probable: Fecha real:

Fecha de certificación: Fecha en que se recibió la referencia: Semanal previo a fecha probable: 1 semana después Una vez al año hasta el destete 2 meses de embarazo 4 semanas previas 2 semana después 1 año 3 meses de embarazo 3 semanas previas 3 semana después 2 años 4 meses de embarazo 2 semanas previas 4 semana después 3 años 5 meses de embarazo 1 semana previa 1-2 semanas antes de regresar a trabajar o a la escuela 4 años 6 meses de embarazo Alrededor de la fecha probable 6 semanas

7 meses de embarazo 2-3 días después del nacimiento 3 meses

8 meses de embarazo 5-6 días después del nacimiento 6 meses

9 meses

Attachment 5.13 B Attachment 5.13 B

Page 1 of 1 Maryland WIC Program Breastfeeding Peer Counselor Program Confidentiality Statement Trust and confidence are needed for a successful program. This trust must be on all levels…between supervisors and peer counselors, between peer counselors and colleagues, and between peer counselors and clients. WIC Participants share personal information in order to be served by WIC. This includes medical, financial, and personal information. At the same time, clients have the right to know that the information they give to the program will be kept confidential to the fullest extent allowed by law. It is our responsibility to respect their privacy and not discuss client information. Discussing confidential information to anyone outside the WIC clinic or WIC Breastfeeding Support group is prohibited. This includes ensuring that the participants’ records and materials in your possession, whether paper or computerized, are not able to be viewed by anyone other than authorized WIC staff. Agreement I have carefully read the above Confidentiality Agreement and understand the confidential nature of all participants' information and records. I understand that it is my job to share participant information only with staff involved in the participant’s case, and I understand that I am prohibited by law from disclosing any such confidential information to unauthorized persons. However, I also understand that there are limited circumstances when the law requires the WIC Program to disclose certain information to government officials, or as properly authorized in writing. If I ever receive a request for participant information that comes from outside of the WIC Program or WIC Breastfeeding Support group, I will immediately forward that request to my supervisor. If I am unsure whether I should disclose participant information, I will ask my supervisor for instructions. Name (please print) _______________________________ Signature _______________________________________ Date ______________

Witness Name (please print) ________________________ Witness Signature ________________________________ Date _______________

Attachment 5.13 C

Attachment 5.13 C

Page 1 of 1 Breastfeeding Peer Counselor Contact Form

Mother’s Name: _____________________________ Baby’s Name: __________________________

Mother’s ID Number: _________________________

Phone number: ___________________ Delivery date: ____________ Birth weight: _____________

Date Contact Method Contact Topic Amount of Breastfeeding No Contact Reasons Call Back Date

Phone

Clinic: Ind

Clinic: Class

Mail

Clinic: Group

Hospital

Text Yes No Protocol(s): Exclusive

Mostly

Some

Toddler Canceled Appointment

Client Refused/Declined

Left Message On Voice Mail/Answering Machine

Left Message w/ Person

Moved Out of State

No Answer

No Show

Phone Busy

Phone Disconnected

Phone Not Accepting Calls

Wrong Phone Number

Is this child routinely fed something other than breast milk? Yes No Age when feeding started: ______________________________________ Type of Food: ___________________________________

Breastfeeding Ended Date or Total Breastfeeding Duration: _________________________________ Breastfeeding Ended Reason: __________________________________________

Breastfeeding Aids:

Referrals:

Comments:

October 2008

Policy and Procedure 5.14 has been removed.

October 2008

Policy and Procedure 5.14A has been removed.

October 2008

Policy and Procedure 5.14B has been removed.

October 2008

Policy and Procedure 5.14C has been removed.

October 2008

Policy and Procedure 5.14D has been removed.

October 2008

Policy and Procedure 5.14E has been removed.

October 2008

Policy and Procedure 5.14F has been removed.

Policy and Procedure 5.15

Page 1 of 3 MARYLAND DEPARTMENT OF HEALTH WIC PROGRAM POLICY AND PROCEDURE MANUAL

Policy and Procedure Number: 5.15 Effective Date: October 1, 2012 Revised Date: February 5, 2019 SECTION: NUTRITION EDUCATION SUBJECT: Staff Breastfeeding Support Roles

A. Policy

All Maryland WIC Program staff influence Maryland WIC participants and therefore are responsible for breastfeeding promotion and support within each staff person’s role. The State Agency provides staff three levels of breastfeeding training during new employee trainings. (For more information about breastfeeding trainings see Policy and Procedure 5.09.) The local agency continues to enhance and build upon this foundation of breastfeeding knowledge.

After all three levels of new employee training are completed, each Maryland WIC employee shall meet with his/her local agency Breastfeeding Coordinator or her designee to discuss breastfeeding support roles. The goal of this process is to: • Provide each employee, regardless of his/her WIC role, an opportunity to use the additional breastfeeding knowledge gained during new employee trainings • Provide growth potential for each employee • Put into practice the philosophy that each employee in WIC has a role in promoting and supporting breastfeeding • Create an environment of breastfeeding support that minimizes wait time for participants

B. Procedure

The Local Agency Breastfeeding Coordinator shall be responsible for overseeing this process.

1. Within two months after each employee completes Grow and Glow, Part 2, the employee shall meet individually with the Local Agency Breastfeeding Coordinator or her designee (the Breastfeeding Peer Counselor Coordinator or other staff IBCLC) to discuss what breastfeeding support roles each sees the employee taking on. This conversation shall include:

Policy and Procedure 5.15

Page 2 of 3

a. What areas within breastfeeding promotion/support the employee feels comfortable with.

b. Which areas within breastfeeding the employee is interested in learning more about and taking on roles in the future.

c. Feedback from the Breastfeeding Coordinator/designee shall be provided to the employee about his/her breastfeeding role(s).

2. After the meeting has concluded, the Breastfeeding Coordinator shall speak with the Local Agency Coordinator to communicate the outcome of the discussion.

3. The Breastfeeding Coordinator or designee shall update the Breastfeeding Support Roles Table in the Nutrition Services Plan. It is recommended that this table be updated throughout the year, after discussion with each employee.

Staff breastfeeding support roles shall be reviewed, and revised if applicable, at least annually, prior to submitting the Nutrition Services Plan (Policy and Procedure Attachment 5.06 A). Staff are encouraged to take on additional breastfeeding support roles after mastering all roles assigned throughout the year.

Attachments:

References:

5.15A Breastfeeding Support Roles

Policy Guidance, Breastfeeding Food Package, Issued May 20, 2009. Using Loving Support to Grow and Glow in WIC (Breastfeeding Competency Training).

Revisions:

10/15 Removed notation allowing that during the transition year, staff have until June 2013 for employees to have the breastfeeding support role discussion. Added that staff are encouraged to take on additional breastfeeding support roles after mastering roles assigned. Added Baby Behavior as a suggested topic on Attachment 5.15 A.

Policy and Procedure 5.15

Page 3 of 3 02/19 Added Enjoye breast pump on Attachment 5.15A. Added Baby Paced Bottle Feeding as a suggested role on Attachment 5.15A.

Attachment 5.15 A

Attachment 5.15 A 02/05/2019 Page 1 of 1

Breastfeeding Support Roles

While all staff participate in providing guidance to breastfeeding participants, staff identified for specific breastfeeding support roles will: • Serve as a resource for the designated areas • Provide counseling in these designated areas when a colleague is not comfortable doing so

Suggested Support Role Options:

Basic Breastfeeding Promotion and Support Roles • Breastfeeding Promotion • “Selling” the Exclusive Breastfeeding Food Package • Persuading Continuation of Exclusive Breastfeeding (Taking no formula) • Encouragement of Skin-to-Skin • Support for Nursing in Public • Referrals

Intermediate Breastfeeding Promotion and Support Roles • Increasing Breastfeeding/Reducing Formula Use • Breast Pump Instruction: o Manual Pump (Harmony) o AC Adapter Pump (Nurture III, Enjoye) o Automatic Suction (Pump in Style) o Hospital-Grade Electric (Lactina/Elite) • Positions for Breastfeeding • Working and Breastfeeding • Baby Behavior • Baby Paced Bottle Feeding

Advanced Breastfeeding Support Roles • Latch • Fitting Nursing Bras • Counseling over the Telephone • Breastfeeding Multiples • Breastfeeding an Older Baby/Toddler Breastfeeding • Vitamin D • Other __________________________________________________