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Section 6.11: Supporting Breastfeeding Through Breast Pump Access and Education on Expressing Milk 1/2024 References: 7CFR 246.14 (b) (iii), USDA Breastfeeding Policy and Guidance Policy: If there is a need or desire to express breastmilk, provide information on milk expression and information on how to access a breast pump. In the rare case that other sources of breast pumps and lactation supplies are not available, WIC can provide select items. Purpose: To support breastfeeding and infant health and assure that WIC participants have information on expressing their breastmilk, including information on how to access a breast pump when a breast pump is indicated. Background: Expressing breastmilk, through hand expression or with a breast pump, can help participants reach their breastfeeding goals. Providing a breast pump without first assessing if milk expression is needed or desired, or by not providing a suitable pump, may make breastfeeding seem complicated, and could lead to shorter breastfeeding duration. Procedures Training - Train local staff on: ▪ Hand expression of breastmilk. ▪ Sources for obtaining breast pumps and supplies. ▪ Types of breast pumps to best meet the need when a breast pump is indicated (see Guidance). ▪ Assembly, use, and cleaning of all breast pumps and related supplies available through the local WIC program. ▪ Local procedures for recording breast pump and supplies issuance.

S E C T I O N 6 . 1 1 : S U P P O R T I N G B R E A S T F E E D I N G T H R O U G H B R E A S T P U M P A C C E S S A N D E D U C A T I O N O N E X P R E S S I N G M I L K 2 Serving Pregnant and Postpartum Participants ▪ WIC breast pumps, attachment kits, and/or supplies may not be given prenatally to WIC participants. ▪ If indicated, provide information on how to obtain a breast pump and/or supplies. ▪ Encourage participant to focus on breastfeeding and getting to know baby in the early days postpartum. Hand expression can be used if milk expression is needed early on. ▪ Inform and instruct about hand expression using a breast model and other print and electronic resources. Serving Postpartum Participants ▪ Refer to other sources for obtaining a breast pump, when available. ▪ Provide a breast pump and/or supplies from WIC when a need for a breast pump is determined and the participant does not have another source for obtaining a breast pump or supplies. ▪ Determine the appropriate breast pump to meet the need. ▪ Demonstrate assembly of the breast pump to the participant. ▪ Have the participant demonstrate assembly of the breast pump. Repeat teaching and demonstration if needed. ▪ Teach how to use and clean the breast pump. ▪ Teach how to store breastmilk. ▪ Teach how to use lactation supplies. ▪ Document the pump and/or supply issuance and that teaching was provided. Types of pumps and materials are listed in the WIC Information System’s “Materials Given” section of the Nutrition Education tab. ▪ Note on the breast pump and supplies inventory the item provided, the date provided, the participant’s name and ID number, and the WIC staff person who issued the breast pump and/or supplies. Program Integrity ▪ Store WIC pumps and supplies in a secure area. ▪ Maintain records of breast pumps and supplies. This includes: ▪ Inventory of pumps and supplies received and distributed. ▪ Record of the participant. ▪ Staff person who issued the pump and/or supplies.

S E C T I O N 6 . 1 1 : S U P P O R T I N G B R E A S T F E E D I N G T H R O U G H B R E A S T P U M P A C C E S S A N D E D U C A T I O N O N E X P R E S S I N G M I L K 3 ▪ If issuing electric breast pumps, first explore if the participant can obtain a pump from their insurance provider. If there are questions about Medical Assistance coverage, reach out to the State WIC Breastfeeding Coordinator for support. ▪ Document that a pump was issued. Additionally, if an electric breast pump is issued from the local agency, document the reason an electric breast pump was needed. ▪ A WIC staff person who is also a WIC participant may not issue any pump, pump kit or supplies to themself. Another WIC staff member must assess the need and document issuance of the pump and /or supplies. Oversight The local WIC Breastfeeding Coordinator, or an alternate identified within the local agency, is responsible for: ▪ Breast pump and lactation supplies procurement, including the type and number of breast pumps/supplies to purchase. ▪ Purchasing not more than a 9-to-12-month supply of breast pumps/supplies at one time. ▪ Contacting the State WIC Breastfeeding Coordinator prior to purchase if there is a need for an item that is not listed in this policy. ▪ Breast pump and lactation supplies inventory. ▪ Assuring that WIC staff who issue breast pumps/supplies are familiar with the different types of breast pumps and lactation supplies available through the WIC program. ▪ WIC staff should have access to a list of resources for obtaining breast pumps/supplies from other sources. ▪ Assuring that WIC staff who issue breast pumps and lactation supplies are trained on assembly, use, and cleaning of all breast pumps and supplies available through the local WIC program. ▪ Seeking reimbursement for breast pumps/supplies that are purchased according to MN WIC policy if the agency wishes to be reimbursed for breast pumps. See Section 2.2: Financial Procedures. Reimbursement and Allowable Purchases The method for purchasing breast pumps and a list of types of breast pumps and lactation supplies for which the state WIC office will reimburse local WIC programs is as follows: No Prior Authorization Needed ▪ Manual breast pumps ▪ Collection kits & tubing to be used with electric breast pumps

S E C T I O N 6 . 1 1 : S U P P O R T I N G B R E A S T F E E D I N G T H R O U G H B R E A S T P U M P A C C E S S A N D E D U C A T I O N O N E X P R E S S I N G M I L K 4 ▪ Flanges ▪ Nipple shields – Note: Before your agency may purchase nipple shields, you must develop an approval protocol for using nipple shields. Submit the protocol to the State WIC Breastfeeding Coordinator. ▪ Protocol should include: ▪ Reasons for nipple shield issuance ▪ Training of staff who issue nipple shields including: ▪ How to use a nipple shield ▪ How to protect milk supply ▪ How to wean from the nipple shield ▪ Documentation of: ▪ nipple shield issuance ▪ reason for issuing ▪ plan for follow-up ▪ Personal electric breast pumps, with conditions: ▪ Prior to purchasing a personal electric pump, you must first see if there is another funding source available – such as Medical Assistance (MA) or a Medical Assistance plan through a prepaid medical assistance plan (PMAP), private insurance, or military insurance. ▪ Document in a note in the WIC Information System why the personal electric breast pump was needed, that education was provided, and that the participant was told that the pump may not be sold. Prior Authorization Required ▪ Renting an electric breast pump ▪ Approval might be granted by the State Agency if the Local Agency determines that: ▪ The family needs an electric breast pump for medical reasons (e.g., baby too ill to be at breast) and ▪ There is no other funding source. ▪ Contact the State WIC Breastfeeding Coordinator to discuss the situation and request approval. If approved: ▪ The Local Agency can cover the rental cost on a month-to-month basis. ▪ The rental agreement and any required damage deposit will be between the family and the company that rents the pump.

S E C T I O N 6 . 1 1 : S U P P O R T I N G B R E A S T F E E D I N G T H R O U G H B R E A S T P U M P A C C E S S A N D E D U C A T I O N O N E X P R E S S I N G M I L K 5 ▪ The Local Agency will pay the pump company and submit for reimbursement as with other breast pump reimbursement claims. ▪ Purchasing a multi-user electric breast pump for use at WIC clinic by participants and staff when not in use by a WIC participant. ▪ Contact the State Breastfeeding Coordinator for purchase approval. You will not be reimbursed for any purchase of a multi-user electric breast pump for which you do not have prior approval. ▪ If you purchase a multi-user electric breast pump, it must be stored in a secure area. Keeping a record of the serial number for electric breast pumps will help in the unlikely event that a multi-user breast pump is stolen. ▪ Cleaning supplies and pressure gauges are allowable expenses. Obtaining Reimbursement ▪ When receiving the pumps/supplies, verify that the number of pumps received and cost for the pumps are correct. ▪ Local Agencies should submit these costs on the monthly Claim for Reimbursement form. Describe the costs under the ‘Other’ section, or if claimed under another category, explain that in the ‘Remarks’ section. ▪ Local Agencies will be reimbursed only for the items purchased according to this policy. If you feel you need a breast pump or supply that is not included in this policy, contact the State Breastfeeding Coordinator. Often there is a solution for participants that have a special need. Guidance Sources of breast pumps ▪ Participants who have MA or a prepaid medical assistance plan (PMAP) have access to breast pumps with a physician’s prescription. ▪ Participants who have private insurance or who have military insurance can often obtain a breast pump through their insurance. ▪ All Minnesota WIC Local Agencies must have hand pumps available for their WIC participants to meet the need when pumps from other sources are not available. What to consider before you purchase If you are considering a pump or supply you are not familiar with, we encourage you to obtain information from the company before purchasing.

S E C T I O N 6 . 1 1 : S U P P O R T I N G B R E A S T F E E D I N G T H R O U G H B R E A S T P U M P A C C E S S A N D E D U C A T I O N O N E X P R E S S I N G M I L K 6 Pump Characteristics (including manual pumps) ▪ Vacuum / Pressure: Range and pressure release mechanism (to prevent vacuum/negative pressure from getting too high) ▪ Flanges: What sizes come with the pump? Are alternate sizes available and easy to access? ▪ Supplies: Where to obtain replacement valves, membranes, tubing, etc. ▪ Sample pumps: Could a sample pump be offered and then WIC staff get a report back on how it works in comparison to other pumps tried? ▪ Electric pumps: Approved as single user or multiple user? Is there a motor warranty? How are problems with the pump handled by the manufacturer? ▪ Instructions: Are there multiple ways to learn about the pump, such as an online video and print materials? Pricing ▪ Ask about WIC and/or wholesale pricing. ▪ Compare prices if you are not purchasing directly from the manufacturer. ▪ Consider shipping costs when comparing prices. Determining need for a breast pump Is manually expressing milk an option? For milk supply concerns, hand expression after birth can increase milk supply. Teaching hand expression prenatally can empower parents and support milk production in the hours and days after birth. Providing breast pumps and supportive education may facilitate longer duration of breastfeeding. Providing a breast pump to someone who does not have a need for a pump, or providing a pump that is not suitable, may make breastfeeding seem complicated. Does the infant have special needs, such as a hospitalized infant, an infant who is not able to breastfeed, an infant with a suck too weak to obtain sufficient breastmilk? In these situations, an electric pump is recommended. The participant should check with their or their infant’s medical caregiver or insurance provider/Medical Assistance regarding breast pump coverage when pumping is indicated. What are the parents’ plans? Will they be away from baby and provide pumped milk only occasionally? Is parent returning to work or school? A manual pump may be an appropriate choice for occasional or short-term separations. For participants who are returning to work full time, a personal electric breast pump may be faster.

S E C T I O N 6 . 1 1 : S U P P O R T I N G B R E A S T F E E D I N G T H R O U G H B R E A S T P U M P A C C E S S A N D E D U C A T I O N O N E X P R E S S I N G M I L K 7 Is there a place and the time to pump milk? An electric pump may be more appropriate if there is limited time to pump. A manual pump may be helpful if there is no access to electricity. Providing follow-up on breast pumps ▪ Participants who are provided with breast pumps should receive a follow-up contact to determine how the pump is working for them, to assess any changes in their milk supply, and to answer any questions they might have. ▪ Sample forms, which can be used to track participants who have received pumps, are included as Exhibit 6-G: Breast Pump and Supplies Issuance and Inventory Log. This form can be modified to meet the needs of the local program. ▪ Another option for tracking breast pump and lactation supplies issuance is to record pump issuance in the WIC Information System and set an alert for providing a follow-up contact. Reuse of breast pumps ▪ Personal pump kits or personal electric pumps should be treated as a single-user item. They should not be re-used. Definitions - For the purposes of this policy, the following definitions have been used: Double or single personal pump kit a personal kit that is attached to, personal electric pump, or electric pump, to collect breastmilk. The kit may be either single (pumps one breast at a time) or double (pumps both breasts at the same time). Flange: the portion of the breast pump that fits over the breast and nipple. Flanges come in different sizes to accommodate different sized breasts and nipples. A properly fitting flange is essential for pumping. Reference – Complete Listing of Hyperlinks Breastfeeding Policy and Guidance (https://wicworks.fns.usda.gov/sites/default/files/media/document/WIC-Breastfeeding-Policy- and-Guidance_1.pdf) Section 2.2: Financial Procedures (https://www.health.state.mn.us/docs/people/wic/localagency/program/mom/chsctns/ch2/sct n2_2.pdf) Exhibit 6-G: Breast Pump and Supplies Issuance and Inventory Log (https://www.health.state.mn.us/docs/people/wic/localagency/program/mom/exhbts/ex6/6g. docx)

S E C T I O N 6 . 1 1 : S U P P O R T I N G B R E A S T F E E D I N G T H R O U G H B R E A S T P U M P A C C E S S A N D E D U C A T I O N O N E X P R E S S I N G M I L K 8 Minnesota Department of Health - WIC Program 625 Robert St N, PO BOX 64975, ST PAUL MN 55164-0975; 1-800-657-3942, health.wic@state.mn.us, www.health.state.mn.us. To obtain this information in a different format, call: 1-800-657-3942 This institution is an equal opportunity provider.