NC WIC Program Manual January 2026 Chapter 9 Breastfeeding Program Management Table of Contents Breastfeeding promotion and support are core functions of the WIC Program. This chapter describes policies and procedures related to the management of breastfeeding promotion and support activities within the WIC Program and within the WIC Breastfeeding Peer Counseling (BFPC) program. Section 1. Breastfeeding Promotion and Support .....................................................................1  Ensure Participant Access to Breastfeeding Promotion and Support Services  Breastfeeding-Friendly Clinic Environment  Breastfeeding Support Phone Line  Consultation and Referral  Community Engagement Meetings Section 2. Staff Training ...........................................................................................................5  Orientation to Breastfeeding Activities for All WIC Staff  Continuing Education for All WIC Staff  Orientation to Breastfeeding Activities for Competent Professional Authorities  Documentation of Participation in Orientation and Continuing Education  Breastfeeding Resources for Staff Reference Section 3. Breastfeeding Coordinator .......................................................................................7  Qualifications  Orientation to the Breastfeeding Coordinator Role  Continuing Education  Responsibilities Section 4. WIC-Designated Breastfeeding Expert…………………………………………..11  Qualifications  Orientation to the Designated Breastfeeding Expert Role  Continuing Education  Responsibilities  Breastfeeding Assessment Section 5. Breastfeeding Supplies...........................................................................................15  Breastfeeding Supply Categories  Breastfeeding Aids  Breastfeeding Accessories Section 6. Issuance, Inventory, and Maintenance of Breastfeeding Supplies ........................19  Eligibility  Selection

NC WIC Program Manual January 2026  Issuance  Inventory  Maintenance of Multi-User Pumps Section 7. Breastfeeding Peer Counseling Program .............................................................. 27  Staffing  Breastfeeding Peer Counseling Program Eligibility  Enrolling Eligible Participants in the Breastfeeding Peer Counseling Program  Service Delivery Model Policy  Peer Counselor Contacts  Caseload Management  Conditions for Termination from the Breastfeeding Peer Counseling Program  Documentation of Peer Counselor Services  Monthly Peer Counselor Program Manager and Peer Counselor Meetings  Participant Satisfaction Survey (optional) Attachments Attachment 1. Local Agency Breastfeeding Consultation and Referral Policy Attachment 2. Classification of Complex Breastfeeding Issues Attachment 3. WIC Designated Breastfeeding Expert Scope of Practice Attachment 4. Pump Issuance/Reservation Reasons Attachment 5. Indications for Use  Indications for Medical Necessity for Supplementation  Indications for Silicone Nipple Shield Attachment 6. Staff Competency Checklist for Breastfeeding Supplies Issuance  Local Agency Protocols and Breastfeeding Supplies Agenda Template Attachment 7. Multi-User Pump Cleaning Log Template Attachment 8. Overdue Multi-User Pump Notification Sample Letter Attachment 9. Peer Counselor Scope of Practice Attachment 10. Peer Counselor When to Yield Attachment 11. North Carolina WIC Breastfeeding Peer Counseling Program Welcome Letter Attachment 12. Monthly Peer Counselor Review Guide Attachment 13. Breastfeeding Peer Counseling Program Client Satisfaction Survey Required Local Agency Written Policies Local agencies must establish and maintain an accessible breastfeeding consultation and referral policy for WIC staff. The policy should provide detailed contact information and methods for each staff role and situation, as well as a referral list with each resource’s contact details. outlined in an optional template. Refer to Attachment 1 for a consultation and referral policy template. (Section 1, pg. 3-4) Local agencies that accept BFPC program funding must have a written policy outlining the local agency’s service delivery model that assures the provision of consistent and quality breastfeeding peer counseling program services (Section 7, pg. 31-32).

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October 2025 Breastfeeding Promotion and Support Local agencies must cultivate an environment that actively supports and encourages families to start and continue breastfeeding. This aligns with the WIC program goal to safeguard the health of women, infants, and children, with a strong emphasis on promoting, protecting, and supporting breastfeeding. The WIC program aligns with the American Academy of Pediatrics’ recommendation for exclusive breastfeeding (defined as only breast milk [includes direct feeding, expressed breast milk, or donor breast milk) for six (6) months. This is followed by continued breastfeeding while gradually introducing suitable complementary foods, for up to two years or longer, as desired by the dyad. All WIC staff must promote exclusive breastfeeding as the normative infant feeding standard and commit to ensuring an environment free from bias for families to make informed infant feeding choices. Ensure Participant Access to Breastfeeding Promotion and Support Services Each local agency is tasked with ensuring that all participants have access to breastfeeding promotion and support services. This is achieved by training staff in breastfeeding support, creating a breastfeeding-friendly environment in clinics, and developing a Breastfeeding Peer Counseling (BFPC) program. Agencies must provide comprehensive and timely breastfeeding support, including a quick response to any questions or concerns, as timely intervention is key to breastfeeding success. Collaborating with community partnerships ensures a continuum of care. Regular, positive communication about breastfeeding across various channels is essential. Additionally, it's crucial to regularly assess the effectiveness of these services by gathering participant feedback, monitoring breastfeeding rates among WIC participants, and adjusting services to meet community needs. All these efforts are geared towards supporting exclusive breastfeeding through detailed assessment, evaluation, and assistance. Breastfeeding-Friendly Clinic Environment Creating a positive breastfeeding environment is crucial in demonstrating the WIC Program's commitment to promoting breastfeeding and enhancing staff efforts in this area. Each clinic, including satellite operations and mobile sites, is required to:  Use Materials That Promote Breastfeeding. • Display culturally appropriate breastfeeding posters, signs, banners, bulletin boards, and pictures; • Integrate consistent breastfeeding messages in all relevant nutrition education and outreach; and • Avoid language that could undermine a participant’s confidence in their ability to breastfeed.  Communicate Positively About Breastfeeding. All WIC staff must: • Promote exclusive breastfeeding as the norm; − Engage pregnant women with open-ended questions about breastfeeding at each contact. Example: What have you heard about breastfeeding?

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October 2025 − Engage breastfeeding and postpartum women in discussions about breastfeeding at the initial postpartum certification and continue to discuss with breastfeeding women at subsequent visits. Example: How can we help you with breastfeeding today? • Inform all pregnant and breastfeeding women about the benefits of the fully breastfeeding food package, regardless of the assigned food package; and • Demonstrate a positive attitude toward breastfeeding regardless of personal beliefs.

 Ensure That Families are Comfortable Breastfeeding in the Agency. • Post signage in each waiting area/room encouraging families to breastfeed anywhere at any time and indicating the availability of a private space for breastfeeding or expressing milk. • Provide at least one private room or space for breastfeeding, lactation counseling, or milk expression, that is equipped with an electrical outlet and ensures privacy free from intrusion. Confirm all WIC staff know the location of and how to access the private room or space for breastfeeding.

 Eliminate Visibility of Breast Milk Substitutes. A breast milk substitute is defined by the World Health Organization (WHO) as any food being marketed or otherwise presented as a partial or total replacement for human milk, even if the product is not suitable for that purpose. This includes infant formula, follow- on formula, infant milk marketed as food for special medical purposes, baby foods, bottles/teats and related equipment. No local agency or WIC staff should be used for the purpose of marketing/promoting breast milk substitutes. • Store all breast milk substitute products and sponsored materials out of sight from participants; Remove any passive promotion of breast milk substitutes, including printed materials, posters, and office supplies (i.e., cups, pens, note pads, lanyards, badge holders, mousepads, etc.) with brand names or logos; • Restrict the display, use, or distribution of materials promoting breast milk substitutes unless provided by the State agency. Education materials provided by the State agency discussing breast milk substitutes may not be displayed and should only be used when it is applicable to the participant. • Avoid in-service and continuing education provided by breast milk substitute manufacturers and representatives; and • Prevent direct or indirect contact between breastmilk substitute manufacturer representatives and WIC participants.

 Breastfeeding Support Phone Line Each local agency is required to establish and maintain a phone line dedicated to providing readily accessible support, education, and encouragement for breastfeeding parents.

 Operational Requirements. • The phone line must be operational 24 hours a day, seven days a week, and equipped with voice message capability. • During clinic operation hours, at least one staff member must be available to answer calls. This staff member must have completed at least Level 2 of the WIC

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October 2025 Breastfeeding Curriculum, ensuring they are equipped to support normal breastfeeding. • The phone line may be used by Peer Counselors as their primary mode of telephone communication.  Message Response. • All messages received on the phone line must be responded to within two business days. Due to the time-sensitive nature of breastfeeding inquiries, responding as soon as possible is considered best practice.  Management and Oversight. • The Breastfeeding Coordinator or designated staff member is responsible for managing the breastfeeding support phone line.  Training and Quality Assurance. • The Breastfeeding Coordinator or designated staff member is responsible for: - Providing documented staff training on the operation of the breastfeeding support phone line. This includes instructions on accessing the phone line, checking messages, handling referrals for situations beyond the scope of practice within WIC services, and tracking messages and follow-ups. - Assigning staff to monitor the phone line during clinic hours to ensure consistent coverage. This includes fielding calls during clinic hours and responding to or referring messages that are outside their scope of practice. - Conducting quarterly reviews and audits to ensure the functionality of the phone line and message capability, as well as reviewing message response times and resolution effectiveness to maintain high-quality support. Consultation and Referral Local agencies are required to establish and maintain a policy for breastfeeding consultation and referral, ensuring it is easily accessible to all WIC staff. The policy must be updated at least annually or whenever changes occur and each update should be clearly dated. An optional template for this policy is provided in Attachment 1.  Policy Content. • Guidance for each WIC staff role and breastfeeding consultation situation (see Attachment 1): - Point(s) of Contact: the individual or organization to be contacted by the WIC staff role for consultation or referral in the identified situation; - Contact Information: contact details for each point of contact; - Contact Method: specific guidance for the preferred methods for initiating contact (e.g. specify that staff should fax the completed form [indicating which form] with the following information to the hospital) • A comprehensive list of both local and non-local resources available to WIC participants (i.e. local lactation consultants, peer-to-peer support groups, pediatrician offices with IBCLCs on staff, relevant hotlines). For each resource, include the resource name, type of service, contact information, estimated cost when applicable, and any additional information.

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October 2025 − Ensure that the referral list is available in printable and digital formats for participants. − This list is designed to complement, not replace, direct discussion with participants. Whenever possible, facilitate warm hand-offs between the local agency and external resources to ensure continuity of care.

 Community Engagement Meetings Attendance at Quarterly community engagement meetings is required for each local agency WIC Director, Breastfeeding Coordinator, and PCPM, with attendance of PCs encouraged but optional. The virtual meetings are hosted by the local agency’s applicable LATCH. These meetings provide a platform for sharing information, networking, collaborating, and solving problems. These meetings support the work of the local agency in fostering community partnerships and developing and sustaining structured internal and external referral systems.

Chapter 9: BREASTFEEDING PROGRAM MANAGEMENT 5 Section 2: STAFF TRAINING NC WIC Program Manual October 2025 Staff Training Breastfeeding promotion and support are core job responsibilities for all WIC staff. Breastfeeding orientation, continuing education, and training per WIC staff role are required to ensure that all WIC staff exhibit a positive and supportive attitude toward and actively endorse the provision of human milk as the standard method for infant feeding. It is a federal requirement that WIC staff who interact with program applicants/participants and the staff supervisor are required to participate in task-appropriate breastfeeding promotion and support training including orientation to breastfeeding activities and annual continuing education on breastfeeding. Orientation to Breastfeeding Activities for All WIC Staff Required. New WIC staff (including volunteers, students, and contractors) must complete training and orientation and retain documentation of completion for the following prior to any independent direct contact with applicants/participants. NOTE: Volunteers, students and contractors must complete prior to providing services in the WIC Program.  Level 1: WIC Breastfeeding Curriculum; and  Local Agency Breastfeeding Program Operations At a minimum, local agency breastfeeding program operations must include the following topics: • Intake procedure for multi-user pumps upon return (refer to Section 6); • Location and how to access each private breastfeeding space (refer to Section 1); • Review and provide a copy of the local agency’s Consultation and Referral Policy (refer to Section 1); • Breastfeeding Peer Counseling program including the peer counselor’s roles and responsibilities (refer to Section 7); • Local agency’s procedure for referring eligible participants to the Breastfeeding Peer Counseling program or equivalent local agency breastfeeding resources to ensure breastfeeding services are offered to all participants (refer to Sections 1 and 7); • Local agency’s service delivery model policy for their provision of Breastfeeding Peer Counseling program services (refer to Section 7); and • Operation of the local agency’s breastfeeding support phone line including instructions for accessing the phone line, checking messages, handling referrals for situations beyond the scope of practices, and tracking messages and follow-ups (applicable staff only). Continuing Education for All WIC Staff Required. WIC staff are required to provide annual continuing education for all local agency staff to ensure staff competency in breastfeeding promotion and support. Continuing education on breastfeeding should differentiate by the level of competency required and/or needed based on the local agency staff function, responsibility, and previously acquired training. Continuing education on breastfeeding may be offered through one or more

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NC WIC Program Manual October 2025 educational platforms (i.e., group session, individually, online, etc.). Continuing education must be provided by an expert in the field of lactation, which includes the local agency’s WIC DBE, RLT, or an IBCLC. Any online training or conferences must be approved by the International Board of Lactation Consultant Examiners. Continuing education approved by the Commission on Dietetic Registration is permissible if related to breastfeeding. The State agency encourages local agencies to utilize their RLT to meet this requirement.

Recommended. Local agencies are encouraged to facilitate participation in additional training opportunities on breastfeeding promotion and support for all local agency staff. WIC funds may be used to sponsor participation of WIC staff in conferences and workshops (local, state, and/or national) that provide breastfeeding education.

 Orientation to Breastfeeding Activities for Competent Professional Authorities Required. CPAs are required to support normal breastfeeding, including early practices to get breastfeeding off to a good start, positioning and latch, and support mothers from pregnancy through weaning. CPAs must complete and provide documentation for the following training within one (1) year of their start date:

 WIC Lactation Camp (Level 2 and 3) • Level 1: WIC Breastfeeding Curriculum is required for all WIC staff (including contractors) and a prerequisite for WIC Lactation Camp (Level 2 and 3).

Recommended. It is recommended that CPAs complete WIC Lactation Camp at least once every 10 years as part of their ongoing training.

 Documentation of Participation in Orientation and Continuing Education The documentation should at a minimum include the date, trainer name, agenda, and sign-in sheet. When this documentation is not available, a certificate of completion is sufficient.

 Retention of Documentation. Local agencies must retain documentation for WIC staff: • Orientation: maintained on file for the duration of employment. • Continuing Education: maintained on file for three (3) years.

 Breastfeeding Resources for Staff Reference Professional references and information on credible helplines and web links on breastfeeding and lactation management should be readily accessible to staff. Local agencies should ensure that only current references and resources are available and that outdated materials are removed and recycled according to local agency policy.

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NC WIC Program Manual October 2025 Breastfeeding Coordinator Local agencies are federally mandated to designate and train a WIC staff member as a breastfeeding coordinator to oversee breastfeeding promotion and support activities within the local agency and community. It is encouraged that local agency breastfeeding coordinators work in partnership with their local agency WIC-DBEs, if the roles are different, to assist in the management and implementation of breastfeeding promotion and support activities. Qualifications Required. A breastfeeding coordinator must be employed by the local agency and may or may not work primarily with the WIC Program. The person in this role must meet the qualifications of a CPA (refer to Chapter 6C). NOTE: A DBE who does not meet the qualifications of a CPA may also serve in this role if the role was assumed prior to October 2018. Preferred. A breastfeeding coordinator:  is an IBCLC or eligible to take the IBCLC exam;  has experience in program management; and  has at least one (1) year experience in counseling breastfeeding parents. Orientation to the Breastfeeding Coordinator Role Required. A breastfeeding coordinator must complete and maintain documentation for the following trainings within one (1) year of assuming the role:  WIC Breastfeeding Curriculum Levels 1, 2 & 3 and  Breastfeeding supplies issuance (refer to Section 6). Continuing Education Required. The breastfeeding coordinator must maintain a record of certificates with credit hours on file in the local agency for each continuing education training completed.  Attend 20 hours of continuing education in breastfeeding every five (5) years. These hours should be approved by the International Board of Lactation Consultant Examiners (IBCLE). Continuing education approved by the Commission on Dietetic Registration (CDR) is permissible if related to breastfeeding. • A breastfeeding coordinator who is an IBCLC may provide evidence of current IBCLC certification in lieu of documentation of the 20 hours of continuing education in breastfeeding. Responsibilities The breastfeeding coordinator must have sufficient time in their schedule dedicated to active involvement in the management and implementation of breastfeeding promotion and support

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NC WIC Program Manual October 2025 activities. Responsibilities include, but are not limited to:

 Oversee planning, implementation, and evaluation of local agency breastfeeding activities. • Work with local agency management and staff to identify ways to integrate breastfeeding promotion and support activities as a standard part of WIC Program clinic services. • Ensure timely and accurate breastfeeding education/counseling and support for participants. • Identify and address any systematic barriers within the local agency or greater community. • Develop, implement, and maintain the local agency’s consultation and referral policy in consultation with WIC Director, Peer Counselor Program Manager, and DBE (refer to Section 1.) • Participate in quarterly community engagement meetings as offered by the regional WIC Lactation Area Training Centers for Health (LATCH).

 Ensure that WIC staff are properly trained on breastfeeding education and support. • Maintain documentation (i.e., names, dates, and certificates of completion) of WIC staff who have completed the required orientation(s), in-service, and continuing education pertinent to WIC role. • Oversee all tasks related to breastfeeding trainings by providing or facilitating orientation to breastfeeding activities (Section 2), breastfeeding supplies issuance (Section 5), annual continuing education on breastfeeding (Section 2), and any other required breastfeeding trainings or in-services for WIC staff. • Ensure that staff has access to current references and resources on breastfeeding management.

 Identify, coordinate, and collaborate with community breastfeeding stakeholders. The Local Agency WIC Program Outreach, Recruitment and Retention Plan (refer to Chapter 10, Section 5) must include at least one goal specific to breastfeeding promotion and support activities targeted to pregnant or breastfeeding women. All activities in support of the goal must be tracked as part of the WIC Program Outreach Activity Log.

 Monitor local agency breastfeeding rates. Local agency breastfeeding rates are tracked annually by: • Breastfeeding initiation and duration (6 weeks and 6 months) and • Issuance of the fully and partially breastfeeding food packages.

 Keep current on breastfeeding program management policies, procedure, and resources. Disseminate this information to local agency WIC staff as applicable.

 Monitor local agency’s compliance to breastfeeding program management policies and procedures. When programmatic deficiencies or practices that undermine breastfeeding are identified, it is the responsibility of the Breastfeeding Coordinator in partnership with other WIC staff to provide technical assistance and follow-up to ensure

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NC WIC Program Manual October 2025 programmatic compliance.  Manage the issuance, inventory, and maintenance of breastfeeding supplies and documentation. Ensure adequate documentation by monitoring on quarterly basis at minimum (Sections 5 and 6.)

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NC WIC Program Manual October 2025 WIC Designated Breastfeeding Expert WIC Designated Breastfeeding Experts (DBEs) provide breastfeeding expertise when WIC staff encounter situations beyond their scope of practice. Local agencies are required to designate one or more trained WIC staff members to serve as a DBE for each clinic, including satellite operations or mobile sites. Each clinic must have a DBE available to accept referrals and provide timely responses to pregnant and breastfeeding participants experiencing complex breastfeeding issues (Attachment 2) beyond the scope of the peer counselor or Competent Professional Authority (CPA). Qualifications Required. A DBE must be employed by the local agency and may or may not work primarily with the WIC Program. The person in this role must meet the qualifications of a CPA (refer to Chapter 6C) or be an International Board Certified Lactation Consultant (IBCLC.) Recommended. A minimum of one (1) year of experience counseling breastfeeding dyads. Orientation to the Designated Breastfeeding Expert Role Required. The DBE must complete the following trainings within one (1) year of assuming the role and maintain documentation of completion:  WIC Breastfeeding Curriculum Levels 1, 2 & 3, and 4, and  Breastfeeding supplies issuance (refer to Section 6). Continuing Education Required. Each DBE must participate in ongoing breastfeeding-related continuing education and maintain a record of certificates with credit hours on file in the local agency for each continuing education training completed.  DBE Continuing Education as offered by your local agency’s regional WIC Lactation Training Center for Health (LATCH), and  Attend 20 hours of continuing education in breastfeeding every five (5) years. These hours should be approved by the International Board of Lactation Consultant Examiners (IBCLE). Continuing education approved by the Commission on Dietetic Registration (CDR) is permissible if related to breastfeeding. • A DBE who is an IBCLC may provide evidence of current IBCLC certification in lieu of documentation of the 20 hours of continuing education in breastfeeding. Responsibilities Responsibilities of a DBE(s) include but are not limited to:  Assessment and Counseling. Accept referrals for complex breastfeeding issues and promptly conduct breastfeeding assessments for pregnant and breastfeeding participants

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NC WIC Program Manual October 2025 to create care plans that align with participant feeding goals. • Provide follow-up support to monitor progress and address ongoing breastfeeding issues. • Initiate referrals to healthcare providers when issues exceed the DBE’s scope of practice (Attachment 3).

 Oversight and Consultation. • Support staff development through training, mentoring, and consultation on complex breastfeeding issues. • Promote integration of peer counselors into participant care by facilitating referrals, clarifying roles, and strengthening communication between peer counselors and CPAs. • Ensure the appropriate issuance of breastfeeding supplies in accordance with policy and current best practices.

 Professional Development. Complete required continuing education to maintain current lactation knowledge and skills.

 Documentation. Ensure the breastfeeding care plan is developed, recorded, and integrated with the nutrition assessment and care plan in coordination with the CPA, as appropriate.

 Collaboration. Coordinate with healthcare providers for continuity of care for medical follow-up or additional lactation support.

 Breastfeeding Assessment The DBE provides a specialized extension of the nutrition assessment that focuses on the breastfeeding dyad experiencing complex breastfeeding issues to include a detailed evaluation of breastfeeding adequacy, challenges, goals, and support needs, and is used to supplement the CPA’s findings and inform an individualized nutrition care plan.

 Frequency. Breastfeeding assessments are initiated based on referrals from peer counselors, CPAs, other WIC staff, and external health professionals. The DBE is responsible for reviewing all referrals in a timely manner and must prioritize the assessment based on the urgency and complexity of the issue.

 Categories of Breastfeeding Assessment Information. To complete a breastfeeding assessment, DBEs review and evaluate information in each of the following categories. • Care Plan Detail. The DBE must review the Care Plan Detail, which includes CPA nutrition assessment data, peer counselor notes, and previously documented breastfeeding concerns. • Breastfeeding Information and History. A comprehensive breastfeeding history must be reviewed to determine current breastfeeding status, identify concerns, and explore previous experiences that may affect feeding. This may include information on breast changes, medical history, surgeries, or early feeding practices. • In-Depth Assessment. As necessary, focused DBE assessment of the breast, feeding,

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NC WIC Program Manual October 2025 and infant contributes toward individualized care planning when addressing specific concerns. These more in-depth assessments are not performed routinely but based on DBE professional judgment and with participant permission. Focused assessments are conducted when additional information is needed to better understand and address a complex breastfeeding issue (Attachment 2). In-Depth Assessment Indication Assessment Type Purpose Signs, symptoms, or participant- reported concerns may be related to: Breast To evaluate physical or structural issues with the breast that may impact lactation. breast anatomy, tissue integrity, or physiological factors affecting lactation. Feeding To evaluate the interaction between parent and infant during feeding. the feeding interaction between the parent and infant including the effectiveness of positioning, latch, or milk transfer. Infant To identify infant-related factors that may impact breastfeeding success. infant feeding behaviors, appearance, or physical responses.  Summary of the Breastfeeding Assessment The DBE must synthesize findings from the information gathered from the breastfeeding assessment and evaluate if the participant care plan requires update. A summary of findings from the breastfeeding assessment must be documented in the Family Care Plan, including identified concerns and barriers or potential problems or barriers.  Developing the Care Plan The DBE must work with the participant or dyad to determine if any of the identified barriers or concerns or the potential barriers or concerns warrant the participant or breastfeeding dyad’s nutrition plan of care (refer to Chapter 6C) to be updated. Consideration must be given to the individual’s education, understanding of breastfeeding principles, beliefs, skills, cultural practices, family and social environment resources, access to health care resources, practicality of the recommendation, and stage of readiness to make changes.  Documenting the Breastfeeding Assessment and Care Plan DBEs are required to document the breastfeeding assessment and update the care plan (if necessary) in the participant’s health record in Crossroads system. • If the DBE is a qualified CPA, they may make the appropriate additions and updates in accordance with the breastfeeding assessment. • When the DBE is not a CPA, they must document the breastfeeding assessment and care plan in the participant’s record and refer the assessment findings to the CPA for review. The CPA is responsible for updating the nutrition plan of care.

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Chapter 9: BREASTFEEDING PROGRAM MANAGEMENT 15 Section 5: BREASTFEEDING SUPPLIES NC WIC Program Manual October 2025 Breastfeeding Supplies This section describes policies for the purchase, use, and appropriate conditions for the issuance of the required and optional breastfeeding supplies. Refer to Chapter 12: Fiscal Management for additional information on using WIC Program funds to purchase additional breastfeeding supplies. Breastfeeding Supply Categories Local agencies must emphasize the benefits of feeding the infant at the breast and promote exclusive direct breastfeeding as the norm while supporting a participant’s decisions and goals. The provision of breastfeeding supplies should not circumvent or take place of appropriate breastfeeding education and support. Pregnant and breastfeeding participants need anticipatory guidance, breastfeeding skills, and support from trained breastfeeding staff when issues arise more than any breastfeeding aid or accessory the WIC Program can provide. Each breastfeeding supply identified in this section is categorized by:  Aid or accessory • Aid: devices that directly support the efforts of some breastfeeding women who may need assistance to remove milk from the breast and/or to provide human milk to their infants, such as pumps, supplemental nursing systems, and nipple shields. • Accessory: Devices or products that, while not directly aiding the removal of milk from the breast, may facilitate breastfeeding, such as breast shields or breast pads.  Multi-user or single-user • Multi-user: a breastfeeding aid, which is designed to decrease the risk of contamination between different individuals. • Single-user: a breastfeeding aid or accessory that cannot be effectively cleaned or disinfected between uses by different individuals, so it cannot be shared.  Required or optional • Required: local agencies must maintain an inventory of the identified, manufacturer specific breastfeeding aid or accessory as provided by the birthing hospitals and neonatal intensive care units serving the WIC participants of the local agency. • Optional: local agencies are encouraged, but not required to maintain an inventory of the breastfeeding aid or accessory. Local agencies may only purchase required breastfeeding aids from manufacturers approved by the Community Nutrition Services Section (CNSS). While local agencies may use WIC Program funds to purchase required breastfeeding aids, the Community Nutrition Services Section does an annual bulk purchase of all required breastfeeding aids to support each local agency.  Breastfeeding Aids  Pumps. Pumps are medical devices regulated by the U.S. Food and Drug Administration used to mechanically express human milk from the breast. Pumps can be used to establish, maintain, or increase a parent’s milk supply and to relieve plugged/clogged milk ducts or engorged breasts, etc.

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NC WIC Program Manual October 2025 • Manual Pump (Single-user item, required): This hand-operated pump does not require electricity or batteries. The user manually controls the level of vacuum and pumping speed by operating the pump handle. It can only express milk from one breast at a time. The collection kit is integrated as part of the pump. • Single-user Electric Pump (Single-user item, required): This motor-operated pump requires electricity or batteries. It allows for expressing milk from either one or both breasts simultaneously. The level of vacuum is adjustable through motor settings, controlled by the user. The collection kit, while separate from the motor, is included as part of the breast pump unit and not issued separately. • Multi-user Electric Pump (Multi-user item, required): This motor-operated pump also requires electricity or batteries (depending on the manufacturer). It allows for expressing milk from either one or both breasts simultaneously. The level of vacuum and pumping speed (depending on the manufacturer) is adjustable through motor settings, controlled by the user. Unlike single-user models, the collection kit is separate from the motor and must be issued individually to each user. • Collection Kit (Single-user item, required): This apparatus attaches directly to the breast, as a conduit to transfer the flow of negative pressure (vacuum) from the pump’s motor or handle to the breast, facilitating the collection of expressed milk. The components of a collection kit vary between different manufacturers and models, but it generally includes a breast flange, connector, tubing, valve/membrane, and collection container/bottle. The collection kit is integrated with manual pumps. In contrast, electric pumps have separate motors and collection kits. Single-user electric pumps come with the collection kit included as part of the unit, whereas multi-user electric pumps require the collection kit to be issued separately. • Breast Flanges (single-user item, required): A breast flange is a funnel-shaped device that fits over the breast, with the nipple centered within the funnel’s cylindrical portion. A seal is formed around the areola, which creates a vacuum to allow milk extraction during pumping. Breast flanges come in many sizes and must be fit to the user. A correctly sized breast flange is required for safe and effective milk extraction via a manual or electric pump.

 Nipple Shield (single-user item, optional). A nipple shield is a thin, flexible silicone cover that fits over the nipple and areola, designed with small holes at its tip to allow the transfer of milk. It is a device to facilitate latch during breastfeeding. Nipple shields come in many sizes and must be fit to the user and infant mouth. Rarely are nipple shields appropriate in the first 24 hours of attempting breastfeeding.

 Supplemental Feeding Device (single-user item, optional). A supplemental feeding device is a container that holds supplemental milk or infant formula connected to a system of tubes that deliver this liquid to the infant while suckling. When utilized in combination with breastfeeding, this device permits continued stimulation of the breast during periods of supplementation. The baby receives both breast milk directly from the breast and the supplemental nutrition through the tubes simultaneously during breastfeeding. No single supplementation device has been proven superior for infants, as some may respond better to one type of device than another.

Chapter 9: BREASTFEEDING PROGRAM MANAGEMENT 17 Section 5: BREASTFEEDING SUPPLIES NC WIC Program Manual October 2025 Breastfeeding Accessories  Breast Pads (single-user item, optional). Breast pads are made of layered, absorbent materials that are placed inside a bra, designed to soak up leaking milk. The breast pad must be washable or disposable without plastic or waterproof liners. Breast pads with plastic or waterproof liners are not permitted because they encourage bacterial and fungal growth.  Breast Shells (single-user item, optional). Breast shells consist of two parts: the inner ring and the dome. Breast shells are worn over the nipple and areola and may be used to allow air circulation for sore and/or damaged nipples. There is no scientific evidence to support the use of breast shells for flat or inverted nipples, therefore breast shells may not be issued for this purpose.

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NC WIC Program Manual January 2026 Issuance, Inventory, and Maintenance of Breastfeeding Supplies Local agencies are accountable for the inventory, issuance, and overall management of all breastfeeding supplies. The local agency’s breastfeeding coordinator is responsible for the inventory, issuance, and maintenance of breastfeeding supplies as outlined in this section. While individual tasks may be designated to one or more local agency staff members, the responsibility is still that of the local agency’s breastfeeding coordinator. All clinics, including satellite operations and mobile sites, must maintain a minimum inventory of breastfeeding supplies and have at least one WIC staff available to issue all required breastfeeding aids. If the required minimum inventory is not stored at the clinics the local agency must demonstrate that participants have access to the required breastfeeding aids without the need for additional travel. Eligibility All women who are currently breastfeeding and certified in the WIC Program are eligible for breastfeeding supplies, regardless of food package assignment or category of pregnant in Crossroads. The type and justification for issuing a breastfeeding supply are contingent upon a comprehensive nutrition assessment conducted by a Competent Professional Authority (CPA) or a breastfeeding assessment conducted by a WIC Designated Breastfeeding Expert (DBE). These assessments are crucial for identifying infant feeding behaviors and documenting any criteria or factors affecting breastfeeding. Such documentation is essential for tailoring nutrition education, which includes breastfeeding promotion and support, to the family's needs. The decision to issue a breastfeeding supply follows the completion of a nutrition or breastfeeding assessment that identifies it as a beneficial component of the dyad’s nutrition plan of care. The provision of breastfeeding supplies is one way to support a subset of breastfeeding women and infants in special circumstances. Before any supply is issued and as appropriate:  The CPA/DBE must document that efforts to support direct breastfeeding were offered and deemed insufficient or inappropriate for the situation.  It must be established that the issuance of any breastfeeding supply is part of a broader plan of care and not the sole intervention. Breastfeeding supplies are not issued merely for convenience but based on specific, identified needs that can resolve specific issues or circumstances. For instance, parents experiencing chronic low milk supply, who receive a fully formula-based food package yet wish to breastfeed to the maximum extent possible, could be eligible for a pump. Importantly, parents are not required to pump/feed a specific number of times per day to demonstrate their commitment. The CPA/DBE must engage in meaningful conversations to balance the parents' goals with the practical feasibility of suggested actions. Conversely, parents who opt for a partial breastfeeding food package out of preference, rather than a documented breastfeeding complication, do not qualify for these supplies as this choice

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NC WIC Program Manual January 2026 is considered a matter of convenience. Additionally, breastfeeding supplies may not be offered to breastfeeding women solely as an inducement to consider or to continue breastfeeding. Ultimately, breastfeeding supplies are intended to complement but not replace anticipatory guidance, education, support, and encouragement provided by the WIC Program. NOTE: The issuance of breast pads does not require a nutrition or breastfeeding assessment. If available, any trained staff member at the local agency can provide breast pads to any enrolled pregnant or breastfeeding woman who expresses a need. Selection Each type and model of breastfeeding supply is designed for specific uses and frequencies, considering the parent's preferences, comfort, and specific situation. Detailed descriptions of the types and purposes of each supply available in the WIC Program can be found in Section 5. While the nutrition or breastfeeding assessment and the identified complications help to determine the appropriate supply, the ultimate choice of the supply also depends on the parent's preferences, comfort, and specific situation. When a breastfeeding supply is selected that does not align with the standard indications for use and frequency, the CPA/DBE must document the reasons for this choice within the Crossroads care plan. Personalized considerations should be integrated into the decision-making process to ensure that breastfeeding supplies meet the unique needs of each family, thereby enhancing the effectiveness of breastfeeding support provided by the WIC Program.  Indications for Use • Pumps. Pumps are utilized to initiate, maintain, supplement, or increase milk supply when direct breastfeeding is not feasible, and efforts to maintain direct breastfeeding have been unsuccessful or are inappropriate for the specific reason. − Justification for Issuance. Pumps may be offered to breastfeeding participants based on need. The CPA/DBE must document that one or more of the circumstances listed under “Pump Issuance/Reservation Reasons” (Attachment 4) have been met within their nutrition or breastfeeding assessment. The primary reason for issuance must then be entered into the Crossroads Breast Pump Issuance screen. − Type of Pump. The recommendations for the type of pump are always an integration of scientific evidence with manufacturers' guidelines for product use. However, it is important to note that the type of pump recommended may be adjusted following a discussion with the breastfeeding mother to better suit her specific needs and comfort level. As well as the likely duration of the need. The accompanying chart is intended to guide local agencies in selecting the appropriate type of pump based on the stage of lactation and the degree of pump dependency. Please be aware that this chart does not encompass all considerations for selecting a pump type.

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NC WIC Program Manual January 2026 Phase of Lactogenesis Degree of Pump Dependency Complete (> 6x day) Partial (< 6x day) Minimal (< 1x day) I*-Initiation Single-user or multi- user electric pump Short-term need: Multi-user electric pump Long-term need: Single-user electric pump None or single-user manual pump II-Onset of Copious Milk Production Single-user or multi- user electric pump III-Maintenance Single-user or multi- user electric pump * Lactogenesis I begins during pregnancy; however, the issuance of pumps during pregnancy is not permitted within the WIC Program. Therefore, this guidance applies only to Lactogenesis I following the delivery of the infant. • Nipple Shields. Current evidence does not support their long-term safety regarding milk supply, infant weight gain, or breastfeeding duration. − Justification for Issuance. Refer to “Indications for Use” (Attachment 5) for a complete list of indications for the issuance of a nipple shield. • Supplemental Feeding Devices. These devices are used when additional nutrition (breastmilk or infant formula) is necessary due to reasons such as low milk supply, delayed lactogenesis, poor infant suck, or induced/re-lactation. They allow the infant to receive extra nutrition while nursing at the breast, facilitating continued stimulation of the breast. − Justification for Issuance. Refer to “Indications for Use” (Attachment 5) for a complete list of indications for the issuance of a supplemental feeding device. • Breast Shells. The use of breast shells is determined by the size of their base opening. − Justification for Issuance. Shells with a large base opening are employed to protect damaged or sore nipples to promote healing, while shells with a small base opening may be used to reduce swelling in engorged breasts, aiding the infant in achieving a deeper latch. Despite marketing claims, there is no evidence supporting the use of breast shells to elongate flat or short nipples or to keep inverted nipples everted. Consequently, local agencies should not issue breast shells for these purposes. • Breast Pads. − Justification for Issuance. Breast pads are used to absorb milk leakage between feedings or to manage prenatal milk leakage, thus preventing wet clothing and protecting sensitive skin.

 Issuance  All Breastfeeding Supplies Issuance requirements applicable to all breastfeeding supplies: • Documentation. Issuance must be documented in Crossroads including, but not limited to the nutrition or breastfeeding assessment, completion of all sections of the pump issuance screen, follow-up (including attempts), and loan extensions for multi-user pumps. • Liability. The participant and WIC staff member must read and sign the “Breastfeeding

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NC WIC Program Manual January 2026 Supplies Release of Liability and Loan Agreement” generated by Crossroads. A copy of the completed Agreement must be provided to the participant, and the original should be scanned into the participant’s health record. • Contingency Plan. In the event supply issuance cannot be conducted with the participant (incarceration, hospitalization, quarantine, etc.), issuance may be conducted, and requirements completed with the Parent/Guardian 1 or 2 or Caretaker as listed in the family’s Crossroads profile. Follow-up(s) should be with the participant, if possible.  Pumps The requirements in this section extend to collection kits and breast flanges unless specifically stated otherwise. • Staff Competencies. Each local agency is required to ensure that at least one WIC staff member is available at each clinic to issue pumps. Once a CPA has completed a nutrition assessment or the DBE has completed a breastfeeding assessment and determined the appropriate supply, pumps may be issued by any WIC staff member who has met the current training requirements specified by the Community Nutrition Services Section (CNSS), as detailed in the “Staff Competency Checklist for Breastfeeding Supplies Issuance” (Attachment 6.) NOTE: CNSS training requirements for issuing pumps are subject to updates based on new recommendations, evidence, or product changes. It is the responsibility of each local agency to keep their staff updated on these training requirements. • Participant Education. At a minimum, the WIC staff member must: ­ Support Direct Breastfeeding. When a pump is used as a temporary aid to support the continuation of breastfeeding during challenges with direct breastfeeding, it is important to emphasize that WIC staff will continue to assist in facilitating effective latch techniques and provide referrals for services beyond their scope of practice. ­ Teach Hand Expression. ­ Develop a Personalized Plan for Use. Collaborate with the participant to develop a personalized pumping plan, including the frequency, location, and duration of pumping sessions. ­ Proper Fit. Size and provide the appropriate breast flange to ensure comfort and efficiency. ­ Provide Instructions for Use. Provide both verbal and written instructions on the proper assembly, use, and cleaning of the pump. ­ Milk Storage Instructions. Offer verbal and written guidance on how to collect, store, warm, and feed expressed human milk. ­ Troubleshoot. Provide a phone number for the participant to call for help or support regarding any aspect of product use or breastfeeding. Instruct the participant on what to do if the product malfunctions. NOTE: Education should be participant-centered. WIC staff should assess the participant’s knowledge and tailor the education to their individual needs. • Follow-Up. At a minimum, participants who are issued a: ­ Single-user pump: must be contacted within 24 to 72 hours of pump issuance and as requested thereafter to answer any questions. ­ Multi-user pump: All participants issued a multi-user pump must receive close follow-up to support them in achieving their desired goals. WIC staff are required

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NC WIC Program Manual January 2026 to communicate the expected return date for the multi-user pump both verbally and in writing, documenting in Crossroads if the loan period is extended. At minimum, the participant must be contacted:  Initial Contact: Within 24 to 72 hours of multi-user pump issuance.  Ongoing Contact: At a minimum, every three (3) months, or more frequently, if needed, based on the participant’s nutrition or breastfeeding assessment and until the pump is returned. Follow-up and any discussions regarding loan extensions can occur through any form of verbal or written communication with the participant. Effective and ongoing follow-up is crucial as it significantly enhances the likelihood of breastfeeding success. NOTE: Refer to “Overdue Multi-User Pumps” for contact requirements specific when multi-user pumps become overdue. Overdue multi-user pump contacts are designed for pump retrieval while follow-up during the agreed upon rental period is designed for the provision of breastfeeding support. Local agencies are not permitted to add any additional procedures/policies that impose a burden on the participant, such as on-site monthly pump checks.

 Nipple Shield and Supplemental Feeding Device Issuance • Staff Competencies. WIC staff who issue these breastfeeding aids must meet the qualification of a DBE. NOTE: Each local agency is required to have one or more DBE(s) available to each clinic (including satellite operations and mobile sites) even if the local agency opts to not provide either nipple shields or supplemental feeding devices. • Participant Education. At a minimum, the DBE must: − Supporting Direct Breastfeeding. When a breastfeeding accessory is used as a temporary tool to support the continuation of breastfeeding during challenges with direct breastfeeding, it is important to emphasize that WIC staff will continue to assist in facilitating effective latch techniques and provide referrals for services beyond their scope of practice. − Teach Hand Expression. − Develop a Personalized Plan for Use. Collaborate with the participant to develop a tailored plan covering monitoring, maintenance of optimal milk supply, and strategies for weaning from the breastfeeding aid. − Provide Instructions for Use. Provide both verbal and written instructions on the proper assembly, use, and cleaning of the breastfeeding supply. − Proper Fit (Nipple Shield). Ensure the nipple shield is correctly sized and fitted to provide comfort and effectiveness during use. − Safe Fluids Guidance (Supplemental Feeding Device). Verbalize that nutritional supplemental provided in a supplemental feeding device should be only human milk or infant formula. − Troubleshooting. Provide a phone number for the participant to call for help or support regarding any aspect of product use or breastfeeding.  Instruct the participant on what to do if the product malfunctions. NOTE: Education should be participant centered. WIC staff should assess the participant’s knowledge and tailor the education to their individual needs.

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NC WIC Program Manual January 2026 • Follow-Up. Participants issued any breastfeeding aid should receive close follow-up to assist them in achieving their desired breastfeeding goals. The following minimum contact schedule should be adhered to: ­ Initial Contact: Within 24 to 72 hours of multi-user pump issuance. Inquire about the participant’s preference for the frequency or continuation of follow-up. Document in the Crossroads’ Care plan. ­ Ongoing Contact: Based on participant needs. Adhere to the agreed follow-up discussed during the initial contact. It is recommended that at a minimum one to two more follow-ups occur.

 Breast Pads and Breast Shells Issuance • Staff Competencies. Each local agency, including satellite operations and mobile sites, is required to ensure that at least one WIC staff member is available at each clinic to issue breastfeeding accessories, if available. Once a CPA has completed a nutrition assessment or the DBE has completed a breastfeeding assessment and determined the appropriate supply (breast pads do not require a breastfeeding assessment), breastfeeding aids may be issued by any WIC staff member who has met the current training requirements per “Staff Competency Checklist for Breastfeeding Supplies Issuance” (Attachment 6). NOTE: CNSS training requirements for issuing breastfeeding accessories are subject to updates based on new recommendations, evidence, or product changes. It is the responsibility of each local agency to keep their staff updated on these training requirements. • Participant Education. At a minimum, the WIC staff must: ­ Teach Hand Expression. ­ Provide Instructions for Use. Provide both verbal and written instructions on the proper assembly, use, and cleaning or disposal of the breastfeeding accessory. ­ Troubleshooting. Provide a phone number for the participant to call for help or support regarding any aspect of product use or breastfeeding.  Instruct the participant on what to do if the product malfunctions. NOTE: Education should be participant centered. WIC staff should assess the participant’s knowledge and tailor the education to their individual needs.

 Inventory Each local agency must maintain a secure and perpetual inventory of all the local agency’s breastfeeding supplies. At a minimum, the local agency must:

 Inventory Entry. • Single user inventory. ­ Catalog single-user breastfeeding aid and accessory by product name and the total number of units available for issuance. ­ Store single-user supplies in their original, unopened packaging until they are issued to a participant. • Multi-user inventory. ­ Catalog each multi-user aid by product name, individual serial number, and current status.

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NC WIC Program Manual January 2026 ­ Label each multi-user electric pump and its case with “Property of the North Carolina WIC Program” using a permanent marking system.

 Inventory Maintenance. • Conduct a quarterly reconciliation of the physical inventory with the records in Crossroads. These reconciliations should occur in February, May, August, and November. • Ensure that all items are accounted for, whether they are in the local agency, on loan to a participant, associated with overdue pump letters, or out-of-commission (due to being damaged, lost, or stolen).

 Maintenance of Multi-User Pumps

 Intake. Upon return, each multi-user pump must be received at the participant’s initial point of contact with any WIC staff. Staff are responsible for the cleaning and maintenance of these pumps and must be trained in the procedure for accepting returned multi-user pumps. • Initial Inspection: Immediately inspect the pump for all parts, documenting anything that is missing or broken. • Bug Infestation Assessment: Evaluate for possible signs of a bug infestation. If an infestation is identified, seal the pump in a plastic bag immediately and refer to the "Repairs" section for further instructions. • Documentation: Print and have the participant sign the "Multi-User Electric Breast Pump Return Receipt" from Crossroads, providing a copy to the participant.

 Cleaning. WIC staff must clean all multi-user pumps, within one (1) business day of return. The WIC Program cannot always guarantee what environment the multi-user pump may have been subject to and therefore thorough cleaning between users is required. • Cleaning Details: Clean the motor casing and carrying case according to the manufacturer’s instructions. • Operational Check: Assemble and run each returned multi-user pump to determine that is working properly. • Tracking Cleaned Pumps: Maintain a multi-user pump cleaning log, refer to the “Multi-User Pump Cleaning Log Template” (Attachment 7) for minimum cleaning log requirements and a sample cleaning log. • Documentation: Document the return in Crossroads, including scanning the completed "Multi-User Electric Pump Return Receipt" into the participant’s health record.

 Repairs. Local agencies are responsible for contacting the manufacturer to initiate repair of a damaged or broken multi-user electric breast pump. The local agency is responsible for the cost of breast pump repairs not under manufacturer’s warranty and for any shipping or handling fees associated with the repair. CNSS recommends repairing pumps versus replacement, when fiscally appropriate. • Disposal: When multi-user pumps cannot be repaired, refer to disposing of surplus equipment in Chapter 12: Fiscal Management.

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NC WIC Program Manual January 2026  Overdue Multi-User Pumps. Local agencies should take reasonable steps to ensure that they have accurate contact information for the participant including contact the secondary contact from the “Breastfeeding Supplies Release of Liability and Loan Agreement.” All contacts and attempts must be documented in Crossroads.

In the event that a multi-user pump is not returned by the communicated return date. At a minimum, the local agency must adhere to the following process: • Return date to two (2) weeks overdue: WIC staff should make a minimum of one (1) contact. • Quarterly Inventory: As part of the quarterly inventory process, review the “Breastfeeding Supplies Release of Liability and Loan Agreement” forms with overdue pump return dates from the previous quarter. Participants identified with overdue pumps must be mailed a written letter with attached copy of the signed “Breastfeeding Supplies Release of Liability and Loan Agreement”, sent by certified mail. A copy of the mailed letter should be scanned into the breastfeeding woman’s Crossroads’ record. Refer to the “Overdue Multi-User Pump Notification Sample Letter” (Attachment 8) for a letter template. − Optional: If an email address is provided by the family, consider emailing a copy of the letter and the “Breastfeeding Supplies Release of Liability and Loan Agreement” form. • Resolution: If after ten (10) business days from delivery of the certified letter, the local agency has not been able to get into contact with the participant or the participant reports the pump as lost or stolen, no further attempts should be made. Document the pump status in a Crossroads family alert titled “Pump Not Returned” with alert text indicating the agreed upon return date, pump manufacturer, type, issuance date, and serial number. − Optional: WIC staff should inquire about the pump status at each appointment and document the inquiry within the family alert, including date of inquiry and staff member name. If the participant indicates that the pump has been lost, then the WIC staff member may document and then deactivate the family alert.

NOTE: Local agencies are not permitted to add any additional procedures that impose a burden on the participant including the filing of a police report, withholding food benefits, etc.

Chapter 9: BREASTFEEDING PROGRAM MANAGEMENT 27 Section 7: BREASTFEEDING PEER COUNSELING PROGRAM NC WIC Program Manual October 2025 Breastfeeding Peer Counseling Program The Breastfeeding Peer Counseling (BFPC) program is designed and funded to advance the unique benefit to provide mother-to-mother breastfeeding support. The BFPC program trains paraprofessional peer counselors (PCs) to provide basic breastfeeding education to WIC Program participants who are pregnant or breastfeeding. This evidence-based intervention has been proven to increase breastfeeding initiation, duration, and exclusivity rates, emphasizing its effectiveness and scientific backing. The BFPC program serves as an important complement to the broader WIC Program services. PCs receive formal training to provide basic information, encouragement, and support about breastfeeding to pregnant and breastfeeding participants. This mother-to-mother support is a cornerstone, ensuring the success of breastfeeding promotion and support efforts within the WIC Program. All staff must be oriented to the BFPC program upon hire (refer to Section 2). Staffing  Peer Counselor Program Manager (PCPM). The local agency must designate a local agency staff member, who may or may not work primarily with the WIC Program, to be the PCPM. • Qualifications. Required. A PCPM must meet the qualifications of a CPA (Refer to Chapter 6C Section 4). NOTE: A DBE who does not meet the qualifications of a CPA may also serve in this role if the role was assumed prior to October 2018. Recommended. It is recommended for a PCPM to: − be an IBCLC or be eligible to take the IBCLC exam. − have experience in program management. − have at least one (1) year of experience in counseling breastfeeding parents. • Orientation to the Peer Counselor Program Manager Role. Required. The PCPM must complete and maintain documentation for the following trainings within one (1) year of their start date. These orientation trainings include: − Peer Counselor Program Manager Orientation Course. − Peer Counselor Care Plan Training. − DBE Boot Camp (Level 4). Prior completion of Level 1: WIC Breastfeeding Curriculum (NC WIC Staff Only) and WIC Lactation Camp (Level 2 and 3) are prerequisites for attending DBE Boot Camp (Level 4). • Continuing Education. Required. The PCPM must attend and maintain an up-to-date record of certificates for each required BFPC Program Quarterly Continuing Education, as provided by your local agency’s LATCH. • Roles and Responsibilities. The PCPM must perform the following roles and responsibilities:

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NC WIC Program Manual October 2025 − Contribute to the development of program goals and objectives for the local agency BFPC program. − Conduct a needs assessment to identify gaps in breastfeeding resources and services within the local agency and community that the BFPC program can address. − Oversee training and continuing education for PCs. − Oversee the planning, management, implementation, and evaluation of local agency BFPC program activities and policies. − Stay current with the latest breastfeeding information and updates from the Community Nutrition Services Section (CNSS). − Share relevant breastfeeding information and CNSS updates with local agency staff. − Mentor new peer counselors, providing routine follow-up and guidance in the early days of the job. − Provide ongoing supervision and feedback for PCs.  Conduct and document Monthly Peer Counselor Program Manager and Peer Counselor Meetings. This includes scheduling, preparing and completing applicable documentation, leading discussion, and ensuring that all required worksheets are completed, signed, retained, and made available during monitoring. − Establish an effective peer counseling program caseload tracking system and periodically review its maintenance and organization to ensure optimal provision of peer counseling services. − Report on peer counseling program activities to supervisor and CNSS. − Coordinate with local community stakeholders such as hospitals and health care providers to enhance effectiveness of the peer counseling program.  Participate in community engagement meetings as offered by the LATCH. NOTE: Adequate supervision is defined as the PCPM having at least a 0.25 full time equivalent (FTE) for every 3-5 peer counselors supervised.

 Peer Counselor • Qualifications. A PC must have: − Personal experience with breastfeeding: The individual has successfully breastfed at least one child for a minimum duration of 6 weeks. − Paraprofessional background:  The individual's professional background should not include extensive training in health, nutrition, or clinical breastfeeding management.  Assists professionals in the field but does not require the individual to be licensed or credentialed as a healthcare, nutrition, or lactation consultant professional.  Receives specific training and ongoing supervision to perform specific tasks within a defined scope of practice. − Positive attitude toward breastfeeding: The individual is expected to positively represent and advocate for breastfeeding. − Cultural and community connection: Ideally, the individual comes from the target

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NC WIC Program Manual October 2025 population, often sharing the cultural background and language(s) of most participants. This might include past or current participation in, or eligibility for, the WIC Program, enhancing relatability and trust. − Flexibility and accessibility:  The individual must be willing to work outside traditional work hours, including evenings and weekends.  The individual must have access to reliable transportation.  The individual must be able to travel for required in-person trainings. NOTE: Local agencies with concerns about limiting PC hires based on FNS definition of a PC can address the issue with their local agency’s Human Resources and/or Legal departments to determine appropriate language to be used when hiring peer counselors who meet the FNS definition. • Dual-Role Peer Counselor. Local Agencies are permitted to employ a PC who undertakes additional role(s) within the local agency, if these roles do not compromise the PC’s ability to meet the qualifications and responsibilities of the PC position. If a local agency opts for a dual- role PC position, the local agency must ensure the following criteria: − The additional duties or set work hours must not prevent the PC from attending state-required training and continuing education. Specifically, PCs should not miss Quarterly Continuing Education training due to their other roles. − Job descriptions for dual-role PC must clearly outline both sets of responsibilities: those related to the BFPC program and the additional role(s). − Sufficient time must be allocated and documented to BFPC program duties to ensure all programmatic requirements are fulfilled. − The PCPM is responsible for regularly evaluating the impact of dual roles to ensure they do not compromise the quality or availability of BFPC program services. − If any conflicts arise from holding dual roles, immediate corrective measures must be taken to support the integrity of the BFPC program. • Orientation to the Peer Counselor Role. Required. Before beginning their duties as a PC, individuals must complete WIC Breastfeeding Curriculum: Level 2, Peer Counselor Compass Training. • Continuing Education. Required. The PC must maintain an up-to-date record of certificates for the completion of each required BFPC Program Quarterly Continuing Education, as provided by your local agency’s LATCH. Recommended. As part of ongoing professional development, it is recommended that the PC completes the WIC Breastfeeding Curriculum: Level 2, Peer Counselor Compass Training at least once every 10 years. • Roles and Responsibilities. PC must: − Adhere to the defined scope of practice as outlined in the “Peer Counselor Scope of Practice” (Attachment 9). − Offer support and information to pregnant and breastfeeding women enrolled in the BFPC program, facilitating uncomplicated, normal breastfeeding experiences while helping to prevent, correct, and manage common breastfeeding challenges.

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NC WIC Program Manual October 2025 − Conduct themselves professionally, respecting the dignity of mothers, WIC Program staff, and personnel at locations where peer counseling services are offered. − Build and maintain relationships with pregnant and breastfeeding women enrolled in the BFPC program, keeping in regular contact in line with the local agency's service delivery model. − Maintain a caseload tracking system that assists in prioritization, organization and scheduling of required peer counseling contacts. − Issue breastfeeding supplies as determined by the local agency. − Complete required documentation in Crossroads of services provided. − Refer mothers to the CPA or DBE(s) for situations outside their scope of practice, as appropriate. − Maintain regular communication with the PCPM including participating in monthly one-on-one meetings with PCPM to review the prior month’s activities referred as “Monthly Peer Counselor Program Manager and Peer Counselor Meetings.” Participant interactions with PCs do not count towards the WIC Program's mandated nutrition education contacts. Breastfeeding promotion and support are fundamental benefits of the WIC Program, and the mother-to-mother support services provided by PCs enhance this foundational requirement. • Wage Compensation. Individuals who meet the definition of a PC and serve in this capacity for the WIC Program—whether on a permanent, temporary, or contractual basis—should receive adequate compensation for their work hours, training sessions, and any travel related to their duties, as outlined in the FNS-approved “WIC Breastfeeding Model Components for Peer Counseling”. PCs cannot serve as volunteers in this role. Additionally, the provision of benefits is at the discretion of the local agency and should align with their Human Resources policies. • Scope of Practice. PCs provide basic breastfeeding education and support based on their personal experiences and training. They encourage, address common issues, and yield to CPAs/DBEs for complex breastfeeding situations. Their practice is conducted professionally, respecting the dignity of the mother, WIC staff, and community partners. − Peer Support: Offering mother-to-mother breastfeeding support including information and encouragement. − Education: Helping mothers make informed decisions about feeding their babies, sharing breastfeeding strategies, and providing guidance throughout their breastfeeding journey. − Counseling: Assisting mothers in addressing their barriers to breastfeeding and mentoring women to support the initiation and maintenance of breastfeeding. − Yields: Yielding to local agency DBEs or CPAs for issues beyond their scope. PCs continue supporting the mother while coordinating with the DBE/CPA on her care plan. PCs should not refer outside of the local agency’s DBEs/CPAs. For further details on when to yield, refer to the “Peer Counselors When to Yield” (Attachment 10). − Community Outreach: Engaging in efforts to promote breastfeeding and educating the public about its benefits.

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NC WIC Program Manual October 2025 Peer Counselors are supportive and educational members of the WIC team, not licensed healthcare professionals. They do not perform clinical tasks such as handling mother’s breasts or conducting infant oral assessments, focusing instead on encouraging and empowering mothers to reach their infant feeding goals. Refer to the “Peer Counselor Scope of Practice” (Attachment 9) for more information.

 Breastfeeding Peer Counseling Program Eligibility Women who are pregnant or breastfeeding and are currently enrolled in the WIC Program through their local agency are eligible to participate in the corresponding local agency’s Breastfeeding Peer Counseling program.

In situations where individuals seek support but do not meet these criteria (an individual is awaiting WIC certification appointment, is living in a different county or state, is breastfeeding a child older than one year, or other changes in WIC eligibility), PCs are encouraged to consult with their PCPM. Together, they can assess whether it is possible to extend support within the Peer Counselor scope of practice, with the goal of identifying the most beneficial course of action to support the family.

 Enrolling Eligible Participants in the Breastfeeding Peer Counseling Program Before receiving any services from the BFPC program, participants need to be officially enrolled. It's crucial for WIC staff to prioritize enrolling participants during their pregnancy to maximize the benefits offered by the BFPC program.

Enrollment involves the participant and any WIC staff member both signing and dating a “Breastfeeding Peer Counseling Program Welcome Letter” (Attachment 11). During enrollment, WIC staff are responsible for clearly explaining the scope of BFPC program services, determining the participant’s preferred methods of communication, and providing guidance on how these preferences can be updated in the future. The participant should receive a copy of their signed “BFPC Program Welcome Letter,” with the original document being scanned into the participant’s health record within the Crossroads system.

 Service Delivery Model Policy Each local agency must have a defined policy that ensures the provision of consistent and high-quality peer counseling services to participants enrolled in the BFPC program. Each local agency must communicate this policy to all staff upon hire and whenever updates are made. At a minimum, the policy must include:

 Referrals to the BFPC Program. Local agencies must define how and when WIC staff will refer pregnant and breastfeeding participants to the BFPC program. WIC staff must notify the PC within two (2) business days of referral or enrollment to ensure timely support during the prenatal and early postpartum periods.

 BFPC Program Service Locations. Local agencies must specify the settings where PCs will provide services. Possible settings include agency premises, hospitals, participants' homes, or home-based offices. NOTE: PCs must adhere to the local agency policy for confidentiality. Local agencies that allow PCs to work from their home must ensure the local agency’s confidentiality

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NC WIC Program Manual October 2025 policy addresses home-based services.

 BFPC Program Service Hours. Local agencies must determine the hours during which PCs are available, including provisions for evenings and weekends. Local agencies with more than one PC may need to stagger PC work schedules to assure coverage during local agency hours.

 Continuity of Services. Local agencies must establish a backup plan for providing services when a PC is unavailable and have a strategy for maintaining service continuity if the PC position becomes vacant. • If the PC position becomes vacant, no other staff positions may serve in the PC role unless they meet the qualifications of a Peer Counselor and complete Level 2 Training.

 BFPC Program Participant Communication Methods. When PCs communicate with participants outside of face-to-face interactions, the policy must identify each approved voice and digital communication permitted. • Voice Communication. At a minimum, PCs must offer BFPC Program services via telephone service. • Digital Communication. All digital communications must comply with the "Local Agency Texting/Digital Platform Policy," which outlines the standards and protocols for such interactions (refer to Chapter 6A Section 2.) −Written Digital Communication Requirements. Written digital communication may not be used as the initial method of contact with newly enrolled or referred participants. Written digital communication, whether messenger, texting, or email, should be restricted to limited purposes. These include simple check-ins, sharing basic breastfeeding information, encouragement, and praise, following up on referrals, sending invitations to classes and support groups, and fielding general inquiries about breastfeeding.

 Implementation. Each local agency is tasked with implementing, regularly reviewing, and updating this policy. This responsibility ensures that the policy remains aligned with the agency’s practices, operational needs, and program requirements. The policy must be reviewed annually. Each review and update should be clearly documented. The local agency must date the policy at the time of each review and any subsequent updates.

 Peer Counselor Contacts PCs are tasked with regularly scheduled contacts with pregnant and breastfeeding WIC participants enrolled in the BFPC program.

 Definitions. • Contact. This is defined as a successful two-way communication exchange between a PC and a pregnant/breastfeeding WIC participant enrolled in the BFPC program. − Required Contact. This is defined as a scheduled or intentional interaction between a PC and a WIC participant. This interaction is part of the structured support offered at predefined critical times for breastfeeding success.

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NC WIC Program Manual October 2025 − Follow-Up Contact. This is defined as a contact that occurs after required contacts have been completed.  Recommended Contact. Recommended contacts are outlined in the chart within ‘Contact Frequency’ later in this section. Recommended contacts are not mandated by the program but are believed to contribute positively to the participant's breastfeeding journey and may include additional follow-ups, support group meetings, or informal check-ins.  Participant-Initiated Contact. These are defined as contacts that are initiated by the participants enrolled in the BFPC program, rather than scheduled or prompted by the peer counselors, and occur outside the standard timelines for required or recommended contacts. • Declined. This is defined as an interaction where a PC offers program services to a pregnant or breastfeeding woman, and she declines to participate. This applies only when the PC reaches out to a potential participant who then declines enrollment, either verbally or in writing. Should they choose to decline, they are free to re-enroll in the program at any point during their pregnancy or breastfeeding period. Refer to Attempt below for situations when potential participants cannot be reached. NOTE: Participants who decline enrollment in the BFPC program are not counted toward their caseload as they do not require further follow-up. • Non-Enrolled Contact. This is defined as an interaction between a PC and participant who is not enrolled in the BFPC program. Such interactions may involve follow-ups for breastfeeding supplies, general WIC program inquiries, or breastfeeding questions that fall within the PC’s scope of practice. If contacted with breastfeeding-related questions, the PC should encourage enrollment in the BFPC program but should still assist the mother regardless of her enrollment status. NOTE: Participants who are not enrolled in the BFPC program are not counted toward their caseload as they do not require further follow-up. This includes participants who require further follow-up for a multi-user pump as this activity is not within the mission of the BFPC program. • Attempt. In situations where the participant is not immediately available for contact, the PC is required to make two separate attempts to reach out. These attempts should be spaced a minimum of two hours apart to ensure a reasonable opportunity for the participant to respond. If, after these two attempts, the participant remains unreachable, the contact requirement for that specific time period is considered fulfilled.

When PCs encounter circumstances where required contacts are not completed due to late enrollment of a participant, or lack of timely information regarding a participant's change in status, it is a lapsed contact(s). Examples may include: a prenatal participant who is enrolled at 38 weeks gestation and the resultant two (2) prenatal contacts are combined, one of the required prenatal contacts is lapsed; or, a participant who delivers at 35 weeks of gestation, but the local agency is only first notified when the infant is three (3) weeks old. In such instances, the PC is required to note in their next documentation the inability to complete any of the required contact(s) and provide an explanation for why the required contact(s) were not completed as scheduled.

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NC WIC Program Manual October 2025  Service Locations and Communication Methods. The local agency should outline the permitted methodologies that the local agency’s PC(s) utilize to contact enrolled BFPC participants in their Service Delivery Model Policy.

 Contact Frequency. The minimum required and recommended PC contacts are outlined below.

Category Required Contacts Recommended Contacts* Pregnant Women • Initial Prenatal: Contact once within 30 days of enrollment in the BFPC Program. • Second Prenatal: Contact once two weeks prior to a woman’s expected delivery date. • Follow-Up (after initial prenatal): Contact monthly until 37 weeks gestation. • Follow-Up (after second prenatal): Contact weekly until 40 weeks gestation. Breastfeeding Women • Week 1 Postpartum: Contact twice (every 2-3 days). • Week 2, 3, 4 Postpartum: Contact once each week.

• Follow-Up (after week 4 postpartum): Contact monthly until 6 months postpartum. • Follow-up (prior to return to school or work): Contact once. * Recommended contacts are documented as “Follow-up” contacts in Crossroads

 Caseload Management  Definitions • Overall Caseload. This represents the total number of participants enrolled in the BFPC Program who are assigned to a PC for support. Overall caseload encompasses individuals who: − are enrolled and have signed the Welcome Letter; − receive or have received the required contacts, including breastfeeding participants beyond the first month postpartum who may reach out for continued support; and − actively engage with the PC, regardless of the frequency of their interactions. Overall caseload excludes WIC participants for whom the PC issues a breastfeeding supply or provides follow-up, or WIC participants who are referred for BFPC Program enrollment but opt to not receive. • Active Caseload. The number of participants enrolled in the BFPC Program who had at least one contact or two attempts with a PC during a specific month.

 Guidelines for Caseload Count. To calculate how many participants a peer counselor can support, consider their caseload and experience level. The complexity of participants' needs also plays a crucial role, impacting the time required for each case. Additionally, the method of contact—whether it's in-person at clinics, hospitals, homes, or through electronic means—affects a counselor's ability to manage a certain caseload size. Regular

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NC WIC Program Manual October 2025 evaluations are essential to adjust to changing participant needs, resource availability, and peer counselor performance, ensuring the workload remains manageable.

 Conditions for Termination from the Breastfeeding Peer Counseling Program Pregnant/Breastfeeding WIC participants are enrolled in the BFPC program until any of the following conditions are met:

 The breastfeeding dyad (breastfeeding woman and infant) discontinues breastfeeding.

 The participant’s WIC status changes to non-breastfeeding due to miscarriage, fetal death, or neonatal death. • Should assistance be needed (i.e. milk suppression), refer the participant to one of your local agency’s DBEs.

 The participant voluntarily requests to withdraw from the BFPC program.

 The participant becomes ineligible to participate in the North Carolina WIC Program due to changes in category, residence, or income.

 The child reaches their first birthday. NOTE: PCs may offer continued support beyond the child’s first birthday, subject to the discretion of their PCPM, provided the support remains within the PC's scope of practice.

The inability to reach a participant using their preferred contact method does not constitute grounds for termination from the BFPC program. Local agencies are required to make reasonable efforts to establish communication with the participant.

 Documentation of Peer Counselor Services All contacts or contact attempts with participants must be entered in the “Breastfeeding Peer Counselor Care Plan Screen” of the Crossroads system.

 Required information. The Peer Counselor Care Plan must document the following information, as appropriate: • Relevant education and support provided: Education and support should be appropriate to the participant's breastfeeding stage, concerns, and readiness to learn. • Topics discussed: Topics discussed should be selected based on the reported concerns or current breastfeeding needs of the participant and should be reflective of the participant’s understanding, interest, and knowledge about breastfeeding. • Referrals: Referrals made to the CPA or DBE should be documented if complex breastfeeding concerns arise or if a question or concern is outside of the PC scope of practice. • Plans for follow-up: A plan for follow-up should include at minimum, a date and purpose, reason or action required for the next contact.

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NC WIC Program Manual October 2025  Special Circumstances. If a PC does not have access to Crossroads during home or hospital visits, the local agency must ensure contacts are documented in Crossroads system by the PC within 72 hours of the contact.

 Monthly Peer Counselor Program Manager and Peer Counselor Meetings At a minimum, the PCPM must meet individually with each PC once per month to review the previous month’s activities including caseload management, participant interactions and documentation. These regular meetings are essential to maintaining open communication, supporting staff satisfaction and retention, and strengthening quality assurance across the program.

To guide this process, the “Monthly Peer Counselor Review Guide” (Attachment 12) includes three required tools:

 Peer Counselor Monthly Report Worksheet (PC) Prior to the meeting, the PC completes the worksheet based on the previous month’s activities. This worksheet documents caseload counts, enrollment changes, participant contacts, additional activities, and self-reflection prompts that inform supervision and monitoring.

 Spot Check Worksheets (PCPM) Prior to the monthly meeting, the PCPM reviews three participant charts and completes a Spot Check Worksheet for each. These worksheets assess care plan documentation for accuracy, completeness, participant-centered support, and appropriate referrals and follow-up. Review outcomes should be used to highlight strengths and identify opportunities for growth and quality improvement.

 Monthly Peer Counselor Meeting Worksheet (PC and PCPM) Completed during the meeting, this worksheet incorporates the Monthly Report and Spot Check data to guide structured discussion. It provides space to review trends, set goals, offer feedback, and document how the PCPM can support the PC. Signatures (electronic or written) are required to verify meeting completion.

All worksheets must be completed monthly for each PC, retained on file, and made available for review during monitoring.

 Participant Satisfaction Survey (optional) Participant satisfaction surveys may be useful for gathering information to strengthen the BFPC program. Refer to Attachment 13 for an example survey.

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October 2025 Classification of Complex Breastfeeding Issues

General Definition A complex breastfeeding issue is any breastfeeding-related concern that involves conditions, challenges, or risks beyond the knowledge, training, or scope of practice of peer counselors and Competent Professional Authorities (CPAs). These concerns often require enhanced assessment, advanced lactation support strategies, and collaboration with healthcare providers.

The presence of a medical, physiological, or anatomical condition does not automatically make a breastfeeding issue complex. A situation is considered complex when such conditions: • Contribute to current breastfeeding issue, or • Identified during pregnancy as factors that may increase the risk of breastfeeding difficulties.

Note: While WIC Designated Breastfeeding Experts (DBEs) provide assessment, education, and support for complex breastfeeding concerns, they do not provide clinical care. When appropriate, the next step following a DBE assessment may include referral to a medical provider. Education and support may be provided in conjunction with ongoing medical care. DBEs operate within a public health framework and are not expected to diagnose or manage medical conditions.

Criteria for Complex Breastfeeding Issues The following situations are considered complex when observed or reported and warrant a referral to a DBE:

I. Infant-Related Complexities Complex breastfeeding issues that may affect the infant’s ability to feed effectively, gain weight, or safely breastfeed, including but not limited to: • Feeding Effectiveness and Coordination: o Persistent latch difficulties that do not improve with basic support o Weak or disorganized suck o Feeding difficulties associated with common infant illnesses that interfere with latch or intake o Feeding challenges related to Neonatal Abstinence Syndrome (NAS)/Neonatal Opioid Withdrawal Syndrome (NOWS) • Growth and Weight Concerns: o Poor weight gain or growth faltering that does not improve with basic breastfeeding support. • Anatomical or Developmental Differences: o Suspected anatomical anomalies (e.g., cleft lip/palate, ankyloglossia, cranial differences) o Prematurity or delayed oral feeding development o Congenital conditions that interfere with feeding function • Health Conditions:

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October 2025 o Failure to thrive (as diagnosed by a qualified healthcare provider) o Jaundice that impacts feeding behavior or intake o Signs of gastroesophageal reflux disease (GERD) o Chronic illness in the infant that affects breastfeeding (e.g., cardiac, metabolic, or respiratory conditions diagnosed by a healthcare provider) • Milk Management and Feeding Tools: o Concerns related to milk overproduction o Infant use of or need for special feeding devices (e.g., nipple shields, supplemental nursing systems) II. Maternal-Related Complexities Complex parent-related breastfeeding issues that may interfere with breastfeeding comfort, effectiveness, or continuation, including but not limited to: • Pain, Trauma, and Breast Conditions: o Chronic or unresolved nipple or breast pain o Nipple trauma, bleeding, or persistent discomfort unrelieved by basic positioning support o Nipple blebs o Unresolved engorgement o Unresolved plugged ducts o Suspected or confirmed breast infection (e.g., mastitis, abscess, fungal infection) o Vasospasm or suspected circulatory issues affecting the nipple • Skin Conditions Affecting the Breast or Nipple: o Rashes or reddened areas o Lesions of various sizes, shapes, or colors o Dry, scaly, or peeling skin o Itching, irritation, or pain associated with skin breakdown • Anatomical or Surgical History: o Anatomical variations (e.g., inverted or flat nipples, insufficient glandular tissue) o History of or current breast surgery (e.g., augmentation, reduction, biopsy) • Health Conditions and Medication Use: o Hormonal or endocrine disorders (e.g., polycystic ovary syndrome [PCOS], retained placenta, thyroid dysfunction) o Physical disabilities, chronic illnesses, or medical conditions that impact feeding position or milk production o History of bariatric surgery (e.g. gastric bypass, sleeve gastrectomy) o Use of medications or treatments that may be incompatible with breastfeeding • Breastfeeding History and Intentions: o Efforts to relactate or induce breastfeeding after not breastfeeding.

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October 2025 WIC Designated Breastfeeding Expert Scope of Practice

Purpose: This document defines the professional scope of practice for the WIC Designated Breastfeeding Expert (DBE). It outlines the permitted boundaries, limitations, and role expectations for the DBE working within the public health framework of the WIC Program. DBEs provide supportive, educational breastfeeding services that complement—but do not replace—clinical care.

Role Overview: A DBE is a trained breastfeeding professional who supports pregnant and breastfeeding participants experiencing complex breastfeeding challenges. DBEs conduct structured breastfeeding assessments, develop care plans, provide education, and collaborate with WIC staff and external providers as needed. Their work must remain within the public health scope outlined in this document and align with the competencies taught in the WIC Breastfeeding Curriculum (up to Level 4).

Assessment • Use observational techniques to evaluate breastfeeding behaviors, latch, positioning, and feeding effectiveness. • Apply structured approaches to gather and interpret information shared by participants related to infant feeding and breastfeeding challenges. • Identify signs that may indicate breastfeeding complications or conditions that require referral to a healthcare provider. • Develop participant-centered strategies and care plans that align with the family’s breastfeeding goals and needs. Participant Education and Support • Provide evidence-informed guidance on breastfeeding management, techniques, and effectiveness. • Offer anticipatory education to help families prepare for transitions in breastfeeding, including returning to work, introducing supplementation, or weaning. • Support the safe and appropriate use of breastfeeding aids (e.g., nipple shields, supplemental nursing systems) in line with WIC policy and within the DBE’s scope of training and experience. Referral and Coordination • Serve as a liaison between WIC and healthcare providers to support coordinated care. • Refer participants for medical evaluation when health concerns or breastfeeding complications are observed. Staff Consultation and Capacity Building • Provide guidance and share breastfeeding knowledge with CPAs and peer counselors, consistent with the DBE’s training and expertise. • Support a collaborative learning environment that promotes skill development and enhances the quality of breastfeeding services across the local agency. Professional and Ethical Standards • Uphold WIC values by providing participant-centered care with cultural sensitivity and

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October 2025 respect for confidentiality. • Participate in ongoing training and continuing education to stay current on lactation science, WIC policies, and best practices.

Scope Limitations It is beyond the DBE's scope of practice to: 1. Diagnose maternal or infant medical conditions (e.g., infections, hormonal imbalances, tongue-tie, failure to thrive, etc.). 2. Perform suck assessments of the infant. 3. Conduct weighted feeds to evaluate transfer of milk. 4. Prescribe, recommend, or manage medications, hormones, or herbal supplements for lactation (e.g. fenugreek, moringa). 5. Create treatment plans for medical conditions. 6. Interpret diagnostic labs or imaging. 7. Initiate or manage induced lactation or relactation protocols, including hormonal or pharmaceutical regimens. 8. Provide care that exceeds the competencies taught in the Level 4 Breastfeeding Curriculum.

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October 2025 Pump Issuance/Reservation Reasons Competent Professional Authorities (CPAs) assess participants' nutrition risks to collaborate in creating personalized nutrition care plans, which include breastfeeding assessments. These assessments may identify the need for breastfeeding supplies as supportive measures. It's crucial that these supplies align with the goals and needs of the breastfeeding dyad. When a breastfeeding assessment determines that a pump is a necessary component of the participant’s care plan, the CPA/DBE must document the reason and type of pump indicated in the Care Plan Summary. The CPA’s/DBE’s plan of care must also illustrate how the issuance of a pump positively contributes to the parent’s infant feeding goals as part of a comprehensive plan of care. The goal of all pump issuances is to support breastfeeding to the maximum extent possible, aligned with the parent’s feeding goals. After conducting a breastfeeding assessment, a pump may be issued by any trained WIC staff member through the Crossroad’s Breast Pump Issuance screen. The documentation entered by the CPA/DBE on the care plan summary enables the staff member issuing the pump to clearly select the reason and the appropriate product, promoting continuity of care among all WIC staff. The reason for issuing a pump focuses on addressing practical and logistical challenges of breastfeeding. For example, if a premature infant is hospitalized, the reason for pump issuance is “Dyad Separation”. Conversely, if a premature infant is not hospitalized but becomes easily tired at the breast, thus inadequately stimulating and transferring milk, the identified reason is “Difficulty latching onto mother’s breast.” The chart below outlines each pump issuance/reservation reason, provides a description of each reason, how a pump can be used to manage the situation, and the recommended type of pump for each reason.

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October 2025 Reason Description Pump Management Support Recommended Type of Pump(s)* Chronic low milk supply (after 4 weeks postpartum) Chronic low milk supply refers to a situation where a lactating parent consistently produces insufficient breast milk to meet their baby's nutritional needs, despite efforts to optimize milk production and appropriate breastfeeding practices. The underlying etiology may be unknown, or it could be due to a medical condition, early breastfeeding practices, or medication. In this situation, the management support provided by the pump is influenced by the parent's stage of lactation and their specific goals. Parents may use the pump to provide additional stimulation to the breast or as a complete replacement for breastfeeding. In cases of chronic low milk supply, an infant may lose interest in feeding directly from the breast, making the parent's goals even more critical. While continuing to breastfeed might be important, other factors, such as the preservation of mental health, must be considered. The frequency of pump usage, therefore, should be tailored to balance these factors appropriately. The determination of whether the use of a pump is a short-term or long-term intervention should be individualized to the parent’s goals. Single or Multi-User Electric Pump Cracked, bleeding, or severely sore nipples (602) Cracked, bleeding and severely sore nipples result in pain and discomfort lasting throughout feedings. Pain persisting beyond one week postpartum is atypical and suggests an assessment of feeding is warranted. In these cases, nipple trauma often correlates with ineffective breast stimulation and milk removal, which can compromise the establishment or maintenance of milk supply. Therefore, a CPA/DBE may determine that issuing a pump is necessary to both establish and maintain the milk supply while latch issues are being resolved. During this period, the degree of pump dependency will vary depending on the effectiveness Multi-User Electric Pump

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October 2025 Reason Description Pump Management Support Recommended Type of Pump(s)* of individual breastfeeding sessions. Typically, this is a short-term need. Difficulty latching onto mother’s breast (603) Difficulty latching onto the mother's breast refers to an infant’s struggle to effectively attach to the breast for feeding, which can be influenced by a variety of factors and/or may also be affected by medical conditions, oral aversions, or anatomical reasons from either the mother or infant. In situations where there is difficulty latching to the breast, it is likely that milk is not being sufficiently removed to generate or maintain an adequate supply. Therefore, a pump may be necessary to enhance milk removal. Consequently, a CPA/DBE may determine that issuing a pump is essential to establish and maintain milk supply while the latch issue is being addressed and resolved. Depending on the underlying cause of the latching difficulty, the need for a pump may be either short-term or long-term. Single or Multi-User Electric Pump Dyad Separation Breastfeeding women and infants who are separated for an extended period or experience consistent, frequent separations. Separation of the dyad necessitates replacing direct breastfeeding sessions to stimulate and maintain milk production. Consistent pumping effectively mimics the natural demand and supply rhythm of breastfeeding, which is essential for initiating and maintaining adequate milk supply. Depending on the length and frequency of separation, the need for a pump may be short-term or long-term. Single or Multi-User Electric Pump Failure of milk to come in by 4 days postpartum (602) A delay in the transition from colostrum to mature milk, expected to occur between 24 to 72 hours postpartum. Delays may be influenced by biological Management involves regular and effective emptying of the breast to stimulate milk production. A pump may be necessary for complete, partial, or supplementary breast stimulation, Multi-User Electric Pump

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October 2025 Reason Description Pump Management Support Recommended Type of Pump(s)* factors, medical interventions, or psychological stress. depending on the underlying causes of the delay. The need for a pump is most likely short-term. Induced lactation Induced lactation refers to initiating milk production in a person who has never given birth. A pump is used to mimic physical conditions that trigger the hormonal responses necessary for milk production. The success of induced lactation can be optimized through consistent pumping schedules and, where applicable, pharmacological support from healthcare providers. The approach, time demand and duration of the intervention varies by individual, and ongoing guidance from a lactation expert is recommended. For induced lactation regular use of a pump is likely going to be part of the duration of their breastfeeding journey. Single or Multi-User Electric Pump Parental Request** The parent may express a request for pumping rather than breastfeeding directly. The reasons for this choice can vary—some are stated clearly, while others might not be shared or could even be unknown to the parent. Nevertheless, the ability to continue breastfeeding often depends on obtaining a pump. Pump management support will be tailored to the specific needs identified by the parent. The primary goal is to support breastfeeding to the maximum extent possible, this includes providing education on the benefits of direct breastfeeding, when appropriate. To determine your plan of care for the participant, consider the frequency of use, the stage of lactation, and the duration of the need. Single-User Manual Pump, Single-User Electric Pump, or Multi-User Electric Pump Recipient of Abuse (901) Defined as the experience of physical, sexual, emotional, WIC staff may encounter participants who report that past abuse has affected Single or Multi-User Electric Pump

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October 2025 Reason Description Pump Management Support Recommended Type of Pump(s)* economic, or psychological maltreatment that may frighten, intimidate, terrorize, manipulate, hurt, humiliate, blame, injure, and/or wound a woman. The abuse may be self-reported by the individual, by a family member, a social worker, health care provider or other appropriate personnel. Types of abuse include but are not limited to Domestic Violence (DV) and/or Intimate Partner Violence (IPV). their willingness or comfortability to feed their infant directly at the breast. In such cases, a pump may be necessary to fully replace breastfeeding, often leading to a long-term need for pumping support. Relactation A parent who has previously breastfed is restarting breastfeeding after a period of little or no milk production. During relactation, the extent of pump dependency tends to correlate with the milk supply. Initially, a pump may be necessary for complete breast stimulation, especially while the infant is uninterested or unwilling to latch. As the milk supply improves and the infant shows greater interest and ability to latch, the pump's role can transition to providing partial stimulation. The frequency and intensity of pump usage are thus guided by the infant’s interest in and success of transferring to direct breastfeeding. Typically, pump usage is more intensive early on and decreases as the milk supply becomes more established. These individual factors also Multi-User Electric Pump

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October 2025 Reason Description Pump Management Support Recommended Type of Pump(s)* help to determine whether the use of a pump is a short-term or long-term intervention. Severe breast engorgement (602) Severe breast engorgement is a condition that can occur when there is an excessive accumulation of milk, blood, and other fluids in the breast tissue. It can also happen at any point during the breastfeeding period due to various factors affecting milk removal or production. The issuance of a pump to address severe engorgement requires careful consideration. Severe engorgement is typically caused by the accumulation of excess fluids in the breast, which may not always be breastmilk. In these situations, using a pump provides only palliative support. Therefore, it is crucial for the DBE/CPA to assess the likely origin of the fluid buildup. Additionally, when providing instructions for palliative support, the DBE/CPA should recommend pumping only to the point of comfort. This helps avoid exacerbating issues such as hyperlactation or increased swelling. When the underlying cause is determined and it is addressed appropriately, severe breast engorgement requires only short-term pump use. Single-User Manual Pump Slowed/Faltering Growth Pattern (135) • Infants birth to up to 2 weeks of age (at the time of certification): Excessive weight loss after birth, defined as >7% birth weight. • Infants 2 weeks up to 6 months of age (at the time of certification): Any weight A slowed or faltering growth pattern usually indicates a need for supplementation, which can be met with expressed breastmilk, infant formula, or a combination of both. Often, a breast pump is provided to complement direct breastfeeding while helping to support the infant’s nutritional needs. The nature Multi-User Electric Pump

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October 2025 Reason Description Pump Management Support Recommended Type of Pump(s)* loss. Use two separate weights taken at least 8 weeks apart. of the underlying issue will dictate whether the use of a pump is a short-term or long-term intervention. Weak or ineffective suck (603) A weak or ineffective suck in infants is characterized by the infant's inability to create a strong enough vacuum to extract and swallow milk efficiently during breastfeeding. This issue can stem from various causes, including prematurity, neurological challenges, muscle tone problems, or anatomical anomalies like tongue-tie. It can lead to inadequate nutritional intake. In situations where there is a weak or ineffective suck, it is likely that milk is not being sufficiently removed to generate or maintain an adequate supply. Therefore, a pump may be necessary to complement the limited milk removal. Consequently, a CPA/DBE may determine that issuing a pump is essential to establish and maintain milk supply while infant’s suckling issue is being addressed and resolved. Depending on the underlying cause of the infant’s suckling issue, the need for a pump may be either short-term or long-term. Single or Multi-User Electric Pump *The type of pump is a recommendation is general guidance based on the likely stage of lactation, degree of pump dependency, and duration of need based on the identified reason. Importantly, as stated in Chapter 9, Section 6, “However, it is important to note that the type of pump recommended may be adjusted following a discussion with the breastfeeding mother to better suit her specific needs and comfort level.” ** The decision to issue a pump based on parental request requires careful consideration by the CPA/DBE and should be documented in the care plan. Factors to consider include the availability of pump resources at the local agency, access to quality pumps from other sources, the parent’s willingness to address any identified issues (such as pain), and the expected positive impact of the pump on the parent’s breastfeeding experience. North Carolina WIC does not have the resources to provide a pump based on parental preference when an underlying identified etiology is not apparent.

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October 2025 Indications for Use Indications For Medical Necessity For Supplementation

The status of the infant requiring supplementation should be determined by a healthcare provider and/or WIC designated breastfeeding expert and any decisions should be made on a case-by-base basis for the indications outlined in the table below. The indication for supplementation is diagnosed by the participant’s healthcare provider and documented by a clinical assessment or laboratory evidence. The below chart is for term infants.

The following is the preferred order to consider when there are indications for supplementation: 1. Expressed breast milk 2. Human donor milk 3. Infant formula

Definitions: Supplementary feedings: Additional fluids provided to a breastfed infant before 6 months (recommended duration of exclusive breastfeeding). These fluids may include donor human milk, infant formula, or other breast milk substitutes (e.g., glucose water).

Term infant: In this protocol ‘‘term infant’’ also includes early-term infants (gestational age 37– 38 6/7 weeks).

Hypoglycemia: condition in which your blood sugar (glucose) level is lower than normal.

Hyperbilirubinemia: Higher-than-normal amount of bilirubin in the blood. Bilirubin is a substance formed when red blood cells break down. Also known as jaundice.

WIC Category Indications for Supplementation Clinical or Laboratory Evidence

Infant

Asymptomatic hypoglycemia  Laboratory blood glucose measurement and clinical assessment by healthcare provider Inadequate milk intake  Clinical assessment of dehydration documented by healthcare provider  Clinical assessment to determine weight loss greater than 8-10% when feeding is not going well  Delayed bowel movements: o Fewer than four (4) stools on day four (4) of life or o Continued meconium stools on day five (5)

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October 2025 Hyperbilirubinemia (Jaundice)  Poor breast milk intake despite intervention  Laboratory bilirubin measurement and clinical assessment by healthcare provider Inborn error of metabolism (e.g. galactosemia)  Laboratory measurement in birthing facility and/or healthcare provider office

Breastfeeding Woman

Delayed onset of stage II of lactation (secretory activation)  Phase II of milk (transitional milk) delayed 3-5 days (72-120 hours)  Inadequate intake by infant Primary glandular insufficiency  Clinical assessment by healthcare provider to show abnormal breast shape, poor breast growth during pregnancy, or minimal indications of secretory activation Breast pathology or prior breast surgery  Clinical assessment by healthcare provider to show poor milk production Certain Medications  Clinical assessment by healthcare provider to determine medication and breastfeeding compatibility Temporary separation without breast milk available  Clinical assessment by healthcare provider Intolerable pain during feedings unrelieved by intervention  Clinical assessment by healthcare provider

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October 2025 Indications for Use Indications For Silicone Nipple Shield

Definition. A nipple shield is a flexible silicone nipple worn over the lactating parent’s nipple during a feeding. Nipple shields allow for stimulation to the nipple and areola. This device should be considered a short-term solution and should be used under the guidance of a WIC designated breastfeeding expert (DBE).

Nipple shields should be used only after other methods to achieve successful breastfeeding have been attempted. Rarely are nipple shields appropriate in the first 24 hours of attempting breastfeeding. Nipple shields may be provided after client instruction is given, a breastfeeding assessment to include observation of a feeding session at the breast is complete, and a follow-up plan is made prior to client leaving the local agency.

Indications for use of nipple shield include: A. Latch difficulty: a. Nipple anomalies (flat, inverted) b. Nipple pain and damage c. Mismatch between small infant mouth and large nipples d. Artificial nipple preference (bottle, pacifiers) e. To transition and infant from bottle to breast f. Infant with weak, disorganized or dysfunctional suck (preterm, neurological problems) g. Infant with high or low muscle tone h. Overactive milk ejection reflex or overproduction of milk i. Tongue tie

B. Infant oral cavity issues: a. Cleft palate b. Bubble palate c. Lack of fat pads (preterm, small for gestational age) d. Recessed jaw

C. Infant with upper airway issues: a. Tracheomalacia b. Laryngomalacia

D. Other potential indications, when all other interventions have been unsuccessful (i.e. adjust latch and position), include: a. Participant has sore nipples b. Participant has damaged nipples c. Painful latch

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Staff Competency Checklist for Breastfeeding Supplies Issuance WIC staff who issue breastfeeding supplies must complete each training requirement outlined below. When documentation is available for training completion, it must be included with the checklist.

WIC Staff Name:

Role:

Local Agency Name:

Required Training Date Completed Documentation Breastfeeding Supplies Competency Training Unit 1: Milk Expression

☐ Certificate Breastfeeding Supplies Competency Training Unit 2: Hand Expression

☐ Certificate Single User Electric Pump Ameda Mya Joy Training

☐ Certificate Single User Electric Pump Medela Pump In Style with Max Flow

No documentation available Local Agency Protocols and Breastfeeding Supplies

☐ Agenda ☐ Sign-in Sheet Crossroads Resources Breast Pump Issuance

No documentation available Crossroads Resources Breast Pump Return in Crossroads

No documentation available Crossroads Resources Breastfeeding Supplies

No documentation available

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Local Agency Protocols and Breastfeeding Supplies Agenda This agenda provides a list of all required topics for issuance of breastfeeding supplies pertaining to local agency protocols. Trainer :

Date :

Agenda Topics • Purpose, use, demonstration, and cleaning of: o Manual pumps o Multi-user pumps • Inventory o Physical location o Access o Storage requirements o Organization o Quarterly physical inventory • Multi-User Pumps o Intake o Cleaning o Follow-up o Overdue multi-user pumps • Documentation o Crossroads  Issuance  Follow-up • Issuance • Overdue Pump  Return  Cleaning  Reconciling of inventory  Broken, Surplused, Out for Maintenance Pump o Overdue Multi-User Pumps  Reminder prior to pump return  Overdue pump contact  Certified mail

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Multi-User Pump Cleaning Log Instructions This log is pre-formatted for clinics to track multi-user breast pump cleaning and inventory. The report is designed to be completed in Excel but can also be printed and filled out by hand if preferred. How to Complete Each Entry 1 Enter the Return Date when the multi-user pump is returned to the local agency.

a. When a Return Date is entered, the entire row will automatically turn green or orange depending on whether the pump is still within the cleaning window outlined in the WIC Program Manual (WPM) or has exceeded that timeframe. Once a date is entered in the Cleaned Date cell, the row will revert to its original color, regardless of whether the cleaning occurred within or beyond the required timeline.

b. Conditional formatting highlights overdue cleaning: •Green: Within one business day of return •Orange: Beyond one business day •No Color: Either no Return Date or a Cleaned Date has been entered Note: Weekends are automatically excluded from the one-business day count.

2 Enter the multi-user pump's Serial #. 3 Select the Pump Type from the drop-down list. Options include Symphony PLUS, Symphony, Lactina, Lactina Plus, Elite, or Pearl multi-user pumps.

4 Select the pump’s Return Condition from the drop-down list. The options match those listed on the return receipt: Working Properly, Not Working, Broken Parts, or Bug Infestation.

a. Working Properly: Pump powers on, runs smoothly, and has no visible damage.

b. Not Working: Pump does not power or operate correctly.

c. Broken Parts: Physical damage (e.g., cracked casing, missing cord, broken knob).

d. Bug Infestation: Evidence of insect activity inside or around the pump. 5 If the multi-user pump is Working Properly, enter the Cleaned Date. •This date represents when a staff member cleaned the pump and prepared it for return to inventory. •If the pump’s Return Condition is labeled as Not Working, Broken Parts, or Bug Infestation, enter N/A in the Cleaned Date field.

6 If the multi-user pump was cleaned, enter the Staff Initials of the staff member who performed the cleaning. If the pump was not cleaned because maintenance is needed or it will be surplused, enter N/A.

7 Select the Post-Cleaning Status from the drop-down list. Options include Returned to Inventory, Maintenance, or Surplus.

a. Returned to Inventory: Pump is working properly, cleaned, and ready to be issued again.

b. Maintenance: The pump requires a repair or replacement of missing parts before it can be issued again.

c. Surplus: Pump is not repairable/obsolete and will be removed from use. 8 Utilize the Comments field to document any additional or relevant information about the pump cleaning. Important Notes Drop-Down Lists: All drop-down lists are preloaded. Do not type or modify them. Capacity: The log allows up to 1,000 entries. Once that limit is reached, each clinic may choose to either add additional rows or start a new log.

Filtering Data in the Table: The Pump Cleaning Log is formatted as an Excel Table, which allows users to quickly sort and filter information.

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Page 2 of 4 NC WIC Program Manual October 2025 To filter: 1. Click the ▼ arrow beside any column header. 2. Select or deselect the items you want to view based on the entries in the column (e.g. Return Condition column can tell you how many pumps have been returned with a bug infestation.) 3. To clear filters and view all entries again, choose “Clear Filter from [Column Name]” from the same menu. Tip: Filtering helps you review pumps needing cleaning, track by staff initials, or view pumps with specific return conditions without altering or deleting any data.

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Multi-User Pump Cleaning Log Clinic Name:

Return Date Serial # Pump Type Return Condition Cleaned Date Staff Initials Post- Cleaning Status Comments 10/14/2025 ABC123U&ME Symphony PLUS (Medela) Working Properly 10/14/2025 CFP Returned to Inventory

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Page 1 of 2 NC WIC Program Manual October 2025 Overdue Multi-User Pump Notification Sample Letter <Enter Local Agency Letterhead Here>

Hello <Enter Participant Name>, Congratulations on your baby. You have done such a wonderful job to care for your baby including providing your baby with your breast milk. Breastfeeding provides benefits to the parent, baby, and the community. We applaud your efforts to provide breastmilk. Our records show that as part of your breastfeeding journey the <Enter Local Agency and Clinic Name> loaned you a multi-user breast pump. The multi-user pump is <Enter manufacturer and model name> and the following serial number <Enter Serial Number> can be found on the multi-user pump. The multi-user pump was due back to the WIC clinic on Click or tap to enter a date. The multi-user pump is now overdue, and the WIC Program requires the return on the breast pump as soon as possible, so that it may be issued to another breastfeeding family who needs it. Many North Carolina families depend on the WIC Program as a source of breastfeeding support including the availability of breast pumps. There are many families who have sick babies where the parent’s milk is lifesaving, and they require a breast pump to provide their milk. In order for the WIC Program to keep supporting families in need, please return the loaned multi-user pump to <Enter Local Agency Clinic Name> at <Enter Street Address and City Name>. Our clinic is open <Enter days and hours of operation>. If these days and times conflict with your schedule, please call or text <Enter name and number> to schedule alternative options for return of the multi-user pump. If you still require use of the multi-user pump, please contact the name and number above to discuss a pump extension. Thank you for allowing the WIC Program to be part of your breastfeeding journey. We look forward to hearing from you. Sincerely, <Staff Name>

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Peer Counselor Scope of Practice

A peer counselor provides basic breastfeeding information, encouragement and support to WIC participants and performs within the peer counselor scope of practice. Perform in a professional manner in all aspects of the peer counselor role. • Respect the participant’s privacy, dignity and confidentiality. • Respect and respond sensitively to cultural attitudes and practices of participants and the community. • Work within the policies and procedures of the WIC program. • Maintain records according to legal requirements and ethical practices. • Recognize when assistance is needed and consult with the supervisor, Breastfeeding Coordinator and/or Peer Counselor Program Manager and WIC Designated Breastfeeding Expert (DBE). • Identify situations outside the Scope of Practice and refer as appropriate in a timely manner. • Yield to the DBE for situations out of breastfeeding peer counselor Scope of Practice. • Acquire ongoing breastfeeding education to maintain and build knowledge and skills within Scope of Practice. Encourage and support participants to breastfeed. • Use participant-focused communication techniques to best meet participant needs. • Help participants identify the support available to them and educate family members. • Help women identify their breastfeeding concerns, barriers, and solutions. • Teach the reasons to breastfeed and the risks of not breastfeeding. • Teach the importance of exclusive breastfeeding in the early weeks. • Teach participants about the WIC food packages for breastfeeding mothers. • Assist in infant feeding classes and peer support groups. • Be available to WIC participants outside of usual clinic hours and outside of the clinic environment. • Refer mothers to resources for support. • Promote breastfeeding in the community, workplace, and health care system. • Support breastfeeding participants from pregnancy through growth spurts, introducing solid foods, and weaning. Teach basic breastfeeding to participants and help them when difficulties occur. • Teach basic, evidence-based techniques that help ensure a successful start in breastfeeding, including milk production, skin-to-skin care, positioning and latch, and milk expression and storage. • Identify signs of the normal course of breastfeeding, including breastfeeding frequency and duration, infant feeding cues, and normal infant weight gain and stooling patterns. • Provide anticipatory guidance to help prevent the occurrence of problems.

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October 2025 • Provide guidance to mothers regarding non-evidence-based breastfeeding information they receive. • Help mothers plan for a return to work/school that supports the continuation of breastfeeding. • Provide basic and timely problem-solving and support. • Yield mothers experiencing difficulties to the WIC designated breastfeeding expert. Peer Counselors should not address non-breastfeeding questions. When a relationship is built with new moms, they begin to trust the peer counselor to provide information and solutions for other aspects of their lives such as dealing with growth and developmental behaviors of their children, relationship issues, personal crises, and breastfeeding challenges that are beyond the scope of practice of the peer counselor. Burnout can easily occur when peer counselors try to take on more than their role or more than they are capable of managing. Adapted from Scope of Practice for Peer Counselors materials from Michigan, California and Virginia WIC.

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October 2025 Peer Counselor When to Yield

When peer counselors identify any of the following problems or situations, they must immediately consult their WIC Designated Breastfeeding Expert (DBE) to discuss the best plan for supporting the mother and infant. The peer counselor will continue to provide support while the DBE or medical expert is addressing the issue, unless the supervisor or peer counselor determines that it is best to discontinue peer support.

Pregnancy Issues the Mother Reports 1. Spotting or bleeding 2. Excessive vomiting or nausea 3. Swelling 4. Contractions, suggesting premature labor 5. Baby stops moving 6. Other troublesome medical situations

Baby Issues 1. Baby is born preterm or low birth weight 2. Baby is sick 3. Baby has fewer than 6 wet diapers and 3 stools per 24 hours in the first month after the baby is 4 days old 4. Baby fails to gain weight or gains weight slowly: ▪ Baby loses more than 7% of birth weight ▪ Birth weight is not regained by 2 weeks postpartum ▪ Weight gain is less than 4.5 ounces per week 5. Baby has difficulty latching or remaining latched after several attempts 6. Baby appears unhappy at the breast or refuses to breastfeed 7. Baby is still hungry after feedings despite increased frequency and duration of breastfeeding 8. Breastfeeding typically last more than 45 minutes 9. Baby has signs of jaundice 10. Baby has a congenital defect such as cleft lip/palate or Down Syndrome 11. Baby has restricted tongue movement from a tight frenulum

Mother Concerns 1. Mother has engorgement or plugged ducts that do not resolve with basic suggestions after 24 hours 1. Mother has a fever (suggesting possible mastitis or abscess) 2. Mother has nipple discomfort that does not improve with basic suggestions after 24 hours

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October 2025 3. Mother is supplementing with formula before the baby is 1 month old and wants to increase her milk production or reduce/eliminate formula supplements 4. Mother has been formula feeding the baby since birth and now wants to breastfeed 5. Mother is exclusively pumping her milk and now wants to put her baby to breast 6. Mother wants to induce lactation or relactate after discontinuing breastfeeding (e.g., she desires to breastfeed an adopted baby) 7. Mother is breastfeeding more than one baby 8. Mother wants to breastfeed but has been advised NOT to by her HCP 9. Mother finds a lump in her breast

Illness in Mother or Baby 1. Mother and/or baby have symptoms of thrush/yeast infection 2. Mother or baby are vomiting or have diarrhea 3. Mother or baby are hospitalized 4. Mother has symptoms of a breast infection (such as mastitis or abscess) 5. Mother has a physical disability 6. Mother or baby has a chronic or acute illness such as: ▪ Hepatitis B or C, tuberculosis, CMV, or chicken pox ▪ Renal, liver, intestinal, heart problems, or cystic fibrosis ▪ Metabolic disorder such as diabetes mellitus ▪ Hormonal concerns such as Polycystic Ovary Syndrome or thyroid dysfunctions 7. Mother has been diagnosed with HIV/AIDS

Other Medical Situations 1. Mother has been prescribed medications that have not been approved for breastfeeding by current established authorities such as the AAP or Lactmed 2. Mother has prior breast surgery (breast implants, breast reduction, biopsy, breast cancer), chest surgery, or trauma 3. Mother has had gastric bypass surgery

Nutrition 1. Mother has nutrition questions 2. Mother is nutritionally at risk for underweight, has bulimia or anorexia 3. Mother has food insecurity

Social 1. Mother reports concerns of depression 2. Physical abuse of the mother or another family member is reported or suspected

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October 2025 3. Mother reports use of alcohol or street drugs (such as heroin, marijuana, meth, cocaine, etc.)

Other 1. Mother or baby have any other medical problems that are beyond the normal course of breastfeeding and therefore are outside the peer counselor scope of practice 2. Mother feels there is a problem that needs a referral 3. Peer counselor feels there is a situation that needs to be addressed by a lactation expert 4. Mother is not following suggestions given by the peer counselor Adapted from the Minnesota WIC Program, “Yield List”

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October 2025 Instructions For Completing the Breastfeeding Peer Counseling Program Welcome Letter

1. Participant Section: • Enter the participant’s full name, Family ID, and expected or actual delivery date. • Review the program overview with the participant. • Have the participant complete: o Phone number, alternate phone number (optional), and email address. o Preferred method of contact by checking the appropriate box. • Participant signs and dates the form. 2. Peer Counselor Section: • Enter the name and contact information for the assigned peer counselor. 3. WIC Staff Section: • After explaining the program, WIC staff must sign and date the staff section to confirm the participant was given an overview and enrolled. 4. Distribution: • White copy stays with the local agency. • Yellow copy is given to the participant.

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October 2025 Monthly Peer Counselor Review Guide Worksheet #1: Peer Counselor Monthly Report Worksheet This worksheet should be filled out by the peer counselor each month. It helps you reflect on your caseload, track your activities, and share any support you may need from your PCPM. Please complete it before your Monthly PCPM and PC Meeting. Staff Details •Enter your name • Enter the month and year being reviewed • Enter your PCPM's name Note: If completing this document electronically, the Peer Counselor’s name, Peer Counselor Program Manager’s name, and the month and year of the review will automatically populate in the remaining documents. Caseload Management Caseload Count Record the number of participants on your Active Caseload and Overall Caseload during the review month. • Break down by prenatal and breastfeeding participants • Refer to the WPM Chapter 9: Breastfeeding Program Management, Section 7: Breastfeeding Peer Counseling Program for caseload definitions Enrollment Record the number of new participants added to your caseload and those who were terminated (removed from your caseload). •Separate by Prenatal and Breastfeeding categories. Monthly Contacts Record the number of contacts by type. • Refer to the WPM Chapter 9: Breastfeeding Program Management, Section 7: Breastfeeding Peer Counseling Program for a detailed list of contact types. Note: You can use the Crossroads report called “Monthly Activities Breastfeeding Report” to help count your contacts and attempts. This report only shows participants who were charted during the selected time and does not include those who transferred during their certification period. Additional Peer Counselor Activities Check any activities you participated in this month that were outside of direct participant contacts. • If you choose “Other,” briefly describe the activity in the space provided. Note: If you need more space to write, increase the row height by placing your mouse on the bottom edge of the row number. When the cursor changes to a double-headed arrow, click and drag down. Monthly Reflection 1. Confidence: How confident did you feel managing your caseload this month? 2. Timeliness: Did you complete most of your contacts on time? (Check Yes or No) 3. Challenges: Were there any participants you had trouble reaching or supporting? 4. Success: Share one thing you’re proud of doing this month. 5. Support Needs: Do you need anything from your PCPM? (If yes, briefly explain.) Note: You can adjust the row height if your response doesn’t fit. Place your mouse on the bottom edge of the row number, then click and drag down to expand the space. ✅ Reminder: This worksheet isn’t a test—it’s here to help you grow, feel supported, and talk about what’s going well and where you might need help. Everyone’s caseload is different, and it’s normal to have hard days or things that didn’t go as planned. Your answers help your PCPM understand how to support you and what you might need. This is also a chance to celebrate what you’re doing well!

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October 2025 Worksheet #2: Spot Check Worksheets These worksheets, completed by the PCPM, review PC Care Plan documentation for accuracy, participant-centered support, and appropriate referrals. Use findings to identify trends, recognize strengths, and guide improvement. Complete three spot checks before your Monthly PCPM and PC Meeting. Selection Select three participant charts from the peer counselor's caseload, with preference to participants on the PC active caseload, ie: received contact(s) during the review month. Review all contacts and attempts documented during this participant's current Breastfeeding Peer Counseling program enrollment. Staff Details • Enter the PC name • Enter your name • Enter the month and year being reviewed Participant Information • Enter the Family ID • Enter the date the Welcome Letter was signed • Enter the Estimated Delivery Date if pregnant, or Actual Delivery Date if postpartum. Required Contacts In the electronic version of this worksheet, the required contact due dates will autofill automatically based on your entries for the date of the Welcome Letter and estimated or actual delivery date . If completing the form by hand, you may use the Peer Counselor Contact Calculator to determine and enter the due dates manually. For each required contact, check the box if it was completed by the indicated due date if the date has already passed. Care Plan Review Questions For each selected chart, review all two-way communication documented in the Breastfeeding Peer Counseling History Records section of the Peer Counselor Care Plan for the review month. If time allows, consider reviewing all contacts during the participant’s current enrollment. If any contact does not meet the criteria, mark "No." Add comments as needed. 1. Education and Support: Documentation should reflect evidence-based guidance and be relevant to the participant’s stated goals, concerns, or questions. Education must be timely and appropriate for the participant’s circumstances, such as their literacy level, available support systems, or upcoming transitions like returning to work. The support provided should meet the participant where they are and address their immediate needs. 2. Scope of Practice: Peer counselors must document within their defined WIC scope of practice, avoiding clinical assessments or guidance outside of their training. All education and support must align with WIC policies. Refer to WPM Chapter 9, Attachment 9 for the complete scope of practice. 3. Referrals: Documentation should clearly indicate when a referral was made to a CPA or DBE for complex breastfeeding issues, assessments, or food package changes. It should also include any appropriate external referrals, such as to community resources, support groups, or parenting classes, when participant needs extend beyond the peer counselor’s role. 4. Encouragement: Peer counselor notes should reflect supportive communication by including affirming, praising, or reassuring statements. Emotional support is a core part of peer counseling and should be consistently evident in documentation. 5. Follow-Up: Each contact should include a follow-up plan with a specific date or timeframe and the reason for follow-up. This demonstrates continuity of care and ensures ongoing support tailored to the participant’s evolving needs. Additional Comments Provide additional comments as desired, such as noted trends or patterns in completion, timeliness, or documentation.

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October 2025 Worksheet #3: Monthly Peer Counselor Meeting Guide Instructions This worksheet should be completed jointly by the Peer Counselor and Peer Counselor Program Manager (PCPM) during their Monthly PCPM and PC Meeting. It is informed by data completed in advance: the PC Monthly Report Worksheet completed by the Peer Counselor and Spot Checks #1 through #3 Worksheets completed by the PCPM. This worksheet serves as a structured discussion guide, supporting review of key data, recognition of the Peer Counselor’s efforts, goal setting, and identification of specific ways the PCPM can support progress. The form concludes with a section for meeting notes and signatures to ensure proper documentation and recordkeeping. Staff Details •Enter PC name • Enter the PCPM name • Enter the month and year reviewed • Enter the meeting date Caseload Review Review the PC Monthly Report worksheet together. Answer the questions based on your agency's standards. Caseload Management 1. Enrollment: Consider adequacy based on outreach, referrals, and current caseload size. 2. Caseload Fit: Consider whether the PC can realistically engage with her caseload. 3. Inactivity: Discuss reasons for inactivity to identify if further engagement effort or other action is needed. Monthly Contacts In the electronic version of this worksheet, the monthly contact percentage will autofill automatically based on the entries on the PC Monthly Report. If completing the form by hand: 1. Add the number of Prenatal, Postpartum, and Follow Up contacts completed on the monthly report. 2. Add the number of Prenatal, Postpartum, Follow Up and Attempts completed on the monthly report. 3. Divide the first number by the second number and convert to percentage. Check Yes or No and provide the percentage in the space below. 4. If this number is less than 33%, select No and identify ways to increase successful two-way communication. Spot Check Review Review the Spot Check worksheet together. The following questions are intended to guide discussion and help identify trends or patterns in the areas of program requirements and the quality of peer counseling support provided.

Accuracy and Completeness Review the responses for the required contacts and question 1 on the Spot Check worksheets in your discussion of this section. Participant-Centered Support Review the responses for questions 2, 3, 4, and 6 on the Spot Check worksheets in your discussion of this section. Appropriate Use of Referrals and Follow-Up Review the responses for questions 5, 7, and 8 on the Spot Check worksheets in your discussion of this section. Strengths and Goal setting Include positive feedback for the peer counselor and identify a goal for the upcoming month that the PC hopes to achieve, with support from the PCPM. Comments Provide additional comments or meeting notes. Signature and Date When the meeting is complete, sign and date the form to confirm the meeting was held. The PCPM will retain the Meeting Guide worksheet for reference and monitoring purposes. ✅ Reminder: The meeting guidance worksheet is a tool designed to support open communication between the Peer Counselor and the PCPM. The worksheet helps frame a productive discussion that can be tailored to your agency's goals and priorities.

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