710.1 Policy 710 Breastfeeding: Definition, Promotion and Support Standards October 1, 2024 POLICY Local WIC programs provide breastfeeding promotion, education, and support to participants. PURPOSE To promote breastfeeding as the biological norm for infant feeding and to provide lactation support to participants and infants to extend breast/chestfeeding exclusivity and duration. RELEVANT REGULATIONS ♦7 CFR §246.11 (c)(5)—Monitor local program activities ♦7 CFR §246.11 (c)(7)(i)-(iv)—Breastfeeding promotion and support standards ♦7 CFR §246.11 (e)(1) – Encouragement of breastfeeding ♦7 CFR §246.2 – Breastfeeding definition ♦All States Memorandum 96-06—Non-birth Mothers Certified as Breastfeeding Women ♦USDA FNS WIC Breastfeeding Policy and Guidance, 2016 ♦USDA FNS WIC Nutrition Services Standards, 2013 OREGON WIC PPM REFERENCES ♦ 435—Staffing Recommendations ♦ 440—Staff Training Requirements ♦ 460—Program Incentive Items ♦712—Breastfeeding: Breast Pump Ordering, Distribution and Tracking Guidelines ♦713—Breastfeeding: Use of Supplemental Formula ♦716-Breastfeeding Peer Counseling (BFPC) Program Requirements ♦769—Assigning WIC Food Packages APPENDICES Page 710.6 Appendix A Local Agency Breastfeeding Coordinator and WIC Designated Breastfeeding Expert (DBE) Roles and Responsibilities Page 710.8 Appendix B Lactation Support – Special Situations DEFINITIONS Breastfeeding: Breastfeeding is the practice of feeding a participant’s human milk to their infant(s) on the average of at least once a day (CFR 246.2) Breast/Chestfeeding: A participant of any gender directly feeding at the breast/chest.

Breastfeeding: Definition, Promotion and Support Standards, Continued 710.2 Breastfeeding Participant: The category “breastfeeding participant” refers to participants up to one-year postpartum breastfeeding their infant, including. • Participants feeding their human milk to their infant(s) via breastfeeding (fully, mostly, or some) on the average of at least once a day. • Participants their human milk to their infant(s) by expressing their human milk by hand or pump and feeding their expressed human milk to their infant on the average of at least once a day. • Participants feeding their human milk at least on average once a day to an infant on WIC who they did not give birth but have legal responsibility for (custody). (see definition below). A “breastfeeding participant” fits into one of the following three categories: • Fully breastfeeding participant: A breastfeeding participant who is up to one year postpartum, whose infant does not receive formula from WIC. • Mostly breastfeeding participant: A breastfeeding participant who is up to one year postpartum, whose infant receives infant formula from WIC up to the maximum provided for a mostly breastfeeding infant. • Some breastfeeding participant: A breastfeeding participant who is one month to one year postpartum, whose infant receives more than the maximum amount of infant formula from WIC provided for a mostly breastfeeding infant, but less than the amount provided for a non-breastfeeding infant. Category Distinction: The category “breastfeeding participant” does NOT include people who are providing their human milk to infants only by donating their human milk to a milk bank or other source. Non-birth Breastfeeding Participant: A participant who is breastfeeding an infant they did not give birth to and has legal responsibility for. Examples include foster parents, adoptive parents, and parent partners who are both breastfeeding and living in the same household. A non-birth breastfeeding parent may receive WIC services if they meet eligibility criteria and the infant receiving their human milk is a WIC participant, and the birth parent is not on WIC as a breastfeeding participant. Wet Nurse Breastfeeding Participant: A participant who breastfeeds an infant they did not give birth to and does not have legal responsibility (custody) for. A wet nurse may receive WIC services as a breastfeeding participant if the infant is receiving the Wet Nurse’s human milk at least once per day. The Wet Nurse must meet WIC eligibility criteria. The infant receiving the Wet Nurse’s human milk is a WIC participant. There are no additional participants enrolled in WIC as a breastfeeding participant for this infant. Surrogate Breastfeeding Participant: A breastfeeding participant who is the birth parent of a WIC infant and who does not have legal responsibility (custody) for the infant, but the infant is fed the surrogate parent’s human milk on average of at least once a day. To receive WIC services as a breastfeeding participant, the surrogate participant must meet WIC eligibility criteria; the infant is a WIC participant; and there are no additional participants enrolled in WIC as a breastfeeding participant for this infant. A surrogate qualifies as a postpartum participant if they meet WIC eligibility requirements, and the adoptive or foster parent is the breastfeeding participant for the infant.

Breastfeeding: Definition, Promotion and Support Standards, Continued 710.3 PROCEDURE Promotion of breastfeeding 1.0 Oregon WIC staff promote breastfeeding as the biological norm for infant feeding by

Providing breast/chestfeeding promotion and support information at the prenatal certification visit, and throughout the prenatal and postpartum periods.

Encouraging all pregnant participants to breastfeed unless contraindicated for health reasons. Local agency staffing 2.0 Each local agency will identify a Breastfeeding Coordinator to provide breast/chestfeeding promotion, education, and support leadership. See Appendix A for a list of the specific qualifications, roles, and responsibilities of the local agency Breastfeeding Coordinator. See also 435—Staffing Requirements.

Each local agency is recommended to have at least one WIC Designated Breastfeeding Expert (WIC DBE) on staff. Local agencies with a WIC Breastfeeding Peer Counseling Program are required to have a WIC DBE on staff See 716—Breastfeeding Peer Counseling (BFPC) Program Requirements. See Appendix A for a list of the specific qualifications, roles and responsibilities of the WIC DBE. Staff training 3.0 The state WIC agency is required by federal regulations to provide training on breastfeeding promotion and management to all local agency staff who then provide information and assistance to participants.

The local agency Breastfeeding Coordinator helps train staff in providing breast/chestfeeding support services.

All new WIC staff will be trained in task-appropriate breastfeeding as part of their orientation.

The local agency Breastfeeding Coordinator will mentor new and existing staff.

Local agency training supervisors shall use state provided training modules and materials to train local agency staff. Clinic environment 4.0 Establish local program policies, procedures and activities that promote a breastfeeding-friendly clinic environment.

Encourage staff to communicate a positive attitude toward breast/chestfeeding.

Use positive lactation messages and images in educational and outreach materials and displays.

Ensure infant formula, bottles, and related materials are out of the sight of participants and the public.

Do not use or purchase items that market specific brand name products, such as bottles or handouts with a formula company logo. Refuse samples from

Breastfeeding: Definition, Promotion and Support Standards, Continued 710.4 formula representatives for use by local agency staff. See also 460— Program Incentive Items.

Encourage and support local agency staff to breastfeed.

Support breastfeeding in clinics and provide private space if desired for staff and participants to breastfeed and/or express human milk. Special situations 5.0 Special cases requiring careful attention to determine eligibility include adoption, surrogacy, foster care, or households headed by two parents breastfeeding the same infant. See Appendix B for specific details on how to enroll these special cases on WIC. For situations not addressed, contact your assigned Nutrition Consultant.

For each infant, only one parent may be certified on WIC as a breastfeeding participant. If both birth parent and non-birth parent are breast/chestfeeding and apply for WIC services, the birth parent would apply as non-breastfeeding postpartum, and the non-birth parent would apply as breastfeeding. This would accommodate both parents being certified.

If both parents are certified on WIC: 5.2.1. The infant may only be claimed in one household when determining family size and income eligibility. 5.2.2. The infant’s ID number must be documented in the breastfeeding participant’s chart if they are not linked in the data system, and staff must verify infant’s food package prior to assigning and issuing food packages to the breastfeeding participant.

Both participants will be offered nutrition-focused counseling, lactation support, the correct food package for their category, and a referral to a lactation specialist if appropriate.

A non-birth breast/chestfeeding participant must meet specific criteria to qualify for a WIC breast pump. See Appendix B and 712—Breastfeeding: Breast Pump Ordering, Distribution and Tracking Guidelines for more details. Contraindications 6.0 Contraindications to providing human milk, though uncommon, may exist. Staff need to recognize them and make appropriate referrals.

Breastfeeding is contraindicated when: 6.1.1. The lactating participant has tested positive for HIV (human immunodeficiency virus). 6.1.2. The infant has galactosemia (inability to metabolize galactose, a rare condition). 6.1.3. The lactating participant has T-cell lymphotropic virus type I or II. 6.1.4. The lactating participant has untreated brucellosis. 6.1.5. The lactating participant has untreated active tuberculosis. The infant can be fed the parent’s expressed human milk. 6.1.6. The lactating participant has active herpes simplex lesions on their breast/chest. The infant can be fed on the uninfected side if the

Breastfeeding: Definition, Promotion and Support Standards, Continued 710.5 infection is on one side only. The infant can be fed the parent’s expressed human milk.

Special consideration, assessment and counseling should be given to a lactating participant in the following situations. Refer the participant to a WIC Nutritionist, lactation consultant, WIC Designated Breastfeeding Expert, or health care provider for further evaluation and follow up. 6.2.1. The lactating participant uses cannabis, or certain street drugs such as PCP (phencyclidine) or cocaine. These substances can be detected in human milk and there is concern about the potential impact on the infant. 6.2.2. A lactating participant with symptoms of or confirmed COVID-19 is recommended to take steps to avoid spreading the virus to their infant: • Wash hands before touching infant. • Wear a cloth face covering, if possible, while feeding at the breast/chest. • Wash hands before touching pump or bottle parts and clean all parts after each use.

6.2.3. A lactating participant who develops varicella 5 days before through 2 days after delivery will need to be separated from their infant for a period. The infant can be fed their expressed milk. 6.2.4. A lactating participant with H1N1 influenza should be temporarily isolated from their infant. The infant can be fed their expressed milk. 6.2.5. The lactating participant takes medications from the following classes of drugs. In most cases a compatible medication can be found. • Amphetamines • Chemotherapy agents • Ergotamines • Statins 6.2.6. The lactating participant has been exposed to diagnostic radioactive compounds. 6.2.7. The infant has glucose-6-phosphate-dehydrogenase deficiency. 6.2.8. The infant has phenylketonuria (PKU). Infants with PKU can partially breastfeed while using special supplemental formula. Close monitoring by the health care provider is required. 6.2.9. The lactating participant ingests alcoholic beverages. 6.2.10. The lactating participant smokes cigarettes. 6.2.11. A lactating participant enrolled in a supervised methadone maintenance program can be encouraged to breast/chestfeed. 7.0 For the lactating participant and infant who are not fully breast/chestfeeding, refer to  713—Breastfeeding: Use of Supplemental Formula 730—Bid Formula: Use and Description, to determine the appropriate human milk substitute for the infant’s use.

Breastfeeding: Definition, Promotion and Support Standards, Continued 710.6

POLICY HISTORY Date * Major revision, Minor revision 3/8/2016 Revision 6/28/2019 Major revision 8/23/2024 Major revision 10/01/2024 Major revision

The date located at the top of the policy is the implementation date unless an “effective date” is noted on the policy. Policies will become compliance findings 6 months from the implementation date. Release notes can be found in the corresponding document on the Policy and Procedure Manual page. *Major Revisions: Significant content changes made to policy. Minor Revisions: Minor edits, grammatical updates, clarifications, and/or formatting changes have occurred. Date of Origin: Date policy was initially released If you need this in large print or an alternate format, please call 971-673-0040. This institution is an equal opportunity provider.

Breastfeeding: Definition, Promotion and Support Standards, Continued 710.7 APPENDIX A Local Agency (LA) Breastfeeding Coordinator Qualifications, Roles, and Responsibilities

DEFINITION: The Local WIC Agency Breastfeeding Coordinator is a designated staff member who provides leadership to the local WIC agency regarding breastfeeding promotion, support, and protection.

QUALIFICATIONS: • Is experienced in and committed to promoting, supporting, and protecting breastfeeding. • Is a WIC Competent Professional Authority (CPA) or completes all WIC CPA training within 6 months of assuming this role. • Completes Level 4 WIC Breastfeeding Training module within 6 months of assuming this role.

DESIRABLE SKILLS: • Has experience providing breastfeeding counseling to parents who are representative of the WIC population. • Is a WIC Designated Breastfeeding Expert (DBE). • Willingness to pursue the International Board Certified Lactation Consultant (IBCLC), Certified Breastfeeding Specialist (CBS), Certified Lactation Counselor (CLC) or Certified Lactation Educator (CLE)

ROLES • Assesses, plans, implements, and evaluates strategies to meet the lactation education needs within the WIC program. • Assists WIC Coordinator, Training Supervisor and Breastfeeding Peer Counseling Coordinator and Breastfeeding Breast Pump Coordinator in the breastfeeding-related training of local agency staff. • Assures that effective, appropriate, and accurate lactation information and services are provided to WIC participants. • Works with the local agency WIC coordinator or the local agency training supervisor to assign a co-worker the Breast Pump Coordinator role. Authorizes and trains local agency staff in the appropriate assessment and issuance of breast pumps. • Is a breastfeeding advocate and resource within the WIC program, the agency, and the community.

TYPICAL DUTIES & RESPONSIBILITIES The Breastfeeding Coordinator provides leadership to the local agency in the following areas: • Is familiar with Oregon WIC breastfeeding policies and works in coordination with the LA WIC Coordinator to assure compliance. • Advocates within the agency for best practices in breast/chestfeeding promotion, support, and management. • Ensures that the local agency follows federal and state laws regarding the provision of rest periods to breastfeeding employees for milk expression. • Coordinates the breastfeeding activities related to the annual Nutrition Services Plan

Breastfeeding: Definition, Promotion and Support Standards, Continued 710.8 • Tracks breastfeeding rates and trends through the WIC data system and other sources, if available. • Oversees breast pump inventory and tracking of multi-user double electric breast pumps. • Plans and coordinates special projects, activities, and events, such as support groups, peer counseling and National WIC Breastfeeding Week during National Breastfeeding Month. • Is the key breastfeeding contact for the State Agency. • Participates in the quarterly Breastfeeding (BF)/BFPC meeting. The Breastfeeding Coordinator provides leadership regarding information and services to WIC participants: • Keeps current on breastfeeding and lactation science as it applies to WIC services. • Assesses task-appropriate lactation training needs of staff. • Provides to staff (through training or other methods) appropriate, current, and accurate lactation information, and builds skills of WIC staff, using the FNS Breastfeeding Training Level 1- 4 Curriculum as appropriate. • Maintains a positive clinic environment that promotes lactation. • Assures that participant educational materials are appropriate and effective (brochures, videos, posters, etc.) • Assures lactation is promoted to all pregnant participants at their initial certification, unless medically contraindicated • Assures, through review and observation, that WIC staff provide prenatal and postpartum participants with participant-centered lactation education in both individual and group settings. • Assures that WIC participants receive breast/chestfeeding encouragement, support, counseling, and follow-up, if appropriate. • Assures that breastfed infants’ food packages are tailored to support continued breastfeeding. • Assures that WIC participants who need WIC breast pumps receive them in a timely manner, are instructed correctly, and are provided follow-up. • Assures that WIC participants are referred to other lactation resources that are beyond staff expertise and/or the scope of WIC services.

The Breastfeeding Coordinator provides leadership to the local agency and surrounding community: • Acts as the liaison between the WIC agency and the community regarding breastfeeding promotion, education, and support. • Networks with other lactation advocates and professionals and helps to build and strengthen task forces, coalitions or other partnerships and activities. • Identifies lactation resources for the referral and support of WIC participants. • Advocates for lactation services for WIC participants. • Assesses community and agency lactation needs and helps address those needs.

Breastfeeding: Definition, Promotion and Support Standards, Continued 710.9 Local Agency WIC Designated Breastfeeding Expert (WIC DBE) Qualifications, Roles, and Responsibilities

QUALIFICATIONS: • Successful completion of the FNS competency-based training for Oregon WIC Breastfeeding Curriculum (Levels 1-4) • Minimum of one year of experience in counseling breastfeeding parent/infant dyads. • Is a health professional: International Board Certified Lactation Consultant (IBCLC), dietitian, registered nurse, physician, physician’s assistant or has completed a minimum of 8 college courses from an accredited institution in the Health Sciences (suggested coursework includes but is not limited to the following areas: Human Anatomy, Human Physiology, Biology, Infant Growth and Development, Nutrition, Counseling Skills, Sociology, Introduction to Clinical Research, etc.).

ROLES & RESPONSIBILITIES: Provides follow-up lactation support to participants. Acts on all referrals from other WIC staff regarding complex lactation situations beyond their scope of practice. Assesses and counsels participants and infants with complex lactation situations.

Breastfeeding: Definition, Promotion and Support Standards, Continued 710.10 APPENDIX B Breastfeeding Support – Special Situations Birth parent and infant are living apart (adoption, foster care, surrogacy) • A birth parent who is providing their human milk for the infant, even though separated from the infant, may qualify for WIC as a breastfeeding participant if the following criteria are met: They meet the WIC definition of breastfeeding. The infant is enrolled on WIC. There are no additional participants enrolled in WIC as a breastfeeding participant for this infant. The birth parent meets the eligibility requirements of income, residency, and nutritional risk. • If the birth parent is not breastfeeding, they may qualify for WIC as a non-breastfeeding postpartum participant if they meet the eligibility requirements of income, residency, and nutritional risk.

Data System Documentation Food Package Assignment • Make notes in data system for both families regarding this special situation, including WIC ID numbers for each participant • Assign appropriate food packages to birth parent and infant based upon amount of formula, if any, infant is receiving from WIC. • Assign the WN food package if the birth parent is not breastfeeding. See 769—Assigning WIC Food Packages for further information

Birth parent and non-birth parent are BOTH breastfeeding the infant and are living apart (adoption, foster care, surrogacy) • The non-birth parent must be meet the WIC definition of breastfeeding and meet the WIC eligibility requirements of income, residency, and nutritional risk. The non-birth parent is certified as a breastfeeding participant. • The birth parent may apply as a non-breastfeeding postpartum participant because only one parent can be certified on WIC as a breastfeeding participant. • If both the non-birth parent and the birth parent are certified on WIC, the infant may be claimed in only one parent’s household for determining family size and income eligibility. • The infant is not required to live with the non-birth breastfeeding parent to be eligible for WIC.

Data System Documentation Food Package Assignment • Make notes in data system for both families regarding this special situation, including WIC ID numbers for each participant • Assign appropriate food packages to the non- birth parent and infant based upon the amount of formula, if any, infant is receiving. • Assign the WN food package to the birth parent, regardless of breastfeeding status, as only one breastfeeding parent can be tied to an infant. See 769—Assigning WIC Food Packages for further information

Breastfeeding: Definition, Promotion and Support Standards, Continued 710.11 Birth parent and non-birth parent are both breastfeeding the infant and live in the same household. • The non-birth parent must be breast/chestfeeding and meet the WIC eligibility requirements of income, residency, and nutritional risk. The non-birth parent is certified as a breastfeeding participant. • Only one parent in the household may be certified as a breastfeeding participant. • Since the non-birth parent cannot be on WIC as a postpartum participant (they were never pregnant), they must be certified as the breastfeeding participant and the birth parent will be certified as the non-breastfeeding postpartum participant (even if breastfeeding). • The length of the certifications will be determined by the age of the infant. As with birth parents, a non-birth parent’s status as a breastfeeding participant ends when that participant stops feeding the infant their human milk at least one time per day or at the infant’s first birthday, whichever comes first.

Data System Documentation Food Package Assignment • Enroll breastfeeding infant in the family with the WIC breastfeeding participant (non-birth parent) • Enroll birth parent as a non-breastfeeding participant, regardless of breastfeeding status, in a separate family in data system. • Certification of the non-birth breastfeeding participant: Medical Data Screen Enter 999 for “Total Weight Gain, Pregnancy Just Completed” Health History Questionnaire Enter one for the question “For the pregnancy just completed, how many babies were delivered?” even though they did not give birth. • Document the birth parent’s ID number in the WIC Notes of each record to link them • Assign the appropriate food packages to the non-birth parent and infant based upon the amount of formula, if any, the infant is receiving. • Assign the birth parent the WN food package, regardless of breastfeeding status.

See  760- Assigning WIC Food Packages for further information

Breast Pump Issuance • A non-birth breastfeeding participant may qualify for a single-user or multi-user double electric breast pump to increase milk production; pump may not be issued until after the baby is born and the infant is an active WIC participant. • 712—Breastfeeding: Breast Pump Ordering, Distribution and Tracking Guidelines. must be met.