713.1 Policy 713 Breastfeeding: Use of Supplemental Formula January 6, 2025

POLICY Local WIC programs shall adopt policies for tailoring infant food packages to encourage continued breastfeeding when participants are not fully breastfeeding. PURPOSE To support breastfeeding participants and infants by providing appropriate counseling and food packages consistent with their nutritional needs. RELEVANT REGULATIONS 7 CFR 246.10 Supplemental Foods 7 CFR 246.11 (c) (7) (iv) Breastfeeding promotion mandate OREGON WIC PPM REFERENCES ♦ 710- Breastfeeding: Definition, Promotion and Support Standards ♦ 720—General Information on Formula Use ♦ 730—Bid Formula: Use and Description ♦ 769—Assigning WIC Food Packages APPENDICES Page 713.6 Appendix A Determining Supplemental Formula Amounts for the Partially Breastfed Infant 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) 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 average of at least once a day. • Participants feeding 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 average at least once a day. See policy  710-Breastfeeding: Definition, Promotion and Support Standards for additional categories and definitions. See definitions under fully breastfeeding, mostly breastfeeding, some breastfeeding and non-breastfeeding for important distinctions.

Breastfeeding: Use of Supplemental Formula, Continued 713.2 Breastfeeding Self Efficacy (BSE): An individual’s degree of confidence in their ability to successfully breastfeed their child. Participants with a high degree of BSE will expend more energy to overcome challenges because they see themselves as capable of breastfeeding and are quite certain they can succeed. Breastfeeding Assessment: Collects information related to breastfeeding to determine how breastfeeding is progressing. Bid formula: Standard infant formula provided by the Oregon WIC program through a competitive bid process. Standard formula is also called “term” and “non-exempt” formula. The bid formula currently in use in Oregon WIC may change based on contract renewals. According to federal requirements, standard infant formulas must meet the Standard of Identify set by the Food and Drug Administration (FDA) of 20 calories per fluid ounce at standard dilution. Human milk substitute: Infant formula. Supplement: Expressed human milk or human milk substitute provided to an infant who is primarily breastfed. Fully breastfeeding infant: A breastfeeding infant who is up to one year of age and does not receive infant formula from WIC. Fully breastfeeding participant: A breastfeeding participant who is up to one year postpartum, whose infant does not receive formula from WIC. Mostly breastfeeding infant: A mostly breastfed infant who is one month to one year of age and receives infant formula from WIC up to the maximum provided for a mostly breastfed infant. 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 infant: A breastfeeding infant who is up to one year of age and 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. Some breastfeeding participant: A breastfeeding participant who is up 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. Non-breastfeeding infant: An infant who is not breastfeeding and is up to one year of age and receives infant formula from WIC. Non-breastfeeding participant: A participant who is not breastfeeding and is less than six months postpartum. WIC Designated Breastfeeding Expert: An individual who is an expert with special experience or training in helping breastfeeding participants and who provides breastfeeding and lactation expertise and care for more complex lactation and breast/chestfeeding problems when WIC staff face situations outside their scope of practice. Yield: The process WIC staff use to invite another staff with additional lactation expertise to assist when they are working with a participant experiencing a breastfeeding or lactation

Breastfeeding: Use of Supplemental Formula, Continued 713.3 challenge that is complicated and/or unusual. Sometimes it may be necessary to yield to a community International Board Certified Lactation Consultant (IBCLC) if an IBCLC or WIC Designated Breastfeeding Expert (DBE) is not available within the local agency. When staff yield, they continue to assist the family, while the staff who they yielded to work to resolve breastfeeding challenges. BACKGROUND Normative infant and young child feeding includes immediate skin-to-skin contact, early initiation of baby-led breastfeeding (within 1 hour of birth), exclusive breastfeeding for 6 months, and continued breastfeeding for at least 2 years or longer, with age-appropriate complementary feeding. When a breastfeeding participant requests formula from WIC, they may not be fully aware of the impact of formula supplementation on lactation. Giving infant formula to a breastfeeding infant in the first month interferes with establishing breastfeeding and often leads to a decrease in a participant’s milk production. Breastfeeding counseling is required to support continued breastfeeding and builds a participant’s breastfeeding self- efficacy. It helps participants make informed infant feeding decisions.

PROCEDURE 1.0 A Competent Professional Authority (CPA) shall provide counseling to a breastfeeding participant who requests supplemental formula for their infant. The CPA providing counseling must first complete Levels 1-3 of the Oregon WIC Breastfeeding Training.

Breastfeeding Assessment: When possible, the counseling is provided by a WIC Nutritionist, (RDN), nurse (RN), other Health Professional, Lactation Consultant (IBCLC), WIC Designated Breastfeeding Expert,(DBE) or designated staff who has completed the WIC Food and Nutrition Services (FNS) Breastfeeding Training Levels 1-4.

Complete Breastfeeding Assessment to tailor education and support, and assign appropriate food package before issuing formula benefits.

Counseling by the CPA includes the following steps: 1.3.1. Build a rapport with the participant so they feel comfortable conversing and sharing their infant feeding experience. Use participant centered education skills by using open-ended questions, affirmations, reflections, and summaries. Explore how feeding is going and learn what the participant’s desires and intentions are for continued lactation. Asking participants what is most important to them about breastfeeding can be helpful. Participants often request formula when they feel overwhelmed with parenting a new baby and they see formula as an easier option. They may be facing mild, moderate, or severe breastfeeding challenges. Depending on the assessment the CPA may need to yield to a staff with additional lactation expertise. 1.3.2. Find out how the parent feels feeding is going and what their current goals and concerns are.

Breastfeeding: Use of Supplemental Formula, Continued 713.4 1.3.3. Collect relevant information, examples include frequency of feeding and total number of feeds in 24 hours, hunger and satiety cues, number of wet and soiled diapers, infant growth trends including weight gain and loss, positioning, and latch. 1.3.4. Summarize the participant’s goals and experiences with breastfeeding. 1.3.5. Identify the participant’s social support and lactation support in the community. 1.3.6. Assess the participant’s understanding of the potential impact of supplemental formula on milk production, the participant’s health and the health of their infant. 1.3.7. Inform the participant their food package will change based upon how much they are breastfeeding and discuss tailoring options. See policy 769—Assigning WIC Food Packages for details. See Appendix A for details. 1.3.8. Schedule or plan a follow up to reassess breastfeeding and supplementation as needed. 1.3.9 Refer participants with lactation concerns to a WIC DBE or to community lactation support when issues are beyond the CPA’s scope of practice. Infant’s food package 2.0 When the decision is made to provide supplemental formula, issue the infant a food package consistent with their nutritional needs.

If supplementation is indicated, use the bid milk-based formula as the first option for supplementation per 730—Bid Formula: Use and Descriptions.

Provide powdered formula as a supplement, if available, because it can be prepared in as small a quantity as needed.

In some circumstances, a medical condition may warrant a different type of formula. E.g. prematurity and the need for ready-to-feed formula. Refer to policy  720—General Information on Formula Use for a comprehensive list of when ready-to-feed formula can be issued and for documentation requirements. Amount of supplemental formula 2.3.1. Determine the amount of supplemental formula necessary and assign the appropriate food package. Provide the minimum amount of formula, usually starting with one can of powder, to meet and not exceed the infant's nutritional needs. If the infant is receiving no formula and the participant is unsure of how many formula feedings they will be using, assess and counsel the participant on the impact of formula as in 1.3.6 above.

Breastfeeding: Use of Supplemental Formula, Continued 713.5 2.3.2. If the participant is already giving the infant some formula, issue the lowest amount the infant is currently using. See Appendix A for additional guidance on calculating the amount of supplemental formula or the Food and Nutrition Services tailoring calculator: WIC Infant Formula. 2.3.3. Supplemental formula can be increased up to the maximum allowed based on infant’s age and category. See 769—Assigning WIC Food Packages for quantities allowed. 2.3.4. If the infant is using formula but isn’t receiving it from WIC, and the parent meets the definition of a breastfeeding participant, they could receive up to a fully breastfeeding food package once WIC staff have completed a breastfeeding assessment. 2.3.5. Provide additional follow-up with the participant and infant to continue to support breastfeeding success. Food package adjustment

A breastfeeding infant who receives any formula from WIC is no longer in the fully breastfeeding category. The infant’s status and parent’s status need to match and will need to be changed to the appropriate breastfeeding category of mostly breastfeeding or some breastfeeding. Once the categories are changed, the appropriate food packages can be selected. 2.4.1. A parent who is over six months postpartum and is in the “some breastfeeding” category will not receive a food package; however, they will continue to receive all other WIC services. Documentation

Document breastfeeding assessments and food package changes. Documentation of the breastfeeding assessment and plan is required when there is a category change and supplemental formula is issued or changed. 2.5.1. Documentation may include: issues or concerns regarding lactation, infant feeding and/or growth, feeding goals, education provided and/or offered, use of supplemental formula, including how much, any follow-up plans, and food package changes. REFERENCES 1. Oregon WIC Training: FNS Breastfeeding Training Levels 1 – 4, 2020. 2. Wambach, K. Breastfeeding and Human Lactation, 5th edition, 2016.

3. Lauwers, J., Swisher, A. Counseling the Nursing Mother, A Lactation Consultant’s Guide, 6th edition, 2016. 4. Mohrbacher, N., Breastfeeding Answers, A Guide for Helping Families, 2nd edition, 2020 5. Spatz, D. and Lessen, R. Risks of Not Breastfeeding, ILCA, 2011 6. U.S. Department of Agriculture WIC Breastfeeding Support https://wicbreastfeeding.fns.usda.gov/breastfeeding-check

Breastfeeding: Use of Supplemental Formula, Continued 713.6

POLICY HISTORY Date * Major Revision, Minor revision 9/17/2020 Major revision 1/6/2025 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: Use of Supplemental Formula, Continued 713.7 APPENDIX A Determining Supplemental Formula Amounts for the Partially Breastfed Infant

Have you started offering a supplement? ↓ YES ↓ How much supplement is the infant getting each day?

For Bid Formula 0 - 3 oz. per day → 1 can powder per month 4 - 6 oz. per day → 2 cans powder per month 7 - 9 oz. per day → 3 cans powder per month 10 - 12 oz. per day → 4 cans powder per month 13 - 15 oz. per day → *5 cans powder per month 16 - 18 oz. per day → *6 cans powder per month 19 - 21 oz. per day → *7 cans powder per month 22 - 24 oz. per day → *8 cans powder per month 25 - 27 oz. per day → *9 cans powder per month

One can of Similac Advance powder yields 90 ounces of reconstituted infant formula.

* This quantity may exceed the maximum allowed as determined by infant age and category. See 769—Assigning WIC Food Packages for quantities allowed for each infant age and category.

The amount of formula to assign a partially breastfeeding infant can also be found on the USDA WIC breastfeeding Support website’s Tailoring Calculator: WIC Infant Formula.