PENNSYLVANIA DEPARTMENT OF HEALTH Policy Number:5.02 WIC State Agency USDA Approval Date: January 28, 2025 State Effective Date: March 29, 2025

POLICY AND PROCEDURE MANUAL 5. Nutrition and Breastfeeding Services 5.02 Breastfeeding Promotion and Support

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A. POLICY OVERVIEW

PA WIC must provide breastfeeding education to encourage breastfeeding through a combination of promotion and support activities.

B. POLICY

1. Local agencies (LAs) must institute a strategy for breastfeeding promotion and support for pregnant and breastfeeding participants.

2. LAs must train staff in breastfeeding promotion and/or support in accordance with Policy 3.03, Training of WIC Staff.

3. LAs must provide breastfeeding promotion and support services to participants consistent with State agency (SA) guidance.

4. Provision and Documentation of Breastfeeding Promotion Services:

a. Breastfeeding must be promoted among all pregnant participants to enable an informed infant feeding decision using the following guidelines:

(1) Breastfeeding promotion contacts must inquire about all pregnant participants’ prior knowledge of, experience with, and feelings and attitudes towards breastfeeding by conducting a thorough interview and providing appropriate education to counter any concerns or barriers identified. (2) All pregnant participants must be informed of the contraindications to breastfeeding. (3) Regardless of infant feeding intention prior to conversation with WIC staff, all pregnant participants must receive information describing the advantages of breastfeeding. (4) All pregnant participants must be informed of the differences between breastfeeding, partial breastfeeding, and not breastfeeding woman and infant food packages.

b. LAs must provide participants who are considering or planning to breastfeed with follow-up information, education and counseling throughout their pregnancy. Follow- ups during pregnancy must:

(1) Address individual needs and concerns. (2) Assist participants in making an informed infant feeding decision.

PENNSYLVANIA DEPARTMENT OF HEALTH Policy Number:5.02 WIC State Agency USDA Approval Date: January 28, 2025 State Effective Date: March 29, 2025

POLICY AND PROCEDURE MANUAL 5. Nutrition and Breastfeeding Services 5.02 Breastfeeding Promotion and Support

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(3) Assist participants in preparing to successfully breastfeed, including developing a plan to initiate breastfeeding at the hospital and establishing realistic expectations of breastfeeding. (4) Address how family members and peers can support the breastfeeding journey.

c. LAs must document breastfeeding promotion in the MIS in accordance with SA guidance and must include the following:

(1) Prior knowledge and experience with and feelings and attitudes towards breastfeeding. (2) Concerns, barriers, or contraindications to breastfeeding. (3) Infant feeding intentions. (4) Details of breastfeeding education and referrals provided. (5) Plan for follow-up, if needed.

5. Provision and Documentation of Breastfeeding Support Services:

a. LAs must provide adequate support to all breastfeeding participants for the full duration of the breastfeeding journey using the following guidelines:

(1) Breastfeeding management counseling must be based on thorough assessments and with consideration for the breastfeeding dyad’s goals. Refer to B.5.c.-e. in this policy for additional information on breastfeeding-related assessments. (2) Breast pump or breastfeeding aids must be based on a thorough assessment. Refer to section B.7. of this policy for additional information on providing breast pumps and breastfeeding aids. (3) Appropriate food package must be based on breastfeeding status. (4) Supplemental formula must only be provided to the nursing infant in accordance with Policy 5.03, Formula Issuance to Breastfed Infants.

b. Mechanisms for providing support should include: in-clinic contacts, follow-up phone calls by WIC staff (particularly during the critical period in the first 10 days postpartum), peer counselors or lactation consultants, access to breastfeeding helpline, and referrals to breastfeeding support groups.

c. CPA or CPPA must complete an infant feeding screening and assessment at the infant certification and between 4 and 7 months of age and must consist of an evaluation of the infant’s nutritional intake and growth pattern.

PENNSYLVANIA DEPARTMENT OF HEALTH Policy Number:5.02 WIC State Agency USDA Approval Date: January 28, 2025 State Effective Date: March 29, 2025

POLICY AND PROCEDURE MANUAL 5. Nutrition and Breastfeeding Services 5.02 Breastfeeding Promotion and Support

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d. A Detailed Breastfeeding Assessment form must be completed when a thorough assessment of the breastfeeding dyad indicates that infant growth is not within normal limits for age or when a breastfeeding problem is reported or identified. The Detailed Breastfeeding Assessment form shall be completed by a CPA, CPPA, BFPC, or any WIC staff who maintain a CLC or IBCLC credential.

(1) Additional follow-up infant feeding screening and assessments and Detailed Breastfeeding Assessments must be conducted at subsequent appointments when a breastfeeding or growth problem is identified.

e. Breastfeeding support and referrals provided must be documented in the MIS in accordance with SA guidance and must include the following information:

(1) Results of the infant feeding screening and assessment. These results include percent of daily nutritional needs being met by supplemental formula, when applicable. (2) Results of the Detailed Breastfeeding Assessment, when applicable. (3) The mother’s breastfeeding plan and goal(s). (4) Any other pertinent information, such as support system, planned follow-up, mother’s commitment level, etc. (5) Plan for follow-up.

6. Purchase and Management of Breast Pumps and Breastfeeding Aids

a. Breast pumps and the parts necessary to operate breast pumps are considered a program benefit and must be provided to participants free of charge when a need has been determined by WIC staff. A variety of breast pump types must be made available through LAs to best support a wide range of participant needs in a cost- effective manner. Refer to section B.7. of this policy for additional details regarding Issuance and Documentation of Breast Pumps and Breastfeeding Aids.

b. LAs must register with the Pennsylvania Department of Health Drugs, Devices, and Cosmetics Program annually to maintain active status as a medical device distributor as breast pumps are considered medical devices.

c. LAs must receive approval from the SA prior to purchasing or renting breast pumps and purchasing breastfeeding aids to ensure all purchases are reasonable, necessary and conform to Federal Regulation and USDA Breastfeeding Policy and Guidance.

d. The amount of breast pumps and breastfeeding aids kept on-site must be reasonable; therefore, breast pumps and breastfeeding aids should be ordered at intervals throughout the year according to current usage.

PENNSYLVANIA DEPARTMENT OF HEALTH Policy Number:5.02 WIC State Agency USDA Approval Date: January 28, 2025 State Effective Date: March 29, 2025

POLICY AND PROCEDURE MANUAL 5. Nutrition and Breastfeeding Services 5.02 Breastfeeding Promotion and Support

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e. LAs that purchase their own multi-user, hospital grade electric breast pumps must have a SA-approved procedure in place to retrieve them if participants fail to return them in a timely manner or in damaged condition. Procedures may include phone calls, registered letters, email contacts, use of a collection agency, or more frequent WIC appointments until the breast pump is returned. Breast pumps not returned by a participant that cost WIC more than $1,000.00 will result in a 1-year participant disqualification. Refer to Policy 1.02, Abuse and Fraud Prevention and Investigation.

(1) LAs must not charge a breast pump replacement fee for any breast pumps that have not been returned to the WIC program.

f. LAs that have a rental agreement with a breast pump supplier must follow the procedures of their rental contract when a breast pump has not been returned to WIC at the agreed upon time.

(1) This may include the breast pump supplier seeking reimbursement for the cost of the rental breast pump.

g. WIC Staff responsible for the retrieval of breast pump(s) that have not been returned in a timely manner or have received a breast pump in damaged condition must:

(1) Document all contact attempts to retrieve breast pump(s) in the MIS. (2) Update the status of breast pumps in the MIS to indicate that breast pump(s) have been lost, stolen or damaged after a reasonable effort has been made without success of retrieving the breast pump back into WIC possession or immediately upon receipt of a damaged breast pump. (3) If a breast pump is returned to a local agency or clinic other than the agency or clinic that loaned the pump, the receiving agency or clinic must contact the originating agency or clinic to make arrangements to return the breast pump or, to request a transfer of the breast pump. Upon agreement by both parties, the accepting local agency or clinic must document inventory of this pump and notify the State WIC Office of change.

h. LAs must accurately maintain breast pump inventory in the MIS. Additional inventory efforts are at the discretion of each LA. A count of all breast pumps issued or loaned to participants within each Federal Fiscal Year (FFY) must be submitted to the SA at the end of each FFY.

7. Issuance and Documentation of Breast Pumps and Breastfeeding Aids

PENNSYLVANIA DEPARTMENT OF HEALTH Policy Number:5.02 WIC State Agency USDA Approval Date: January 28, 2025 State Effective Date: March 29, 2025

POLICY AND PROCEDURE MANUAL 5. Nutrition and Breastfeeding Services 5.02 Breastfeeding Promotion and Support

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a. Breast pumps and breastfeeding aids may be issued to support breastfeeding success but may not be offered or issued solely as an enticement or incentive to consider or continue breastfeeding.

b. Before offering a breast pump from WIC, staff must determine if the participant’s insurance plan reimburses for breast pumps. If breast pumps are a reimbursable item, staff must refer the individual to their primary insurance provider. However, if the participant must wait an unreasonable amount of time in order to receive a breast pump through the insurance provider or if the insurance provider does not cover a breast pump that is suitable to the participant’s needs, staff may issue a breast pump.

c. Breast pumps and breastfeeding aids may be issued to:

(1) Active participants who have been certified as breastfeeding. i. Exceptions may be approved by the SA on a case-by-case basis. Any approved exceptions must be clearly documented in the MIS. (2) Pregnant participants who are breastfeeding an active WIC infant participant.

d. Participants must receive education from trained, designated staff on the proper assembly, use, and cleaning of breast pumps and parts as well as breastfeeding aids prior to their issuance. Participants must also receive education on safe handling and storage of expressed breast milk at the time of breast pump issuance.

e. All breast pump issuances, information and education provided during the breast pump issuance must be documented in the MIS in accordance with SA guidance.

f. LAs are strongly encouraged to follow-up with participants within 24 hours of breast pump issuance.

g. Signature of the endorser or proxy must be captured in the MIS when issuing serialized breast pumps. When signatures for serialized items cannot be captured in the MIS, the endorser or proxy must sign the Breast Pump Release Form which must be kept on file at the LA.

h. The Breast Pump Release Form must be reviewed with and provided to the endorser or proxy when issuing a serialized breast pump at the time of signature collection.

8. Breastfeeding Supportive Clinic Environment:

PENNSYLVANIA DEPARTMENT OF HEALTH Policy Number:5.02 WIC State Agency USDA Approval Date: January 28, 2025 State Effective Date: March 29, 2025

POLICY AND PROCEDURE MANUAL 5. Nutrition and Breastfeeding Services 5.02 Breastfeeding Promotion and Support

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a. LAs must provide a positive clinic environment that is conducive to the promotion and support of breastfeeding through the following means:

(1) Provide educational and promotional materials that portray breastfeeding as the optimal infant feeding method. (2) Does not display formula or materials, displays or logos featuring formula, or images (posters, pictures, brochures, etc.) that feature bottle feeding. However, brochures on formula and bottle feeding may be provided to participants when appropriate. (3) It is the professional responsibility of all staff to promote and support breastfeeding and to refrain from conveying negative attitudes or opinions about breastfeeding regardless of personal viewpoints. (4) The waiting area should be used to promote breastfeeding as the social and cultural norm through signage indicating breastfeeding is welcome anywhere in the LA. (5) LAs must provide a designated supportive environment in which women can breastfeed their infants with more privacy, if desired (i.e. a comfortable breastfeeding area, chairs with arms, etc.). Refer to Policy 1.00, Program Management, for additional information on breastfeeding in the workplace. (6) Staff must not accept complimentary formula for personal use or for distribution to WIC participants.

9. Breastfeeding Coordination Between WIC and External Programs:

a. LAs must contact healthcare providers and community organizations to coordinate breastfeeding promotion efforts that inform other agencies of WIC goals and philosophy regarding breastfeeding.

b. Coordination with external programs and community organizations may supplement, but not replace, breastfeeding services provided by WIC staff, unless approved by the SA.

c. LAs are encouraged to establish or participate in a local breastfeeding coalition or task force to help promote breastfeeding in its service area.

10. Breastfeeding Plans:

a. LAs must develop and submit to the SA an annual breastfeeding plan in accordance with guidance distributed by the SA.

b. Annual breastfeeding plans must be prepared by the Breastfeeding Coordinator. When feasible, all staff that provide breastfeeding promotion and support services

PENNSYLVANIA DEPARTMENT OF HEALTH Policy Number:5.02 WIC State Agency USDA Approval Date: January 28, 2025 State Effective Date: March 29, 2025

POLICY AND PROCEDURE MANUAL 5. Nutrition and Breastfeeding Services 5.02 Breastfeeding Promotion and Support

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should be given the opportunity to participate in the development of the LA breastfeeding plan.

c. All staff that provides breastfeeding promotion and support services must be familiar with Federal and SA requirements for breastfeeding services and must be familiar with the LA breastfeeding plan contents.

References: 1. WIC Regulations. 7 CFR 246.2 (Participant Violation) 2. WIC Regulations. 7 CFR 246.11 3. WIC Regulations. 7 CFR 246.14(b)(1)(iii) 4. USDA WIC Breastfeeding Policy and Guidance. (July 2016) 5. Pennsylvania Department of Health Drugs, Devices, and Cosmetics Program: Drugs, Devices and Cosmetics Program (pa.gov)

Policy Status: 1. This Policy supersedes Policy Number 5.02 dated February 13, 2017.