Policy and Procedure Manual

Volume 1, Chapter 15 Breastfeeding

Washington WIC Program DOH 960-367 Effective June 1, 2022

This institution is an equal opportunity provider. Washington WIC doesn’t discriminate.

For persons with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-841-1410 (TDD/TTY 1-800-833-6388).

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Breastfeeding | Page i

Breastfeeding

CONTENTS Section 1: Provide Breastfeeding Promotion and Support in the WIC Clinic 1 POLICY: Breastfeeding Promotion and Support is a Core Job Responsibility .......................... 1 POLICY: Promote and Support Breastfeeding ......................................................................... 3 POLICY: Breastfeeding Coordinator ........................................................................................ 7 POLICY: Staff Breastfeeding Education and Training .............................................................. 9 POLICY: The Breastfeeding Review ....................................................................................... 12 POLICY: Breastfeeding Friendly Clinic ................................................................................... 18 Section 2: Breast Pump Policies 20 POLICY: Option to Offer Breast Pumps ................................................................................. 20 POLICY: Order Breast Pumps, Pump Kits, and Breast Pump Supplies ................................... 23 POLICY: Order Breastfeeding Supplies Using Local WIC Funds ............................................. 25 POLICY: Option to Contract with a Third Party to Provide WIC Breast Pumps ..................... 27 POLICY: Issue Breast Pumps ................................................................................................. 28 POLICY: Return Multi-User Breast Pumps ............................................................................ 34 POLICY: Insects in Multi-User Breast Pumps ........................................................................ 36 POLICY: Track Electric Breast Pump Inventory ..................................................................... 37 POLICY: Recover Breast Pumps from Transfer Participants .................................................. 39 POLICY: Lost or Stolen Multi-user Breast Pumps .................................................................. 41 POLICY: Damaged Multi-user Breast Pumps ......................................................................... 43 Section 3: Breastfeeding Peer Counselor Program 44 POLICY: USDA Breastfeeding Peer Counseling Program ....................................................... 44 POLICY: Required Protocols for the USDA Breastfeeding Peer Counseling Program ............ 46

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| Page ii Breastfeeding POLICY: Using a Third Party Contract or a Memorandum of Understanding (MOU) ............ 47 POLICY: Peer Counselor Lead ............................................................................................... 48 POLICY: Recruiting and Hiring Breastfeeding Peer Counselors ............................................. 50 POLICY: Peer Counselor Scope of Practice............................................................................ 52 POLICY: Train Breastfeeding Peer Counselors ...................................................................... 56 POLICY: Supervise and Mentor Peer Counselors .................................................................. 59 POLICY: Peer Counselor Pay ................................................................................................. 62 POLICY: Peer Counseling Program Allowable Costs .............................................................. 64 POLICY: Community Partnerships and Promoting Peer Counseling Programs ..................... 66 POLICY: Participant Confidentiality ...................................................................................... 67 POLICY: Texting and Cell Phone Use ..................................................................................... 69 POLICY: Social Media ............................................................................................................ 70 POLICY: Video Conferencing ................................................................................................. 73 POLICY: Breastfeeding Peer Counseling Program Annual Report and Budget ...................... 75 Section 4: Appendix A 76 Examples of Roles Related to Promoting and Supporting Breastfeeding .............................. 77 Basic skills and training for all WIC staff ................................................................................ 77 Examples of roles related to promoting and supporting breastfeeding ................................ 78 SAMPLE: “Dear Breastfeeding Participant” Letter ................................................................ 82 SAMPLE: Overdue Breast Pump Letter ................................................................................. 83 Testing Electric Breast Pumps ............................................................................................... 84 SAMPLE: Inventory for Multi-user Breast Pumps ................................................................. 86 SAMPLE: Perpetual Inventory for Personal Use Breast Pumps ............................................. 87 SAMPLE: Optional Master Inventory for Multi-user Breast Pumps ...................................... 88 Section 5: Appendix B 89 Required Written Protocols for the Peer Counseling Program .............................................. 90

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Breastfeeding | Page iii Social Media Guidelines ........................................................................................................ 91

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Breastfeeding | Page 1 Section 1: Provide Breastfeeding Promotion and Support in the WIC Clinic

POLICY: Breastfeeding Promotion and Support is a Core Job Responsibility

The Coordinator must:

• Work with the breastfeeding coordinator to develop a breastfeeding promotion plan and include it with the Nutrition Services Plan (NSP).

o State staff sends a numbered memo each year with instructions for the NSP. See Volume 2, Chapter 2, Nutrition Services Plan.

• Work within their agency to include breastfeeding promotion and support as a core job responsibility for all staff who interact with participants.

• Choose a staff person to fulfill the responsibility of breastfeeding coordinator.

• Ensures participant access to a Designated Breastfeeding Expert (DBE).

PROCEDURE:

The Coordinator:

A. Completes the breastfeeding section of the Nutrition Services Plan or delegates another staff person to complete it. See Volume 2, Chapter 2 – Nutrition Services Plan for guidance. Assuring the plan:

1. Includes breastfeeding promotion and support objectives and activities and a specific plan to provide support in the early post-partum period.

2. Has measurable objectives.

3. Is shared with all staff.

B. Chooses a staff person to fulfill the duties of the breastfeeding coordinator.

C. Ensures that a WIC-Designated Breastfeeding Expert (DBE) is available to staff and peer counselors, who may also be the breastfeeding coordinator.

D. Ensures staff understand their role to support breastfeeding and meet the minimum training requirements outlined in this chapter

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| Page 2 Breastfeeding Information:

Training gives staff the knowledge they need to help participants make informed decisions about infant feeding. When staff know state and local agency breastfeeding policies, they can confidently support participants to meet their breastfeeding goals.

BEST PRACTICE: Breastfeeding Promotion and Support is a Core Job Responsibility

The coordinator, working with the breastfeeding coordinator:

• Writes a goal statement reflecting the agency’s pledge to promote and support breastfeeding. • Shares this goal statement during job interviews. • Includes roles and responsibilities to promote and support breastfeeding in staff job descriptions and other related documents. • Develops interview questions assessing a job candidate’s experience, training and attitudes towards breastfeeding. • Includes breastfeeding training goals in annual performance evaluations

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Breastfeeding | Page 3 POLICY: Promote and Support Breastfeeding

Staff must:

• Provide support, education, and offer materials that are participant-centered and culturally appropriate. • Use participant-centered skills to provide breastfeeding information and anticipatory guidance at all WIC appointments with pregnant participants. • Support ongoing breastfeeding at all WIC appointments with breastfeeding participants.

Staff must document the participant’s intention to breastfeed in the Cascades Care Plan Summary.

Staff must support all participants to meet their breastfeeding goals and encourage them to:

1. Fully breastfeed for the first six months of life, unless medically contraindicated.

2. Breastfeed for at least the first year of life and after that, for as long as desired.

Note: To learn more about staff roles in breastfeeding promotion and support, see “Examples of Roles Related to Promoting and Supporting Breastfeeding” in Appendix A.

PROCEDURE:

Staff:

A. Use open-ended questions at each appointment to:

1. Explore questions and concerns pregnant and breastfeeding participants have about breastfeeding.

Note: See the table at the end of this policy on common topics during appointments.

2. Assess and document in the Cascades Care Plan Summary:

• Breastfeeding goals.

• Support systems for breastfeeding.

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| Page 4 Breastfeeding • Barriers and concerns about breastfeeding.

• Plans to return to work or school.

B. Offer information based on the participant’s concerns and questions. Use “explore, offer, explore” counseling method to offer information and hear what the participant thinks and feels about breastfeeding.

1. Provide pregnant participants information on what to expect and how to be successful with breastfeeding (anticipatory guidance).

2. Support participants to fully breastfeed their infants the first six months of life.

3. Support breastfeeding participants to breastfeed for at least the first year of life and for as long as they want to thereafter.

4. Address the unique needs and concerns of each participant.

5. Evaluate position and latch if needed.

6. Provide a Breastfeeding Review when a breastfeeding participant requests formula.

• See “The Breastfeeding Review” policy in this chapter.

7. Refer to the Designated Breastfeeding Expert when concern is outside staff skill level or scope of practice.

8. Identify situations requiring immediate follow-up and take action.

C. Allow support people to be part of WIC appointments and group sessions.

D. Use culturally appropriate and participant-centered breastfeeding support materials. For example, offer educational materials with pictures of culturally diverse families and in the preferred language, if available or use appropriate pronouns and terminology for transgender people.

1. Review all educational materials before offering materials to participants.

E. Support continued breastfeeding by using participant-centered skills and culturally appropriate support.

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Breastfeeding | Page 5 F. Issue breast pumps and other breastfeeding equipment following state and local policies.

G. Document topics covered, materials provided and any referrals made. Indicate topics needing follow-up at the next appointment.

Information:

The table below lists common topics staff may explore with pregnant and breastfeeding participants. Learn about participant’s needs using “explore, offer, explore.” Offer information based on the participant’s questions, concerns, and interests.

The WIC program supports breastfeeding by: • Offering the most foods and food choices for fully breastfeeding participants. • Giving extra benefits for WIC foods for fully and partially breastfeeding participants through the first year post-partum. • Offering extra foods for fully breastfeeding babies. • Providing peer counselor support. • Providing breast pumps when needed. • Not providing formula to breastfed babies the first month of life to protect milk supply. Breastfeeding is a WIC priority because: • Breastmilk provides the best nutrition for all infants. • Breastfeeding saves families’ money. • Breastfeeding reduces the risk of illness and disease; these benefits last a lifetime for both. How to get the best start with breastfeeding in the hospital by: • Sharing plans to breastfeed with partners, medical providers, family, and friends. • Breastfeeding within the first hour after birth. • Breastfeeding often, when baby gives feeding cues. Newborns usually need to feed 8 to 12 times every 24 hours. This helps make milk and can prevent and decrease engorgement. Newborns shouldn’t go longer than 2 to 3 hours during the day or 4 hours at night without a feeding because their stomachs are small. • Delaying pacifier use until after the first month. • “Rooming in” with baby as much as possible at the hospital and at home. • Holding baby skin to skin as much as possible at the hospital and at home. • Not giving bottles of formula or water unless ordered by her medical provider. • Asking to see a lactation professional before leaving the hospital. • Calling WIC, a peer counselor or other lactation support service with questions as soon as they arise. • Assuring participants that having questions is normal.

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| Page 6 Breastfeeding What to expect the first month of life including: • The normal course of breastfeeding. • The value of colostrum. • How to tell if baby is getting enough milk. • Information about normal Baby Behavior, including crying, sleep and infant cues. • How using formula the first month of life can negatively impact breastmilk production. • How keeping the baby in the same room at night helps make night feedings easier. Planning to return to work or school by: • Talking to employers before baby is born about working and breastfeeding. • Developing a plan ahead of time for continued breastfeeding. How to know if baby is getting enough milk. A baby getting enough milk: • Seems happy, alert and satisfied after feedings. • Feeds at least 8 times in 24 hours. • Makes swallowing sounds consistently while breastfeeding. • Has three or more bowel movements and six or more wet diapers by the time the baby is 5 days old. • Has yellow bowel movements by time the baby is 5 days old. • Has clear or pale urine. • Wakes for feedings. Patterns of weight changes including how breastfed infants: • May lose weight in the first few days of life. • Will begin to gain weight after the mature milk comes in on day 3 or 4. • Will gain about 4 to 8 ounces per week after the first week. • Should be at or over birth weight by two weeks of age. • Often eat more often during growth spurts. • May have growth spurts between 3 and 6 weeks of age, and 3 and 6 months of age but may happen any time. State and Federal laws protecting the right to breastfeed in public and express milk in the workplace.

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Breastfeeding | Page 7 POLICY: Breastfeeding Coordinator

The local agency must have a breastfeeding coordinator to organize and guide local agency breastfeeding efforts.

The coordinator chooses a staff person to fulfill the duties of the breastfeeding coordinator. Coordinators can’t assign staff who charge 100% of their time to the peer counseling grant to be the breastfeeding coordinator.

The Breastfeeding Coordinator may also be the WIC-designated Breastfeeding expert (WIC DBE) and the Breastfeeding Peer Counselor Lead.

Breastfeeding coordinators must: • Meet the qualifications of a CPA. • Has a minimum of 1 year experience in counseling breastfeeding participants. • Be International Board Certified Lactation Consultants or completed an intensive lactation management course, or other state approved breastfeeding training. • Be the point-of-contact for the State WIC Breastfeeding Coordinator. • Participate in the development of breastfeeding activities in the Nutrition Services Plan (NSP) and assess outcomes of the activities midway through the year. • Work with the coordinator to assure staff have adequate training to support and promote breastfeeding. See Examples of Roles Related to Promoting and Supporting Breastfeeding, in the Appendix of this chapter. • Work with the coordinator to develop breast pump policies and has them approved by state staff. • Assure staff are trained to issue breast pumps following state and local policies. See Issue Breast Pumps, this chapter. • Work with the coordinator to assure the clinic is “breastfeeding friendly”. See Breastfeeding Friendly Clinic, in this chapter.

The breastfeeding coordinator must receive at least eight hours of breastfeeding training each year to support staff and participants with: • Breastfeeding concerns • Classes • Trainings • In-services

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| Page 8 Breastfeeding When agencies have more than one breastfeeding coordinator, the breastfeeding coordinators must meet at least two times each year to develop and assess the progress on the Nutrition Services Plan.

PROCEDURE:

The breastfeeding coordinator:

A. Updates staff with breastfeeding information from state staff.

B. Works with the coordinator, or designated staff, to develop and carry out breastfeeding activities in the Nutrition Services Plan.

C. Shares the Nutrition Services Plan breastfeeding objectives and activities with staff.

D. Works with the coordinator to develop and update breast pump policies or protocols.

E. Submits breast pump policies or protocols to state staff for approval.

• See the “Option to Offer Breast Pumps” policy in this chapter for more information.

F. Works with the coordinator to develop local agency breastfeeding policies or protocols.

G. Assures staff have adequate training and education to support and promote breastfeeding, and as needed to issue breast pumps.

H. Completes at least eight hours of breastfeeding training each year to provide breastfeeding support to participants and staff.

I. Coordinates clinic breastfeeding promotion and support activities.

J. Participates in community breastfeeding promotion and support activities.

K. Keeps local community breastfeeding resources up-to-date.

L. Coordinates World Breastfeeding Week activities for the agency, if desired, optional.

M. Participates in or conducts breastfeeding education in-services for staff.

N. Interprets the local agency Breastfeeding Reports and shares the clinic’s breastfeeding initiation and duration data with staff. Reports are available from the state.

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Breastfeeding | Page 9 POLICY: Staff Breastfeeding Education and Training

The local agency must have task-appropriate breastfeeding support and promotion orientation and on-going training for all staff who interact with participants.

Staff providing direct services to participants must participate in 4 hours of breastfeeding education every year.

Breastfeeding coordinators and peer counselor leads must receive at least 8 hours of breastfeeding education every year.

• See the “Peer Counselor Lead” policy in this chapter.

Staff must have access to resources and educational opportunities to improve their breastfeeding knowledge and counseling skills.

PROCEDURE:

The coordinator, working with the breastfeeding coordinator:

A. Ensures all new staff receives breastfeeding training within the first six months of employment including:

1. A review of state and local agency breastfeeding promotion and support policies.

2. A review of policies and procedures for issuing the correct food packages to breastfeeding infants.

• See Volume 1, Chapter 23 – WIC Foods.

3. A review of job duties and responsibilities describing staff roles in promoting and supporting breastfeeding, including peer counselors.

• See “Examples of Roles Related to Promoting and Supporting Breastfeeding” in Appendix A.

4. A list of community breastfeeding services.

5. Breastfeeding Review strategies.

6. Culturally appropriate breastfeeding promotion and support strategies.

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| Page 10 Breastfeeding 7. A list of red flags identifying participants who need immediate help and referral.

8. A minimum of four hours of evidenced-based education and training on:

• Normal breastfeeding. • Maintaining milk production. • How using formula negatively impacts the ability to produce enough breastmilk. • The benefits of exclusive breastfeeding. • The few instances when breastfeeding is contraindicated and how to serve these participants.

9. An orientation to:

• The agency’s breast pump loan program. • Breastfeeding materials available in the clinic and how to order materials provided by the state WIC office. • Resources and websites for further education and self-study. • If available, an orientation to the peer counseling program.

B. Ensures all new staff complete the following breastfeeding online course trainings within the first year of employment.

• The Baby Behavior and Breastfeeding courses in the Learning Center (LC) for WIC staff on the Washington State Department of Health WIC website.

C. Ensures all CPAs have access to on-going breastfeeding training and information to gain the knowledge and skills to:

1. Provide participant-centered, researched-based anticipatory guidance to all pregnant and breastfeeding participants.

2. Complete a Breastfeeding Review before issuing formula to breastfeeding infants.

• See “The Breastfeeding Review” policy in this chapter.

3. Review all handouts with participants before offering them.

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Breastfeeding | Page 11 4. Understand and correctly issue breastfeeding food packages.

• See Volume 1, Chapter 23 – WIC Foods.

5. Issue breast pumps and other equipment according to state and local policies.

D. Ensures frontline staff are trained to:

1. Answer basic breastfeeding questions and talk about breastfeeding in a positive way.

2. Provide encouragement to breastfeeding participants.

3. Identify participants who need immediate breastfeeding help.

4. Make appropriate referrals for participants needing breastfeeding help or who have questions.

Information:

For more staff education resources visit:

• The Department of Health WIC website at: http://www.doh.wa.gov/PublicHealthandHealthcareProviders/PublicHealthSystemReso urcesandServices/LocalHealthResourcesandTools/WIC.aspx.

• The USDA WIC Works Resource System at: https://wicworks.fns.usda.gov/

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| Page 12 Breastfeeding POLICY: The Breastfeeding Review

Staff must determine if the participant is meeting the federal definition of breastfeeding, which is breastfeeding on average, one time per day. If the participant meets the federal definition, staff trained in providing breastfeeding support must complete a Breastfeeding Review at the initial contact postpartum.

A Breastfeeding Review must also be completed when a breastfeeding participant: • Requests formula or an increase in the amount. • Has concerns about breastfeeding.

This includes participants who:

• Are currently breastfeeding. • Are in the pregnant or breastfeeding category.

Note: Review Volume 1, Chapter 18 - Certification: Certifying Participants after Delivery policy prior to certifying the pregnant participant and infant.

Staff who complete the Breastfeeding Review must:

• Have a conversation with the participant about breastfeeding goals and concerns. • Address the participant’s breastfeeding concerns. • Determine if formula is needed and issue the minimum amount to reduce the negative effect formula supplementation has on breastmilk production. • Document the Breastfeeding Review in the Nutrition Assessment field in the Care Plan Summary - Family Care Plan. • Meet nutrition education policy and documentation requirements and choose the Breastfeeding Review nutrition topic to count as a NE-Individual if working as a Competent Professional Authority (CPA). o See Required Guidance document: Second Nutrition Education – Individual for policy and documentation requirements.

A Breastfeeding Review may be done:

• By WIC staff trained in breastfeeding support. • By a trained peer counselor. • By non-WIC staff trained in breastfeeding support.

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Breastfeeding | Page 13 • In person, over the phone or virtually. • Outside the clinic, such as during a peer counselor home visit, maternity support service, or other WIC contact, and entered into the Nutrition Assessment field in the Care Plan Summary - Family Care Plan later.

All CPAs may:

• Assign or change food packages. • Document the Breastfeeding Review as a Nutrition Education Individual contact (NE - Individual) when the contact meets nutrition education requirements. See Required Guidance document: Second Nutrition Education – Individual for policy and documentation requirements.

Staff must update the Breastfeeding Information on the Health Information screen in the infant’s file to reflect any changes in infant feeding.

Notes:

• Only a CPA can change the food package.

• Peer counselors must be trained and scheduled to work as CPAs to assign or change food packages and do NE-Individual contacts.

• When qualified staff aren’t available to complete a Breastfeeding Review or assign the food package, staff must not change the infant’s current food package.

A Breastfeeding Review isn’t required when:

• Participants state they are not breastfeeding or are no longer breastfeeding and have no intention of returning to breastfeeding.

o Staff must complete a brief assessment to assure the participant doesn’t need further breastfeeding support.

o Staff must document the participant stopped breastfeeding and update the infant feeding method.

• When participants request less formula.

PROCEDURE:

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| Page 14 Breastfeeding Staff:

A. To complete the Breastfeeding Review:

1. Assess the participant’s breastfeeding goals and situation.

2. Provide participant-centered guidance and encouragement to continue breastfeeding.

3. Skip steps 2-6 if the participant is non-breastfeeding and is providing no breastmilk and has no desire to provide breastmilk.

4. Talk about how giving formula may reduce breastmilk production.

5. Explore returning to exclusive breastfeeding if supplemental formula is needed.

6. Support the participant’s infant feeding decision.

7. Refer the participant for further breastfeeding follow-up if needed.

Note: In many cases giving formula starts the weaning process, especially in the first month of life.

B. Use the Cascades Staff tool – Breastfeeding (BF) Infant and Participant First Month of Life, and Volume 1, Chapter 23 – WIC Foods to help determine the correct food packages.

C. Assure a CPA changes the food prescription when the breastfeeding infant needs formula and the Breastfeeding Review wasn’t done by a CPA.

• Peer counselors not in dual roles and not on the schedule as CPAs can’t assign the food package or issue benefits.

D. Issue the least amount of formula to support ongoing breastfeeding, if formula is needed.

Recommendation: Issue powder formula to healthy full-term breastfeeding infants, unless another formula meets the needs of the breastfeeding pair. Look at all future food prescriptions each time the formula is changed especially in 4-5 month carousal, discuss options with the participant and update.

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Breastfeeding | Page 15 E. Record the Breastfeeding Review in the Nutrition Assessment field in the Care Plan Summary - Family Care Plan.

1. Title the note: Breastfeeding Review or BFR.

2. Peer counselors title the note BFR-PC or Breastfeeding Review – PC. Copy and paste all notes from BFPC Care plan into the Nutrition Assessment field in the Care Plan Summary – Family Care Plan.

3. Include the date the Breastfeeding Review was done in the title of the note if it wasn’t done the same day it was entered.

4. Document the problem and/or parent guardian’s concern.

5. Include notes about what was discussed, type of help offered and what referrals were made.

6. Note if formula was or wasn’t issued and why.

7. Include any other important information.

F. Document the Breastfeeding Review as a Nutrition Education – Individual contact (NE- Individual) when done by a CPA and it meets the criteria of a NE-Individual.

1. Copy and paste the Breastfeeding Review note from the Family Care Plan into the Individual Care Plan when meeting the nutrition education individual contact for the participant(s).

2. Add any goal information if a goal was set.

• See Required Guidance document: Second Nutrition Education – Individual for policy and documentation requirements.

G. Select the Breastfeeding Review nutrition education topic and mark as “Complete” in the Care Plan – Nutrition Education.

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| Page 16 Breastfeeding H. Update all infant feeding information on the Health Information screen in the infant’s file to reflect any changes.

I. Take the following steps when staff qualified to change food prescriptions or trained in breastfeeding support are not available:

1. Affirm the participant’s concerns.

2. Offer support within skill level.

3. Explain that staff trained in breastfeeding support are not available to talk to participant.

4. Schedule the participant as soon as possible for a time when staff are available.

5. Refer to a peer counselor or community breastfeeding resources.

6. Offer to have staff trained in breastfeeding support call the participant as soon as possible to offer support by phone.

7. Document the plan so staff can follow-up.

8. Update the Breastfeeding Information on the Health Information screen in the infant’s file to reflect any changes.

9. Peer counselors will update breastfeeding participants’ information in the peer counselor care plan.

Note: Staff can suggest participants use formula available from other sources or purchase it with SNAP benefits or cash.

J. Assess breastfeeding status when the participant states they are no longer breastfeeding.

1. Use the following statements/question or something similar to determine breastfeeding status and if the participant is satisfied with their decision to quit:

• When was the last time you breastfed your baby? • Tell me more about why you stopped breastfeeding. • Tell me how you feel about your decision to stop breastfeeding.

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Breastfeeding | Page 17 2. Don’t do a Breastfeeding Review if the participant is satisfied with the decision to stop and has no desire to return to breastfeeding.

3. Update the breastfeeding information on the Health Information screen in the infant’s file to reflect the changes.

• Peer counselors will document in the Peer Counselor Care Plan and will copy and paste into the Family Care Plan.

4. Document the discussion in the Nutrition Assessment field in the Care Plan Summary- Family Care Plan. Title the note “Quit BF no BFR”.

5. Have a CPA assign a formula food package.

Note: The Breastfeeding Review is a tool to help participants meet their breastfeeding goals. Because each participant’s breastfeeding experiences and challenges are unique, it’s critical for staff to have adequate training, knowledge and resources to address these concerns.

Information:

• Some of the most common breastfeeding concerns include: • Lack of knowledge about breastfeeding and normal baby behavior. • Perceived low breastmilk production. • Sore nipples. • Engorgement. • How to continue breastfeeding when returning to work or school. • Lack of support in the workplace and at home.

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| Page 18 Breastfeeding POLICY: Breastfeeding Friendly Clinic

The clinic environment must support and facilitate breastfeeding as the normal way to feed infants and children. Formula and other items for formula feeding must be kept out of sight.

Staff must not use formula companies’ breastfeeding education materials or promotional items.

PROCEDURE:

The coordinator working with the breastfeeding coordinator:

A. Creates a comfortable place for participants to breastfeed in the clinic, which may include:

1. “Breastfeeding Welcome Here” signs, posters and window clings. Participants may not know they have a right to breastfeed in public.

2. Comfortable chairs with arms and foot stools.

3. Waiting room materials (newsletters, children’s books, etc.) promoting breastfeeding.

4. A private space for participants to breastfeed or pump, if they request privacy.

B. Assure staff don’t use or display breastfeeding education or promotional items from formula companies.

1. Staff may use educational materials for preparing, mixing and storing formula to educate participants who are formula feeding.

2. Only use materials with pictures of baby bottles provided by state staff.

C. Store formula, baby bottles, nipples, or other items used for formula feeding out of sight.

BEST PRACTICE: Breastfeeding Friendly Clinic

• Display pictures of staff breastfeeding their children. Participants like to see staff follow their own advice.

• Display pictures of staff trained to help participants breastfeed including peer counselors. Participants like to see who they can talk to about breastfeeding.

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Breastfeeding | Page 19

• Post positive breastfeeding messages at each workstation. Positive messages let participants know WIC supports breastfeeding.

• Display pictures of participants with their stories about what breastfeeding means to them. Participants like to see and hear from other WIC moms.

• See our website for more resources to create a breastfeeding friendly clinic.

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| Page 20 Breastfeeding Section 2: Breast Pump Policies

POLICY: Option to Offer Breast Pumps

1. Local staff may offer breast pumps to breastfeeding participants.

2. Local staff may offer breast pumps as an occasional exception to participants in the pregnant category who have delivered, are providing their milk to their breastfeeding infant and have not yet been subsequently certified. In these cases, staff must:

a. Consult with the local agency Designated Breastfeeding Expert (DBE), local agency breastfeeding coordinator, or state breast pump contact for approval.

• Call 1-800-841-1410 and ask to speak with the breast pump contact when local agency breastfeeding staff aren’t available.

b. Document the approval in the Family Care Plan.

Note: If the contact meets the requirements for a Nutrition Education Individual contact (NE - Individual), document in the Individual Care Plan. See the “Breastfeeding Review” policy and the Required Guidance document Second Nutrition Education – Individual for policy and documentation guidance.

c. Complete a subsequent certification as soon as possible to help support breastfeeding efforts.

• A nutrition and breastfeeding assessment identifies nutritional risks, referral needs, nutrition education and concerns related to the breastfeeding dyad. • Subsequent certification ensures the participant receives the appropriate food package for the breastfeeding dyad.

3. The coordinator must assign a staff person to manage and oversee the agency’s breast pump program and be the point of contact for the state staff. This can’t be a peer counselor.

4. The coordinator, working with the breastfeeding coordinator, must develop breast pump policies or protocols before providing breast pumps. State staff must approve policies or protocols.

Policies or protocols must assure:

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Breastfeeding | Page 21

a. Participants aren’t charged deposits or fees for breast pumps, pump kits or any breastfeeding supplies.

b. Only WIC staff, including peer counselors, or staff identified in an agency Memorandum of Understanding (MOU) with a third party can issue WIC breast pumps.

c. Staff keep electric breast pumps in a locked area not easily accessible to non- authorized personnel.

d. Electric breast pumps are tracked and inventoried using Cascades. See “Track Electric Breast Pump Inventory” in this chapter.

e. Used manual breast pumps, personal use electric pumps and pump kits aren’t re- issued.

f. Donated pumps, pump kits, and breastfeeding pump supplies aren’t used or accepted no matter the condition.

g. Only staff trained in breastfeeding support and how to issue and educate participants on breast pump use will issue pumps.

h. Only active participants who are currently breastfeeding can receive breast pumps.

i. Staff follow-up with participants issued breast pumps within 2 business days. Peer counselors may do follow-up and support with active breastfeeding peer counselor program participants only.

j. Pregnant participants who haven’t delivered won’t receive breast pumps as breastfeeding incentives.

k. There is a retrieval process in place for lost or stolen multi-user breast pumps and pumps loaned to terminated participants and participants who transfer without returning the pump first. Contact the state office within 3 business days to report lost, damaged or stolen multi-user breast pumps.

l. Staff who are WIC participants and who qualify for breast pumps will have another staff person issue their breast pump.

m. Staff won’t withhold WIC food benefits because of overdue or lost multi-user breast pumps.

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| Page 22 Breastfeeding

n. Staff protects all participant information, including Breast Pump Release of Liability Forms.

o. Staff won’t copy, scan or record Social Security cards or Social Security numbers, or drivers’ licenses information or any identification from the participant or the participant secondary contact for breast pump loans.

PROCEDURE:

The coordinator or designee:

A. Offers and provides breast pump to participant and documents according to policy.

B. Develops breast pump policies or protocols for the agency and submits to state staff for approval.

C. Use the Breast Pump Release of Liability form in Cascades or develops an agency- approved release of liability form to ensure participants fully understand their rights and responsibilities before receiving any type of breast pump or pump kit. See sample Breast Pump Release of Liability Form on the website.

1. After capturing the signature in Cascades when issuing a breast pump. Review the release of liability form with the participant either from printing the release of liability from Cascades or using an agency-approved form. After reviewing the form with the participant, scan the release of liability form into the participant file under Health Information section.

D. Develops training requirements for staff issuing breast pumps. See “Issue Breast Pumps” in this chapter. This training is in addition to the requirement for breastfeeding training described in this chapter.

E. Documents staff breast pump training in clinic or staff training records. See Volume 2, Chapter 11 - WIC Staff.

F. Keeps serialized inventory for multi-user breast pumps up to date.

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Breastfeeding | Page 23 POLICY: Order Breast Pumps, Pump Kits, and Breast Pump Supplies

Staff must:

1. Use the Breast Pump Supply Order form to order breast pumps, pump kits and supplies.

2. Contact the state staff whenever there’s a change to clinic information that could disrupt the breast pump supply order.

3. Not purchase breast pumps, pump kits or any breastfeeding supplies listed on the form with any WIC funds.

4. Send all packing slips to state staff within 3 business days of shipment arrival.

5. Mark the pumps and cases of multi-user breast pumps with the clinic contact information before loaning them.

6. Update serialized inventory for multiuser breast pumps in Cascades before loaning to participants.

Note: Failure to send packing slips results in vendors withholding orders for breastfeeding supplies statewide. When this happens participants can’t get the support they need to continue breastfeeding.

PROCEDURE:

Staff:

A. Use the Breast Pump Supply Order Form posted online.

B. Determine what and how much to order.

1. Take an inventory of current stock.

2. Order a six month supply, or less.

3. Order no more than twice a month.

C. Review form for the correct number of items in the quantity ordered field.

• Most items are available by the case or package.

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| Page 24 Breastfeeding D. Complete contact information and once done selecting items on the Breast Pump Supply Order form then select Finish.

E. Staff receive confirmation emails from the state office when orders are processed.

F. After receiving the order:

1. Check the packing slip to make sure the number of items received match the number of items ordered.

2. If the order is correct and complete, write the word “complete” on the packing slip.

3. If there is a mistake, make a note on the packing slip about what is wrong with the order.

4. Sign and date the packing slip.

5. Within 3 business days, send a copy of the packing slip to state staff.

• Fax to 360-236-2320, or • Scan and email to wicbreastpumps@doh.wa.gov, or • Mail copies to WIC Breast Pumps, PO Box 47886, Olympia, WA 98504- 7886.

6. Send packing slips for each portion of the order; don’t wait for the complete order if items ship separately.

7. Keep an electronic copy of the packing slip for 60 days or save the packing slip to electronic file where copy is retrievable. Then staff can discard the hard copy of the packing slip.

Note: If the clinic is open only a few days, a week or less, send the packing slip the next business day.

G. Follow policies in this section for issuing pumps

Volume 1, Chapter 15

Breastfeeding | Page 25 POLICY: Order Breastfeeding Supplies Using Local WIC Funds

Use WIC funds to buy allowed breastfeeding supplies except:

• Items on the Breast Pump Supply Order form. • Breast pumps.

Note: See Volume 2, Chapter 4 – Allowable Costs for a detailed list of allowable costs.

Staff may purchase items not on the order form from any vendor.

Note: Staff can only use peer counseling funds to buy breastfeeding supplies for training peer counselors.

Agencies must have policies or protocols approved by state staff for nipple shields, breast shells and Supplemental Nursing Systems (SNS) before ordering these items.

PROCEDURE:

Staff:

A. Review Volume 2, Chapter 4 – Allowable Costs to assure items are allowable.

• Contact wicbreastpumps@doh.wa.gov to request current contract price sheets.

B. Order non-contract items from any vendor.

C. Contact vendors directly when placing orders.

• Follow local agency procedures when ordering breastfeeding supplies and making billing arrangements.

• Ask about shipping costs, taxes and other fees.

D. Assure state staff approves policies or protocols before ordering nipple shields, breast shells, and Supplemental Nursing Systems. Before ordering, assure staff are:

1. Trained to educate and issue these items to participants.

2. Able to assess which participants need these items to breastfeed.

3. Committed to following up with participants after issuing these items.

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| Page 26 Breastfeeding

E. Document issuance of breastfeeding supplies to participants in the Nutrition Assessment field in the Care Plan Summary- Family Care Plan.

Note: Agencies may request training on nipple shields, Supplemental Nursing Systems, and other breastfeeding supplies. Contact state staff for assistance.

Volume 1, Chapter 15

Breastfeeding | Page 27 POLICY: Option to Contract with a Third Party to Provide WIC Breast Pumps

Local agencies may subcontract with third parties to loan breast pumps to current WIC participants. Third parties may include hospitals, pharmacies, private lactation consultants or others.

WIC staff must not receive any personal or financial benefit from this agreement.

The agreement must specify the duties of each party to meet all breast pump policies in this chapter.

WIC staff must continue to manage pumps through serialized inventory.

PROCEDURE:

The coordinator:

A. Assigns a staff person as the point of contact for state WIC staff when subcontracting with a third party.

B. Assigns a staff person to be the point of contact for the third party.

C. Develops a subcontract or interagency agreement (Memorandum of Understanding or MOU). This agreement must describe how the 3rd party will:

1. Assure only current WIC participants are issued breast pumps and breast pump accessories.

2. Issue, educate participants, track and clean breast pumps following the policies in this chapter.

3. Identify who will follow-up with participants within 3 business days.

4. Assure record keeping meets state and local agency standards.

5. Provide the WIC agency copies of participant signed release forms.

6. Follow-up when multi-user pumps are lost, stolen or need repair.

7. Return all pumps and equipment to the agency when the contract is terminated.

8. Keep the MOU updated by reviewing it and extending it on a regular basis.

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| Page 28 Breastfeeding POLICY: Issue Breast Pumps

The coordinator and the breastfeeding coordinator must work together to assure staff authorized to issue breast pumps are:

• Adequately trained in breastfeeding support. • Trained to issue breast pumps. • Follow all state and local breastfeeding policies, procedures or protocols.

Peer counselors may issue breast pumps but aren’t allowed to manage pump programs or have assigned tasks such as cleaning, tracking, or taking inventory of breast pumps.

Staff may count breast pump education as a Nutrition Education- Individual contact if done by a CPA or other appropriate breastfeeding educator and meets the criteria of a NE- Individual. See Volume 1, Chapter 16 – Nutrition Education. Staff can’t count education done by peer counselors as a NE-Individual.

Note: WIC staff can’t diagnose medical conditions or “medical necessity”. Staff should only assess participant need for a breast pump using Guidelines to Issue Breast Pumps.

PROCEDURE:

Staff authorized to issue breast pumps:

A. Receive training on breastfeeding support.

B. Follow state and local agency breast pump policies or protocols.

C. Receive training on how breast pumps work and how to demonstrate their use to participants.

D. Evaluate the participant’s need for a pump. Use Cascades Issue Breast Pump Interview Questionnaire to determine the best pump option or Cascades staff discretion.

E. Determine which pump the participant is eligible to receive and will best meet needs. In addition, you can review “Guidelines for Issuing Breast Pumps” in this chapter.

F. Complete breast pump issuance in Cascades.

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Breastfeeding | Page 29 G. Staff don’t collect secondary contact information or identification documents for manual breast pumps and personal use pumps issuance, staff enter NA for non- applicable.

H. Create a multi-user breast pump issuance alert with breast pump information and no end date. Once the breast pump is returned then deactivate the breast pump issuance alert using the date of breast pump return date as the alert end date in Cascades.

I. Assure all pump parts are included and the pump works before issuing. See Appendix A for information on how to assess if a pump is working properly.

J. Show the participant how to use the pump following the manufacturer’s instructions and offer written information. Use the state interpreter contract service to offer information in the participant’s preferred language.

K. Cover key information including how to:

1. Use the pump.

2. Clean the pump.

3. Manually express breastmilk.

4. Maintain milk supply.

5. Store breastmilk safely.

6. Get help with breastfeeding.

7. Return the breast pump if it is a multi-user pump.

L. Review Cascade’s or an agency approved Breast Pump Release of Liability Form with participant and:

1. Ask participant if they understand and agree to the terms prior to issuing the breast pump.

2. Ask participant to initial the Breast Pump Release of Liability Form after reviewing key points of the form.

3. Give the participant a copy of the Breast Pump Release of Liability Form.

4. Capture signature to complete breast pump issuance.

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| Page 30 Breastfeeding

5. Print form and scan into participants file under health information screen.

Note: If a participant is using a previously issued WIC personal use or manual pump with other children, ask the participant to sign an updated Breast Pump Release of Liability Form.

M. Give the participant a phone number to call for questions. This number can include contacts for clinic staff, peer counselors or other support.

Note: Staff may use the “Dear Breastfeeding Participant” letter in the Appendix A of this chapter and revise as needed.

N. Document pump issuance in Cascades under Care Plan Summary-Family Care Plan in the Nutrition Assessment section, the type of pump provided, why the participant needed the pump and follow-up plan.

• CPA can count pump education as a Nutrition Education- Individual contact (NE- Individual)

O. Contact participants issued breast pumps no later than 2 business day and ask how pumping is going.

P. Refer participants who need additional help to the appropriate support.

Q. Take these additional steps when issuing a manual or personal use pump:

1. Tell the participant the breast pump:

a. Is for one person only.

b. Can transmit disease if used by another person.

c. WIC rules don’t allow to sell or give away.

d. Pump is to keep, no need to return to WIC.

2. Replace broken or defective manual pumps, if needed.

a. Can replace single –use electric pumps in limited circumstances such as theft, domestic violence, and homelessness. Contact state staff for guidance if needed.

Volume 1, Chapter 15

Breastfeeding | Page 31 3. Encourage the participant to:

a. Contact the vendor’s customer service department directly if the pump isn’t working properly. Vendors can often help participants fix the pump or can replace defective pumps within 1 to 2 business days.

Note: Staff can call customer service for the participant if desired. If customer service can’t resolve the problem in a way that meets the participant’s needs, staff may issue a replacement pump. Contact state staff for further guidance if needed.

b. Replace defective breast pumps if the participant is still breastfeeding and meets the criteria for a personal use pump.

R. Take these additional steps for multi-user breast pump issuance:

• Establish the length of the loan based on participant need and clinic demand for multi-user breast pumps.

• Tell the participant:

a. Used pumps kits can transmit disease.

b. WIC rules don’t allow participants to sell or give pump away.

c. WIC rules don’t allow participants to repair multi-user breast pumps doing so could damage or destroy the pump which the participant will be responsible for.

d. To return pump:

• If it’s damaged or not working correctly. • On or before the date it’s due back to the clinic. • If participant stops using it. • If participant is no longer eligible for WIC. • Before leaving the WIC program. • Before moving out of state. Participants can transfer clinics in state with the loaner breast pumps please notify the clinic. • If it’s recalled by the vendor.

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| Page 32 Breastfeeding • Follow-up with the participant at least once monthly for multi- user pump issuance to assess pump use and to answer any questions.

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Breastfeeding | Page 33 Guidelines for Issuing Breast Pumps

* The local agencies must develop breast pump guidelines to help staff evaluate the individual needs of a breastfeeding dyad who are separated from each other.

Type of pump Criteria for Issuing Breast Pumps

Two-handed manual pump This pump is for participants who: • Need a pump for a short period of time for engorgement, or to draw-out flat or inverted nipples. • Are occasionally separated from baby for date nights, appointments, short workdays. • Need a pump and no other pump is available.

One handed manual pump (Harmony pump) This pump is for participants who: • Are looking for work. • Have on-going, short-term separation from their babies. • Are working or going to school less than 20 hours a week. • May not have access to electricity when pumping. Staff can issue two pumps for double pumping, if needed.

Multi-user breast pump

This pump is for participants who: • Have premature or medically challenged infants unable to feed at the breast. • Can’t feed baby at the breast because of medical issues. For example, the participant has had breast surgery resulting in low milk production. • Are having problems breastfeeding and must use a pump to provide breastmilk. • Are separated from their baby for medical reasons. • Are returning to work or school within two weeks and will be separated from their baby a significant portion of the day* and other pumps aren’t available, or don’t meet their needs. • Don’t meet the criteria for a personal use breast pump.

Note: Staff have the option to request proof of work and school schedules.

Personal use electric breast pump

This pump is for participants who: • Are fully breastfeeding and not getting any formula from WIC. • Have good breastmilk production. • Have infants >=8 weeks old. Staff trained in breastfeeding support may issue this pump to participants with younger infants based on professional discretion. • Have no breastfeeding complications such as low weight gain, sore nipples, breast pain, etc. Thrush under treatment is allowable. • Are returning to work or school within 2 weeks and will be separated from their baby a significant portion of the day. • Have infants less than one year of age.

Note: Staff may issue personal use pumps to participants in unique situations who may not otherwise qualify for them, i.e. homeless, migrant farm worker, domestic violence, public health outbreak. Prior approval from state staff is required for situations not listed in this note.

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| Page 34 Breastfeeding POLICY: Return Multi-User Breast Pumps

When participants return multi-user breast pumps to the clinic, staff must:

1. Visually inspect the pump and check for damage, pump parts and insects upon return. See “Insects in Multi-user Breast Pumps” in this chapter.

2. Update all participant files, paper records and computer files.

3. Clean every multi-user breast pump and assure it’s working properly before loaning it to another participant.

PROCEDURE:

Staff:

A. Inspect breast pumps upon return for damage, pump parts and insects.

B. Complete breast pump return using Cascades Breastfeeding Support - Breast Pump Return.

C. Document the Breast Pump Return under Cascades Care Plan Summary, Family Care Plan, in the Nutrition Assessment section that the pump was returned and any important details about the pump.

D. Dismiss the multi-user pump alert and enter the date of pump return as end date.

E. Place returned multi-user pump Out for Maintenance in Cascades inventory during cleaning stage:

1. Staff select Operations, Inventory, Search Product Inventory from Cascades home page.

2. Locate multi-user breast pump.

3. In the Inventory Search Results (Items) window select the pencil image to edit and access the returned multi-user breast pump file.

4. Staff select the box in front of Out for Maintenance then select Save.

5. Once pump is ready to be reissued, use the same steps, then Staff unselect the box before Out for Maintenance then select Save.

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Breastfeeding | Page 35

F. Clean returned multi-user breast pumps and pump cases using these steps:

1. Store returned pump and carrying case in clear plastic bag and note on the bag “Dirty Pump”. Keep bagged for a minimum of 10 days out of contact of staff and participants.

2. Using standard of care following storage period gently shaking the pump with the vented side down to check for insects or damage to the pump.

3. Wiping the pump and pump case with Cavicide* or similar cleaning agent making sure all crevices are well cleaned.

Note: *Cavicide is a cleaning product for breast pumps. Staff may use any cleaning products similar to those used for wiping infant scales and counters. Staff may use WIC funds for purchasing cleaning and other pump supplies.

G. Remove breast pump from maintenance status in Cascades inventory once staff have cleaned the pump and ready for issuance.

H. Store breast pumps in a clean and secure place.

I. Assure pumps work properly before re-issuing. See “Testing Electric Breast Pumps” in Appendix A.

J. Contact state staff if pumps require deep cleaning by the manufacturer.

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| Page 36 Breastfeeding POLICY: Insects in Multi-User Breast Pumps

Staff must check every returned multi-user breast pump for insects.

Contact state staff for guidance when a multi-user breast pump contains insects or needs deep cleaning by the vendor.

Note: Staff may use WIC funds to purchase bags and other supplies.

PROCEDURE:

Staff:

A. Check returned pumps for insects by inspecting the pump and case and shaking the pump, vented side down.

1. When a pump contains insects:

a. Place the pump and pump case in a clear plastic bag label the bag “Dirty Pump”.

b. Close the bag with a twist tie, secure knot or other closure.

c. Date the sealed bag and let it sit closed for at least 10 days.

d. After 10 days, take the bagged pump outside.

e. Open the bag and look for insects in the bag and case. Shake the pump with the vented side down.

f. If there are insects, double bag the breast pump and pump case.

g. Contact state staff for guidance.

2. If there aren’t any insects, follow normal procedures for cleaning.

Note: Vendors will return bug infested breast pumps without cleaning if pumps aren’t double bagged and sealed, or if placed in red bio-hazard bags.

Volume 1, Chapter 15

Breastfeeding | Page 37 POLICY: Track Electric Breast Pump Inventory

Staff must:

• Track the number of personal use and multi-user breast pumps at each clinic site using Cascades’ inventory.

• Permanently mark each pump and pump case with the clinic’s contact information before loaning new multi-user breast pumps.

• Review inventories of multi-user pumps at least twice a year to account for pump stock and check for lost, stolen or missing pumps.

• Review inventories of electric personal use pumps at least once a year.

Recommendation: Run a detail report of Serialized Inventory Products located under Operations reporting in Cascades to monitor inventory multi-user breast pumps at least twice a year, or more often. Peer counselors can’t do this task.

See sample inventories in Appendix A.

PROCEDURE:

Staff:

A. Track multi-user breast pumps using serialized inventory in Cascades.

1. Use the breast pump serial number and the Agency State code for your clinic provided by the State.

a. Track multi-user breast pumps by entering the breast pump serial number under Manufacturer and under State Inventory Number (Agency State code plus multi-user breast pump serial number) into Cascades Inventory.

• If you don’t have the Agency State code for your clinic contact the State breast pump team.

2. History and status are kept current in Cascades inventory. Document when multi-user pumps are:

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| Page 38 Breastfeeding • Issued. • Returned. • Cleaned. • Reported lost or stolen to state staff. • Damaged and destroyed.

B. Keep an inventory of personal use electric breast pumps by adding current stock to Cascade inventory under personal use electric breast pumps:

1. Enter the number of pumps into Cascade inventory by pump product name (for example, Medela WIC ‘N Style).

2. Run a detail report of non-serialized inventory product under Operations reporting to obtain current personal use electric pump issuance records. This report displays:

a. Name of the participant.

b. Type of personal use electric pump issued

C. Use the detail non-serialized pump report to conduct an annual count of personal use pumps and compare to the inventory.

D. Report any pumps suspected stolen from the local clinic to police and submit a lost/stolen/damaged pump form to the State office.

BEST PRACTICE: Track Multi-user Breast Pumps

• Contact participants with multi-user breast pumps monthly. This allows staff to follow- up on breastfeeding issues, keep contact information up-to-date, and recover pumps when no longer needed. • Issue benefits monthly when a pump return is overdue. • Add a family alert to participants file if breast pump is overdue.

Volume 1, Chapter 15

Breastfeeding | Page 39 POLICY: Recover Breast Pumps from Transfer Participants

Staff must:

• Ask participants with multi-user breast pumps to return the pump before transferring out of state.

o Staff can’t withhold transfer information (VOC) or WIC benefits if participants don’t return multi-user pumps before transferring.

• Document on the transfer information the participant has a multi-use pump.

• File a Lost, Stolen or Damaged Breast Pump form within 3 business days when a participant transfers out of state with a multi-user breast pump. See Lost, Stolen or Damaged Multi-user Breast Pump Report.

PROCEDURE:

Staff:

A. Tell the participant they must return the pump within 30 days or the State WIC Program will bill for the cost of the pump.

B. Ask the participant to return the multi-user breast pump when the participant requests transfer information for out of state.

C. Give the participant the transfer information or food benefits even when participant hasn’t returned the multi-user breast pump.

D. Verify at least monthly if pumps have transferred to another agency or out of state.

E. Contact the receiving clinic to discuss pump return.

F. Contact the State office for a shipping label to have the multi-user pump returned.

G. Document details about recovery attempts under Family Care Plan Nutrition Assessment.

1. Include the pump’s serial number when documenting communication with the participant about returning the pump.

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| Page 40 Breastfeeding H. Submit a Lost, Stolen or Damaged Breast Pump Form within 3 business days when a participant doesn’t return a multi-user breast pump before transferring out of state.

I. Notify state staff when the participant returns the pump.

Volume 1, Chapter 15

Breastfeeding | Page 41 POLICY: Lost or Stolen Multi-user Breast Pumps

Staff must:

• Start recovery attempts for multi-user breast pumps within 3 business days when a pump is overdue to the clinic.

• Document all pump recovery attempts in the participant’s file.

• Verify at least once monthly in Cascades under Operations – Inventory - Search Orders and Transfer Request if any pumps have transferred to another agency or out of state.

• Send a Lost, Stolen or Damaged Multi-user Breast Pump Report to state staff after two unsuccessful attempts to recover the pump.

Staff can’t withhold food benefits or WIC services, including transfer information from participants with overdue pumps.

PROCEDURE:

Staff:

A. Contact participants as soon as possible when a pump is overdue to request the pump back.

1. Staff may communicate with participants at WIC appointments or by participant’s preferred method of contact.

B. Continue recovery efforts for two attempts with participants, parent guardian and caretakers.

Note: A sample letter for contacting participants titled “Overdue Pump Letter” is in Appendix A of this chapter.

C. Document in the participant’s file under Care Plan Summary – Family Care Plan – in Nutrition Assessment section:

1. How staff attempted to contact the participant.

2. The dates of contacts or attempted contacts.

3. Any communication with the participant or alternates.

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| Page 42 Breastfeeding

D. Request a police report number when a participant reports a pump stolen from them. Participants providing police report numbers won’t be billed for stolen pumps.

E. Staff can assist participants in requesting this number.

F. Include the police report case number when submitting a Lost, Stolen or Damaged Multi-user Breast Pump Report, if available. Contact state staff for guidance if needed

G. Fax or mail a Lost, Stolen or Damaged Breast Pump Report to state staff within 3 business days after the second unsuccessful attempt to retrieve the pump, or when a participant transfers out of state without returning a breast pump. See “Recover Multi- user Pumps From Transfer Participants”.

1. Scan forms under Health Information screen and title ‘lost/damaged/stolen form’.

2. Add a note under the participant’s Care Plan Summary-Family Care Plan- Nutrition Assessment.

3. Update Cascade’s breast pump inventory and dispose of lost or stolen pumps after State notification.

4. Notify state staff within 3 business days when pumps are returned after filing a Lost, Stolen or Damaged Multi-user Breast Pump Report by emailing wicbreastpumps@doh.wa.gov. Include the serial number of the pump.

H. Continue to issue food benefits and provide WIC services (including Transfer Cards) to participants with an active lost, damaged or stolen multi-user breast pumps.

Volume 1, Chapter 15

Breastfeeding | Page 43 POLICY: Damaged Multi-user Breast Pumps

Staff must contact the vendor’s customer service department about damaged or poorly functioning multi-user breast pumps to find out if the pump is under warranty.

The vendor repairs multi-user breast pumps under warranty and pays for shipping.

The following breast pumps can’t be repaired and must be destroyed. Please notify the State staff by filing a Lost, Stolen or Damaged Multi-user Breast Pump Report.

• Out-of-warranty pumps • Lactina Plus breast pumps • Reconditioned breast pumps

Contact state staff when multi-user breast pumps need deep cleaning by the vendor.

Note: It’s not cost effective to repair breast pumps no longer under warranty.

PROCEDURE:

Staff:

A. Call the vendor’s customer service department to learn if the pump is under warranty.

B. If the pump is under warranty, follow vendor’s instructions to repair it.

C. Destroy breast pumps poorly functioning and no longer under warranty. To do this:

1. Cut off the power cord to prevent it from being used.

2. Send a Lost, Stolen or Damaged Multi-user Breast Pump Report to state staff.

3. Indicate on the form the pump was destroyed by clinic staff.

D. Dispose of breast pump from Cascade’s inventory.

E. Dispose of breast pump by working with your agency’s facilities department.

F. Contact state staff when multi-user breast pumps need deep cleaning by the vendor.

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| Page 44 Breastfeeding Section 3: Breastfeeding Peer Counselor Program

POLICY: USDA Breastfeeding Peer Counseling Program

Local agencies may start a USDA Breastfeeding Peer Counseling Program using separate peer counseling funds. The policies in this section relate to this type of peer counseling program.

The local agency must:

1. Before starting a peer counseling program • Have written approval from both state staff and agency administration. • Complete a proposed budget form provided by state staff. • Orient clinic, administrative and fiscal staff to the program and its requirements.

2. Once the program is established and peer counselors are trained. • The majority of the salary costs must be paid to peer counselors to provide direct services to WIC participants. For a list of allowable costs, see Volume 2, Chapter 4 – Allowable Costs. • Peer counselor services must not replace other WIC breastfeeding promotion and support efforts.

Staff must:

• Track peer counseling program costs separately from WIC program costs. The peer counseling program is a separate grant.

• Do time keeping in order to keep track of time and salary costs for peer counseling separate from WIC program costs when staff work in both programs.

• Use peer counseling funds only to support the peer counseling program.

PROCEDURE:

The coordinator or designated staff:

A. Notifies state staff that the agency wants to start a peer counseling program. If funding is available, state staff will work with the coordinator to start a program.

B. Completes management training for the USDA Peer Counseling curriculum training.

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Breastfeeding | Page 45

C. Receives approval and a timeline for funding from state staff.

D. Completes a program orientation for clinic, administration and fiscal staff.

Information:

The USDA Breastfeeding Peer Counseling Program implements best practice in peer counseling in training and technical assistance. This project is designed to assist the national effort by the USDA, Food and Nutrition Services (FNS) to build and enhance the peer counseling program. Combining peer counseling with ongoing breastfeeding promotion efforts in WIC has the potential to significantly impact breastfeeding rates among WIC participants, and most significantly, increase the harder to achieve breastfeeding duration rates. The long range vision of the USDA/FNS is to institutionalize peer counseling as a core service in WIC.

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| Page 46 Breastfeeding POLICY: Required Protocols for the USDA Breastfeeding Peer Counseling Program

Prior to hiring peer counselors, staff must provide state staff copies of agency-approved protocols listed in the appendix of this chapter. These protocols must state who is responsible for what actions.

State staff will provide technical assistance to help local staff develop these protocols.

Note: Good written protocols reduce liability, provide clear expectations and help all staff, including peer counselors, understand their roles and responsibilities.

PROCEDURE:

The coordinator or designated staff:

A. Develops written protocols and obtains required approvals.

B. Educates staff on program protocols.

C. Sends updated protocols to state staff. See the Breastfeeding Peer Counseling Program Annual Report and Budget in this chapter.

Note: Sample protocols and forms are available in training materials available from state staff.

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Breastfeeding | Page 47 POLICY: Using a Third Party Contract or a Memorandum of Understanding (MOU)

When using a third party contract or a Memorandum of Understanding (MOU) to operate a USDA Peer Counseling Program, staff must:

• Get prior approval from state staff before entering into an MOU or third party contract to share responsibilities related to running a peer counseling program. • Ensure all program requirements are met and staff responsibilities are assigned. • Monitor the contractor’s performance annually to assure the contractor meets program requirements spelled out in the contract. • Ensure the MOU or contract is renewed and resigned every five years. MOU’s should be reviewed yearly for best practice. • Ensure contractors are reimbursed only for actual costs. Contracted peer counselors must be paid hourly for actual work performed; they can’t be paid a salary, or stipend.

PROCEDURE:

The coordinator or designated staff:

A. Notifies state staff of plans to use contractors or have an MOU or contract with another agency to run the program.

B. Works with agency administration and state staff to develop a contract or MOU.

C. Clearly defines the responsibilities to meet program requirements for all parties involved.

D. Sends a final copy of the contract or MOU to state staff.

E. Review contractor’s performance and MOU annually to assure current practices meet contractual and program requirements.

F. Renews, as appropriate, the contract or MOU with enough lead time to avoid a break in service, and ensure responsibilities are carried out per the agreement.

G. Monitors contractor’s budget and assures payment is made for only approved expenditures.

H. Keeps records of contracts, contractor performance reviews and MOUs following WIC and agency record retention policies, see Volume 2, Chapter 7- Record Retention.

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| Page 48 Breastfeeding POLICY: Peer Counselor Lead

Local agencies must identify a peer counselor lead (PCL) for the program. The peer counselor lead:

• Is the point of contact for state staff. • Assures staff working in the peer counseling program follows the policies in this chapter. • Provides leadership to the program in the local agency. • Assures agency programs serving the WIC population know about the program and how to access peer counseling services. • Assures peer counselors are well trained and supervised.

The PCL must have:

• International Board Certified Lactation Consultant (IBCLC) certification • Or completed state approved lactation management training within the last five years • Or complete state approved lactation management training within the first six months in this position and • At least one year’s experience providing breastfeeding support

If the PCL has other WIC duties, such as a certifier or WIC Designated Breastfeeding Expert the PCL must do daily time keeping assuring only peer counselor related duties are billed to the grant.

The duties of a PCL may be shared. Staff must clearly define who is responsible for what aspects of the program.

The PCL must receive at least 8 hours of breastfeeding education every year.

PROCEDURE:

The peer counselor lead (PCL):

A. Assures clinic, administrative, fiscal staff and other agency staff as needed, receive training on program requirements and the role of the peer counselor.

B. Assures peer counselors receive adequate supervision and mentoring. See “Supervise and Mentor Peer Counselors” this chapter.

Volume 1, Chapter 15

Breastfeeding | Page 49 C. Assists in establishing program protocols and policies and updates them as needed.

D. Assists in determining program budget and staffing needs.

E. Facilitates the recruitment and hiring of peer counselors that meet program requirements.

F. Assures peer counselors receive required training. See “Train Breastfeeding Peer Counselors” in this chapter.

G. Establishes caseload and contact requirements for peer counselors.

H. Is available to answer breastfeeding questions or provides timely access to an IBCLC.

I. Helps peer counselors make referrals to medical providers and others, as needed.

J. Assures peer counselors stay within their scope of practice.

K. Assists in the completion of the Breastfeeding Peer Counseling Program Annual Report.

L. Participates in state conference calls and other training.

M. Does daily timekeeping if job duties include work other than peer counseling.

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| Page 50 Breastfeeding POLICY: Recruiting and Hiring Breastfeeding Peer Counselors

Local agencies must hire or contract peer counselors who meet the following requirements:

• Are from the community or can relate to the WIC population served. • Don’t have extensive medical, nutrition or lactation management training and aren’t licensed or credentialed healthcare providers. • Have personal breastfeeding experience and can portray breastfeeding in a positive manner. • Can offer positive breastfeeding support to participants. • Are available to WIC participants outside the usual clinic hours and outside the WIC clinic.

Local agencies may select existing staff as peer counselors only if:

• Staff meet the requirements for peer counselors in this policy. • Peer counseling activities performed by staff provide breastfeeding services beyond current breastfeeding promotion activities.

Recommendation: Hire current or former WIC participants who are currently breastfeeding exclusively or exclusively breastfed for at least six months.

Note: Breastfeeding peer counselors must meet the criteria of a Bona Fide Occupational Qualification.

PROCEDURE:

The coordinator or designated staff:

A. Hires breastfeeding peer counselors with:

1. Enthusiasm for breastfeeding and helping others.

2. Previous or current breastfeeding experience.

3. Connections to the same community as the participants.

4. A work history that doesn’t include extensive professional training or licensed or credentialed in healthcare, nutrition or as a lactation professional.

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Breastfeeding | Page 51 5. A flexible schedule that allows participants to contact them outside of the WIC clinic and normal clinic hours.

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| Page 52 Breastfeeding POLICY: Peer Counselor Scope of Practice

The local agency must have a written job description defining the scope of practice for the peer counselor. Agencies may establish positions for senior peer counselors.

A peer counselor’s scope of practice is defined by:

• United States Department of Agriculture’s (USDA) Breastfeeding Peer Counseling guidelines. • State and local policies.

Peer counselors must:

1. Document all contacts or attempted contacts with participant.

• When peer counselors provide breastfeeding support, they must, at a minimum, follow the same requirements for documenting a Breastfeeding Review. See “Breastfeeding Review” in this chapter.

2. Follow agency procedures for reporting child safety concerns to Child Protection Services (CPS).

• Peer counselors are mandated reporters for child safety concerns.

3. Not replace breastfeeding promotion and support activities done by other WIC staff.

4. Not assign WIC food prescriptions unless working in a dual role as a CPA.

• Staff working in these dual roles must charge the time spent assigning food prescriptions and talking about WIC foods to the WIC grant, not the peer counseling grant.

PROCEDURE:

The coordinator or designated staff:

A. Develops a job description for the peer counselor that includes:

1. The scope of practice or the type of breastfeeding support the peer counselor is allowed to provide. Peer counselors provide:

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Breastfeeding | Page 53 • Basic, evidence-based breastfeeding information using participant- centered skills. • Anticipatory guidance, information about Baby Behavior, encouragement and support to participants. • Help with problem solving common breastfeeding situations, such as latch or keeping milk supply up when returning to work or school. • Support outside normal clinic hours. • Timely referrals when encountering situations outside their scope of practice.

2. Locations where the peer counselor provides services.

3. Expectations on the frequency of prenatal and postpartum participant contacts using the USDA Breastfeeding Peer Counselor guidelines:

Prenatal: • Offer in-person contacts during the participant’s pregnancy. This helps establish rapport. Follow-up with monthly calls. • Close to the participant’s due date, offer more frequent contacts.

Postpartum: • When staff know that the participant delivered, offer to contact the participant every 2 to 3 days in the first week postpartum, or when the participant is working through breastfeeding challenges. • Offer weekly contacts the rest of the first month postpartum and monthly thereafter. Offer to contact the participant before and after the participant plans to return to work or school. • Attempt to contact participants within 24 hours when there are problems.

4. The hours the peer counselor is available to participants.

5. A requirement to document all contacts.

B. Assures peer counselors:

1. Use participant-centered skills to give basic evidence-based breastfeeding information and encouragement to pregnant and breastfeeding participants.

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| Page 54 Breastfeeding 2. Have opportunities to meet prenatal participants to promote breastfeeding, address common concerns and establish rapport.

3. Fill gaps in WIC breastfeeding support, particularly after hospital discharge and before the participant’s next WIC appointment.

4. Are available outside normal clinic hours to provide breastfeeding support.

5. Address issues participants are most concerned about and helps participants explore their barriers and visualize how breastfeeding can work for them.

6. Prepare participants for what to expect, including recognizing Baby Behavior cues, in the early days of breastfeeding after uncomplicated, full-term vaginal births or C-sections.

7. Follow-up in the early postpartum period to discuss normal breastfeeding concerns and provide reassurance and guidance.

8. Refer participants to WIC breastfeeding and other community resources for issues outside their scope of practice, medical issues, or for breastfeeding issues that don’t show improvement within 24 hours.

9. Maintain participant confidentiality and sign annual confidentiality agreements. See Volume 1, Chapter 25 – Legal Considerations and Confidentiality.

10. Meet documentation requirements.

11. Make appropriate referrals when they suspect child abuse.

C. Trains peer counselors on how to issue breast pumps, complete Breastfeeding Reviews or weigh babies if they are assigned these tasks.

D. Assures senior peer counselors meet the following requirements in addition to those above:

1. Have at least 500 hours of providing direct support to breastfeeding participants.

2. Attended at least forty hours of lactation management training.

3. Use participant-centered skills to give both basic and advanced breastfeeding information.

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Breastfeeding | Page 55 E. Decides which responsibilities to include in the senior peer counselor job description. Examples of job duties of senior peer counselors could include:

1. Lead breastfeeding support groups.

2. Assist in interviewing peer counselor applicants.

3. Mentor junior peer counselors by modeling participant-centered counseling and appropriate job skills.

4. Receive referrals from peer counselors and staff to follow-up with participants having breastfeeding issues.

5. Refer participants having problems beyond their scope of practice according to clinic-established protocols.

6. Add to breastfeeding promotion activities currently done at the agency and in the community.

7. Assist staff in promoting the peer counseling program.

F. Assures peer counselors don’t:

1. Diagnose conditions.

2. Provide medical advice.

3. Prescribe or recommend medications, herbs or naturopathic remedies.

4. Assume breastfeeding promotion and support duties normally carried out by WIC staff.

5. Manage breast pump programs, including inventory control, on-going cleaning and maintenance of breast pumps.

Note: Sample peer counselor job descriptions are in the USDA Breastfeeding Peer Counselor curriculum training and available from state staff.

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| Page 56 Breastfeeding POLICY: Train Breastfeeding Peer Counselors

Trainers must use the USDA Breastfeeding Peer Counselor curriculum training and Baby Behavior materials as part of peer counselor training. These training materials are available from state staff.

Local staff must have protocols describing the training peer counselors receive as part of their orientation before seeing participants unsupervised.

After orientation training, the peer counselor lead or designated staff must:

• Conduct regular meetings for peer counselors to interact with the peer counselor lead. • Offer at least 8 hours of breastfeeding training each year. This may be in-person, web- based or via other methods. • Include peer counselors in training that is relevant to their job description provided by state staff. Assure peer counselors complete the breastfeeding courses in The Learning Center (LC) within the first year of employment. • Provide annual training on civil rights, participant confidentiality and other required WIC training.

Staff may provide more training and provide time for independent study as their budget allows.

PROCEDURE:

The peer counselor lead, coordinator or designated staff:

A. Prepares for training:

1. Review the curriculum and identify what will be covered in initial training.

2. Prepare the training materials, schedule room and equipment.

3. Schedule initial training in manageable sections that allows for interaction and maximum learning. The USDA peer counselor curriculum training takes approximately 20-30 hours to complete.

4. Invite WIC staff or community partners, if desired.

5. Tell trainees what to expect, what to bring and to arrange for child care, if needed.

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Breastfeeding | Page 57 6. Review attendance and behavior expectations prior to training.

7. Arrange a graduation ceremony for peer counselors, if desired.

B. Trains peer counselors on:

1. How to provide breastfeeding support using the USDA peer counselor curriculum training and Baby Behavior materials and information.

2. State WIC policies and agency-specific protocols.

3. An overview of the WIC program.

4. Returning program property and all participant records when leaving the job.

5. How to do home or hospital visits, as needed.

6. What to do when participant information, in paper or electronic form, or other items issued to the peer counselor are lost or stolen.

7. Required documentation.

8. How to issue breast pumps, if allowed. See “Issue Breast Pumps” in this chapter.

9. How to complete a Breastfeeding Review, if allowed. See “Breastfeeding Review” this chapter.

10. How to weigh babies, if allowed, including:

• How to use the scales. • How to interpret weight loss and weight gain. • How information about the infant’s weight and growth is shared with parents. • What to do if the weight is a concern. • Where and how to document infant weights.

Note: Train peer counselors how to weigh and measure babies by having them train with WIC staff and by completing the anthropometric course in the Learning Center (LC). Peer counselor leads must train peer counselors how to share information with parents and what to do when the weight is a concern.

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| Page 58 Breastfeeding C. Keeps training and in-service sign-in sheets for four years. See Volume 2, Chapter 7 – Record Retention.

D. Arranges on-going training and continuing education.

Note: Peer Counselor funds can’t be used to pay for childcare. Many programs allow trainees to bring young babies to training. Training is enhanced when parents and babies are available to demonstrate feeding cues, latch and positioning. Trainees should be instructed what to do if a baby’s behavior is distracting.

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Breastfeeding | Page 59 POLICY: Supervise and Mentor Peer Counselors

Peer counselors must receive adequate supervision and mentoring, and have access to a Designated Breastfeeding Expert for assistance with problems outside their scope of practice.

PROCEDURE:

The coordinator or designated staff:

A. Defines work, dress and behavior expectations for peer counselors.

B. Meets with peer counselors on a regular basis to assess workload and performance; with more frequent meetings for new employees and contractors.

C. Monitors the quality and quantity of peer counselors’ work, such as:

1. Spot checking weekly activity reports, chart notes and participant contact logs.

2. Monitoring email and cell phone accounts.

3. Following up directly with participants.

D. Conducts or participates in annual peer counselor performance monitors and evaluations.

E. Ensures peer counselors:

1. Have access to computers, cell phones or other equipment and supplies necessary to complete their job duties.

2. Have access to updated breastfeeding materials.

F. Mentors peer counselors by taking actions such as:

1. Arrange regular one-to-one meetings.

2. Conduct observations and providing shadowing opportunities.

3. Make resource materials available for self-study and reference.

4. Reinforce positive behaviors.

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| Page 60 Breastfeeding 5. Review case studies or actual situations and coach peer counselors on how to appropriately respond and document outcomes.

6. Provide opportunities for training and development on participant-centered and interpersonal skills.

7. Coach peer counselors on how to deal with the challenges of balancing career, family and other life challenges.

8. Reinforce agency expectations.

BEST PRACTICE: Supervise and Mentor Peer Counselors

During the first six months of their employment or contract, the coordinator or designated staff may conduct the following activities in supervising and mentoring peer counselors.

A. Review weekly activity reports prior to approving time sheets.

B. Meet weekly with the peer counselor in-person or by phone to discuss:

1. Caseload. 2. Time management. 3. Counseling encounters. 4. Successes and issues of concern. 5. Progress and skill building. 6. Review weekly activity reports.

C. Hold monthly meetings with the peer counselor(s) to:

1. Discuss program logistics, planning and workflow. 2. Provide on-going training and agency orientation. 3. Provide opportunities for skill development.

D. Review participant documentation; ten percent of pregnant and breastfeeding caseload for small agencies or five to ten charts in large agencies.

E. Observe counseling sessions and provide feedback. Role play if this is not feasible.

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Breastfeeding | Page 61 F. Conduct monthly random phone surveys of pregnant and breastfeeding participants who received peer counseling services to assess participant satisfaction. Ten percent of caseload for small agencies or five to ten surveys in large agencies.

The second six months and thereafter, the peer counselor lead may choose to:

A. Review weekly activity reports prior to approving time sheets.

B. Meet monthly with the peer counselor in-person or by phone to:

1. Assess the peer counselor’s progress. 2. Review counseling style and skills. 3. Address concerns and further training needs. 4. Review the peer counselor’s satisfaction with the program. 5. Support and mentor the peer counselor’s professional development. 6. Review weekly activity reports.

C. Conduct quarterly meetings for agencies with more than one peer counselor.

D. Conduct quarterly random phone surveys of pregnant and breastfeeding participants who received peer counseling services to assess participant satisfaction. Ten percent of caseload for small agencies or five to ten surveys in large agencies.

E. Conduct quarterly chart reviews; ten percent of caseload pregnant and breastfeeding participants for small agencies or five to ten charts in large agencies.

F. Arrange for annual professional development for peer counselors.

G. Conduct annual performance evaluations for peer counselors who are employees or annual contract monitoring for peer counselors who are contractors.

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| Page 62 Breastfeeding POLICY: Peer Counselor Pay

Local agencies may hire the peer counselors as employees, hire them as independent contractors, or contract with a third party to hire and manage the peer counselors. See “Using a Third Party Contract or Memorandum of Understanding (MOU)” this chapter.

Local agencies receiving peer counseling funds must:

1. Pay peer counselors at least minimum wage.

2. Reimburse peer counselors for job-related expenses such as:

• Mileage. • Training registrations. • Other expenses needed to do their jobs.

3. Not hire and contract peer counselors for the same program.

4. Assure any contracted peer counselors have a signed contract before paying for their services.

PROCEDURE:

The coordinator or designated staff:

A. Determines whether to hire the peer counselor as an employee or as a contractor.

B. Follows agency protocols for hiring peer counselors as employees or contracting peer counselors.

C. For third party contracts:

1. Develops an agency-approved contract and confidentiality statement for contracted peer counselors.

2. Uses an agency-approved contract that spells out responsibilities for both the agency and the contractor.

3. Assures the contractor meets the statement of work and provides acceptable contract deliverables in a timely manner.

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Breastfeeding | Page 63 4. Determines how liability for contracted peer counselors is covered.

5. Keeps copies of all signed contracts and statements following agency personnel or contract protocols.

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| Page 64 Breastfeeding POLICY: Peer Counseling Program Allowable Costs

Agencies must:

1. Use peer counseling funds for allowable costs only.

• See Volume 2, Chapter 4 – Allowable Costs for specific information on allowable costs. • The agency can’t use peer counseling funds for other WIC or agency activities.

2. Assure only staff directly involved with peer counselors bill their time to these funds.

3. Assure staff working in WIC or other programs complete daily time keeping and document time working in the program verses other duties.

PROCEDURE:

A. Staff request reimbursement by reporting peer counseling costs as a separate line item in A-19’s sent to state staff. Examples of allowed peer counseling program costs include:

1. Staff salary and fringe benefits: Time spent by peer counselors, peer counselor leads, International Board Certified Lactation Consultants and peer counselor supervisors.

2. Supplies: Items for the Peer Counseling Program, including notebooks, books, demonstration teaching aids, files, cell phones and office supplies.

Note: Resources for the peer counselor coordinator or supervisor can be purchased with this funding only if the resources are related to peer counseling, such as training manuals for peer counselors. Otherwise, breastfeeding resources for peer counselor supervisors and other WIC staff should be paid using WIC funds.

3. Travel: Expenses for peer counselors, leads, DBEs and peer counseling staff and managers to travel to WIC State required trainings for FNS breastfeeding trainings or WIC State approved comparable trainings. Expenses for peer counselors to travel to home and hospital visits.

4. Training: Expenses related to training peer counselors or peer counselor leads.

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Breastfeeding | Page 65 5. Promotional materials: Costs for producing and giving handouts educating WIC participants and others about the peer counseling program. Staff must use WIC funds for breastfeeding educational materials.

• All handouts and flyers advertising the peer counseling program must include the WIC Non-discrimination Statement.

6. Clothing: Costs for shirts, name tags or lanyards identifying staff as peer counselors.

7. Indirect Costs: Refer to Volume 2, Chapter 4 – Allowable Costs, for more information.

B. Example of costs not allowable for the USDA Breastfeeding Peer Counseling Program include:

1. Childcare: Any childcare costs.

2. Discharge bags or other breastfeeding promotion items: Peer counseling funds can’t be used to buy breastfeeding promotion items. Peer counselors can give away items purchased with other funds.

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| Page 66 Breastfeeding POLICY: Community Partnerships and Promoting Peer Counseling Programs

Community support is important for a successful peer counseling program.

Agencies with peer counseling programs must coordinate with community organizations that target the WIC population about the peer counseling program.

PROCEDURE:

The peer counselor lead or coordinator:

A. Identifies which organizations should know about the peer counseling program.

B. Include a list of community partners and a summary of activities conducted in the Breastfeeding Peer Counseling Program Annual Report.

Information:

The following community partners are important to consider: • Local hospitals or birthing facilities where WIC participants deliver their babies. • Health care providers serving WIC participants. • Local breastfeeding coalitions.

Other recommended organizations include: home visiting programs outside the agency, area IBCLCs, La Leche League, Early Head Start, teen pregnancy centers, minority health organizations, parenting groups, and child care providers.

Suggested steps include: • Provide written information about the peer counseling program and its benefits. • Provide information about how to refer participants to the program. • Keep community partners up-to-date with program changes. • Have face-to-face meetings with community partners. • Participate in local breastfeeding coalitions. • Present to medical providers.

Distribute peer counseling promotional materials.

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Breastfeeding | Page 67 POLICY: Participant Confidentiality

Peer counselor leads and peer counselors must ensure participant confidentiality and security of participant information.

Peer counselor laptops must be connected to the local agency network at least one time per month to receive security updates.

Peer counselors, including contractors, must sign confidentiality agreements annually.

Peer counselors must: • Not share passwords. • Use only their own password when logging onto WIC or peer counseling computers. • Lock the screen or log out of their computers when they leave it. • Log out and shut down their computers when not in use. • Keep all mobile equipment password protected and hard copies of participant information locked-up and in a secure location. This includes items such as participant files, cell phones and laptops. • Work with the coordinator to report any loss or suspected loss of participant information to state staff within one business day.

Staff must work with state staff to follow-up on lost or stolen paper or electronic participant information.

PROCEDURE:

The peer counselor lead or coordinator:

A. Includes WIC and agency policies on confidentiality in peer counselor orientation.

B. Ensures peer counseling laptops are regularly updated with software and security.

C. Has all peer counselors review and sign confidentiality statements prior to seeing participants or viewing participant files, then annually thereafter.

D. Has all peer counselors sign a statement requiring the return of all equipment, resources and participant files before resigning or when terminated.

E. Assures staff use the USDA referral forms or a similar form, to make referrals to peer counselors and other staff.

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| Page 68 Breastfeeding

F. Trains peer counselors on how to keep equipment secure and what steps to take when participant information, paper or electronic, is lost or stolen, see Volume 2, Chapter 5 – Purchasing and Inventory: Lost, Stolen or Destroyed Electronic Devices on Loan from DOH policy.

G. Retrieves all equipment and documents with participant information from peer counselors who are terminated or who have resigned.

H. Works with state staff to follow-up on lost or stolen paper or electronic participant information.

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Breastfeeding | Page 69 POLICY: Texting and Cell Phone Use

A key component of the USDA Breastfeeding Peer Counseling Program is having peer counselors available to WIC participants outside of normal clinic hours.

Peer counselors must have access to agency provided cell phones to meet this requirement. If the requirement can’t be met, contact state staff for guidance.

Cell phones for peer counselor must:

• Have contracts held by local agency. • Be free of charge to peer counselors. • Be monitored to ensure peer counselors are using phone for work purposes only.

Protocols for cell phone use and texting must be reviewed annually with peer counselors.

Recommendation: For safety and participant confidentiality, peer counselors shouldn’t use personal cell phones to provide services to WIC participants. All personal cell phones used for WIC business are subject to subpoena and public discloser requests. This means personal cell phones may be seized and the information in that phone may be made public.

See Volume 2, Chapter 8 – Electronic Devices, Security and Service Interruption Plan for more information about cell phones and cell phone use.

PROCEDURE:

The peer counselor lead or WIC coordinator:

A. Develops a cell phone protocol and trains peer counselors on their use.

B. Develops a method of monitoring cell phone usage, at least semi-annually.

C. Reviews the protocol annually with peer counselors.

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| Page 70 Breastfeeding POLICY: Social Media

Local agencies may establish social media sites for their peer counseling programs or allow peer counselors to use social media to engage participants.

Social media isn’t:

• A substitute for medical advice. This must be clearly communicated to peer counselors and posted on any WIC peer counseling social media sites. • A way to remind individual participants about their appointments.

Local agencies may:

• Allow peer counselors limited time to use social media to interact with one another and gain access to breastfeeding information. • Use peer counseling funds to develop and use social media to: o Promote the peer counseling program. o Share short bios about the peer counselors. o Help participants connect with peer counselors.

• Use WIC funds or other agency funds to:

o Promote WIC services. o Promote prenatal breastfeeding classes or support groups for new moms. o Share World Breastfeeding Week activities or other breastfeeding promotion events. o Promote the fully breastfeeding food package. o Share short bios about WIC staff. o Provide general breastfeeding tips. o Link to other breastfeeding resources. o Help participants connect with peer counselors and other breastfeeding participants.

Local agencies that use social media must:

• Be fully responsible for their content. • Follow local agency guidelines for social media use.

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Breastfeeding | Page 71 • Develop an agency approved protocol on: o How peer counselors will access and use social media. See further recommendations in Social Media Guidelines in this chapter. o How agency staff will monitor and maintain the media.

• Post the USDA non-discrimination statement if WIC funds or Peer Counselor funds are used to develop the site or page.

• Not post any of the following:

o Violent, obscene, profane, hateful, or racist comments. o Comments that threaten or defame any person or organization. o Solicitations, advertisements, or endorsements of any financial, commercial, or non-governmental agency. o Comments that suggest or encourage illegal activity. o Unsolicited photos. o Any comments with participant names. o Personal information such as home addresses.

• Monitor posts daily, except weekends and non-work days and remove:

o Off-topic comments by a single user. o Repetitive comments copied and pasted by multiple users. o Inappropriate comments.

Peer counselors must not use social media:

• To provide individual counseling, dispense breastfeeding advice, or make contact with participants. • To communicate information, thoughts, and opinions about participants or to use participant names. • For personal gain or communication if the media is developed using WIC or Peer Counseling funds.

Note: Social media messages are visible to the public and subject to public records disclosure laws.

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| Page 72 Breastfeeding PROCEDURE:

The peer counselor lead or coordinator:

A. Works with agency administration to identify which social media platform to use and its related protocols on use and maintenance.

B. Trains peer counselors on the appropriate use of the social media.

C. Monitors the social media and its use by peer counselors.

D. Includes a report on the media and its use in the Breastfeeding Peer Counseling Program Annual Report.

Note: Social media is an effective way to foster engagement and increase access to evidence- based health messages. The Washington State WIC Nutrition Program has a Facebook page to promote the breastfeeding peer counseling program and foster engagement among peer counselors.

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Breastfeeding | Page 73 POLICY: Video Conferencing

Local agencies may establish video conferencing support options with their peer counseling programs and allow peer counselors to use video conferencing to engage participants using a DOH approved video platform.

Video conferencing is a virtual face to face appointment via smartphone, tablet or computer and is an effective way to foster engagement, increase access to peer counselors and to build rapport.

Video conferencing isn’t:

• A substitute for medical advice. This must be clearly communicated by peer counselors. • A way to remind individual participants about their appointments.

Peer counselors may:

• Use video conferencing as an option for virtual face to face appointments when other options are not available. • Text or email video links for breastfeeding support that are appropriate at each stage of a participant’s breastfeeding journey. o See Texting and Cell Phone Use policy in this chapter for information about texting. o See Volume 2, Chapter 8 – Electronic Devices, Security and Service Interruption, “Cell Phones” for more information about cell phones and cell phone use.

Local agencies that use video conferencing must:

• Use state approved video conferencing platform. • Develop an agency approved protocol for video conferencing. • Follow local agency guidelines. • Not text or email videos that have any of the following:

o Violent, obscene, profane, hateful, or racist comments. o Comments that threaten or defame any person or organization. o Solicitations, advertisements, or endorsements of any financial, commercial, or non-governmental agency. o Comments that suggest or encourage illegal activity.

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| Page 74 Breastfeeding

• Use a disclaimer at the beginning of the conversation that the platform is non-secure if the participant initiates contacts with staff using a non-secure platform such as FaceTime.

Peer counselors must not use video conferencing to communicate information, thoughts, and opinions that replace medical advice.

Note: Peer counselor cell phones are subject to public records disclosure laws.

PROCEDURE:

The peer counselor lead or coordinator:

A. Works with agency administration to identify which video conferencing platform to use and its related protocols on use and maintenance.

B. Trains peer counselors on the appropriate use of video conferencing.

C. Monitors video conferencing and its use by peer counselors.

D. Includes a report on the video conferencing and its use in the Breastfeeding Peer Counseling Program Annual Report.

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Breastfeeding | Page 75 POLICY: Breastfeeding Peer Counseling Program Annual Report and Budget

Agency staff, including the coordinator, peer counselor lead and agency fiscal staff must complete and submit an annual report and budget.

PROCEDURE:

A. Agency staff:

1. Completes the Breastfeeding Peer Counseling Program Annual Report.

2. Completes the peer counseling portion of the WIC Budget Workbook for the current year, including expenditures for the previous year. See Volume 2, Chapter 1 – WIC Contract.

3. Submits the annual report and budget to state staff on or before the deadline.

B. State staff:

1. Sends local agencies instruction on how to complete the report.

2. Acknowledges receiving the annual report and budget.

3. Reviews each agency’s annual report and budget.

4. Communicates to the peer counselor lead and coordinator that the report is complete or needs revision.

5. If revisions are needed, state staff will tell the peer counselor lead and coordinator what needs revision and when the revisions are due.

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| Page 76 Breastfeeding Section 4: Appendix A

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Breastfeeding | Page 77 Examples of Roles Related to Promoting and Supporting Breastfeeding

Federal regulations require local agencies to incorporate task-appropriate breastfeeding promotion and support training into orientation programs for new staff having direct contact with participants.

Although clinic-staffing patterns vary and job descriptions are always changing, there are defined staff roles in WIC. Below are examples of task-appropriate roles and responsibilities for WIC clerks/front-line staff, Competent Professional Authorities (CPAs), nutritionists, breastfeeding coordinators, coordinators and Designated Breastfeeding Experts (DBEs).

Breastfeeding is well supported in the WIC program when all staff, including front-line staff, have the following basic skills and training.

Basic skills and training for all WIC staff • Know why WIC promotes and supports breastfeeding as the normal way to feed infants. • Know the benefits of breastfeeding. • Understand the basics of normal breastfeeding. • Promote breastfeeding to all pregnant participants at every WIC visit. • Ask breastfeeding participants how breastfeeding is going at every WIC visit. • Enlist the help of a CPA for participants who have questions or problems with breastfeeding. • Not issue formula to breastfeeding infants without referring participants to a CPA for a Breastfeeding Review. • Understand the negative impact introducing formula has on breastmilk production. • Have the skills to identify “red flags” for breastfeeding and provide appropriate referrals. • Provide up-to-date breastfeeding resources to pregnant and breastfeeding participants. • Have skills to provide positive encouragement to breastfeeding participants. • Know the few circumstances in which a participant should not breastfeed. • Are oriented to and carry out local agency breastfeeding promotion and pump distribution policies. • Participate in activities to complete the breastfeeding portion of the Nutrition Services Plan. • Participate in breastfeeding training and in-services for staff.

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| Page 78 Breastfeeding Examples of roles related to promoting and supporting breastfeeding

Clerks Clerks play a critical role in breastfeeding promotion and support because they are the first point of contact for participants and see them most often. It’s important for clerks to have the basic skills and training listed above to promote and support breastfeeding.

WIC Certifier/CPA Within the duties of a CPA, breastfeeding will be promoted and supported when staff in these positions have the basic skills and training, and in addition:

• Uses participant-centered skills to educate pregnant participants on how to successfully initiate and sustain full breastfeeding. • Has skills to help breastfeeding participants problem solve common breastfeeding concerns. • Has skills to complete a Breastfeeding Review prior to issuing formula to breastfeeding infants. • Has additional training to provide more in-depth breastfeeding support to participants with special concerns.

Registered Dietitian Nutritionist or WIC nutritionist Within the duties of the nutritionist, breastfeeding will be promoted and supported when staff in these positions have the basic skills and training, and in addition:

• Has additional training to provide more in-depth breastfeeding support to participants with special concerns. • Assists in developing local agency breastfeeding promotion and support policies. • Assists in developing protocols for triaging participants with breastfeeding concerns. • Participates in or conducts breastfeeding education in-services for staff. • Coordinates breastfeeding support services with Maternity Support Services and other health care organizations and providers. • Participates in the development, review or selection of breastfeeding education materials. • Accurately interprets the Breastfeeding Report and shares the clinic’s breastfeeding initiation and duration data. • Works with the breastfeeding coordinator to develop the breastfeeding objectives and activities for the Nutrition Services Plan. • Is familiar with breastfeeding resources such as books, professional internet sites and journals, and other sources of breastfeeding education and shares them with staff.

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Breastfeeding | Page 79 Breastfeeding Coordinator The agency breastfeeding coordinator serves as the point-of-contact for the State WIC Breastfeeding Coordinator, coordinates breastfeeding activities within the clinic and with other organizations and participates in the development of the Nutrition Services Plan.

Breastfeeding coordinators must be International Board Certified Lactation Consultants or attend an intensive lactation management course, or other state approved breastfeeding training.

Within the duties of the breastfeeding coordinator, breastfeeding will be promoted and supported when staff in these positions have the basic skills and training, and in addition: • Coordinates activities in the clinic to promote breastfeeding. Assesses the “look” and “feel” of the clinic to reflect breastfeeding as the normal way to feed infants. • Has additional training to provide more in-depth breastfeeding support to participants with special concerns. • Keeps local community breastfeeding resources updated. • Coordinates World Breastfeeding Week activities. • Participates in or conducts breastfeeding education in-services for staff. • Coordinates breastfeeding promotion and support activities with other agency programs, organizations and community partners to provide consistent information and support to breastfeeding participants. • Accurately interprets the Breastfeeding Report and shares the clinic’s breastfeeding initiation and duration data with staff. • Presents the breastfeeding objectives and activities from the Annual Nutrition Education Plan to staff. • Is familiar with breastfeeding resources such as books, professional internet sites and journals and other sources of breastfeeding education and shares them with staff. • Works with the coordinator to meet the breastfeeding promotion requirements within the agency’s statement of work.

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| Page 80 Breastfeeding Coordinator Within the duties of the coordinator, breastfeeding will be promoted and supported when staff in these positions have the basic skills and training and, in addition:

• Assures local agency policies are developed and carried out to meet all breastfeeding requirements in the Washington State WIC Manual. • Designates a staff person(s) to carry out the role of the agency’s breastfeeding coordinator. • Assures the breastfeeding coordinator receives required training in breastfeeding promotion and support annually and attends state-sponsored scheduled Breastfeeding Coordinator Meetings. • Works with the breastfeeding coordinator to develop a breastfeeding promotion plan and includes it in the Nutrition Services Plan. • Provides time for the breastfeeding coordinator to carry out the duties outlined in this chapter. • Assures all staff receives task-appropriate breastfeeding orientation. • Assures all staff receives on-going breastfeeding training. • Assures CPAs provide all breastfeeding participants with a complete Breastfeeding Review prior to issuing formula. • Assures all staff know how to correctly enter breastfeeding information into the infant’s record in Cascades and update fields as needed. • Assures coordination with other agency programs, organizations and providers to assure accurate and consistent breastfeeding information and support is provided to participants. • Works with the breastfeeding coordinator to prioritize the use of WIC funds for breastfeeding promotion and support activities. • Supports staff to carry out World Breastfeeding Week activities (August 1-7).

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Breastfeeding | Page 81 Designated Breastfeeding Expert

The WIC DBE performs the following roles and responsibilities:

• Acts on all referrals from WIC staff regarding complex breastfeeding situations beyond their scope of practice.

• Assesses the breastfeeding dyad and offers counsel to participants with complex breastfeeding situations.

• Provides follow-up breastfeeding support to participants.

The DBE has all the following qualifications:

• Successful completion of a State-approved competency-based breastfeeding training that is consistent with the FNS WIC Breastfeeding Curriculums.

• Minimum of one year of experience in counseling breastfeeding dyads.

• Meets one of the following criteria:

o A physician or nutritionist (Masters or Bachelor’s degree in Nutritional sciences, Community Nutrition, Clinical Nutrition, Dietetics, Public Health Nutrition or Home Economics with emphasis in Nutrition) o IBCLC o RD/RDN o RN o Physician’s Assistant certified by National Committee on Certification of Physician’s Assistants o Completion of a minimum of 8 college courses from an accredited institution in Health Sciences.

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| Page 82 Breastfeeding SAMPLE: “Dear Breastfeeding Participant” Letter

Agency Letterhead

Dear Breastfeeding Participant,

Congratulations on doing the best for your baby and yourself by breastfeeding! Call us at ( ) if you have any questions or concerns about using the breast pump or breastfeeding.

If we loaned you a multi-user breast pump, please return it on time so we can help other breastfeeding participants. Call us if you need to continue to use the pump.

Thank you for your cooperation!

Sincerely,

Your Name Agency/Clinic Contact Phone Number

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Breastfeeding | Page 83 SAMPLE: Overdue Breast Pump Letter

Agency Letterhead

Dear breastfeeding participant,

Congratulations on doing the best for your baby and yourself by breastfeeding.

We loaned you a multi-user breast pump from the ________________________WIC Clinic.

The pump was due back to the clinic on __________________.

Please return the breast pump as soon as possible, or call us at ( ) to discuss extending the pump loan agreement.

If not returned, in the next 7 days, the state office may send you a bill for the replacement cost of this pump.

Thank you for your help.

Sincerely,

Your Name Agency/Clinic Contact Phone Number

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| Page 84 Breastfeeding Testing Electric Breast Pumps

When to test breast pumps: Test any pump making noises, squeaking, or when participants complain about low suction or a decreasing milk supply when other factors have been ruled out. Best Practice: Test multi-user breast pumps each time staff clean them after they’re returned.

Testing multi-user breast pumps 1. Set aside one double pumping accessory kit for testing. 2. Use the 24mm (Medela) or Medium (Hygeia) sized flanges. 3. Inspect the kit before testing to assure the flanges, membranes or valves are intact and in good condition. 4. Assemble the kit for single pumping by securely attaching all the parts and a single bottle to the tubing. You only need to test one side. 5. Firmly press the plug into the second opening on the piston ensuring it’s completely closed. 6. Assure the vacuum gauge is firmly inserted into the hole in the rubber stopper with the pull tab at the back of the gauge. 7. Firmly press the rubber stopper into the flange assuring the rubber stopper seals the flange completely. 8. Adjust the vacuum regulator by turning the piston’s indicator ring down for the lowest suction and up for the highest suction. 9. Turn on the pump and read the number on the gauge at the lowest setting and record it. 10. Gradually increase the suction by turning the piston’s indicator ring up. The numbers on the gauge should increase as you turn the indicator upwards. 11. Move the arrow to the highest setting and record this number. 12. Compare the number you recorded to the numbers below.

Evaluating pressure readings WIC multi-user electric pumps should have pressure readings between: • 50 and 90 mmHg at the lowest setting • Between 200 and 270 mmHg at the maximum setting These values are accurate up to 1650 feet above sea level. Vacuum levels can vary based on weather so try to avoid testing during storms. Step 7: Rubber stopper correctly inserted into Step 5: Plug firmly inserted into 2nd opening

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Breastfeeding | Page 85 Testing pump pressure at higher elevations The elevation of your clinic will affect pressure readings. The higher the elevation, the lower all values will read. Most clinics can use the readings on the previous page.

Staff in clinics with elevations between 1650 and 3300 ft. may see maximum pressure readings of about 240 mmHg, or a range of between 220 and 260 mmHg. This is normal at higher altitudes and pumps with readings within these lower ranges are working properly.

These agencies include: Cle Elum 1913ft, Colfax 1972ft, Nespelem 1841ft, Pullman 2,352ft, Republic 2569ft, Spokane 1843ft, and Wellpinit 2,411ft.

If you’re unsure of your clinic’s elevation use Google to determine the elevation or contract state office staff.

For guidance, see Chapter 15 - Breastfeeding when multi-user pumps aren’t working properly. Contact WICbreastpumps@doh.wa.gov with questions.

Personal–use pumps Pressure gauges are designed for multi-user breast pumps and aren’t accurate for personal use pumps. If you or your participant have questions about if a personal use pump is working properly, contact the vendor’s customer service department. WIC personal use pumps have a 1 year warranty. This warranty starts the day the pump is issued to the participant. Customer service can often help the participant troubleshoot the problem, or send a replacement overnight, if needed.

General information: You can tell if a breast pump is working properly by measuring the vacuum or suction. The most accurate way to do this is with a pressure gauge. Negative pressure is measured in millimeters of mercury, mmHg. Compare the readings on the gauge to the standard range to determine if pumps are working effectively. Pressure gauges measure the vacuum but not the speed of pumps. You can test the pressure at varying speeds if there are concerns. Pumps should meet at least the minimum pressure at about half speed or higher. When there are concerns about how a pump is working, the concern is usually about the vacuum. When there are concerns about the speed of the cycles, turn the pump on and count the number of cycles for 1 minute. The normal range for a multi- user breast pump is 40-60 cycles per minute.

Adapted from the Oregon WIC Program- Using a Pressure Gauge to Assess Breast pump Performance.

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| Page 86 Breastfeeding SAMPLE: Inventory for Multi-user Breast Pumps

Instructions: Track multi-user breast pumps by routinely completing an inventory and following up on overdue and missing pumps.

Staff may modify this sample inventory form to best meet the clinic’s tracking and inventory needs.

Pump serial # Date issued Issued by Participant Name or participant ID number Due date Date returned Date cleaned & staff initials Date Lost/Stolen report sent to state staff or reported damaged and destroyed?

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Breastfeeding | Page 87 SAMPLE: Perpetual Inventory for Personal Use Breast Pumps

Instructions: Complete an inventory of personal use breast pumps least once a year.

Modify this sample inventory form to best meet your clinic’s tracking and inventory needs.

Number of pumps in inventory Date pump issued

Name of staff issuing pump Participant name or participant ID number Date of inventory Name of staff taking inventory

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| Page 88 Breastfeeding SAMPLE: Optional Master Inventory for Multi-user Breast Pumps

Instructions: Track inventory of multi-user breast pumps at least once a year. An inventory of multi-user breast pumps is required with the Annual Nutrition Education Plan. Staff are strongly encouraged to inventory pumps more often.

Staff may modify this sample form to best meet your clinic’s tracking and inventory needs.

Pump Serial Number Status • Loaned • In the clinic • Reported lost or stolen to state staff • Damaged and destroyed • Permanently removed from inventory because of loss Date inventory completed Name of staff taking inventory

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Breastfeeding | Page 89 Section 5: Appendix B

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| Page 90 Breastfeeding Required Written Protocols for the Peer Counseling Program

1. The peer counselor lead’s responsibilities. 2. Peer counselor job duties, scope of practice and expectations on where peer counselors will provide services. For employees, this would be a job description. For contractors, this would be in the contract’s Statement of Work. 3. Initial and on-going training requirements for peer counselors including expectations for peer counselors to attend staff meetings and other meetings. 4. How peer counselors document client contacts. 5. How peer counselors document their work done outside normal clinic hours. 6. What the referral process is when peer counselors encounter situations outside their scope of practice. 7. How peer counselors make referrals to CPS. 8. How client confidentiality will be protected and what to do if it is breached. 9. How mentoring and orientation will take place in the early days of a peer counselor’s job to ensure she: • Stays within their scope of practice. • Provides evidence-based, client-centered services. • Meets all documentation and referral requirements. 10. How to monitor and evaluate peer counselor performance, whether they are employees or contractors. 11. Guidance on using cell phones, email, texting and social media. 12. The peer counselor’s role in the agency’s breast pump program. 13. Guidance for the peer counselor lead on how to mentor peer counselors. 14. Conditions for terminating employment. These can include: not performing job duties, or contractual duties, fraud, violating client confidentiality and inappropriate behavior for a “role model” in the community. 15. Steps to take when peer counselors leave the program. Peer counselors must return all WIC items issued to her, such as laptops, cell phones, client contact logs, supplies, etc.

Note: Other recommended protocols include: • Appropriate dress in the clinic • How to conduct home or hospital visits • How to weigh babies

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Breastfeeding | Page 91 Social Media Guidelines Social media is simply a public conversation. Social media sites change rapidly. Examples include Facebook, Twitter, My Space, Instagram, Snapchat, and YouTube and may include website blogs from organizations or individuals. Social media guidelines for WIC peer counselors are part of wider WIC agency guidelines and should be consistent with those standards.

Below are some general tips for using any social media sites.

Use Common Sense: • Use only the WIC clinic address and WIC –assigned phone number, and don’t give out personal information such as your home address. • Use the site(s) only for WIC-related business. Don’t use the site(s) for personal communications with non-WIC related friends and family. • Keep your messages focused on the purpose for the site, which is to have discussions with WIC participants about breastfeeding.

Be Responsible for what you write: • There is no such thing as “private information” on social media. Anything you write on a blog or other social media venue can be forwarded. Ask yourself: Would I be okay if this post is on the front page of my local newspaper? Would I be okay if my partner, my mother, or my boss saw it? • Share ideas, thoughts and information in a respectful way. Validate feelings when possible so that mothers feel they are being heard. • Remember confidentiality! Don’t divulge personal information about another person.

Do: • Keep messages short and simple. • Focus on providing education and information. • Be kind and friendly. • Check facts before you post. Only give website links that have been approved by your WIC supervisor or agency. • Use acronyms that everyone understands and uses. • Be sensitive when writing about issues that can cause strong feelings. These may include: smoking and breastfeeding, co-sleeping, child discipline, bottle-feeding, alcohol use, circumcision, epidurals, scheduled feedings, cesarean birth, depression, and others. • Provide evidence-based information in a respectful way and allow participants to make decisions they feel are best for their family.

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| Page 92 Breastfeeding • Include a disclaimer that advice from other parents should never replace the advice from medical experts. If they have questions or concerns about their health or the baby’s well-being, they should always contact their physician or a lactation expert.

Don’t: • Post important messages on Friday. Weekdays have more visitors. • Write provocative, discriminatory, or rude statements. • Use profanity or foul language. • Post on topics such as religion and politics. Focus only on pregnancy, birth, and breastfeeding discussions. • Advertise or promote products (including breastfeeding products or any businesses you may be involved with). • Use social media to provide individualized lactation support.

Guidance for Facebook Groups If your agency allows groups, have “closed groups” requiring administrator approval for others to join the group.

All groups should state: • The purpose of the group. • The intended audience. • Rules for posting. • A contact for questions or concerns.

“Pin” a disclaimer as the top post so it can’t be missed by any new members. Below are some examples of disclaimers:

• This site is for providing breastfeeding support, information and encouragement to pregnant women and breastfeeding mothers. Have a question? Ask here! Have a good tip? Share here!

• The comments and content posted on this group do not necessarily represent the view and opinions of the WIC staff or the WIC agency. The group is meant to be peer to peer support.

• Don’t advertise any items, including breastfeeding items, for sale.

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Breastfeeding | Page 93 • This group is NOT a substitute for medical advice. Please contact a healthcare provider to have specific questions answered regarding your personal or your family’s medical needs.

• If you need to contact a breastfeeding counselor please call: (include appropriate agency contact information).

Identify a moderator for hosting the group. This should be a WIC staff person trained in providing breastfeeding support or a senior peer counselor.

Routine monitoring • It is best to review profile pages daily to ensure that content is still correct and hasn’t been compromised. • Hide the friends list so no one else can see it. • Monitor the comments section so only appropriate comments show. • Routinely scan links to see that the destination pages have not been compromised or are being used to promote attacks.