West Virginia WIC Policy & Procedure 5.20 Effective Date: 3/1/21 5.20 West Virginia Breastfeeding Program

1 of 13 POLICY:

The purpose of the West Virginia Breastfeeding Program is to increase the frequency and duration of breastfeeding among women in the WIC Program per set goals cited in the annual West Virginia WIC State Plan.

DEFINITIONS:

Breastfeeding: The practice of feeding breastmilk to an infant on the average of at least once per day.

Breastfeeding Coordinator Training: The Breastfeeding Coordinator will be expected to maintain lactation credentials through completion of USDA specialized training, GOLD Lactation Training or other specialized breastfeeding training.

Breastfeeding Peer Counselor Training Program: The Breastfeeding Peer Counselor will be expected to maintain lactation credentials and/or specialized knowledge of breastfeeding to provide up-to-date counseling for WIC participants. This may include USDA specialized training, GOLD Lactation Training or other specialized breastfeeding training approved by Breastfeeding Coordinator.

PROCEDURE:

A. Program Objectives:

1. To identify, recruit and train women with successful breastfeeding experience as Breastfeeding Peer Counselors.

2. To promote breastfeeding among WIC participants through the placement of sufficient Breastfeeding Peer Counselors at designated WIC sites.

3. To plan, administer, monitor, and evaluate the Breastfeeding Peer Counselor Training Program to ensure Program growth stability, efficiency, and effectiveness within the community. The Breastfeeding Peer Counselor Training Program will be tailored to meet the needs of the WIC community and the capabilities of the Local Agency.

4. To foster greater participation in breastfeeding promotion efforts between public and private health professionals. Coordinates with local community stakeholders such as hospitals, birthing centers, and health care providers to enhance the effectiveness of the Breastfeeding Peer Counselors.

5. To identify and overcome barriers to breastfeeding among WIC participants through the development of intervention strategies.

West Virginia WIC Policy & Procedure 5.20 Effective Date: 3/1/21 5.20 West Virginia Breastfeeding Program

2 of 13 B. Breastfeeding Coordinator Staffing and Job Description (see Attachment #1 5.20)

1. Each Local Agency must have at least one (1) Breastfeeding Coordinator.

2. Qualifications of the Breastfeeding Coordinator:

a. WIC Competent Professional Authority (CPA) or an International Board-Certified Lactation Consultant (IBCLC), Certified Lactation Counselor Training (CLC), or State approved training in lactation management.

b. Personal experience in breastfeeding required; teaching and coordination experience preferred.

c. All participant information is handled in a confidential manner (see Policy 5.20 Attachment #3 Confidentiality Agreement).

3. Summary of responsibilities:

a. Ensure all agency WIC staff are trained to support a breastfeeding friendly environment.

i. All newly hired staff, including Breastfeeding Peer Counselors (BFPC), WIC Nutritionists and Nutrition Associates (CPA) and clerical staff will receive the USDA Breastfeeding Training.

ii. All Local Agency Lactation Consultants will attain and maintain lactation certification credentials.

iii. All Local Agency Breastfeeding Peer Counselors will attain and maintain USDA Breastfeeding Training and updates as appropriate.

b. Coordinate and implement the Breastfeeding Peer Counselor Training which includes but is not limited to:

i. Quarterly Breastfeeding support and training for the local agency staff; ii. Quarterly Breastfeeding Peer Counselor training; iii. Monthly communication with local agency Breastfeeding Peer Counselors. Contact may be made by phone or other technology platforms for those Breastfeeding Peer Counselors at another site location.

West Virginia WIC Policy & Procedure 5.20 Effective Date: 3/1/21 5.20 West Virginia Breastfeeding Program

3 of 13 c. Monitors and oversees the planning, management, implementation, and evaluation of breastfeeding peer counseling activities which includes but is not limited to:

i. Priority staffing in counties with birthing hospitals.

ii. Quarterly chart reviews of Breastfeeding Peer Counselor follow-up documentation

d. Evaluate and report results which includes but is not limited to:

i. Weekly review of Pacify reports and addition of any lactation notes into the Crossroads Family Care Plan.

ii. Monthly review of Breastfeeding Peer Counselor Hours

iii. Monthly submission of Breastfeeding Peer Counselor Service Hours to the State Breastfeeding Coordinator (see Policy 5.20 Attachment #4 Breastfeeding Peer Counselor Service Hours).

iv. Submission of the Annual Breastfeeding Plan, the Mid-Year Evaluation and Final Evaluation to the State Breastfeeding Coordinator.

v. Annual review of Local Agency breastfeeding initiation and duration rates, in comparison to the State rates.

e. Build and coordinate community relationships with hospitals, physicians, medical schools, and other community partners.

f. Evaluate eligibility for USDA Breastfeeding Awards (Gold, Premier, and Elite) and submit application if eligible.

C. Breastfeeding Peer Counselor Staffing

1. The Local Agency is required to provide Breastfeeding Peer Counselor services at each WIC clinic as determined by the caseload of pregnant and breastfeeding women.

a. Breastfeeding Peer Counselor service hour requirements will be determined by the State Agency at the beginning of each fiscal year. Dependent upon caseload, the Local Agency will increase the number of Breastfeeding Peer Counselors to provide sufficient coverage by providing Breastfeeding Peer Counselor service hours at each WIC clinic.

West Virginia WIC Policy & Procedure 5.20 Effective Date: 3/1/21 5.20 West Virginia Breastfeeding Program

4 of 13 b. A complete description and evaluation of this caseload assignment will be reported in the Progress Report and the Breastfeeding Promotion and Education Plan submitted annually to the State Breastfeeding Coordinator.

c. A Breastfeeding Peer Counselor working in the county in which she is familiar with the community is desirable. This also facilitates accessibility for participant contacts.

2. The State WIC Agency will provide partial funding of calculated required Peer Counselor service hours, for the fiscal year.

a. This funding is contingent upon the Local Agency providing at least the minimum required Peer Counselor service hours for the fiscal year within the Local Agency and providing Peer Counselor services at each site. Funding for each year will be contingent upon compliance during the previous fiscal year.

b. The Local Agency should attempt to stay above the minimum required hours, so in the event of sick leave, annual leave, or temporary staff shortage of Peer Counselors, they will still meet the number of required service hours for the fiscal year.

c. Local Agency Breastfeeding Coordinators will be required to submit monthly documentation of Peer Counselor service hours.

d. If the Local Agency’s monthly documentation of Peer Counselor service hours shows a deficit for any given month, it will be the responsibility of the Local Agency to make-up those service hours before the end of the fiscal year.

3. Qualifications of the Breastfeeding Peer Counselor (see 5.20

Breastfeeding Peer Counselor Job Description Attachment #2):

a. Past or present breastfeeding experience and a positive attitude about breastfeeding; b. Past or present participation in the WIC Program preferred; c. Ability to discuss and demonstrate breastfeeding aids; d. Possess effective communication skills; and e. Handle all participant information in a confidential manner (see Policy 5.20 Attachment #3).

4. Summary of responsibilities: Provides information, as delineated in the USDA Breastfeeding Program to pregnant and breastfeeding women identified in the Local Agency.

West Virginia WIC Policy & Procedure 5.20 Effective Date: 3/1/21 5.20 West Virginia Breastfeeding Program

5 of 13 5. Newly hired WIC Nutritionists and Nutrition Associates (CPA) will also receive the USDA Breastfeeding Training Program. All staff will receive breastfeeding updates as appropriate.

6. All Local Agency Lactation Consultants will attain and maintain lactation certification credentials. Breastfeeding Peer Counselors will receive breastfeeding updates as appropriate.

D. Initial Prenatal Contact

1. A minimum of one (1) contact will be made by the Breastfeeding Peer Counselor, preferably during WIC certification.

2. During this contact, the Breastfeeding Peer Counselor will:

a. Discuss the woman’s interest in breastfeeding and whether she harbors fears or anxieties about breastfeeding; b. Dispel any inappropriate fears or anxieties that she may have c. Identify barriers which may exist; d. Determine the level of support for breastfeeding; and e. Give the woman appropriate materials based upon identified barriers as reported by the WIC participant. f. Explain the Pacify App, including, how it gives tips for a healthy pregnancy and how participants will have access to a 24/7 IBCLC that will provide answers about feeding babies after delivery and during the weeks / months postpartum.

3. When the Breastfeeding Peer Counselor is not able to meet the women for the initial prenatal contact, the WIC CPA will complete the task delineated above during the first WIC nutrition education contact during the initial certification. The CPA will:

a. Discuss the USDA Breastfeeding Program with the participant including, promoting breastfeeding as the recommended feeding choice and exploring barriers or misinformation about breastfeeding; b. Discuss the importance of following medical advice, keeping prenatal and WIC appointments, and following prenatal dietary guidelines; and c. Ensure that the participants are scheduled for the prenatal breastfeeding class or a one-on-one nutrition education with the Breastfeeding Peer Counselor.

4. All contacts will be documented in the Crossroads Computer System in the Family Care Plan.

E. Follow-Up Prenatal Contacts

West Virginia WIC Policy & Procedure 5.20 Effective Date: 3/1/21 5.20 West Virginia Breastfeeding Program

6 of 13 1. One (1) group nutrition education class or one-on-one nutrition education about breastfeeding techniques will be offered to each pregnant participant prior to delivery.

a. The class will be taught by the Breastfeeding Coordinator, WIC CPA or Breastfeeding Peer Counselor trained by the Breastfeeding Coordinator. Other instructors will be approved by the State Agency Breastfeeding Coordinator.

b. The class will be a WIC nutrition education contact and be documented on the Crossroads Nutrition Education Screen as a Prenatal BF Class. A participant who refuses to attend or who is not able to attend the class will be provided with an appropriate breastfeeding handout.

i. Nutrition Education classes are coded to Nutrition Services Administration funds, and not to Breastfeeding Peer Counselor Funds.

c. The Breastfeeding Peer Counselor will be present, if possible, to show support if not leading the class.

d. The educator will ensure that participant information is documented in Crossroads and:

i. The address and phone number of the participants is verified; obtain phone numbers of friends, relatives or neighbors, if appropriate (i.e. breast pump loan); (see Policy 2.04 Residency Requirements and 2.17 Identification of Applicant/Participant and Parent, Guardian or Caretaker) ii. Screen participants for those who will most likely breastfeed following delivery by documenting “Great Idea”, “Not Sure” or “Not for Me” to the question: “How do you feel about breastfeeding?” (if using Infant Feeding Response Card (WIC-47); and iii. Provide participants with a personalized breastfeeding counselor business card and the Breastfeeding Counselor Identification Card (WIC-48) and the WIC clinic phone number. iv. Assist participant with registration for the Pacify App, providing a free clinic sign up code and ensuring that the participant allows push notifications to receive weekly reminders.

e. During each group Breastfeeding class, the educator will:

West Virginia WIC Policy & Procedure 5.20 Effective Date: 3/1/21 5.20 West Virginia Breastfeeding Program

7 of 13 i. Clarify misconceptions, questions, or concerns that the participant may have; and ii. Offer the woman appropriate breastfeeding materials, if desired.

f. The educator will strive to teach basic breastfeeding information and techniques with priority given to topics marked with an asterisk (*):

i. *How the breast makes milk as a physiological process of pregnancy and childbirth; ii. *Participant comments, questions, and concerns; iii. *Breastfeeding benefits for the woman and child; iv. Importance of mother-baby togetherness and skin to skin contact; v. Clothing to wear for breastfeeding discreetly, if desired; vi. Nipple assessment, preparation, and care; vii. *Proper positioning; viii. *Latching on and letting go for effective emptying of the breast and prevention of soreness; ix. The letdown reflex; x. Normal engorgement and problem prevention; xi. Nursing schedule; xii. *Ways to tell that baby is getting enough milk during the first month because of motor activity, moist oral cavity, at least four (4) wet diapers and three (3) to four (4) stools per day, regain birth weight by two (2) to three (3) weeks; xiii. *Social support services, including the WIC Breastfeeding Peer Counselor, La Leche League and hospital/clinic organized support groups, if available; and xiv. Dealing with hospital policy and personnel.

2. Breastfeeding Peer Counselors routinely contacts participants (mothers), at a minimum, monthly during pregnancy and weekly two (2) weeks prior to a woman’s expected delivery date (EDD).

a. All prenatal contacts and referrals will be documented in the Crossroads’ Family Care Plan section.

i. Referrals include but are not limited to Physicians, La Leche League, Community Support Groups, Pacify, etc.; and ii. Referrals will be made as needed concerning any breastfeeding issue or problem.

b. Contacts may be made in person during a clinic visit, group class, by phone or by mail if a phone is not available.

West Virginia WIC Policy & Procedure 5.20 Effective Date: 3/1/21 5.20 West Virginia Breastfeeding Program

8 of 13 3. Pregnant participants will be encouraged to call their Breastfeeding Peer Counselor, WIC CPA, Pacify, or La Leche League volunteer, if available, during all prenatal contacts with any concerns or questions they may have.

F. Initial Postpartum Contact 1. Initial postpartum contact will be made after delivery or initiation of breastfeeding between 3-5 days, but no later than 7 days postpartum dependent upon participant reported actual delivery date.

2. The Breastfeeding Peer Counselor will obtain a list of names of breastfeeding women who have notified the WIC clinic each week.

3. For the remaining women who had not notified the WIC clinic, a contact will be made by the Breastfeeding Peer Counselor.

4. Using the VENA approach, during this initial postpartum contact, the Breastfeeding Peer Counselor will strive to:

a. Document all postpartum contacts and referrals in the Crossroads Family Care Plan; b. Encourage the scheduling of certification appointments within three (3) weeks postpartum or initiation of breastfeeding; c. Reinforce positive aspects of breastfeeding and the woman’s positive feelings about it and give her encouragement and support; d. Ensure that she has an appropriate Breastfeeding handout; e. Discuss the infant’s nursing patterns, including the frequency and duration of each feeding; f. Explain problem prevention by reviewing basic breastfeeding techniques, such as, proper attachment, correct positioning, successful “let-down” reflex, nursing on both breasts during each feeding, frequent feedings; g. Discuss normal engorgement as mature milk comes in; h. Discuss possible solutions within the scope of the West Virginia Breastfeeding Peer Counselor Training Program to problems identified by the woman, for example, sore nipples, inadequate milk supply; i. Stress the adequacy of breast milk as the sole source of nutrition and of the importance not to routinely supplement with formula; and j. Stress the importance of seeking help early by calling her Breastfeeding Peer Counselor, WIC CPA, Pacify, or La Leche League volunteer, if available. The Breastfeeding Peer Counselor should give, at her discretion, the breastfeeding woman her phone number during this contact.

5. When postpartum contacts are made at hospitals, the Breastfeeding Peer Counselors/Coordinators may use either Policy 5.20 - Breastfeeding Peer Counselor Hospital Participant Contact Evaluation - Attachment #5 or

West Virginia WIC Policy & Procedure 5.20 Effective Date: 3/1/21 5.20 West Virginia Breastfeeding Program

9 of 13 Policy 5.20 - Breastfeeding Peer Counselor Hospital Lactation Specific Participant Contact - Attachment #6, in order to guide and document the contact.

a. Completed forms are to be reviewed by the Local Agency Breastfeeding Coordinator; and b. Document the contact in Crossroads’ Family Care Plan section.

G. Follow-Up Postpartum Contacts

1. Additional follow-up contacts by the Breastfeeding Peer Counselor by phone or face-to-face will be made following delivery or initiation of breastfeeding: a. Follow-up contacts will be made every 2-3 days for breastfeeding women with breastfeeding problems; b. Contacts will be made within 24 hours if the mother reports problems with breastfeeding and weekly throughout the rest of the first month; c. Contacts will be made during the first month postpartum for women without breastfeeding problems at seven (7) to ten (10) days and again at three (3) weeks postpartum; d. Breastfeeding Peer Counselor routinely contacts mothers after a woman’s first month postpartum visit, at a minimum, monthly, if breastfeeding is going well;

Note: Mailings (including email) will be made when the Breastfeeding Peer Counselor is not able to make the contact in person or by phone or if the participant has not been in contact with the local WIC clinic. .

2. Using the VENA approach, during the seven (7) to ten (10) day contact, the Breastfeeding Peer Counselor will strive to:

a. Document the contact on the Crossroads’ Family Care Plan section; b. Ensure that a WIC appointment for certification as a breastfeeding woman has been scheduled; c. Reinforce positive aspects of breastfeeding and her positive feelings about it, and give her encouragement and support; d. Discuss possible solutions, within the scope of the USDA Breastfeeding Support and Encouragement Training, to problems identified by the woman; e. Review how to assess that the baby is getting enough milk and the frequency and appearance of normal stools; f. Discuss growth spurts, including appropriate weight loss in the first week for the newborn infant; g. Stress the importance of seeking help early by calling her Breastfeeding Peer Counselor and WIC CPA; and

West Virginia WIC Policy & Procedure 5.20 Effective Date: 3/1/21 5.20 West Virginia Breastfeeding Program

10 of 13 h. Inform the woman of optional WIC support groups for breastfeeding women, Pacify, the La Leche League or other community support groups, if available i. Assist the participant with sign-up for the Pacify App, providing a free clinic code and instructions for use 3. Using the VENA approach, during the three (3) week contact, the Breastfeeding Peer Counselor will strive to: a. Document the contact on the Crossroads’ Family Care Plan section; b. Discuss the infant’s progress, including any problems within the scope of the USDA Breastfeeding Support and Encouragement Training Program, previously identified; c. Review the woman’s personal situation, including: her plans to return to work or school; how she feels physically and emotionally; whether she has a social support system at home, within her family and among friends; d. Discuss pumping techniques or manual expression of milk and storage, if appropriate; e. Discuss adequacy of breast milk as a sole source of nutrition for an infant’s first six (6) months. No other cereal or other solids are needed. The American Academy of Pediatrics (AAP) recommends breastfeeding of the first year and as long thereafter as the nursing dyad chooses; f. Mom may need to discuss supplementation; g. Discuss how to discreetly breastfeed, if desired; h. Stress the importance of seeking help early by calling her Breastfeeding Peer Counselor or WIC Nutritionist or Nutrition Associate (CPA); i. Inform the woman of optional WIC support groups for breastfeeding women, including Pacify. Inform the woman of the La Leche League or other community support groups, if available

4. When the Breastfeeding Peer Counselor is not present during the woman’s breastfeeding certification appointment, the WIC CPA will ensure that she has an appropriate breastfeeding handout. The WIC CPA will discuss appropriate topics on breastfeeding as outlined above. The WIC CPA is not responsible for the phone contacts or mailings which are done by a Breastfeeding Peer Counselor.

5. Using the VENA approach, during the three (3) and (6) month contact, the Breastfeeding Peer Counselor will strive to:

a. Document her overall personal experience with breastfeeding on the Crossroads’ Family Care Plan section; b. Discuss the infant’s progress, including any problems within the scope of the USDA Breastfeeding Training Program, previously identified, and encourage and compliment the woman;

West Virginia WIC Policy & Procedure 5.20 Effective Date: 3/1/21 5.20 West Virginia Breastfeeding Program

11 of 13 c. Review the woman’s personal situation, including: her plans to return to work or school; how she feels physically and emotionally; whether she has a social support system at home, within her family and among friends; d. Discuss exclusive or partial breastfeeding. If appropriate, discuss supplementation; document change in breastfeeding status in the Family Care Plan Section (see Policy 5.04 The Nutrition Care Plan). e. Discuss teething; f. Encourage the woman to call when she is ready to wean. Document when mother quits breastfeeding on the Crossroads’ Health Information Screen and in the Family Care Plan Section; g. Inform the woman of optional WIC focus groups for breastfeeding women, if available. Inform the woman of La Leche League or other community support groups, if available. Remind her to use the Pacify App for 24/7 breastfeeding support.

Note: Questions regarding nutrition requirements for the lactating woman and breastfed infant will be referred to a WIC CPA.

6. When the infant has been weaned, “age at weaning” and “reason for weaning” will be documented on the Health Information Screen before or during the six (6) month follow-up appointment for the infant or the certification appointment as a child, up to eighteen (18) months of age.

H. Optional WIC Support Groups

1. The Local Agency may offer an optional WIC focus group facilitated by a Breastfeeding Peer Counselor for breastfeeding women and infants.

2. The support group contact may count as a WIC nutrition education contact and will be documented on the Crossroads Nutrition Education Screen.

3. The purpose of the support group is: a. To provide a postpartum support group; b. To allow the breastfeeding women to set the agenda; c. To allow breastfeeding women to share experiences with each other; d. To set a positive attitude/model for others to emulate; e. To address common problems and concerns.

I. Positive Clinic Environment

It is important to portray breastfeeding as the preferred infant feeding method with a clinic environment in support of initiation/continuation of breastfeeding through the following methods:

West Virginia WIC Policy & Procedure 5.20 Effective Date: 3/1/21 5.20 West Virginia Breastfeeding Program

12 of 13 1. Display attractive and culturally appropriate breastfeeding posters and pictures;

2. Make breastfeeding pamphlets available in the waiting area; 3. Remove print materials and office supplies containing formula product names; 4. Provide a private area for breastfeeding counseling; 5. Provide a private area for breastfeeding.

J. Breastfeeding Education Materials

1. The nondiscrimination statement must be included, in full, on all breastfeeding materials that are produced for public information, public education, or public distribution (see Policy 1.08 Civil Rights).

a. When space prohibits use of the lengthy statement, the following statement may be used, in print size no smaller than the text:

“This institution is an equal opportunity provider.”

2. Locally developed breastfeeding education materials must be reviewed and approved by the State Agency and include the nondiscrimination statement (see Policy 1.08 Civil Rights).

REFERENCES:

1. WIC Regulations 246.2, Definitions 2. WIC Regulations 246.7, Certification of Participants 3. FNS Instruction 803-16, WIC Program – Certification: Participation of Breastfeeding Women and Their Infants 4. “WIC’s Promotion and Support of Breastfeeding: Making Breastfeeding Accessible and Equitable for the WIC Population,” National WIC Association Position Paper 5. “How WIC Supports Breastfeeding,” National WIC Association 6. USDA, FNS, Breastfeeding Policy and Guidance, July 2016 7. USDA Nutrition Services Standards, Standard 7: “Nutrition Education and Counseling” 8. USDA Nutrition Services Standards, Standard 8: “Breastfeeding Education Promotion and Support” 9. USDA Nutrition Services Standards, Standard 9: “Breastfeeding Peer Counseling”

ATTACHMENTS:

1. Breastfeeding Coordinator Job Description 2. Breastfeeding Peer Counselor Job Description 3. Confidentiality Agreement 4. Monthly Documentation of Peer Counselor Hours 5. Breastfeeding Peer Counselor Hospital Participant Contact Evaluation

West Virginia WIC Policy & Procedure 5.20 Effective Date: 3/1/21 5.20 West Virginia Breastfeeding Program

13 of 13 6. Breastfeeding Peer Counselor Hospital Lactation Specific Participant Contact