1. Breastfeeding Education for Home Visiting Programs Toolkit Copyright © Ann & Robert H. Lurie Children’s Hospital of Chicago. All rights reserved.

2. What’s In This Toolkit Page 3………………………...……….……....................Introduction Page 4……….…………………….......……How This Toolkit Works Page 5……….…………………...……Talking About Breastfeeding Page 6…………………………….…………..Motivational Interviewing Page 16…………..………….....Resources: Motivational Interviewing Page 18……………………..…….....How to Introduce Breastfeeding Page 22………….……………......Resources: Baby Behavior Basics Page 31……………………………….......The Choice to Breastfeed Page 34…..………….……......Resources: The Choice to Breastfeed Page 45…………………….................Preparing for Breastfeeding Page 46………………………...................Planning for Breastfeeding Page 49………………...........Resources: Planning for Breastfeeding Page 55………………………......................Maternity Leave Planning Page 56…………..…………….Resources: Maternity Leave Planning Page 68……………………………..…..………...Educating Employers Page 77…………………………....…..………..…...How to Breastfeed Page 78…………………………...……Resources: How to Breastfeed Page 81…………………………………Is Baby Getting Enough Milk? Page 82……..……………Resources: Is Baby Getting Enough Milk? Page 88……..………………..……………………...……Bottle-Feeding Page 89…………………………..…………Resources: Bottle-Feeding Page 94……………………….Overcoming Breastfeeding Barriers Page 95………….…..Resources: Common Breastfeeding Problems Page 101………………………..…………Resources: Family Support Page 105..……………..…………Resources: Breastfeeding in Public 2

3. Introduction Breastfeeding in early childhood has many health benefits. It has been shown to reduce the risk of ear infections, asthma, eczema, childhood leukemia, necrotizing enterocolitis (an intestinal disease usually seen in preemies), diarrhea, severe lower respiratory tract infections (i.e. pneumonia), sudden infant death syndrome (SIDS) and type 1 and 2 diabetes. Additionally, not breastfeeding is associated with a 32% higher risk of childhood obesity. The Consortium to Lower Obesity in Chicago Children (CLOCC) has made a commitment to breastfeeding work through its support of the Baby-Friendly Hospital Initiative (BFHI) in Chicago. Under this initiative, hospitals and birthing centers are awarded a Baby-Friendly designation if they successfully implement the Ten Steps to Successful Breastfeeding and take actions to restrict the marketing of baby formula. However, there have been calls to build upon BFHI by offering additional breastfeeding support in the community to help mothers continue breastfeeding once they have been discharged from the hospital. Community breastfeeding support is an important piece of the fight against childhood obesity. Home visiting programs represent an important community-based service through which health professionals and home visiting workers may provide additional breastfeeding education and support. Yet many home visiting models approved by the United States government do not emphasize breastfeeding support. We recognize the unique position you, as a home visitor, are in to support mothers in their breastfeeding journey. This toolkit’s goal is to arm you with the resources you need to effectively educate families about breastfeeding. 3

4. How This Toolkit Works We want this toolkit to be as useful as possible for you. All of the pages are for your reference, but some are designed to be shown to your participants and others are not. Any page with a green header is designed so that you can show it to a mother or other family member, if you’d like: Any page with a blue header is designed for your reference: Additionally, there are “resource” sections throughout this toolkit. Generally, all handouts in those sections are designed to be used with your participants unless they have blue headers. Typically, these pages include links to videos that we recommend you share with participants on your computer. 4

5. Talking About Breastfeeding 5 You may have experienced conflict around breastfeeding in the past, and you’re likely not alone; the decision to breastfeed (or not) is a personal one that people sometimes feel strongly about. We understand the personal nature of this choice and recognize that the ability to breastfeed depends upon much more than scientific evidence and health benefits. The goal of this toolkit is not to judge anyone for how they choose to feed their babies or to tell you how to do your job. We realize that you are the expert on your program and participants, and we recommend you incorporate the information and resources in this toolkit into your curriculum as you see fit. All of the information in this toolkit is supported by science, and we hope you find it useful. In this section, we review some techniques and information you can use to approach breastfeeding in a non-confrontational way: Motivational Interviewing Baby Behavior

6. Section 1: Motivational Interviewing Motivational interviewing (MI) is a method of communication that may make it easier for you to introduce and discuss breastfeeding. It’s based on the idea that people get defensive when they’re given advice they didn’t ask for and may be described as “giving advice with permission.” The communication style is non- authoritarian, supportive and emphasizes reflective listening and why to change rather than how. A more formal definition is below. “Motivational interviewing is a person-centered, directive method of communication for enhancing motivation to change by exploring and resolving ambivalence.” Motivational interviewing is also based on the Stages of Change Model. This model assumes there is a natural process to change – depicted by the illustration below – and you can use this technique to facilitate the process by recognizing which stage your participants are in and responding appropriately. On the following pages, we’ve included a variety of MI tip sheets to help you learn this communication style. 6

7. How to Introduce Breastfeeding Five General Principles of Motivational Interviewing: 1.Express empathy 2.Develop discrepancy (between participant’s behavior and ideals/goals) 3.Avoid arguing 4.Roll with resistance 5.Support self-efficacy Specific Motivational Interviewing Strategies: 1.Ask open-ended questions 2.Use reflective listening 3.Affirm what you hear 4.Summarize 5.Elicit self-motivational statements Assumptions to Avoid in Motivational Interviewing: 1.This person OUGHT to change 2.This person WANTS to change 3.This person’s health (or their baby’s health) is the main motivating factor for him/her 4.If he or she does not decide to change, the consultation has failed 5.Individuals are either motivated to change or they’re not 6.Now is the right time to consider change (see the Stages of Change on page 9!) 7.A tough approach is always best 8.I’m the expert – he or she must follow my advice 9.A negotiation approach is always best 7 What’s reflective listening? When you repeat or paraphrase what a person shares with you; you understand the underlying feeling in their statement and repeat that to them. This encourages them to share more! Motivational Interviewing Tip Sheet for Home Visitors Adapted from: http://www.motivationalinterview.org/Documents/Skills%20Tip%20Sheet.pdf

8. How to Introduce Breastfeeding 8 Signs of Resistance 1.Arguing Challenging Discounting Hostility 2.Interrupting Talking over Cutting off 3.Ignoring Inattention Non-answer No response Sidetracking 4.Denying Blaming Disagreeing Excusing Claiming the rules don’t apply to them Minimizing Pessimism Reluctance Unwilling to change Strategies for Handling Resistance: 1.Simple Reflection: simple acknowledgement of the participant’s disagreement, emotion or perception 2.Double-sided Reflection: acknowledge what the participant has said and add to it the other side of the participant’s ambivalence 3.Clarification: verify your understanding matches the participant’s perspective 4.Shifting Focus: shift the participant’s attention away from what seems to be a stumbling block 5.Emphasizing Personal Choice and Control: assure the participant that in the end, it is he or she who determines what happens Motivational Interviewing Tip Sheet for Home Visitors Adapted from: http://www.motivationalinterview.org/Documents/Skills%20Tip%20Sheet.pdf

9. MI Procedure and Stages of Change Use the Stages of Change to help move your participants through the change process. 9 Stage of ChangeCharacteristicsTechniques Pre-contemplation Not currently considering change: "Ignorance is bliss" Validate lack of readiness Clarify: decision is theirs Encourage re-evaluation of current behavior Encourage self-exploration, not action Explain and personalize the risk Contemplation Ambivalent about change: "Sitting on the fence" Not considering change within the next month Validate lack of readiness Clarify: decision is theirs Encourage evaluation of pros and cons of behavior change Identify and promote new, positive outcome expectations Preparation Some experience with change and are trying to change: "Testing the waters" Planning to act within 1 month Identify and assist in problem solving with obstacles Help participant identify social support Verify that participant has underlying skills for behavior change Encourage small initial steps Action Practicing new behavior for 3-6 months Focus on restructuring cues and social support Bolster self-efficacy for dealing with obstacles Combat feelings of loss and reiterate long- term benefits Maintenance Continued commitment to sustaining new behavior Post-6 months to 5 years Plan for follow-up support Reinforce internal rewards Discuss how to handle relapse Relapse Continuation of old behaviors: "Fall from grace" Evaluate trigger for relapse Reassess motivation and barriers and plan stronger coping strategies Adapted from: http://www.motivationalinterview.org/Documents/Skills%20Tip%20Sheet.pdf

10. MI Techniques O.A.R.S. Open-Ended Questions Invite person to talk freely versus answering with a “yes” or “no” Affirmations Nodding, looking in the eye  encourages person to continue talking Reflections Use reflective or active listening: repeat or paraphrase what the person shares, understand the underlying feeling in their statement and repeat that to them  encourages them to share more Summarization Gather the person’s statements from the conversation and present them back to the person in a “bouquet” 10

11. MI Techniques Elicit-Provide-Elicit Elicit: ask what the participant knows, would like to know or if it’s okay if you offer them information “Could you tell me what you know about breastfeeding?” “Would you be interested in hearing what I know about breastfeeding?” Provide: share information in a neutral, nonjudgmental fashion “What we know is that formula can actually put your baby at risk for a variety of diseases.” “Research shows that breastfeeding can reduce the risk for illnesses like ear infections and pneumonia.” Elicit: ask about the participant’s interpretation of the information you shared “What do you think about what I just said?” “What do you think your next step should be?” “How can I help?” 11 Use neutral language as much as possible: “Folks have found…” “What we know is…” “Others have benefited from…” Avoid sentences starting with “I” or “You” Use conditional words rather than concrete words: “might” “perhaps” “consider” vs. “should” “must” When “instructing” is necessary, recognize what stage of change your participant is at and only provide relevant advice/information. E-P-E Tips! Tips adapted from: http://www.motivationalinterview.org/Documents/Skills%20Tip%20Sheet.pdf

12. How to Introduce Breastfeeding Mother who says she thinks she wants to formula-feed her baby when she is born ELICIT Could you tell me what you know about breastfeeding? How about formula-feeding? INSTEAD OF: If I fed my daughter formula, I’d be scared she would get sick all the time. PROVIDE What we know is that formula can cause children to get sick more often and make them gassy or constipated. ELICIT What do you think about that information I shared? INSTEAD OF: It’s obvious from this information that you need to breastfeed your child. 12 Case Study: E-P-E and Breastfeeding

13. MI Techniques Recognize Change Talk Change talk is an important step in encouraging healthy behavior and signals a participant may consider the positive behavior at hand Desire: statements participants make about preference for change “I would like to breastfeed” Ability: statements participants make about self-capability “I think I could breastfeed” Reasons: statements participants make that are specific arguments for change “Breastfeeding helps make my baby healthy” Need: statements participants make about feeling an obligation to change “I should breastfeed” Commitment: statements participants make about the action(s) they will take to change “I’m going to breastfeed” Encourage and strengthen these statements – this is where summarization or “bouquet” skills should be used! 13 Adapted from: http://www.motivationalinterview.org/Documents/handout.pdf

14. MI Techniques Strategies for Eliciting Change Talk 1.Use Open- Ended Questions Why would you want to make this change? (Desire) How might you go about it, in order to succeed? (Ability) What are the three best reasons for you to do it? (Reasons) How important is it for you to make this change? (Need) So what do you think you’ll do? (Commitment) 2.Ask for Elaboration When a change talk theme emerges, ask for more detail: In what ways? How do you see this happening? What have you changed in the past that you can relate to this issue? 3.Ask for Examples When a change talk theme emerges, ask for specific examples: When was the last time that happened? Describe a specific example of when this happens. What else? 4.Looking Back Ask about a time before the current concern emerged: How have things been better in the past? What past events can you recall when things were different? 5.Look Forward Ask about how the future is viewed: What may happen if things continue as they are? If you were 100% successful in making the changes you want, what would be different? How would you like your life to be in the future? 14 Adapted from: http://www.motivationalinterview.org/clinicians/Side_bar/skills_maintenence.html

15. MI Techniques Strategies for Eliciting Change Talk 6.Talk About Extremes Ask about the best and worst case scenarios to elicit additional information: What are the worst things that might happen if you don't make this change? What are the best things that might happen if you do make this change? 7.Use Change Rulers Ask open-ended questions about where the participant sees himself or herself on a scale from 1 – 10. On a scale where one is not at all important, and ten is extremely important, how important is it to you to change _______? (need) Follow up: Explain why are you at a ___ and not [lower number]? What might happen that could move you from ____ to a [higher number]? How much do you want _________? (desire) How confident you are that you could _________? (ability) How committed are you to ______? (commitment) 8.Explore Goals and Values Ask what the person's guiding values are. What do you want in life? What values are most important to you? How does this behavior fit into your value system? What ways does [the behavior] conflict with your value system? 9.Come Alongside Explicitly side with the negative side of the person’s ambivalence. Perhaps ____________ is so important to you that you won't give it up, no matter what the cost. This may not be the main area that you need to focus on in our work together. 15 Adapted from: http://www.motivationalinterview.org/clinicians/Side_bar/skills_maintenence.html

16. Resources: Motivational Interviewing 16

17. Change Ruler Worksheet On the scale below, mark how important it is for you to: _____________________________________________________________. 1 2 3 4 5 6 7 8 9 10 17 Not important Most important Adapted from: http://www.motivationalinterview.org/Documents/handout.pdf

18. Section 2: How to Introduce Breastfeeding Recommendations Educate families about baby behavior and infant cues to ease into infant feeding discussions. If you have more than one prenatal visit, discuss general baby behavior and infant cues during your first visit. On your second visit, briefly review infant cues related to breastfeeding, then introduce breastfeeding using motivational interviewing techniques. If you only have one prenatal visit, consider using the baby behavior discussion to transition into infant feeding topics later in your conversation. Ask: “What have you heard about infant feeding?” or “What have you heard about breastfeeding?” Note: Starred topics on the following three pages are closely related to infant feeding; consider reviewing these to transition into breastfeeding discussions. 18

19. How to Introduce Breastfeeding Taking care of a new baby can be confusing Newborns are uncoordinated and may accidentally send confusing cues! Take the 1-2 hours after birth when they are alert to get to know each other and practice feeding. Babies use “engagement cues” when they want to interact Babies are born knowing how to use these cues to speak to their parents. Babies who want to engage with you will look at what they’re interested in, relax their face or smile or, when they’re older, try to touch and taste things they’re interested in. Babies use “disengagement cues” when they need a break New babies are easily over-stimulated, and disengagement cues mean that something is bothering your baby. She may close her eyes, turn her face away from you, arch or twist her body away, get tense or frown. It won’t always be obvious what’s bothering her, but begin reducing stimulation to figure out what the problem is. Babies “cluster” cues to convey important messages Sometimes, the message is, “I’m hungry!” Your baby will move her head to and fro, pull her hands and knees towards her face, making sucking noises, open her mouth and increase her movement. She will also cluster cues when she’s full: she’ll relax, slow her eating, let her hands fall from her face and sometimes fall asleep. Crying doesn’t always mean babies are hungry Sometimes babies cry when they’re hungry, but usually when they’ve already used other feeding cues and no one has fed them. If baby isn’t using feeding cues, crying also may mean she could be: tired, frustrated, bored, lonely, over- stimulated, startled, scared, sick, in pain or have a dirty diaper. 19 Baby Behavior Basics

20. How to Introduce Breastfeeding Crying increases dramatically on the second day On the second day, babies become more alert and work harder to give cues, but – again – newborns are uncoordinated and may not express themselves well! Often their cues mean they’re hungry. Don’t be shocked; it’s healthy and normal for baby to feed often and it stimulates your milk supply. Feed frequently and hold your baby skin-to-skin to soothe her. Paying close attention to babies can mean less crying To prevent crying, try to anticipate things around you that may upset your baby and then limit them. You should also pay close attention to your baby’s cues and address them early. Finally, remember that no one is perfect! Babies can be hard to understand, so just try to learn from your mistakes. The two of you will get better at communicating with time! Babies are soothed by repetition Sometimes, even when you fix what’s upsetting your baby, she won’t stop crying. And sometimes you won’t be able to figure out what’s upsetting her! You can still calm her using repetition: rocking, singing or even riding in the car. Choose one action and do it for a few minutes. If nothing changes, switch to another action. Doing more than one at a time may upset her more. It may take a lot of practice to master feeding Sometimes babies have a hard time learning to eat at first – coordinating breathing and sucking can be difficult! That said, babies usually learn very quickly and can feed well after a few days. This is why it’s important to practice feeding your baby whenever she gives feeding cues. New babies also have very small tummies and can only consume about a small amount of milk each feeding, so this helps make sure they don’t get hungry. 20 Baby Behavior Basics

21. How to Introduce Breastfeeding Young babies are not supposed to sleep through the night Unfortunately, new babies wake up every few hours – but for good reasons! Since their new brains, muscles and lungs aren’t quite in sync yet, sleeping too deeply could mean they get too hot or too cold or that they don’t wake up when they need more air. Additionally, new babies have tiny tummies and need to eat often. Dreaming helps babies’ brains develop Babies dream for half of the time they’re asleep – this is when their brain develops and grows! Dreaming is a light stage of sleep, and unlike adults, babies fall into dream sleep right away, then move into deeper sleep. This is why babies wake up so easily. To keep your baby from waking up when you lay her down to sleep, look for signs she’s moved from light sleep to deep sleep: her eyelids will stop fluttering and she’ll stop twitching. Over time, new babies do sleep longer New babies develop quickly, so by the time they’re 6-8 weeks old, they can sleep for longer periods of time (with fewer nighttime feedings). By the time she reaches 4 months of age, your baby will start sleeping like you – falling into a deeper sleep right away and staying asleep for even longer at night. By 6 months your baby will begin sleeping through the night completely! But, sometimes new babies sleep too much Sometimes, newborns sleep for long stretches, and this can be a sign of trouble. If your baby does this, you’ll need to wake her for feedings. You can do this by using a variety of actions: undress your baby, change her diaper or position, or talk or sing in different voices. If your baby isn’t interested in feeding, sucks weakly or doesn’t have dirty diapers often, you should go to the doctor. 21 Baby Behavior Basics

22. Resources: Baby Behavior Basics 22

23. 23 Source: http://www.nal.usda.gov/wicworks/Sharing_Center/CA/Training1/Infant_States.pdf

24. 24

25. 25 Source: http://www.nal.usda.gov/wicworks/Sharing_Center/gallery/FitWICBaby.htm

26. 26 Source: http://www.nal.usda.gov/wicworks/Sharing_Center/gallery/FitWICBaby.htm

27. 27

28. 28

29. 29

30. 30 Source: http://www.nal.usda.gov/wicworks/Sharing_Center/gallery/FitWICBaby.htm

31. The Choice to Breastfeed 31 The American Academy of Pediatrics recommends mothers only feed their babies breast milk (nothing else, not even water or infant cereal!) for the first 6 months of life and to continue for at least 12 months as they introduce the baby to new foods. They make this recommendation for good reason: formula- feeding is associated with a higher risk for a variety of illnesses in mothers and babies. In this section we provide you with resources to help you educate families about breastfeeding and to help families decide how to feed their infants.

32. Concerns with Formula-Feeding For Infants Higher risk of… Ear infections Diarrhea Severe lower respiratory tract infections (like pneumonia) Eczema (a skin condition) Asthma Obesity Type 1 and 2 diabetes Childhood leukemia Sudden Infant Death Syndrome (SIDS) Necrotizing enterocolitis (a condition usually seen in premature babies that causes the death of tissue in the intestines) Breast milk passes antibodies onto babies to protect their underdeveloped immune systems – formula-fed babies don’t get this immunity! Formula can cause gas and constipation in babies 32 DID YOU KNOW? The American Academy of Pediatrics recommends mothers feed their babies only breast milk for the first 6 months of life.

33. Concerns with Formula-Feeding For Mothers Higher risk of… Type 2 diabetes Breast cancer Ovarian cancer Stopping breastfeeding early can cause a higher risk for postpartum depression Breastfeeding can help you lose baby weight Formula will cost you about $1,500 per year Breastfeeding saves you money – it’s free! Cleanliness and preparation hazards Formula can be complicated to prepare! All equipment must be sterilized before each feeding to kill germs Measurements must be exact to avoid watering down, which can cause seizures in babies Water needs to be boiled and cooled to kill any germs Manufacturing errors Formula is processed and can be contaminated, or mislabeled, just like any other store-bought products 33 DID YOU KNOW? No babies – breastfed or formula-fed – should drink water for the first 6 months.

34. Resources: The Choice to Breastfeed 34

35. Breast Milk versus Formula Consider sharing this video with mothers and family members to show how breastfeeding has made a difference in the lives of their peers. Available at: http://womenshealth.gov/itsonlynatural/planning-ahead/making-the-decision- to-breastfeed.html. http://womenshealth.gov/itsonlynatural/planning-ahead/making-the-decision- to-breastfeed.html There are also many other videos about breastfeeding – including secrets to success, “what breastfeeding means to me” and breastfeeding benefits – available at: http://womenshealth.gov/itsonlynatural/planning-ahead/index.htmlhttp://womenshealth.gov/itsonlynatural/planning-ahead/index.html. 35

36. Source: http://www.unicef.org.uk/Documents/Baby_Friendly/Leaflets/otbs_leaflet.pdf

37. Source: Ready Set Baby Patient Booklet (version 1e), Carolina Global Breastfeeding Institute, July 2014. Available at: breastfeeding.unc.edu.

41. 41

42. 42

43. Breast Milk versus Formula Consider playing the “Does Formula Stack Up?” game with your participants to show them the differences between breast milk and formula. The game available at: http://www.breastmilkcounts.com/educational-activities/game.swfhttp://www.breastmilkcounts.com/educational-activities/game.swf Remind parents that use of formula can be a concern because: Formula use is associated with higher risk for many diseases No immunologic benefits for baby’s underdeveloped immune system Gas and constipation Cleanliness and preparation hazards Manufacturing errors Economic burden However, remind them there are legitimate reasons that parents sometimes need to use formula and that they should be proud of any breastfeeding they can do! 43

44. Breastfeeding Decision Worksheet When we make a decision, most of us don’t really consider all “sides” in a complete way. Instead, we often do what we think we “should” do, avoid doing things we don’t feel like doing or just feel confused or overwhelmed and give up thinking about it at all. Thinking through the pros and cons of all options is one way to help us make sure we have made the best decision possible. This can help us stick to our plan in times of stress or temptation. Below, write in all of the reasons that you can think of in each of the boxes. This will help you make the best feeding decisions for you and your baby! 44 Benefits/ProsCosts/Cons Breastfeeding Formula-Feeding Adapted from: http://www.motivationalinterviewing.org/sites/default/files/decisionalbalance.pdf

45. Preparing for Breastfeeding 45 So your participant has decided to breastfeed – great! Mothers often have a lot to learn about breastfeeding and making it work for them. There are some adjustments to make, and despite the fact that breastfeeding is natural, it is a learned task that they may need help with. In this section we provide you with resources to help mothers prepare for breastfeeding and to educate them about the following topics: Planning for Breastfeeding Maternity Leave Planning How to Breastfeed Is Baby Eating Enough? Bottle-Feeding

46. Section 1: Planning for Breastfeeding 46 Birth Plan The first time a women breastfeeds, she will likely be at a hospital or maternity center. But, hospital policies, medical procedures and medications can all affect how easy it is for a woman to breastfeed after birth. So, it makes sense that birth is the first step women should think about when they’re planning for breastfeeding! Mothers should be encouraged to speak with doctors and other hospital staff about their wishes for their birth. A birthing plan is a helpful tool to gather all of a mother’s wishes on one piece of paper (see page 50) so she can quickly and easily share it with hospital staff. Birthing plans typically address the following topics: Breastfeeding – mom can state that she does not want her baby to be fed any formula, only breast milk, and that they would like help breastfeeding within the first hour, when baby’s sucking reflexes are strongest. No bottles or pacifiers – artificial nipples should be avoided when babies are learning to breastfeed. Artificial nipples work differently than breasts, so this can be confusing for baby! Skin-to-skin – baby should be placed onto mother’s bare chest immediately after birth, even before any medical tests or cleaning. This helps baby breastfeed and bond with mom right away and regulates baby’s temperature, breathing, heart rate and blood sugar. Emergency C-Sections – mothers who need surgery can request skin-to-skin as soon as possible afterwards to help them breastfeed right away. Continued on next page…

47. Section 1: Planning for Breastfeeding 47 Rooming in – mom can tell hospital staff that she would like baby to stay in her room 24 hours a day and never be taken to a nursery. This helps mom learn baby’s feeding cues, to feed baby whenever he is hungry (which helps her produce milk and prevents crying) and bond with her baby. Breastfeeding assistance – moms can request support from hospital staff, such as lactation consultants, on how to position and latch her baby for breastfeeding. She can also ask for contact information for a breastfeeding support worker for when she leaves the hospital. Breast pumps – mom can ask for access to a breast pump in the event she needs to be separated from her baby. Pumping milk can help mom produce milk to be fed to the baby wherever she is. No discharge bags – mom can request she not be given any formula marketing materials or free formula. DID YOU KNOW? Non-medicated vaginal birth with immediate skin-to-skin contact makes breastfeeding easiest. This is because medications used during birth and c-sections can make mom and baby less alert. So, elective c-sections should be avoided.

48. Section 1: Planning for Breastfeeding 48 The Two-Week Plan Breastfeeding for 6 months to a year may seem daunting when a mom is first learning how to do it. This is normal – she’s also recovering from pregnancy and childbirth! Because of this, moms may find it more manageable to make a two-week commitment to breastfeeding. See page 53 for a template for mom’s two-week plan. Encourage mothers to seek help if they have trouble breastfeeding and tell them not to be too hard on themselves! The Six-Week Plan It usually takes about six weeks for moms to get into a breastfeeding “groove.” By then, she and her baby have gotten to know each other, her milk has matured and she’s had several well-baby visits to show her how breastfeeding is helping her baby develop and grow. After two weeks, work with mom to make a new goal of six weeks – and reevaluate what was written in her two-week plan – to encourage her to keep going. See page 54 for the plan.

49. Resources: Planning for Breastfeeding 49

50. My Birthing Plan Source: http://www.breastfeedingpartners.org/images/Hospital%20Infant%20Feeding%20Plan%20Document.pdf

51. 51 Source: Ready Set Baby Patient Booklet (version 1e), Carolina Global Breastfeeding Institute, July 2014. Available at: breastfeeding.unc.edu.

53. Two-Week Breastfeeding Plan 53 The reasons I want to breastfeed for at least two weeks are: The steps I plan to take to breastfeed for two weeks are: The ways other people can help me are: I will know my plan is working if: Some things that could interfere with my plan are: What I will do if my plan isn’t working or if breastfeeding is difficult: Adapted from: http://www.motivationalinterviewing.org/sites/default/files/changeplan.pdf

54. Six-Week Breastfeeding Plan 54 The reasons I want to breastfeed for at least six weeks are: The steps I plan to take to breastfeed for six weeks are (remember to include things that worked from your two-week plan!): The ways other people can help me are: I will know my plan is working if: Some things that could interfere with my plan are: What I will do if my plan isn’t working or if breastfeeding is difficult: Adapted from: http://www.motivationalinterviewing.org/sites/default/files/changeplan.pdf

55. Section 2: Maternity Leave Planning 55 Maternity leave and combining breastfeeding with work or school is a particularly important part of planning for breastfeeding because usually mom cannot take breaks to go breastfeed her child. You should encourage mothers to: Tell employers they plan to breastfeed Take 6 weeks maternity leave, breastfeed exclusively and return to work gradually, if possible Seek support from a lactation consultant or counselor if they need to go back to work before 6 weeks Learn to pump and remind them it takes practice Complete a breastfeeding and work plan (see pages 58-60) Find breastfeeding-friendly child care in advance Be proud of any breastfeeding they can do! This section is composed of resources from a variety of sources that you can use to help moms and families: Communicate with employers about their breastfeeding plans Prepare themselves and their babies for a return to work or school How to pump milk and store it safely Educate employers about how to create a breastfeeding-friendly workplace

56. Resources: Maternity Leave Planning 56

57. Working Mom Videos Consider sharing this video with mothers and family members to show how their peers have combined work and breastfeeding. Available at: http://womenshealth.gov/itsonlynatural/planning-ahead/making-the-decision- to-breastfeed.html. http://womenshealth.gov/itsonlynatural/planning-ahead/making-the-decision- to-breastfeed.html Another helpful video discusses how to handle stress of being a new mom: http://womenshealth.gov/itsonlynatural/fitting-it-into-your-life/handling- stress.htmlhttp://womenshealth.gov/itsonlynatural/fitting-it-into-your-life/handling- stress.html. 57

58. 58

59. 59 Source: http://www.breastfeedingpartners.org/images/pdf/My%20Breastfeeding%20Plan.pdf

60. 60 Illinois. Source: http://www.breastfeedingpartners.org/images/pdf/ForMomsFINAL.pdf

61. How to Talk with Your Supervisor 61 Don’t be afraid! Most supervisors are happy to support you and it’s the law! Let your supervisor know you want to breastfeed before you have your baby so she has time to prepare a place for you to pump while you’re away. Share “My Lactation and Work Plan” with your supervisor to help you both agree on pumping locations and times. Things you can say to your supervisor (Source: the New York “Making it Work” Toolkit): “I will plan to use my usual breaks and lunch period to express milk. It will take around 20 minutes each time. If I need a little more time while I’m first learning, would you be open to letting me come in a little earlier or staying just a little later to make up the time? “I am planning to breastfeed my baby because it so healthy for both the baby and for me. After I come back to work, I plan to continue giving my milk to my baby by expressing my milk every 2 or 3 hours while I am at work. Lots of working women do this every day.” “Breastfeeding is so important that there are laws that ask employers to give time and space for expressing milk at work. This also benefits you because companies save money when babies are breastfed – they get sick less often, so parents miss work less and have fewer health care costs!” Adapted from: http://www.breastfeedingpartners.org/images/pdf/ForMomsFINAL.pdf

62. How to Talk with Your Co-Workers 62 Bring your baby to work so they can meet her and fall in love with her just like you have. If you need to ask co-workers to cover for you while you are pumping, return the favor when they need your help. Listen if your co-workers share stories about breastfeeding with you, even if it did not work for them. Everyone wants to be heard and to know that they’re good parents. Things you can say to your co-workers (Source: the New York “Making it Work” Toolkit): “I’m breastfeeding because research shows that breastfeeding moms miss less work in the long run, and it saves companies money in the long run because babies get sick less!” “I’m expressing milk for my baby because the health benefits are so amazing. Your support will make pumping easier for everyone! “I’m going to be taking my usual breaks to pump milk for my baby and I’ll be making up extra time when I need to.” Adapted from: http://www.breastfeedingpartners.org/images/pdf/ForMomsFINAL.pdf

63. Tips for Pumping and Storing Milk 63 Pump every time your baby would normally eat. Double electric pumps (ones that express milk from both breasts at the same time) can express your milk in 20-30 minutes, but manual pumps or expressing by hand may take longer. Be patient – you’ll get faster with time! Pump during your regular breaks and meal period. If you need a little extra time, talk to your supervisor about making up time before or after your normal hours. If you work in a restaurant or retail store, pump milk when business is slower, or ask about working a “split shift,” which means you work during the busiest periods (ex: lunch and dinner at a restaurant) and go home in between. If you work in a factory, you can see if “floaters” can be used to cover your station while you are pumping. If you don’t have co-workers to cover for you while you pump milk, see if it’s all right to post an “I’ll be back later” sign while you’re away. In any of these situations, ask your supervisor if a family member or your child care provider can bring your baby to you to breastfeed in person. Store your milk in an insulated lunch box, a cooler or a refrigerator until you can take it home. Make sure your containers and pump are sterilized before use. Adapted from: http://www.breastfeedingpartners.org/images/pdf/ForMomsFINAL.pdf

64. Tips for Pumping and Storing Milk 64 Do’s Do store milk in small amounts (1-4 ounces) so it doesn’t go to waste Do store milk at room temperature for 3-4 hours (65-80 degrees) Do refrigerate milk for up to 3 days Do freeze milk if you won’t use it within 3 days (for up to 6 months) Do store milk in sterilized BPA-free milk storage bags or glass/hard plastic containers Do label milk with the date it was pumped Do thaw frozen milk by running containers under warm water Do use thawed milk right away and only for that feeding Don’ts Don’t place milk near freezer door (to keep it from thawing when door opens) Don’t microwave milk to thaw it Don’t worry if frozen milk changes color – this is normal! Don’t save milk left in a bottle after a feeding Don’t refreeze milk that has been frozen

65. 65 Source: http://www.breastfeedingpartners.org/images/pdf/ForMomsFINAL.pdf

66. 66 PlaceTemperatureHow LongThings to Know Countertop, table Room temp (60°F - 85°F) Up to 3-4 hours is best. Up to 6-8 hours is okay for very clean expressed milk. Containers should be covered and kept as cool as possible; covering the container with a clean cool towel may keep milk cooler. Throw out any leftover milk within 1 to 2 hours after the baby is finished feeding. Smaller cooler with a blue-ice pack. 59°F24 hoursKeep ice packs in contact with milk containers at all times; limit opening cooler. Refrigerator39°F or colderUp to 72 hours is best. Up to 5-8 days is okay for very clean expressed milk. Store milk in the back of the main body of the refrigerator. Freezer0°F or colderUp to 6 months is best. Up to 12 months is okay. Store milk toward the back of the freezer where temperature is most constant. Milk stored at 0°F or colder is safe for longer durations, but the quality of the milk might not be as high. Guide to Storing Fresh Breast Milk for Healthy Babies Room temperature (60°F to 85°F) Refrigerator (39°F or colder) Any freezers Thawed breast milkUp to 1-2 hours is best. Up to 3-4 hours is okay. 24 hoursDo not refreeze. Thaw milk by running under warm water. Guide to Storing Thawed Breast Milk Adapted from: http://womenshealth.gov/breastfeeding/pumping-and-milk-storage/index.html

67. 67

68. 68 Source: http://www.breastfeedingpartners.org/images/pdf/ForMomsFINAL.pdf

69. Educating Employers 69 Hopefully, most mothers you work with will have employers that support their decision to breastfeed. However, if employers insist on mothers pumping in a bathroom (which is never acceptable) or don’t allow them time to pump at all, they need to be educated about nursing mothers’ rights in the workplace – in Illinois, employers are required to give mothers unpaid break time to pump and to provide a room other than a bathroom to do so. Mothers may also want to educate their employers if they do not understand the benefits of breastfeeding for businesses (and babies!), don’t have a workplace lactation policy or if they think their employers’ policy or pumping room could be improved. The following pages are for mothers to share with their employers to educate them about nursing mothers’ rights and how they can support breastfeeding in their workplace. If a mother you work with needs additional support, the United States government has a “Business Case for Breastfeeding” website. It includes additional resources beyond what is included in this toolkit; the booklet entitled “The Business Case for Breastfeeding: Easy Steps to Supporting Breastfeeding Employees” may be particularly helpful. The website is accessible at: http://mchb.hrsa.gov/pregnancyandbeyond/breastfeeding/. http://mchb.hrsa.gov/pregnancyandbeyond/breastfeeding/

70. 70 Source: http://www.illinoisbreastfeeding.org/media/951db617803effddffff8b01ffffe415.pdf

71. Source: http://www.breastfeedingpartners.org/images/pdf/ForEmployersFINAL.pdf

72. 72 The Illinois Nursing Mothers in the Workplace Act Source: http://www.illinoisbreastfeeding.org/media/c65e6fd0803efb61ffff89a5ffffe415.pdf

73. 73 Source: http://www.illinoisbreastfeeding.org/media/c65e6fd0803efb61ffff89a5ffffe415.pdf

74. 74 Source: http://www.illinoisbreastfeeding.org/media/c65e6fd0803efb61ffff89a5ffffe415.pdf

75. Lactation Support Program Components 75 From the Health Resources and Services Administration Website: Privacy to Express Milk If women do not work in a private office, a small, private space (as small as 4’ x 5’) can be set up for a lactation room. Many companies also provide a hospital-grade electric breast pump that makes pumping quicker and more efficient. Employees should never be asked to express milk or breastfeed in a restroom. Flexible Breaks Milk expression sessions usually take around 15 minutes, plus time to get to and from the lactation room, and are needed about every 3 hours. Breastfeeding employees typically need no more than an hour per work day to express milk, which can easily be divided between usual paid breaks and the meal period. Education Employees value information they receive during their pregnancy about continuing to breastfeed upon returning to work. Pamphlets, resources, lunchtime prenatal classes, and access to a lactation consultant can help employees feel more prepared. Support Supportive policies and practices that enable women to successfully return to work and breastfeed send a message to all employees that breastfeeding is valued. Support is a temporary need for each breastfeeding employee – once babies begin eating solid foods at 6 months, milk expression requirements gradually diminish.

76. 76 SAMPLE Source: http://mchb.hrsa.gov/pregnancyandbeyond/breastfeeding/toolkit/policy.pdf

77. 77 SAMPLE Source: http://mchb.hrsa.gov/pregnancyandbeyond/breastfeeding/toolkit/policy.pdf

78. Section 3: How to Breastfeed 78 In this section, we provide you with resources to share with mothers to help them learn how to position (there are different ways!) and latch their babies, as well as teach them about their breast milk. DID YOU KNOW? Breast milk changes from the beginning of a feeding to the end. The milk at the beginning – or foremilk – is low in fat. The milk at the end – or hindmilk – is high in fat. It’s important to drain each breast at a feeding to give baby that high-fat milk because it helps her brain develop. Stage of MilkQualities Colostrum – first few days after birth Infant’s “first immunization” – full of antibodies to boost immature immune system Laxative effect to help clear infant digestive tract Transitional Milk – begins to appear 2-5 days after birth Combination of colostrum and mature milk Mature Milk – comes in around 2 weeks after birth Thin, watery and bluish in color Breasts will feel fuller, heavier and more sensitive Continues to change to meet baby’s nutritional needs as she grows

79. Resources: How to Breastfeed 79

80. 80 Visit the following website for more detailed information: http://womenshealth.gov/breastfeeding/learning-to-breastfeed/#b

81. 81

82. Section 4: Is Baby Getting Enough Milk? 82 Many mothers worry that their babies aren’t getting enough milk, particularly at the beginning. You can ease mom’s worries by assuring her that: Her baby has a tiny tummy when she’s born – just the size of a marble or almond! This is why feeding on demand is important – baby’s tummy empties out quickly This is why colostrum is produced in such small amounts It’s normal for babies to lose weight the first few days You can also teach mothers to track their babies’ diapers and feedings to help reassure them their babies are getting enough food. Remind them to feed on demand, but babies generally eat about 8-12 times a day. See the following pages for these resources.

83. Resources: Is Baby Getting Enough Milk? 83

84. 84

85. 85 Baby’s AgeNumber of Wet Diapers Number of Bowel Movements Color and Texture of Bowel Movements Day 1 (first 24 hours after birth) 1First usually occurs within 8 hours Thick, tarry and black Day 223Thick, tarry and black Day 35-63Looser greenish to yellow Day 46 or more3Yellow, soft and watery Day 56 or more3Loose seedy, yellow color Day 66 or more3Loose seedy, yellow color Day 76 or more3Larger amounts of loose seedy, yellow color Dirty Diaper Facts Adapted from: http://womenshealth.gov/publications/our-publications/diaper_checklist.pdf

86. 86 Source: http://www.beststart.org/resources/breastfeeding/pdf/breastfdeskref09.pdf

87. 87 Source: http://images.thenestbaby.com/tools/pdfs/breastfeeding_tracker.pdf

88. 88 Source: http://www.womenshealth.gov/publications/our-publications/breastfeeding-guide/breastfeedingguide-general-english.pdf

89. Section 5: Bottle-Feeding Key Fact: There are different types of formula. Ready-to-feed Concentrated Must be diluted with the proper amount of water Powdered Must be measured and mixed with water according to package instructions 89 Bottle-Feeding Do’s: Do sterilize the bottle, formula container and all other equipment before preparing Do make sure the nipple hole is the right size Do try different nipple shapes to see which the infant likes best Do angle the bottle so the baby isn’t sucking in air Do burp the baby a few times each feeding Do encourage dad to feed using a bottle – it’s bonding time for him! Do wipe milk from baby’s teeth before putting her to bed Do listen to baby’s hunger cues! Bottle-Feeding Don’ts Don’t prop the bottle Don’t warm a bottle in the microwave Don’t let the baby fall asleep with a bottle in her mouth Don’t ever put cereal in the baby’s bottle! Key Fact: There are types of milk you should not feed babies. Cow, sheep and goat milk Soy, rice, almond and oat milk Dried milk Condensed milk Evaporated milk Your baby should only drink breast milk or formula for the first 6 months of life! No water!

90. Resources: Bottle-Feeding 90

91. 91 Source: http://www.unicef.org.uk/Documents/Baby_Friendly/Leaflets/guide_to_bottle_feeding.pdf

92. 92

93. 93

94. 94

95. Overcoming Breastfeeding Barriers 95 Despite the harms of formula feeding, there are legitimate reasons mothers are not able to breastfeed. It’s important that we keep these in mind and support moms as they overcome challenges for the health of their babies. Remind mom that breastfeeding is a learned skill and that she is not alone as she works through any problems! Lactation consultants are a great resource. Also encourage family support, as fathers and grandmothers are significant influences in a mother’s choice to breastfeed. Finally, remind her that it’s her right to breastfeed in public, and Illinois has laws in place to help her do so. In this section we provide you with resources to help mothers overcome the following barriers to breastfeeding: Common breastfeeding problems Lack of family support Breastfeeding in public

96. Resources: Common Breastfeeding Problems 96

97. 97 The ProblemWhat You Can Do Sore nipples1.Make sure your latch is correct 2.See a lactation consultant 3.Try changing positions 4.Rub expressed milk on your nipples – it has natural healing properties! 5.Don’t use creams, nipple shields or hydrogel pads without talking to a health care professional first 6.Avoid tight clothing that puts pressure on your nipples 7.Change nursing pads often to avoid trapping moisture 8.Avoid putting soaps or ointments with chemicals on your nipples 9.Ask your doctor about non-aspirin pain relievers if your nipples are very sore Low milk supply1.Remember, usually your milk supply is just fine! Babies eat more or less depending on whether they’re having a growth spurt or not. 2.Make sure your baby’s latch and position are good 3.Feed on-demand 4.Offer both breasts at each feeding – keep baby on the first breast until feeding slows, then offer the second 5.Avoid formula or cereal – this may make her less interested in breast milk 6.Avoid pacifiers while doing any of the tips above Oversupply of milk1.Breastfeed on one side per feeding and continue to offer the same breast for the next two hours until the next full feeding. 2.If the other breast feels uncomfortable before you’re ready to feed on it, hand express milk to relieve pressure or use a cold compress or washcloth to reduce swelling. 3.Feed your baby before she get very hungry to avoid aggressive suckling. 4.Try positions that don’t allow gravity to help with milk ejection as much, like side-lying or football hold. 5.Burp baby frequently if she is gassy. Adapted from: http://womenshealth.gov/breastfeeding/common-challenges/index.html Breastfeeding Troubleshooting

98. 98 The ProblemWhat You Can Do Engorgement When your breasts feel hard, swollen, tender, throbbing or painful. 1.Feed your baby often and on-demand. Wake her up to feed if it’s been more than four hours. 2.Work with a lactation consultant to improve baby’s latch. 3.Breastfeed on the affected breast often to keep it from getting too full. 4.Avoid using pacifiers or bottles to supplement feedings. 5.Hand express or pump milk to soften the breast before a feeding. 6.Massage the breast or use a cold compress in between feedings to ease the pain. 7.When returning to work, try to pump on the same schedule your baby ate, or at least every 4 hours. 8.Get enough rest, proper nutrition and fluids. 9.Wear a properly-fitting, supportive bra that isn’t too tight. Plugged ducts Feels like a tender, sore lump in the breast. 1.Breastfeed on the affected side often to help loosen the plug (as much as every two hours). 2.Massage the area starting behind the sore spot and moving towards the nipple. 3.Use a warm compress on the sore area. 4.Get extra sleep or relax with your feet up to speed up healing – plugged ducts are often a sign you’re doing too much! 5.Wear a properly-fitting, supportive bra that isn’t too tight – consider one without an underwire. Breast infection (mastitis) Soreness or lump in the breast accompanied by a fever and/or flu-like symptoms. 1.Breastfeed on the affected side often to keep the breast from becoming too full (as much as every two hours). 2.Massage the area starting behind the sore spot and moving towards the nipple. 3.Use a warm compress on the sore area. 4.Get extra sleep or relax with your feet up to speed up healing – infection is often a sign you’re doing too much! 5.Wear a properly-fitting, supportive bra that isn’t too tight. Breastfeeding Troubleshooting Adapted from: http://womenshealth.gov/breastfeeding/common-challenges/index.html

99. The ProblemWhat You Can Do Fungal infections (yeast infection or thrush) Sore nipples that last more than a few days, even after checking baby’s latch. Nipples may also be achy, flaky or blistered. 1.Change disposable nursing pads often. 2.Wash any towels or clothing that comes in contact with the infection in very hot water. 3.Wear a clean bra every day. 4.Wash your and your baby’s hands very often. 5.Boil pacifiers, bottle nipples and toys baby puts in her mouth daily, then discard after one week. 6.Boil all pump parts that touch milk daily. 7.Make sure other family members are thrush-free and get them treated if they have symptoms! Nursing strike When baby has been breastfeeding well for months and then suddenly begins refusing the breast because she’s in pain, stressed, sick or upset. 1.Try to express your milk on the same schedule baby used to breastfeed to avoid engorgement. 2.Keep track of baby’s wet and dirty diapers to make sure she’s getting enough milk. 3.Keep offering your breast to baby – try when she’s very sleepy and stop when she’s frustrated. 4.Try various breastfeeding positions and skin-to-skin. 5.Focus all your attention on baby and give her extra cuddling time. 6.Try breastfeeding while rocking in a quiet room free of distractions. Inverted, flat or very large nipples May make it hard for baby to attach 1.Talk to a lactation consultant or your doctor if you’re concerned about your nipples. 2.Use your fingers (or a special device) to try and pull your nipples out. 3.If you have very large nipples your baby’s latch will improve as she grows – it may take several weeks. But, if you have a good milk supply, your baby should still get enough milk. DID YOU KNOW? LactMed is a website where you can check whether it’s ok to take your medicine when you breastfeed. Access the website at: http://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm Breastfeeding Troubleshooting Adapted from: http://womenshealth.gov/breastfeeding/common-challenges/index.html

100. 100 Source: http://womenshealth.gov/publications/our-publications/breastfeeding-guide/BreastfeedingGuide-General-English.pdf

101. 101 Source: http://womenshealth.gov/publications/our-publications/breastfeeding-guide/BreastfeedingGuide-General-English.pdf

102. Resources: Family Support 102

103. Videos: Breastfeeding and Family Support Consider sharing the following videos with mothers and fathers to show how dads can support breastfeeding moms. Available at: 1.http://womenshealth.gov/itsonlynatural/finding-support/daddy-duty.html.http://womenshealth.gov/itsonlynatural/finding-support/daddy-duty.html 2.http://womenshealth.gov/itsonlynatural/my-breastfeeding-story/dads- perspective-on-breastfeeding.html.http://womenshealth.gov/itsonlynatural/my-breastfeeding-story/dads- perspective-on-breastfeeding.html Another helpful video discusses how to build a support network if you’re a single mom: http://womenshealth.gov/itsonlynatural/finding-support/breastfeeding-as-a- single-mom.htmlhttp://womenshealth.gov/itsonlynatural/finding-support/breastfeeding-as-a- single-mom.html. 103

104. 104

105. 105

106. Resources: Breastfeeding in Public 106

107. Video: Breastfeeding in Public Consider sharing the following video with mothers and families to educate them about women’s rights to breastfeed in public. Available at: http://womenshealth.gov/itsonlynatural/fitting-it-into-your-life/breastfeeding-in- daily-life.htmlhttp://womenshealth.gov/itsonlynatural/fitting-it-into-your-life/breastfeeding-in- daily-life.html. 107 BREASTFEEDING TIP To help get comfortable breastfeeding in public, practice breastfeeding in a mirror – you’ll be surprised at how little of your breast shows.

108. Source: http://www.illinoisbreastfeeding.org/media/4731878d4b25fe75ffff837fffffe41e.pdf