Infant Feeding in the First 30 Days of Life

Infant Feeding in the First 30 Days of Life
Welcome to the Infant Feeding Support for the First 30 Days training Day 2! We are so excited about the new breastfeeding food packages that will truly support a mother to feed her infant for the first 30 days of life and beyond. Show of hands, how many people were here yesterday? [Wait for hands to be raised] You learned the different packages for breastfeeding mothers and infants. Yesterday you learned about the new breastfeeding food packages: Fully Breastfeeding and Combination breastfeeding with 2 packages now: Mostly and Some Breastfeeding. This whole day will be filled with fun learning activities, closely looking at the new breastfeeding policy, “Supporting Fully Breastfeeding for the First 30 Days” and how to implement the protocols and procedures. [CLICK] Families Grow Healthy with WIC

Logistics Lunch Restroom Breaks Let’s do some logistics first:
lunch will be served from 12:00 – 1:00 in the ____area; the restrooms are _________; parking instructions are _________ [if any] Before we do anything else, we’d like to know who is here today. Please raise your hand if you are a: WIC Nutrition Assistant (WNA), Registered Dietitian., Breastfeeding Coordinator, Certified Lactation Educator, Peer Counselor, International Board Certified Lactation Consultant (IBCLC), WIC Director. Great! – [make appropriate comment on the composition of attendees] [CLICK]

Afternoon Information
Folder Information Please open your folder Afternoon Information Morning Information I’d like you to open your folder if you haven’t already done so. There is a lot of great information inside. On the left side is what we will be covering this morning and on the right side is this afternoon’s information. [CLICK] Right Side Left Side

Objectives Please pull out the objectives for today and spend a few minutes reviewing. Throughout today we will revisit these objectives to “chart our route to our final destination”. Let’s review our objectives for today. In your packet you’ll find a copy of these objectives. I’d like for you to spend a few minutes reading through these objectives. ***Room monitors hold up objective sheet and walk around*** [Allow 3 minutes for them to read.] Today we will go for a ride in the WIC Taxi Cab to learn new ways to support WIC postpartum moms in their decisions about feeding their babies. [CLICK] Throughout the day we’ll come back to check in and see if we are on our way to our final destination. And for those of you who really need to know the plan for today, find your agenda. ***Room monitors hold up agenda***

Morning Agenda Welcome and Warm Up Activity
Review of Objectives & Agenda Review of Healthy Habits Begins at Birth Breastfeeding Support Policy Review of Counseling Skills Morning Break Baby Behavior Skills Baby Nutrition Questions Form As you can see we have a pretty packed agenda! All of the information that we’ll be presenting to you today will help you in your interaction with postpartum mothers. We’ll start with a quick review of the training you received in the spring entitled Health Habits Begin at Birth. Then we’ll move into the new Breastfeeding Support Policy After that we’ll learn about some tools that will help you in your complete feeding assessment of the baby which will meet the requirements of the policy. [CLICK]

Afternoon Agenda Lunch and Physical Activity Infant Feeding Choices
Afternoon Break Infant Feeding Choices Continued Next Appointment That reMinds me – Idea 2B Used Questions & Answers Trainers’ Gathering After lunch we’ll spend a lot of time practicing using these new tools and skills and then talk about the second appointment. On your table you will find some index cards for writing questions you might have throughout the day. Periodically, we will try to address as many questions as possible. And then at the end of the day we’ll devote some time to this. But, because of our limited time we will also post a Frequently Asked Questions form on our website under “Breastfeeding”. The last 30 minutes of the day will be a “Trainers’ Gathering” for those of you who will be training staff at your site. We will be providing suggestions and resources to help you with your training. Show of hands, how many of you plan to do this training with your staff when you return to your agency? [CLICK]

Sharing Successes Share with a partner Think about a positive experience you have had supporting a WIC Mom’s feeding choice… Let’s start with our first activity. Please spend the next 3 minutes sharing with the person next to you positive counseling experiences you have had with postpartum women supporting their feeding choices for their babies. We will invite a few of you to share responses with the group. ***Room monitor be ready with microphones to get feedback*** Thank you for the enthusiasm in sharing your positive counseling experiences with one another. [CLICK]

Infant Feeding Support
Materials & Toolbox Every time you see this symbol we will be referring to the toolbox on your table. You also might have some materials in your folder. These tools are to for you to help participants. They included counseling skills, educational materials and resources. ***Room monitors hold up toolboxes*** These toolboxes will be reused at other trainings we’ll be having this summer. Please be sure to leave everything on the table when you leave this afternoon! One thing before we move on… we need a promise from you. I’d like for you to raise your right hand and place your left over your heart and repeat after me…. “I…. Will not…. Steal the taxis or the toolkits…. [CLICK] Infant Feeding Support in the First 30 Days

Roadmap to Infant Feeding
WIC Next let’s take a look at the Roadmap to Healthy Infant Feeding which is on your table. It looks like this slide. ***Room monitors – point out road map or carry copy around room like Vanna White*** We will be referencing this roadmap throughout our training today. Notice the taxi cab in the top left hand corner of the roadmap. “YOU” will be the taxi driver who will be navigating this road today, and the passengers in your taxi cab will be the WIC mothers you work with on a daily basis. Your goal is to get the mother to her destination safely. We know there are many things that can influence how mothers decide to feed their babies, such as the media, family members, their partner and their culture. But did you know that “YOU” can also be an important influence? Like a taxi driver, YOU can help them on their motherhood journey by providing education, information and resources; you both want the same thing, a healthy infant. However, we need recognize that the mother is the ultimate decider on the road she chooses that will lead to a healthy infant. Please take note of the various signs along the routes; these are the topics we will be addressing today in our training. What we are showing you today is one way to address the Infant Feeding Support policies, but each agency will follow their own protocols and processes to address these policies. [CLICK]

Prenatal Education Prenatal Education
WIC On your roadmap move your taxi cab to prenatal education…. [CLICK]

Keys to Success From local agencies that have already implemented “no formula in the first 30 days” Lessons learned 14 years/few months Many say “it’s not as hard as we thought” That reMinds Me…. Also throughout the day we’ll be sharing “keys to success” which are from local agencies that have already been “down this road”. [CLICK] These are lessons learned that you can bring back to use at your agency. These agencies are already not giving out formula in the first 30 days. Some have been doing this for 14 years and some for only a few months. Many say it’s not as hard as we thought. These agencies have found success with these techniques! Don’t worry, there is a handout in your packet listing all of these “keys”. ***Room monitors show “Keys to Success” handout*** There is another handout in your folder called “That reMinds Me . . .”. Please pull it out and review for a few seconds. Throughout the day as we introduce the different keys please jot down any ideas you might have regarding implementing them at your agency. We’ll have an activity at the end when this sheet might come in handy…” ***Room monitors show “That reMinds me….”

Keys to Success Provide breastfeeding education to prenatal women at each visit. Include a reminder that no formula will be issued in first 30 days. Here is our first Key to success Provide breastfeeding education to prenatal women at each visit. [CLICK] Include a reminder that no formula will be issued in first 30 days The result? Less mothers are asking for formula after delivery. Result: Less mothers are asking for formula after delivery. 12

Earn Healthy Bucks Healthy Buck = Raffle Ticket
Raffle at end of the day. In your packet you’ll find a Healthy Buck. Throughout the day, you’ll have opportunities to win more healthy bucks. [CLICK] The more questions you answer correctly, the more opportunities you will have to win Healthy Bucks! AND at the end of the day we’ll have a raffle for FABULOUS PRIZES!! ***Room monitors show healthy bucks*** Please write your name legibly on the back of your Healthy Bucks. During the breaks or at lunch time, put your Bucks in the box we have placed here in the front of the room. [Point to box] The format of our questions will be based on the Cash Cab show on Discovery Channel. In the show you answer questions and earn money for correct answers. The WIC cash cab will work in the same format. Who has seen the show? We have a short video to show for those who haven’t… $ Earn healthy bucks for correct answers. $ Write your name on the back. $ Place your healthy bucks in box.

[show video] [CLICK TWICE] Like I said Cash Cab is based on answering questions correctly. If you answer the questions right, you’ll earn healthy bucks. Each activity is run a little differently, so pay attention to the instructions we give you. [CLICK] 14

Healthy Habits Begin at Birth
Focused on pregnant, postpartum and breastfeeding women and infant participants Helped staff become more familiar with food package changes Promoted and support breastfeeding Ensured appropriate formula feeding In a minute we are going to give you a chance to show us how much you remember about Healthy Habits Begin at Birth. Healthy Habits Begin at Birth (HHBB) is the portion of the Healthy Habits California campaign that focuses on pregnant, postpartum and breastfeeding women and infant participants. WIC Staff have varying degrees of knowledge and experience with the new food package changes relating to breastfeeding and infant feeding. moms and babies. [CLICK] This in-service was designed to help staff become more familiar with the changes to better enable staff to support and promote breastfeeding and ensure appropriate formula feeding.

Let’s Play Cash Cab THE RULES WAIT!! Questions in Envelope
Work as a table Write answers on Quiz When complete – Raise Hand 1st TWO tables to get ALL questions CORRECT will get Healthy Bucks! THE RULES Questions in Envelope WAIT!! Let’s Play WIC Cash Cab!! [CLICK] We have put a quiz in a sealed envelope on your table. But please wait until I say “Ready, Set, Go!!!”. [CLICK] ***Room monitors hold up or point to envelope*** You’ll have 5 minutes to work as a table to answer all the questions. [CLICK] When you have completed all the questions, raise your hands and we will come to your table to check your answers. [CLICK] If you see that a table has their hands raised, keep working because the first table may not have all the correct answers. The first two tables to get all of the answers correct will receive one Healthy Buck per person. 16

Let’s Play Cash Cab Ready! Set! GO! Ready! [CLICK] Set! [CLICK] GO!!!
***Room monitor times for 5 minutes.*** ***Room monitors have correct answers and will float through the room to check answers*** Great job, now let’s review the answers. [CLICK] GO! 17

HHBB Review (Healthy Habits Begin at Birth)
Beginning in October, fully breastfed babies on WIC will receive twice the amount of baby fruits and vegetables as other babies from age 6 to 12 months. Answer: True Beginning in October, fully breastfed babies on WIC will receive twice the amount of baby fruits and vegetables as other babies from age 6 to 12 months. [CLICK] Answer: True 64 (4-ounce jars per month) vs. 32 (4-ounce jars per month) 64 (4-ounce jars per month) vs. 32 (4-ounce jars per month)

HHBB Review Beginning in October, a mom who is breastfeeding and receiving more than half of the full formula package for her baby can receive a food package until ____ months postpartum. Beginning in October, a mom who is breastfeeding and receiving more than half of the full formula package for her baby can receive a food package until (blank) months postpartum. [CLICK] Answer: 6 Answer: 6

HHBB Review Beginning in October, an 8 month old baby on WIC who is fully formula fed will receive more formula than WIC currently provides. Answer: False Baby will receive LESS formula ------ 7 cans powdered formula vs. 9 cans WIC currently provides Beginning in October, an 8 month old baby on WIC who is fully formula fed will receive more formula than WIC currently provides. [CLICK] Answer False Baby will receive LESS formula 7 cans powdered formula vs. 9 cans WIC currently provides

HHBB Review To make plenty of breastmilk in the first month, breastfeed often, at least ____ times in 24 hours. Answer: 8 To make plenty of breastmilk in the first month, breastfeed often, at least (blank) times in 24 hours. [CLICK] Answer: 8

HHBB Review It’s great for a baby to learn to hold her bottle on her own. Answer: False Babies should be HELD for bottle feeding! It’s great for a baby to learn to hold her bottle on her own. [CLICK] Answer: False Babies should be HELD for bottle feeding!

HHBB Review After the first week, a baby should have ____ wet diapers a day. Answer: 6 to 8 After the first week, a baby should have (blank) wet diapers a day. [CLICK] Answer: 6 to 8

HHBB Review Beginning in October, WIC will not routinely provide formula for breastfed babies in the first month because giving formula interferes with breastmilk production. Beginning in October, WIC will not routinely provide formula for breastfed babies in the first month because giving formula interferes with breastmilk production. [CLICK] Answer: True Great job!! Now we are going to move into Breastfeeding Support in the first 30 days. Answer: True

Remember Breastfeeding ROCKS!!
[CLICK] It Rocks!

Keys to Success Invite prenatal and postpartum mothers to attend a breastfeeding support group. Invite prenatal and postpartum mothers to attend a breastfeeding support group. [CLICK] Result – Mothers learn about and see other women breastfeeding. They see that a support system is available for them. Result: Mothers learn about & see other women breastfeeding. They see that a support system is available for them. 26

Breastfeeding Support
Move Taxi to Policy WIC On Roadmap [CLICK] Please move your taxi to the “Policy” sign on your roadmap. We are going to briefly review the Breastfeeding Support Policy. Please note that this is a draft policy. Just as a reminder there are index cards on your table. If you have any questions or comments about the policy, please write them down on an index card and we will come by and pick them up. There is a copy of the policy in your folders.

Breastfeeding Support How can you support your
Breastfeeding Moms? Breastfeeding Support Policy Supporting fully and combination breastfeeding moms Conducting complete assessment The second month appointment How can you support your breastfeeding moms? [CLICK] This policy encourages support of the breastfeeding mother by requiring a complete assessment and a second month appointment for the combination feeding mother. 28

Policy Review Keep In Mind
This is just one step in supporting breastfeeding. State WIC is requiring 20 hours of breastfeeding training for all WIC staff (by 2011). This policy meets the new federal regulations. You can still influence the final rule by sending in your comment to USDA by February, 2010. Keep in Mind This is just one step in supporting Breastfeeding [CLICK] State WIC is requiring 20 hours of breastfeeding training for all WIC staff by 2011 per NSP requirement. A new breastfeeding campaign and trainings will be developed by State WIC in the next few years. State WIC already has a great training “in a box” developed – the California Breastfeeding Peer Counselor training. This might help with the requirement for training your staff. This policy meets the new federal regulations. but you can still influence the final rule by sending in your comments to USDA by Feb

Breastfeeding Support Policy
Supports breastfeeding mothers and babies by not routinely issuing formula during the first 30 days because formula: interferes in the development of full milk production, and decreases the chances that a mother will continue breastfeeding. The policy supports breastfeeding mothers and babies by not routinely issuing formula during the first 30 days because formula: [CLICK] interferes in the development of full milk production, and decreases the chances that a mother will continue breastfeeding.

WIC is committed to: Providing timely counseling and education Scheduling of a second month appointment Additional incentives based on Institute of Medicine recommendations WIC is committed to: [CLICK] Providing timely counseling/education Scheduling the second month appt Designing the new food packages with additional incentives based on Institute of Medicine recommendations which includes….Breastfeeding moms getting more food…..

Conducting Complete Assessment The Components: Dialogue with Mom Baby Nutrition Questions ISIS Questions Counseling Questions The breastfeeding support policy requires staff to conduct a complete assessment. Today we will review how to conduct a complete assessment. All staff can conduct the first assessment and refer if necessary. [CLICK] The complete assessment involves a dialogue with the mother. Your discussion will include: Baby Nutrition Questions ISIS Questions Counseling questions These questions are woven throughout your assessment of the mother and baby.

The Second Month Appointment A follow up breastfeeding assessment and counseling by a lactation specialist Local agencies established procedures and protocols for the second month appointment based on the Breastfeeding Policy 600XXX The second Month appointment [CLICK] Follow up breastfeeding assessment and counseling by a lactation specialist. Local agencies need to establish procedures and protocols for the second month appointment based on the Breastfeeding Policy 600XXX

How comfortable do you feel about implementing the policy in your agency? ON A SCALE OF 1 to 10 Who says 1, 2, or 3? Who says 4, 5, or 6? Who says 7, 8, 9, or 10? Let’s do another activity. Pull out the Breastfeeding Policy on your left side of your folder and read silently and then talk at your table about how comfortable you feel about implementing it at your agency. We’ll give you 10 minutes for your reading and discussion time. ***Room Monitor: Time 10 minutes and tell trainer*** Based on the number scale of 1 – 10, 1 being not ready at all and 10 is totally ready, I want to see who says they are at about a 1, 2 or 3? Would anyone like to share why do you say you are in this range? [CLICK] Who says 4, 5, or 6? Great!! Okay, now would anyone like to share why they say they are within this range and not a 1,2, or 3? Okay, now who is at 7, 8, 9 or 10? Wow!! Would you like to share why you are so confident? Now, I’d like you to find the index cards on your table. We’d like for you to spend a few minutes writing down what would help you implement the new policy. ****Room monitor time 5 minutes*** We hope to address most of your needs with this training. Our room monitors will look over your cards to identify needs that are not met by this training and we’ll try to address them during our question and answer periods. 34

Research: More moms are breastfeeding their babies until 1 year of age How can we best support a combination breastfeeding dyad? During prenatal period we have been successful in promoting breastfeeding through our GP classes, breastfeeding support groups, and through individual counseling. More and more WIC mothers are now deciding to breastfeed their baby. Statistics showed during the hospital stay 83% of mothers are exclusively or fully breastfeeding their babies and 40% continued to fully breastfeed up to two months. What are the different ways we could support combination breastfeeding moms and babies? we support and encourage them to attend a breastfeeding support group/class so they could hear successes, challenges, and joy from moms who successfully breastfeeds their babies. We also give them breastfeeding books so they could read more benefits of breastfeeding. Last but not the least, we have peer counselors who frequently call them who provide individual breastfeeding counseling. These are the pregnant and breastfeeding mothers we are going to talk about. Mothers who already made the choice to breastfeed her baby. Who have learned the benefits of breastfeeding through our group or individual breastfeeding classes. Moms who know they have the ability to provide the best food for their babies. [CLICK]

Let’s Define: Who is a Lactation Specialist? “not routinely issuing formula” Some of the ways we will support our breastfeeding mother is to have a lactation specialist see breastfeeding mothers and to “not routinely issue formula during the first 30 days”. So let’s start by defining who is a lactation specialist? And, what do we mean by , “not routinely issuing formula during the first 30 days”? [CLICK]

Who is a lactation specialist? Any staff who have >20 hours of breastfeeding education and training CLE, IBCLC, CLC, RDs, PCs Your agency will designate a lactation specialist based on your definition Who is a lactation specialist? [CLICK] Any staff who has >20 hours of breastfeeding education and training CLE, IBCLC, CLC, RDs, PCs Your agency will designate and define your lactation specialist. What will be the role of a lactation specialist? the policy states, “if a mother requests supplemental formula, the LA shall only issue formula after: Doing a complete assessment to determine if breast milk alone can support the infant’s growth and development Counseling mom by a staff trained with at least 20 hours of breastfeeding education, and Reviewing the WIC benefits based on infant feeding choices. Our newly developed pamphlet, “Your WIC Foods”, will give you these benefits. Later today you will have the chance to see this new handout.

“…not routinely issuing formula during the first 30 days” “not routinely” not habitually, not in an expected or customary manner not generally What do we really mean by “….not routinely issuing formula during the first 30 days”? [CLICK] Let’s start with the definition of not routinely, it means, not habitually, not in an expected or customary manner, or not generally. As we all know, currently when a mom says, “I’m feeding my baby both breast milk and formula", we habitually or generally issue formula and breastfeeding package right away and mother stay with our program for 1 year. Starting October 1st, we are changing our habitual practice. Just like what we see on the roadmap, we’re taking an extra step to help mom breastfeed as much as possible. During the Healthy Habit Begins at Birth (HHBB) training we said, “there are only 2 infant packages during the first 30 days, Fully Breastfeeding and Fully Formula Feeding, NO Combination feeding at all”. In HHBB we discussed the IFV package, “Infant Feeding Variable”. These are now gone. We now have two categories: Some Breastfeeding and Mostly Breastfeeding. Yesterday we saw these packages. [For those of you who were not here we will show you the various infant packages this afternoon. Hold your thoughts and questions].

Reasons for issuing formula: USDA interim regulation states, “not routinely issuing formula” There will be moms who will ask for formula Anticipating gradual change Value in data collection Here are the reasons why we will continue to provide formula during the first 30 days of life. Yesterday we learned infant formula will be less depending on the age of the baby starting October 1st. USDA has an interim regulations that says, “not routinely issuing formula during the first 30 days”. Most of us agree and prefer not to issue any formula at all because a breastfed baby does not need it. Once again, you have time to write your comments to USDA until Feb However, we still have moms for some reasons will still ask for some formula. These are baby steps in implementing “no formula during the first 30 days”. [CLICK] There will be moms who will still ask for formula. Some moms who did not receive any formula will call USDA and complain about it and then, USDA will call us and will be asked to investigate how local agency made the decision on not providing formula at all. Anticipating gradual change = remember just like what happened when we shifted our formula from Similac to Enfamil. It took 3 months after August 1st to fully convert all WIC participants to ask for Enfamil. We are in the same situation, it will take some time to promote “No Formula during the first 30 days” and to train each WIC staff in promoting breastfeeding and supporting each mom who choose to breastfeed her baby. Keys to Success mentioned local agencies who started not issuing formula during the first 30 days from few months to 14 years. Is it possible to not issue formula during the first 30 days? YES but gradually. As we say, “Baby Steps”, eventually we will reach our goal of “not issuing formula in the first 30 days and beyond. One bright side to this – We’ll be able to do a bit more data collection because of the 2 breastfeeding categories: Mostly and Some Breastfeeding. We’ll be able to differentiate the real numbers for breastfeeding moms who truly are providing more breast milk.

Keys to Success Have your Registered Dietitians see postpartum women for infant enrollment. An agency who has implemented the new policy decided to have registered dietitians see postpartum women for infant enrollment. This was decided because staff were concerned about participants yelling at them about not being able to get formula! [CLICK] Results: The agency also started prenatal education at the same time and found that mothers weren’t yelling and accepted not being able to get any formula. The WNAs saw how easy it was and now want to see postpartum mother again! Results: Participants not asking for formula due to prenatal education. WNAs want to see postpartum mothers. 40

Move Taxi Cab to “Tune-Ups”
Roadmap to Infant Feeding WIC Move Taxi Cab to “Tune-Ups” Move your taxi cab to the “Tune-Ups” building for information on Counseling skills and baby behavior. [CLICK] Baby Tune-Ups Behavior Skills

Breastfeeding Support Policy # 1
Part One: Supporting Fully and Combination Breastfeeding Moms How are we going to support our breastfeeding moms? Breastfeeding Support Policy #1 Part One: [CLICK] Support Fully and Combination Breastfeeding Moms How are we going to support our breastfeeding moms? Let’s look at our toolbox which will give us the tools on how to support our fully and combination moms.

Table Toolbox Infant Feeding Support in the First 30 Days [Read slowly] Inside the toolboxes on your table are toolkits. Every toolbox has the same toolkits. [CLICK] Please take out toolkit #1 which is your counseling skills. Counseling skills are an important factor in implementing the breastfeeding support policy. Part of the policy requires staff to do a complete assessment of the infant feeding situation. To do this they must have good counseling skills! ***Room monitors show if necessary*** Toolkit # 1 Counseling Skills

3 Step Counseling Overview
The Dance of Dialog "Good counseling is like a dance -kinda like our picture here. Our goal is to gently guide the participant through the steps. What we don't want is a wrestling match - where each partner is fighting with the other!" The counselor and the participant need to be moving in the same direction. [CLICK]

The 3-Step Strategy A way to talk with mothers about breastfeeding to help them overcome challenges. 3-Step Strategy: Ask open-ended questions Affirm her feelings Educate We know that most mothers know that breastfeeding is better than formula feeding. So why do mothers choose not to breastfeed if they know it’s better? Many mothers feel the challenges of breastfeeding outweigh the benefits. These challenges can include embarrassment, time and pain. [CLICK] The 3 step counseling strategy is a way to talk with mothers about breastfeeding to help them overcome these challenges. This strategy may also be useful for you when talking with your husbands, children, family members and friends. The 3 steps are: 1. Ask open-ended questions 2. Affirm her feelings 3. Educate

Step 1: Open-Ended Questions
Many answers Find out what the mother “thinks” Start a conversation Start with “What” or “How” “What do you know about Breastfeeding?” The first step is to ask open-ended questions. An open-ended question is one that can have many answers. It is a good idea to ask mothers what they think about breastfeeding rather than if they plan to breastfeed. Open-ended questions help you find out what the mother thinks. It helps start a conversation. Open-ended questions often start with What or How. For example: • “What have you heard about breastfeeding?” • “What do you know about breastfeeding?” • “What are your feelings about breastfeeding?” [CLICK]

Avoid Closed-Ended Questions
“Yes”, “No” or very short answers Don’t encourage a mother to share her thoughts Many begin with “do” “Do you plan to breastfeed?” Closed-ended questions get a yes, no or very short answers. [CLICK] When asked a closed-ended question, the mother will likely think that the right answer is “yes” and not share any real thoughts with you. Many times a closed ended question will begin with “do”. For example, “Do you plan to breastfeed?” is a closed-ended question as the answer is either yes or no.

Open or Closed Ended? What does that feel like? Where do you live?
What time is it? How do you feel about that? Is he still in the house? What’s a good plan for you? Open Closed Closed Open Are these open or closed questions? What does that feel like? [CLICK] Opened. Where do you live? Closed. What time is it? How do you feel about that? Open. Is he still in the house? What’s a good plan for you? Open Closed Open

Open-Ended Questions 3 minutes Review list of open ended questions
Circle questions that might be helpful In your packet is a list of examples of open ended questions that will be useful when talking to mothers about breastfeeding. Take a few minutes to review this list and circle those that might be helpful to you. ****Room monitor hold up the open-ended example page*** ***Room Monitor: Time 3 minutes and tell trainer*** Please refer back to this sheet as needed during the activities you will be doing today. [CLICK] 3 minutes 49

Don’t understand what the mother is thinking…
Need to Know More? Don’t understand what the mother is thinking… There are ways to get more information: Extending Clarifying Reflecting After asking an open-ended question, you might need to ask another question to better understand what the mother is thinking. Most people do not answer a question with enough information to say what they mean. [CLICK] There are ways to get more information. These methods will help you better understand what she is thinking: Extending, clarifying and reflecting.

Getting More Information
Extending questions help you get more information. For example: Could you tell me a little more about that? What else can you tell me about breastfeeding? When you say breastfeeding hurts, could you tell me a little more about that? Extending questions help you get more information. [CLICK] For example: Could you tell me a little more about that? What else can you tell me about breastfeeding? When you say breastfeeding hurts, could you tell me a little more about that?

Clarifying questions find out what she really means. For example: When you say that it would be uncomfortable, are you saying it would be uncomfortable for you, or for someone else who might see you? Clarifying questions find out what she really means when you say [CLICK] For example: When you say that it would be uncomfortable for you are you saying it would be uncomfortable for you, or for someone else who might see you? When you say it hurts, are you saying it hurts the entire time you are breastfeeding? When you say it hurts, are you saying it hurts the entire time you are breastfeeding?

Reflecting shows her you understand what she said; often we use statements. For example: So you think your mother doesn’t want you to breastfeed So you feel uncomfortable breastfeeding in front of your family Reflecting shows her you understand what she said. Statements are often used when reflecting as opposed to questions. For example: [CLICK] So you think your mother doesn’t want you to breastfeed So you feel uncomfortable breastfeeding in front of your family So you feel your baby is still hungry after you feed her So you feel your baby is still hungry after you feed her

Helpful hints Using mother’s name Repeating her own words Adding extra words “Why not?” vs. “Margie, can you tell me about why you don’t think that’s a good idea?” Sometimes it is also a good idea to add extra words that sound kind. [CLICK] Using the mother’s name, repeating her own words, and adding extra words helps when talking to other people. For example, “WHY NOT!?” may not seem respectful. . A nicer way to say “why not?” could be, “Margie, what can you tell me about why that’s not a good idea?”

Pull out the “Ways of Getting More Information” activity sheet. In pairs or trios, think of ways you could get more information after a mother says the statement on the sheet. Write extending or clarifying questions or reflective statements for these statements made by mothers. Pull out the activity sheet “Way of getting more information”. [CLICK] In pairs or trios, think of ways you could get more information after a mother says the statement on the sheet. Write extending or clarifying questions or reflective statements for these statements made by the mothers. ***Room monitor hold up “Ways of getting more information” activity sheet*** [Give 5 minutes and then have group come back to report] ***Room monitors time five minutes and ring bell*** Who would like to share their answers? Please read the question too. ***Room monitors wander with microphone for sharing***

Step 2: Affirm Her Feelings
Figure out what a mother is concerned about… Affirm her feelings Feelings are normal & okay Shows respect Builds confidence Feels “safe” to open up & listen to ideas After you have figured out what a mother may be worried about, the next step is to affirm her feelings. [CLICK] This will help her know that her feelings are normal or okay. Affirming a mother’s feelings is respectful and builds trust. Mothers who feel safe will be more likely to open up and listen to your ideas.

Affirming Statements “I’ve heard a lot of women say that.”
“That’s a pretty common reaction or belief.” “I felt that way too.” “My mother told me the same thing.” “Most women go through a period like that after the baby is born.” “I can tell you are a concerned mom and want the best for your baby.” Here are examples of affirming statements: “I’ve heard a lot of women say that.” “That’s a pretty common reaction or belief.” “I felt that way too.” “My mother told me the same thing.” “Most women go through a period like that after the baby is born.” [CLICK]

Activity: Affirm Her Feelings
Pull out the page titled “Affirming Activity”. In pairs or trios, read the statements & write affirming responses. Pull out the page titled “Affirming Activity”. In pairs or trios, read the statements & write affirming responses. But remember you are not giving information yet. You are only affirming her statements and feelings!! [CLICK] ***Room monitor hold up “Affirming activity” sheet ***Room monitor time 3 minutes to do activity then ring bell*** Who would like to share their answers? Please read the question too.

Step 3: Educate Only share information related to her concerns or questions Give information in small amounts Have repeated conversations In Step 1, you asked open-ended questions to find out what worries a mother may have about breastfeeding. In Step 2, you let her know her feelings are okay. Now, in Step 3, you share helpful information with her. [CLICK] Only share information that relates to her concerns or questions. She will pay attention to you if you talk about something that’s meaningful to her. Give information in small amounts. Most new mothers are feeling overwhelmed. It is hard for new mothers to remember a lot of information. If you give her too much information, she may think breastfeeding is too hard. Have repeated conversations. The number of times breastfeeding is talked about is more important than the total amount of time spent talking about breastfeeding. This means it is a good idea to talk to mothers several times before and after the baby is born.

Explore/Offer/Explore
Explore before giving information: Ask what she already knows or does Offer information Explore their reaction after giving information How can you use this information? How might this work for you? What do you think about this? Any time you offer information it helps to: [CLICK] Start by exploring what they already know about the topic, or what experience they already have with the topic. For people to use your information – they need to process it. You can help them by asking what they think or feel about this information. Some examples are: How can you use this information? How might this work for you? What do you think about this?

Activity: Putting it All Together
Read the 2 conversations In pairs or trios discuss the following: What did the counselors do well? How could the counselors improve? Please pull out of your folder the activity called “Putting it all together”. Silently read the 2 conversations and then in pairs or trios discuss the following: What did the counselors do well? How could the counselors improve? Compare your answers with the other groups at your table. You have five minutes…. ***Room monitor time 5 minutes to do activity then ring bell*** [After time is up say:] Okay, compare your answers with ours, found on the putting it all together answer sheet. We’ll give you 2 minutes to look this over. ***Room monitor time 2 minutes and chime*** [Ask participants to share their answers] [CLICK]

Morning Break 15 minutes Break time!! Please come back at _____.
[Tell them what time to be back!] ***Room monitor time 15 minutes and ring bell*** [CLICK AFTER BREAK] 15 minutes

Table Toolbox Infant Feeding Support in the First 30 Days The training on Counseling skills prepared you to support post partum women in their decision to feed their baby. These tools will help you support all post partum women, especially the fully and combination breastfeeding women. [CLICK] Pick up Toolkit #2, the Infant Educational Materials, from your box and please take the next few minutes to review each handout. It is a combination of new and existing infant materials. I want you to think to yourself: Toolkit # 2 Education Materials

Education Materials THINK to yourself:
Which of these materials do you currently use? Which ones would you like to use in the future? Which of these materials do you currently use? [CLICK] Which ones would you like to use in the future? ***Room Monitor: Time 3 minutes and tell trainer*** This afternoon you’ll have a chance to use these handouts in a role play. These materials and the information we are about to give you are also important in implementing the new breastfeeding support policy. In counseling the mother during the first 30 days it is important to give her accurate developmental information about her baby so that she will know why her baby behaves in certain ways… If you and your staff can explain this to her, she might not need formula in the first 30 days! 64

Baby Behavior Study What does my baby need? Why is he always crying?
Is it normal for her to wake up 4 times a night? How can I tell if she is hungry? Why can’t I calm him down? How many of you have heard these questions? What does my baby need? Why is he always crying? Is it normal for her to wake up 4 times a night? How can I tell if she is hungry? Why can’t I calm him down? Do you want to know the answers? Do you want to be a baby whisperer? In the Healthy Habits Begin at Birth some information was included in infant behavior. Now we’d like to give you a little more. All of this information is based on a project that State WIC has been involved in with UC Davis Human Lactation Center. Dr. Jane Heinig and her staff have developed a training curriculum and handouts on Baby Behavior. This is just a small piece of that training. [CLICK]

Study Messages on Cues Babies can tell moms what they want by using their bodies and noises – cues. Babies are not always hungry when they cry. Learning your baby’s cues and how to respond will make you both happy. These are the main messages about infant cues: Babies can tell moms what they want by using their bodies and noises or cues. [CLICK] Babies are not always hungry when they cry. Moms need to look for other cues too. If moms learn their babies cues and how to respond appropriately life will be much easier!!

Results - Baby Behavior Study
All Sites Combined: More exclusive Breastfeeding Food Packages selected. Intervention = 43.6% Control = 16.5% Less formula given: 3.4% reduction in Formula Feeding 7% reduction in distribution of cans of formula while caseload increased 3.6% This project has been funded at least in part with Federal funds from the USDA, Food & Nutrition Service. [Do not read slide – read notes only] The results of the study were great! At all of the intervention sites there was an increase in the issuance of the exclusive food package selection. And there was a decrease in formula use. [CLICK]

Baby Behavior Misunderstanding their baby’s behavior was the reason many of the mothers we talked to: Stopped breastfeeding Gave too much formula and ran out Gave solid foods too early Gave unhealthy foods to their babies Why are we giving you this information? Misunderstanding their baby’s behavior was the reason many of the mothers we talked to: [CLICK] Stopped breastfeeding Gave too much formula and ran out Gave solids too early And Gave unhealthy foods In the first 30 days some mothers will come in to your clinic and say “I need formula because….”. This information is another tool for you to offer to the mother to avoid formula! Understanding why babies act the way they do will help to alleviate many fears about feeding.

Baby Behavior Inappropriate feeding may lead to overweight.
Parents want to know more about their baby! And …. [CLICK] Inappropriate feeding my lead to overweight. Parents want to know more about their baby!

Baby Behavior Moms believe babies:
cry because of hunger, wake because of hunger, and that formula and cereal will prevent this. They think their babies will stay full longer if they are overfed. Mothers are pressured by others to feed. Focus Groups (2003) An earlier study done by Dr. Heinig and her staff in 2003 found that : Mothers believe [CLICK] crying means their baby must be hungry. Mothers believe that their babies wake up at night because they are hungry Mothers believe that formula and cereal prevent hunger and therefore keep babies asleep at night longer. They also think their babies will stay fuller longer if they give them just a little bit more (top them off) And mothers are pressured by others to feed (“are you sure you are giving that baby enough? – He looks too skinny to me!”)

Baby Behavior Parents need tools to help them believe they can handle their infants’ crying and waking behavior without overfeeding. So parents need the tools to help them believe they can handle their problems such as infant crying and waking. And these tools can help prevent overfeeding! [CLICK] Glanz J Occup Med 1992; 34:

Helping Caregivers Understand Baby States & Cues
So let’s talk about the tools you can give to your participants…baby states and cues. First we’ll talk about infant states. In your folder is a handout you can use to follow along called Infant states. This handout is just for WIC Staff, not participants. *** Room monitor hold up handout*** [CLICK]

Infant “States” Group of behaviors that occur together: Body movement
Eye movement Breathing (fast or slow) BODY A “state” is defined by a group of behaviors that occurs together. [CLICK] These behaviors include body movement, eye movement, the babies breathing pattern and how much the baby is able or willing to respond. How much they respond EYES BREATH NCAST Keys to Caregiving

Baby “States” Crying Irritable Quiet Alert Drowsy Active Sleep
Quiet Sleep Increasing intensity This slide lists all of the infant states. Babies move in and out of these states. And notice the increase in intensity as you move up the list. [CLICK] Let’s learn more about each state. Most people have seen babies in each of these states so try to picture each state as I describe it. Let’s start with the most intense and most obvious first… 74

Crying Tears Jerking motions Color changes Tight muscles
When a baby cries you will see some or all of these behaviors. Tears, although some newborns don’t make tears right away, [CLICK] jerking motions, color changes like a red face, tight muscles and rapid breathing. And it is important for mothers to know that a baby that has been crying for an extended period will respond more slowly to his or her caregiver’s comfort measures. Rapid breathing Responds slowly to comforting measures 75

Irritable Lots of body & facial movement
Eyes open but may not want to interact Sometimes fussy Sensitive to what’s going on inside & outside their bodies An irritable baby will show these behaviors. Lots of body and facial movement (grimacing). [CLICK] Their eyes might be open but he or she does not want to interact. Sometimes they will be fussy. It is important for moms to know that newborns are sensitive to what is going in inside their bodies and outside their bodies. Everything is new to them. For example most babies find the sensation they feel when they need to poop uncomfortable. And some babies don’t like the feeling of being tired…. This state can be common before a feeding. Think about how you feel when you are hungry! Do you get irritable? Common before feeding 76

Quiet Alert Little body movement Eyes open and wide
Steady, regular breathing Highly responsive Wants to learn and play Quiet alert is the infant state that every mom loves…. This baby is ready to interact and learn. There is little body movement, [CLICK] eyes are open wide and alert. Baby has regular steady breathing. This baby is very responsive to whatever caregiver is doing. Baby wants to learn and play However it is very hard for babies to stay in this state for a long period because it takes so much effort. It is very tiring. Think about how hard it is for you to sit here for two full days of training concentrating on every word we are saying!! Learning is hard work! That’s why we just gave you a nice, long break! And no, you can’t have another one right now… Can be tiring for young babies Requires effort to control! 77

Drowsy Variable movement Irregular breathing Opens and closes eyes
Eyes glazed Drowsy is a transitional state meaning that either the baby is waking up or going to sleep… A drowsy baby will have: Variable movements [CLICK] Irregular breathing, His or her eyes will slowly open and close and will have a glazed look, like staring off into space. It takes time for a baby to react to a stimuli when in this state. And these babies are easily startled. Takes time to react Easily startled

Active Sleep Moves every now & then Breathing pattern changes
Facial twitches Rapid Eye Movement (REM) A baby in active sleep will show some or all of these behaviors. He or she will move every now and then [CLICK] will have a changing breathing pattern, for example -slow then fast and then slow again. You will often see facial twitches in this state (smiles) and Rapid Eye Movement. Babies in this state often wake up easily. This is the state that babies dream in. Newborns fall asleep in this state and then move to quiet sleep. Remember this point because we’ll be talking about sleep patterns in a little bit. Easy to wake 79

Quiet Sleep No body movement Rhythmic breathing Bursts of sucking
Startles but does not wake Quiet Sleep is the other infant state parents appreciate!! These babies are in a deep sleep. With this baby there is no body movement [CLICK] breathing is regular and rhythmic. Often babies will have bursts of sucking, however this is a natural reflex and doesn’t necessarily mean hunger. Babies in quiet sleep will startle but do not wake up [if you feel comfortable demonstrate by pretending to sleep, lift your arms quickly in the air and let them drop slowly]. Babies in quiet sleep do not respond easily and are definitely hard to wake up! Does not respond Hard to wake 80

Help Baby Control State
Healthy infants will try to control their own state and give cues to “tell” others what they need. Caregivers can play an important role in helping infants feel comfortable and safe. Healthy infants try to control their movements from state to state, but often they need a little bit of help from their caregivers. [CLICK] They can communicate with their caregivers by “telling” them what they need through cues. Caregivers have an important role in helping their babies!! Adapted from: NCAST Keys to Caregiving

Helping Baby Change States
To awaken use variety Use different positions, touch, words Will take longer if very drowsy or in deep sleep Can take longer for very young infants To soothe use repetition Addresses the baby’s needs Repeat actions or words over and over May take time if infant is very upset Change in position or situation might help How can caregivers help? By using “variety to waken” and “repetition to soothe”. [CLICK] Variety to waken is often used when mothers need to wake their baby to feed. She can use different positions, touch and words or change the pitch in her voice. Sometimes this process will take a bit longer if baby is in a deep sleep. Also it can take longer for very young babies. Repetition to soothe is used to address the baby’s needs. This process often involves repeating actions or words over and over and over. Often mothers will not spend enough time repeating an action to soothe their baby. They will attempt different actions to try to calm a baby. It is important for mothers to repeat, repeat, repeat…. It often helps to change positions or the situation. For example going from a loud environment to a quiet one, or changing diaper. 82

Infant Cues Two types of cues Engagement Disengagement
There are two types of infant cues: Engagement and disengagement I am using the terms engagement and disengagement with you but with participants we use “I want to be near you” or “I need a break”. Engagement and disengagement are difficult concepts to grasp. If I said engagement to you right now what pops into your brain? “Oh, you’re getting married! Congratulations” How about disengagement? Oh, I’m sorry…. [CLICK]

Types of Infant Cues Engagement “Near You” cues: Young infants try to tell caregivers when they want to interact Disengagement “Need a break” cues: Young infants try to tell caregivers when they need to “take a break” or do something different. Engagement cues are how babies tell their caregivers they want to interact or like what is happening. A good example would be when a baby uses feeding cues. Some examples are rooting, tight muscles, and moving toward the breast or bottle. All of the movements are toward the caregiver. [CLICK] Disengagement cues are when babies are saying they need a break or for something to be different. A good example would be when a baby uses “I’m full cues”. Letting go, falling asleep, pushing away. All of these movements are away from the caregiver. Interactions will have both types of cues, caregivers need to look for pattern. Kelly et al. Promoting First Relationships, NCAST Pub 2003

Let’s Play WIC Cash Cab Now it’s time to see what you’ve learned! Let’s play WIC Cash Cab! [CLICK] 85

GET READY TO RAISE YOUR HAND!
Let’s Play Cash Cab GET READY TO RAISE YOUR HAND! ENGAGEMENT CUE? OR I have some pictures that I’m going to show you. I want you to call out what state the baby is in and whether the baby is showing an engagement cue - I want to be near you, or a disengagement cue, I need a break. Use your infant states handout to help. [Have participant raise their hands when they know the answer. Call on one person. Correct answers get a healthy buck.] ***Room monitor gives healthy buck for each correct answer*** [CLICK] DISENGAGEMENT CUE? 86

Disengagement / Crying
What Cue? What State? ***Room monitor run to person with microphone and have them say the answer, give a buck for correct answer*** [CLICK] Disengagement / Crying

What Cue? What State? Engagement --- Quiet Alert
***Room monitor run to person with microphone and have them say the answer, give a buck for correct answer*** [CLICK]

Disengagement / Quiet Sleep
What Cue? What State? ***Room monitor run to person with microphone and have them say the answer, give a buck for correct answer*** [CLICK] Disengagement / Quiet Sleep

What Cue? What State? Disengagement --- Drowsy

What Cue? What State? Disengagement --- Irritable

Understanding Baby Cues
Key Messages Babies show their parents what they need with cues. Babies let you know when they want to be with you or need a break. Okay so you have information about cues – how are you going to share it with participants? In your toolkit #2 is a handout entitled “Understanding Your Baby Cues”. All of the Baby Behavior handouts will be available this fall. The key messages that are covered in this handouts are: [CLICK] Babies can show their parents what they need with cues Babies let you know when they want to be with you or need a break There are also ideas for responding to baby’s cues.

Infant Sleep Patterns Now let’s talk about healthy newborn sleep patterns. [CLICK]

Messages on Infant Sleep
Babies wake often in the first few months. Babies need to dream and wake up to be healthy. Babies wake less often as they get older. These are the main messages regarding infant sleep for mothers: Babies wake often in the first few months. [CLICK] Babies need to dream and wake up to be healthy Babies wake less often as they get older.

Your Turn Whole Group: How many times on average do babies wake up at night (10pm – 6am)? At 2 mo? _______ At 4 mo? _______ At 6 mo? _______ Working as a group… How many times on average do babies wake up at night (10pm – 6am)? [CLICK] At 2 months? [Have participants call out numbers] At 4 months? At 6 months?

Average Night Waking Average waking at night is:
2-3 times by 2 months 2 times by 4 months 1 time at 6 months Babies wake when sick, uncomfortable, or because of a change of routine. Average waking at night is: [CLICK] 2-3 times by 2 months 2 times by 4 months 1 time at 6 months Now remember, these are averages – not all babies fall into this range When talking to parents it is important to define what their perception of a night is - 6pm to 6am? 11pm to 6am? Babies will wake more depending on the length of “their” night. Babies will wake when they are sick, uncomfortable or because something has changed in their routine – like having a very busy day, or being in a strange place. For those of you staying here at the hotel – did you wake up in the middle of the night and wonder where you were? Was this a change in your routine? But too much waking can sometimes be stressful to parents and if necessary refer the mother to a lactation specialist or to the baby’s pediatrician. Too much waking is stressful and should be investigated (before infants are switched from breastfeeding to formula). Peirano et al. J Pediatr 2003; 143: 70-9. 96

Babies sometimes wake up because moms put them down in Active Sleep.
Newborn Sleep Cycle Infants sleep hrs. per day from 2-12 Mo. (but not all at once!) They spend equal time in active & quiet sleep. AS QS Wake Starts in active sleep Quiet Sleep Let’s look at the newborn cycle more in-depth. Up to 2 months of age newborns spend an equal amount of time in active and deep sleep. Newborns will begin their sleep cycle in active sleep. Remember that active sleep is light sleep. Therefore if a baby is put down in a crib right after falling asleep he or she is probably going to wake up!! Take home note: this is why newborns will often wake when put down after falling asleep at the breast. If mom waits just a little bit longer it might be easier to put baby down. [CLICK] Babies sometimes wake up because moms put them down in Active Sleep. Babies sometimes wake up because moms put them down in Active Sleep. 97

Sleep Cycle of 2-Month Old
QS Wake AS At 2-3 months, infants begin with shorter Active Sleep cycles then move into Quiet Sleep At 2-3 months an infant’s sleep pattern will change. They will still start in active sleep but move into a short phase of quiet sleep. [CLICK] Here is the opportunity moms are waiting for!! They might find it a bit easier to put baby down to sleep, IF they catch that brief period of quiet sleep. If not they are going to have to wait until the longer period. Remember the behaviors of quiet sleep? No body mov’t, rhythmic breathing, burst of sucking, startles w/o waking, no response to stimuli and very hard to wake. Moms might find it’s easier to put baby down to sleep… 98

Sleep Cycle of 4+ Month-Old
Fall asleep in Quiet Sleep and sleep more like mom and dad. Wake QS QS AS QS AS At 4 months infant’s sleep cycles really change. They fall asleep in quiet sleep! Sometimes you will hear a mother tell of starting her infant on solid foods around this time and state “oh, my baby is sleeping much better because I started solids”. BUT the solids are not the reason why!! It is this change in sleep patterns. [CLICK] Much easier to put baby down to sleep… 99

Infant Sleep Patterns As they mature, infants can link cycles together. (won’t require caregiver with every cycle) So, infants will sleep longer and will not be as easy to wake as they get older. As infant grow and mature they will start to link their sleep cycles together and not wake up as often. [CLICK] So, infants will sleep longer and will not be as easy to wake as they get older. Peirano et al. J Pediatr 2003; 143: 70-9.

Infant Sleep State Active Sleep (REM) is important for brain development. Babies dream and blood flows to the brain bringing nutrients to active brain cells Images stimulate brain function Quiet sleep is deep sleep, no dreaming or movement, important for the brain to rest. Why is active sleep healthy? REM is important for brain development. [CLICK] As babies dream blood flows to the brain bringing much needed oxygen and nutrients. The images seen while dreaming stimulate brain function. Why is quiet sleep healthy? It is a deep sleep that allows the brain to rest. Infants cycle through three states throughout the night. Active sleep, quiet sleep and waking. Often adults sleep the same way…. How many of you wake up at night? This information gives new meaning to “sleep like a baby…”, right? Peirano et al. J Pediatr 2003; 143: 70-9.

Beneficial for Mother & Baby.
Waking & Active Sleep Beneficial for Mother & Baby. Waking and Active sleep are important for the brain development of the baby. Waking may be essential to survival—needs must be met for breathing, feeding, warmth. Breastfeeding mothers’ hormonal cycles are interrupted by night feeds, not having periods may lower risk for hormone related cancers. What are the benefits of waking and active sleep? [CLICK] As we’ve already discussed, waking and active sleep are important for brain development Waking is important for survival, baby’s needs must be met for breathing, feeding, warmth How about the mother? Waking and breastfeeding help to interrupt the mother’s hormonal cycle which leads to no periods. This may lower her risk for hormone related cancers. So Active sleep and waking at night are good for mother and baby! So the question I pose to you – why are mothers trying to get their babies to sleep through the night? Peirano et al. J Pediatr 2003; 143: 70-9.

Infant Feeding & Sleep Breastfed infants wake more than formula-fed infants and: Spend more time in Active Sleep Digest breast milk more quickly best for growth & development Formula-feeding moms can promote Active Sleep by putting babies “back to sleep” and using pacifiers. Breastfed infants wake more often that formula-fed infants. [CLICK] Breastfed infants have more active sleep and are therefore more likely to wake up. Babies digest breast milk more quickly than formula – this is best for their development and growth. The American Academy of Pediatrics recommends formula feeding moms help their babies spend more time in Active Sleep (which we now know is important) by putting babies on their back to sleep and by using pacifiers. The sucking action promotes active sleep. Breastfed babies already spend enough time in Active Sleep so NO pacifiers for them! Horne et al. Ped Resp Rev 2004; 5:

Healthy Sleep Key Messages – Active vs. Quiet Sleep Sleep cycles
Why Active Sleep is good for babies Sleep cycles How sleep patterns change Tips for sleepy parents Okay so you have information about sleep – how are you going to share it with participants? In toolkit #2 is a handout entitled “Healthy Sleep”. The key messages that are covered in this handouts are: [CLICK] active sleep vs. quiet sleep, why active sleep is good for babies and how sleep patterns change as baby grows. There is also information for sleepy parents. Remember these handouts will be available this fall.

Let’s Play WIC Cash Cab I am going to show you some information about some babies and I want you to answer the question. When you know the answer raise your hand and a room monitor will come to you with a microphone. The first correct answer gets a healthy buck! [CLICK] 105

Was he in active or quiet sleep?
Baby Marcus is 4 weeks old. His mother tries to put him down after falling asleep at the breast but he: Wakes up, Cries loudly Baby Marcus is 4 weeks old. His mother tries to put him down after falling asleep at the breast but he: [CLICK] Wakes up Cries loudly Was he in active or quiet sleep? Answer: Active sleep ***Room monitor gives healthy buck for each correct answer*** Was he in active or quiet sleep? Active

Is she in active or quiet sleep?
Baby Anna is 4 months old. Her mother tries to put her down after falling asleep at the breast. She stays asleep! Baby Anna is 4 months old. Her mother tries to put her down after falling asleep at the breast. [CLICK] She stays asleep! Is she in active or quiet sleep? Answer: quiet sleep Great job!! ***Room monitor gives healthy buck for each correct answer*** Is she in active or quiet sleep? Quiet Sleep

Crying Now let’s talk about crying… [CLICK]

“Normal” Crying Crying makes adults want to help. All babies cry
(Important for survival) All babies cry Crying begins in first hours of life, and on average, peaks at 2.6 hours per day at 6 wks. Crying decreases over the next 10 weeks, much better by 3-4 months. Crying is a normal everyday thing! However our society is becoming more and more intolerant of this survival mechanism. What would happen if a baby made a nice little noise instead? Like…”sigh” or “coo..”. Would his or her needs be met as quickly or at all? [CLICK] So - All babies cry!! Crying begins when a baby is born and the amount of crying peaks around 6 weeks at 2.6 hours. It decreases over the next 10 weeks and is much less once the baby reaches 3-4 months of age.

Pre-Crying “I need a break” Cues Watch for these pre-crying signs:
Turning or pushing away Stretching out of fingers Tense muscles in his or her face & body Some mothers think that crying is a random act. One minute the baby is fine and then next he or she is crying. BUT in most cases this is not true. A mother can watch for her baby to show “I need a break” or disengagement cues. These pre-cry signs include: [CLICK] Turning or pushing away Stretching out of fingers Tense muscles in his or her face & body Watching for these signs and meeting the baby’s needs before baby starts to cry will make her life a lot easier!

Is there a “Hunger Cry”? Hungry babies might cry but they will also:
Bring their hands to their face Clench their hands Flex their arms and legs Root Make sucking motions and noises All these behaviors together help us know baby is hungry. Is there a “hunger cry”? Yes, but it is also important for mother’s to watch for other signs too: [CLICK] Bringing their hands to their face Clenching hands Flexing arms and legs Rooting Making sucking motions and noises All of these signs are called feeding cues and let us know that baby is hungry. The important message – a crying baby is not always a hungry baby. Look for other signs to tell if baby is really hungry.

Help Parents Deal with Crying
Help parents learn to stay calm. Parents can often prevent or control crying. Encourage them to get help from friends & family. Help parents learn their baby’s cues. They won’t stop all crying but they will feel more in control. Ask them to try your ideas. How can you help parents deal with crying? Help them learn to stay calm. [CLICK] Often their calmness can prevent and control crying. Babies can sense when their parents are stressed. Encourage them to get helps from friends and families. Often mothers don’t want to burden others with their crying babies but point out that these people don’t have to deal with it on a daily basis. They want to help. Help parents to learn their baby’s cues. This won’t stop all the crying but there will be more control to the situation and less of a perception of “random” crying. Lastly, ask them to try your ideas. It can’t hurt, right?

Let’s Play WIC Cash Cab Here are some more scenarios about babies. I want you to tell me why this baby is crying. Remember when you know the answer raise your hand and a room monitor will come to you with a microphone. The first correct answer gets a healthy buck! [Have participant raise their hands when they know the answer. Call on one person. Correct answers get a healthy buck.] ***Room monitor gives healthy buck for each correct answer*** [CLICK] 113

Check her diaper in a few minutes.
Why is this Baby Crying? Baby Tanya is 3 weeks old min. after nearly all feedings she becomes: Fussy, Arches her back, Stiffens her hands & legs. Baby Tanya is 3 weeks old min. after nearly all feedings she becomes: [CLICK] Fussy Arches her back, Stiffens her hands & legs. ***Room monitor gives healthy buck for each correct answer*** Answer: She needs to poop!! Check her diaper in a few minutes . She needs to poop. Check her diaper in a few minutes.

She is tired, over-stimulated, irritable, or colicky
Why is this Baby Crying? Baby Luz is 3 weeks old. Every evening between 6 to 8 p.m. she becomes: Quite Fussy, Closes her eyes, Tightens her face, Cries unless she is constantly held & rocked. Baby Luz is 3 weeks old. Every evening between 6 to 8 p.m. she becomes: [CLICK] Quite Fussy Closes her eyes Tightens her face Cries unless she is constantly held & rocked. ***Room monitor gives healthy buck for each correct answer*** Answer: She is tired, over-stimulated, irritable, colicky [listen for any of these answers.] She is tired, over-stimulated, irritable, or colicky

Why is this Baby Crying? She is hungry.
Baby Elena is 4 weeks old. Despite being fed an hour ago, she begins to cry: Draws her fist toward her chin, Pulls legs into her body, Moves her head from side to side. Baby Elena is 4 weeks old. Despite being fed an hour ago, she begins to cry. [CLICK] Draws her fist toward her chin Pulls legs into the body Moves her head from side to side ***Room monitor gives healthy buck for each correct answer*** [CLICK] Answer – She is hungry! We don’t want you to think that babies are NEVER hungry. Just watch for the right cues! She is hungry.

Why do Babies Cry? Key messages Crying is normal
Babies cry for many reasons, not just because they are hungry Babies show other cues when they are hungry In your toolbox is another Baby Behavior handout, “Why do Babies Cry”. This handout focuses on preventing and dealing with crying babies. [CLICK] The key messages focus on how crying is normal. Every baby cries! Babies cry for many reasons besides hunger Babies show other cues when they are hungry.

Getting to Know Your Baby
For pregnant women at the end of their pregnancy Contains facts and tips to help new moms cope during the first 6 weeks postpartum I have one more handout/booklet to tell you about that is in Toolkit #2. [CLICK] This booklet is for pregnant women and moms with babies under one month old. It has facts and tips to help the new mom cope with all of the changes and uncertainty of the 6 weeks postpartum. We highly recommend at some point training your staff fully with the baby behavior training so they are more comfortable with offering the information to participants.

That’s All Folks So that is the end of the new information in toolkit #2. The other handouts you should be familiar with already. All of these educational materials can assist you in supporting the breastfeeding mother in the first 30 days. Explaining baby behavior to participants can lead to increased breastfeeding and reduced formula usage. Isn’t that what the policy is leading us to? [CLICK] 119

Let’s Play Simon Says! “Simon Says”
Stand up and walk around your table clockwise one time and sit back down Let’s play Simon Says! [CLICK] Simon Says… If you are able to, stand up and walk around your table clockwise one time and sit back down.

Breastfeeding Support Policy #2
Conducting Complete Assessment DIALOGUE WITH MOMS BABY NUTRITION QUESTIONS Breastfeeding Support Policy #2 Part two: Conducting a complete assessment A Complete assessment involves dialoguing with the mother and asking her: Baby Nutrition Questions Counseling Questions ISIS Questions [CLICK] COUNSELING QUESTIONS ISIS QUESTIONS

Moms & Babies INTRODUCING Our WIC babies and moms...
Gloria and Gustavo INTRODUCING Our WIC babies and moms... Here are some mothers and babies we are going to get to know a little better today. We will be introduced to each breastfeeding mother and learn about their feeding issues. [CLICK] This is Gloria and her son Gustavo;

Moms & Babies Susie and Sammie Susie and Sammie [CLICK]

Moms & Babies Wilma and Wil Wilma and Wil [CLICK]

Moms & Babies Cyndie and Carrie And Cyndie and Carrie.
In a little while we will learn what’s been going on with our mom and baby dyads. What do you think it takes to provide breastfeeding support to these mothers and babies? Today we will be learning different tools to support these moms in their situations. [CLICK]

Assessment Conducting Complete Assessment DIALOGUE WITH MOMS
BABY NUTRITION QUESTIONS For the next 20 minutes or so, we will be working with the “Baby Nutrition Questions” forms. [CLICK] COUNSELING QUESTIONS ISIS QUESTIONS

Baby Nutrition Questions
Recently changes were made to this form and three new questions were added. I would like to see a show of hands, how many of you currently use this form? Great, that’s wonderful!! Next we will be doing an activity using three questionnaires completed by moms you met earlier: Gloria, Susie and Cyndie. In your packet please pull out the “Baby Nutrition Questions” forms for Gustavo, Sammie and Carrie which are stapled together. ***Room monitors show example of stapled forms *** [CLICK]

Questions to ask about Gustavo We are going to discuss Gustavo as a group and then we are going to ask you to get into groups of two or three to work on the other two. Please take a minute and review the Baby Nutrition Questions form about Gustavo. *** Room monitor hold up the back of Gustavo form *** What are the feeding issues and some additional open-ended questions you would ask the mother? Please write them on the back of the form. [Solicit 2-3 responses from the group.] ***Room monitor solicit responses using microphone*** [listen for open ended questions that ask why she might need the extra can of formula, what kind of behaviors/cues the baby is using, etc. “Tell me why…, etc” There aren’t any right or wrong answers. They just need to start a dialogue with the mother] These are great questions. So how can this information help you when you are counseling a mother? [Solicit a few responses from the group.] [CLICK]

In pairs discuss what other questions you would ask about Sammie and Carrie Now we would like you to work on Sammie and Carrie’s Baby Nutrition Question Forms in groups of two to three. [CLICK – INSTRUCTIONS ON NEXT SLIDE]

Sammie and Carrie In pairs or trios, review scenarios
What are the feeding issues for both scenarios? What are some additional open-ended questions you would ask each of these mothers? Review each questionnaire and define the feeding issues. What additional questions would you ask each mom? Write your questions on the back of your questionnaires. You have 10 minutes. We will let you know when time is up. ***Room monitor time for 10 minutes and chime the bell*** What are the feeding issues and some of the additional open-ended questions you would ask the mother? [Solicit 2-3 responses from the group for each scenario.] ***Room monitor solicit responses using microphone*** ***Room monitors please collect Q & A index cards again and start sorting by topic*** [CLICK]

Answers For You Questions & Answers
Now we will answer some of your questions from the index cards. [trainer and room monitors answer questions to your best ability. All questions not answered will be put in Q and A and sent out this fall] [CLICK]

Lunch Time! Be back on time! Simon Says . . . It’s time for lunch!!
[CLICK] BE BACK ON TIME!! And we’ll give you a healthy buck! And we won’t make you cry! 132

Thank you. Now, it’s LUNCH time
Thank you. Now, it’s LUNCH time! Those of you who come back on time will get an extra healthy buck. So, please come back on time. You will have 60 minutes which is ________ o’clock. [CLICK WHEN BACK FROM LUNCH]

Welcome Back! Freeze! Simon Says . . .
Welcome back! Thank you for returning on time. Simon says … [CLICK] FREEZE where you are to get your healthy buck. Room monitors will give you a healthy buck. ***Room monitors pass out bucks to those present***

Review of Morning New Breastfeeding Support Policy
Support Fully and Combination Breastfeeding mothers Reviewed Counseling and Baby Behavior skills Started on Components on Complete Assessment Baby Nutrition Questions Dialogue with Moms = Driving Down that Route Soon Let’s quickly check our journey so far. We started by looking at the new breastfeeding support policy. [CLICK] And then we spent time going over helpful counseling skills, such as open-ended questions and affirmation. We explored baby behavior cues that tell us why babies cry, and what normal infant sleeping patterns look like. Then we practiced using the new Baby Nutrition Questions to help you with your complete assessment of the infant.

Let’s Play WIC Cash Cab Now we’re ready for the next round of CASH CAB!!!! In a moment we will show you a question based on this morning’s session. I will read the question. After I finish reading the question, the first table to raise their hand with the correct answer will all be awarded an additional healthy buck. Everyone at the table will get one! A table will only be able to win one time in this round, so once you’ve won – you won’t be eligible for the next question. Are you ready? Remember you have to WAIT until I’m done reading the slide. ***Room monitor be ready with microphone to run to table that raises their hand first*** ***Room monitors give one packet of bucks to ONE winning table PER question. Once a table wins, they can’t win again.*** [CLICK] 136

“Is your baby sleeping well?”
Open or Closed? Is this question open or closed-ended? “Is your baby sleeping well?” Is this question open or closed-ended? [CLICK] Is your baby sleeping well? Close-ended ***Room monitors give one packet of bucks to ONE winning table PER question. Once a table wins, they can’t win again.*** Closed-ended

Open or Closed? Closed-ended Is this question open or closed-ended?
You are planning to breastfeed, right? Is this question open or closed-ended? You are planning to breastfeed, right? [CLICK] Close-ended ***Room monitors give one packet of bucks to ONE winning table PER question. Once a table wins, they can’t win again.*** Closed-ended

Question What are the minimum number of hours of training a lactation specialist needs to have? What are the minimum number of hours of training a lactation specialist needs to have? [CLICK] 20 hours ***Room monitors give one packet of bucks to ONE winning table PER question. Once a table wins, they can’t win again.*** 20 Hours

True or False True or False: A one month old baby falls asleep in quiet sleep. True or False: A month old baby falls asleep in quiet sleep. [CLICK] False ***Room monitors give one packet of bucks to ONE winning table PER question. Once a table wins, they can’t win again.*** False

Question Is this infant engaged or disengaged? Disengaged
[CLICK] Disengaged ***Room monitors give one packet of bucks to ONE winning table PER question. Once a table wins, they can’t win again.*** Disengaged

Infant Feeding Crossroads
Fully Breastfeeding? Formula Feeding? Combination Feeding? WIC I’d like everyone to look at the road map again. Move your taxi cab until you reach the crossroads. [CLICK] Breastfeeding Expressway Combination Blvd. Formula Toll Road

Breastfeeding Expressway
Roadmap to Infant Feeding WIC Mom has made the choice to fully breastfeed – GREAT JOB! Move the taxi along on the BF Expressway, for the Fully Breastfeeding choice. Notice the Expressway has a diamond lane for easy cruisin’! What a difference from formula feeding… Now let’s talk about what is going to be different for this breastfeeding mother come October 1st! [CLICK] Breastfeeding Expressway 143

With your partner discuss:
Fully Breastfeeding With your partner discuss: What will be different for fully breastfeeding moms and babies? How will you discuss your breastfeeding services with mothers? With a partner discuss [CLICK] what will be different after October 1 and how will you discuss services you offer for your fully breastfeeding mom. Let’s take 5 minutes. ***Room monitor time 5 minutes and ring bell***

Fully Breastfeeding What will be different?
Moms and babies will receive the largest amount and most variety of foods. At 6 months babies will receive baby fruits, vegetables and meats. Fully breastfed babies receive MORE baby food than other babies. Babies will no longer receive juice. What will be different? [CLICK] Moms and babies will receive the largest amount and most variety of foods. At 6 months babies will receive baby fruits, vegetables and meat. Fully breastfed babies receive MORE baby food than other babies Babies will no longer receive juice So as you can see there isn’t a big change for fully breastfeeding infants.

Fully Breastfeeding What resources might be available?
Lactation specialists (IBCLC, CLE, CLC, Peer Counselor) Breast Pumps Education Materials and Classes Community Resources La Leche League, Public Health Nurses Agency and community resources that may be available depending on the agency are [CLICK] Lactation specialists such as International Board Certified Lactation Consultants, Certified Lactation Educators, Certified Lactation Counselors or Peer Counselors. Additional resources include breast pumps, educational materials and classes, and community resources such as La Leche League and Public Health Nurses.

Key to Success Designate a “Lactation Specialist” for the day to…
Provide pregnant and breastfeeding women with needed support and help Be accessible to staff for any breastfeeding help and questions Here is another Key to success. Designate a lactation specialist for the day to [CLICK] Provide pregnant and breastfeeding women with needed support and help Be accessible to staff for any breastfeeding help and questions. Result: staff feels more confident that breastfeeding mother’s needs will be met, which they are! Result: Staff feel more confident. Breastfeeding mother’s needs are met! 147

“Your WIC Foods” Overview of new food packages
What do you see that is new? What differences do you notice between the packages? How will you use this tool to encourage as much breastfeeding as possible? On your table is a NEW handout entitled “Your WIC Foods”. Please find it. ***Room monitors hold up handout*** This handout is an overview of the food packages for all the different categories starting October 1st.. You can compare the four different postpartum categories of mom and baby. Take a few minutes to look at this handout and after you are done, discuss with your partner these questions: [CLICK] What do you see that is new? What differences do you notice between the packages? How will you use this tool to encourage as much breastfeeding as possible? When you are finished, we will hear your ideas about how you would use the handout to encourage breastfeeding. We’ll give you ten minutes for this activity. ***Room monitor time for 10 minutes*** [Allow time for comments if needed]

Formula Toll Road [CLICK]
WIC Another mother has chosen to only give her baby formula, so let’s move the taxi cab to the Formula Toll Road. Notice that on the Toll Road there are additional detours and expenses. Such as they’ll receive less food, spend more money on supplies, see the doctor more often. They also have to learn how to prepare formula properly and get up to prepare it at 2am. And don’t forget they have to wash the bottles and nipples too!! [CLICK]

Formula Feeding With your partner discuss: What will be different for
Formula feeding moms and babies? How will you discuss formula feeding with moms? With a partner discuss [CLICK] what will be different after October 1 and how will you discuss formula feeding with Mom. Let’s take 5 minutes for this activity. ***Room monitor time 5 minutes and ring bell***

Formula Feeding What will be different?
Babies will receive less formula. The amount of formula will change according to baby’s age. Babies will receive baby food starting at 6 months. Babies won’t receive as much baby foods as breastfed babies. Babies will no longer receive juice. What will be different [CLICK] Babies will receive less formula. The amount of formula will change according to baby’s age. Babies will receive baby food starting at 6 months. Babies won’t receive as much baby foods as breastfed babies Babies will no longer receive juice.

Formula Feeding What will you discuss?
Always holding baby while feeding Proper preparation of formula Here are some things you might discuss with formula feeding mothers. [CLICK] Always holding baby while feeding Proper preparation of formula

Let’s Play WIC Cash Cab [CLICK]
Before we go into detail, let’s first have a cash cab question. I’m going to read the question. When your table decides on an answer, your entire table must jump up and we’ll call on you. The first two tables that give the right answer will receive healthy bucks. Everyone at the table will get a buck. I want you to practice jumping up. Ready, set, go! Great Job!! Remember you have to WAIT until I’m done reading the slide. ***Room monitor be ready with microphone to run to table that jumps up first*** [CLICK] 153

Cash Cab How do you plan to support your fully breastfeeding Moms
starting Oct 1? 154

Cash Cab How do you plan to support your fully formula feeding Moms
starting Oct 1? 155

Combination Feeding WIC Now we have a breastfeeding mom who is also thinking about giving her baby formula. Move your taxi cab to the Combination Blvd. [CLICK] Now you will learn how to assess and address moms breastfeeding issues, refer when necessary, and determine the appropriate food package to meet the health and nutritional needs of mother and baby. WIC

Combination Feeding With your partner discuss:
What will be different for… Combination feeding moms and babies? How will you discuss combination feeding using “Your WIC Foods” to support breastfeeding? With a partner discuss what will be different after October 1 [CLICK] How will you discuss combination feeding with Moms. Also discuss how you will use “Your WIC Foods” to support breastfeeding with the potential combination feeder. Let’s take 5 minutes for this activity. ***Room monitor time 5 minutes and ring bell*** 157

Combination Feeding What will be different?
2 Categories – mostly and some. Babies will receive less formula. The amount of formula will change according to baby’s age. Babies will receive baby food starting at 6 months. Babies won’t receive as much baby foods as fully breastfed babies. Babies will no longer receive juice. Here are some things you may have discussed [CLICK] 2 Categories – mostly and some. Babies will receive less formula. The amount of formula will change according to baby’s age. Babies will receive baby food starting at 6 months. Babies won’t receive as much baby foods as fully breastfed babies. Babies will no longer receive juice. 158

Combination Feeding What are some of the reasons breastfeeding moms ask for formula? I’m going back to work or school. I want formula just in case… I don’t have enough milk. My family members want to feed my baby too. I (or my baby) have a health issue and can’t fully breastfeed. What are some of the reasons breastfeeding moms ask for formula? [CLICK] I’m going back to work or school. I want formula just in case…. don’t have enough milk. My family members want to feed my baby too. I (or my baby) have a health issue and can’t fully breastfeed. Now we will practice addressing some of these issues. 159

BABY NUTRITION QUESTIONS Using the tools and skills you now have you will be able to educate and support her feeding choice. We’d like you to practice using these tools. But first we have a scenario for you to watch. [CLICK] COUNSELING QUESTIONS ISIS QUESTIONS

Find your “Observer’s Checklist”
Combination Feeding Let’s watch our WIC actors as they model a challenging breastfeeding scenario. Find your “Observer’s Checklist” Let’s revisit our WIC moms and babies. We have actors from WIC Broadway that came all the way from New York. They will role play the Wilma and Wil scenario. While watching, think about how you would counsel the mom and the tools you will use. What will happen is two people will play the roles of WIC staff person and participant. We’d like you to act as an observer by using your “Observer’s Checklist”. Please pull this out of your folder. [allow time for ppt to pull this out] We’d like for you to watch the role play and see if the counselor uses the skills listed on this checklist. After we demonstrate, you all will have an opportunity to give feedback about the counseling session. Let’s watch the role play now. ***Room monitors: First piece of role play - Two people play out roles of counselor and participant. Use written scenario for Wilma/Will.*** So how did the counselor do, observers? Would anyone like to share what they observed? [***room monitors solicit responses from group***] [CLICK]

Combination Feeding Work in trios – Counselor WIC mom Observer (Roles)
Role play the “Gloria/Gustavo” scenario. How will you counsel the mom? What tools would you use? Now we’d like you to work in trios with the other two scenarios in the same way. One person will act as the participant, another as the counselor and the third as the observer. Observers, remember to say the positives first and use “how about” in your comments. In your groups of three, decide who will be counselor, WIC mom, and observer. Raise your hand if you will be the counselor....[raise hands] WIC mom….[raise hands] observer…[raise hands]. Spend 3 minutes of your 5 minutes on the role play and the other 2 minutes on the feedback. [CLICK] Please pull out the Gustavo Baby Nutrition Question form. Now you will role play the scenario. Don’t forget to use the toolkits in your toolbox! Questions to consider: How will you counsel the mom? What tools would you use? Refer back to the questions you wrote on the back of the form. You have 5 minutes for this activity. We’ll come back to the big group to hear some of your ideas. ***Room monitor ring bell at 3 minutes and at 5 minutes*** 162

Combination Feeding What went well? What were some issues?
What tools did you use? We’d like to hear from a few of you about your counseling sessions. Let’s hear from the counselor, the WIC participant and the observer. What went well? ***Room monitor walk around with microphone soliciting answers*** [CLICK] What were some issues? What tools did you use?

Combination Feeding Switch roles Now role play “Sammie” scenario.
How will you counsel the mom? What tools would you use? In your groups switch roles for counselor, mother, observer. Let’s role play the Sammie scenario using Sammie’s Baby Nutrition Question form. Don’t forget to use the questions you wrote on the back of the form. We’ll come back in 5 minutes. Spend three minutes of your 5 minutes on the role play and the other two minutes on the feedback. Then we’ll share some of your ideas in the big group. ***Room monitor time and ring bell at 3 minutes and at 5 minutes*** ***Room monitor time 5 minutes and ring bell*** [CLICK]

Combination Feeding What went well? What were some issues?
What tools did you use? We’d like to hear from a few of you about your counseling sessions. Let’s hear from the counselor, the WIC participant and the observer. What went well? ***Room monitor walk around with microphone soliciting answers*** [CLICK] What were some issues? What tools did you use?

Key to Success At anytime when a fully or combination breastfeeding mom asks for formula, have a lactation specialist see her to assess her breastfeeding. Result: Increase in breastfeeding duration Decrease in formula issuance Here is our last key to success. Some agencies automatically refer mothers who request formula within the first 30 days to the lactation specialist. [CLICK] This has resulted in a longer duration of breastfeeding and a decrease in the cans of formula distributed. 166

Table Toolbox Infant Feeding Support in the First 30 Days Look in your toolbox for toolkit #3. [CLICK] This toolkit focuses on resources for you to use with the breastfeeding mother. Toolkit # 3 Resources

WIC Reference Tools Guidelines for Referrals Formula Table
Breastfeeding Resource List Report: “Amount of formula issued by your agency” Toolkit #3 in the toolbox has three tools: [CLICK] Guidelines for Referral, A Formula Table and A Breastfeeding Resource list you will be able to find on-line. We have a placeholder in the toolbox but we decided to put the papers in your folder because they are important for each one of you to have, and CWA offered to do the copying! In the future the state will have a report available to local agencies on the amount of formula issued by individual WIC staff. This report can be used as an incentive to congratulate your staff who excel in breastfeeding support!

Guidelines for Referrals
Health & Nutritional Condition May need referral to support mother May affect infant’s growth pattern May still fully breastfeed First let’s look at the Guidelines for Referrals. Please take a minute to look at it. [Give them a minute to look at it] [CLICK] This handout lists health and medical conditions that may need a referral to a lactation specialist. Some are common issues that you may encounter in your clinic. It is very important to support and encourage the mother to see your lactation specialist because these cases are resolvable. If you do not have one, please refer her to an outside lactation specialist. The earlier we support a breastfeeding mother, the longer she will breastfeed her baby. In very rare cases a health condition may affect an infant’s growth pattern requiring formula supplementation. For example, a baby with a heart defect that is breastfeeding may need additional calories due to his condition. However, babies with the conditions listed often are able to fully breastfeed. Sometimes, a mother may not be able to breastfeed due to her health condition such as when she is HIV positive or receiving chemotherapy for cancer treatment.

Let’s Play WIC Cash Cab Now it’s time for another cash cab!!
I’m going to give you an issue a breastfeeding mother might be experiencing. I want you to tell me if she should be referred to the lactation specialist or not. Use your “Guidelines for Referral” as a reference! Raise your hand when you know the answer. [CLICK] 170

Guidelines for Referral
Breastfeeding Infant is: Twins Jaundice Constipated Yes Yes Breastfeeding Infant is [CLICK] Twins, Do you refer the mother? Yes Jaundice, Do you refer the mother? Constipated, Do you refer the mother? No ***Room monitors wander with microphone and hand out healthy bucks for correct answers*** No

Minimum amount of formula needed
Formula Table Minimum amount of formula needed The next resource is the Formula Table. This table is to help your staff determine the minimum amount of formula to be given for the mostly and some breastfeeding food packages. The ounces per day will help you fill out the required ISIS question. As with the rest of the training if you have any questions about this please write them on your index cards. [CLICK]

Resources Breastfeeding Resource List Online
California Breastfeeding Coalition La Leche League United States Breastfeeding Committee Office of Women’s Health Breastfeeding Resource List Online California Breastfeeding Coalition La Leche League USBC Office of Women’s Health [CLICK]

Data Collection Report: Amount Formula Issued by your agency
Recognize your employees who excel in breastfeeding promotion Identify the training needs Monitor your exclusive breastfeeding rates (fully, mostly, and some bf) Canned Report on # of cans Issued by your WIC staff [CLICK] Recognize your employees who excel in breastfeeding promotion Identify the training needs Monitor your exclusive breastfeeding rates

BREAK Let’s now have a 15-minute break and please come back on time for the remaining of the “Crossroad to Infant Feeding” session. Thank you. [CLICK AFTER BREAK]

Honk if you love Breastfeeding
Come up with a bumper sticker slogan to support fully breastfeeding in the first 30 days. Use only 15 words or less Write on flipchart paper w/markers Come up with a bumper sticker slogan to support fully breastfeeding in the first 30 days. [CLICK] Use only 15 words or less Write on flipchart paper w/markers Add graphics if you like. - - Add Graphics if you like - -

What Would You Do? In pairs or trios discuss how you would counsel Carrie’s mother. What are the feeding issues? What questions would you ask? What actions would you take? Using the Carrie’s Baby Nutrition Questions form and all the skills and tools we have presented to you today in pairs or trios discuss how you would counsel Carrie’s mother. [CLICK] What are the feeding issues? What questions would you ask? What actions would you take? We will give you 10 minutes to do this part and then, we will come back in large group for discussion.

Activity Time 10 minutes What are the feeding issues?
What questions would you ask? What actions would you take? ***Room monitor time for 10 minutes*** [CLICK] Let’s hear some of your thoughts on this scenario. ***Room monitor wander with a microphone and solicit responses*** What are the feeding issues? What questions would you ask? What actions would you take? [at this point we are looking for “this baby is a failure to thrive” and needs IMMEDIATE help] 10 minutes

What Would You Do? Questions to ask Things to do
Tell me about a typical feeding. Let’s talk more about her diapers. Tell me more about how your baby sleeps. Things to do Refer to Lactation Specialist or send to the Emergency Department Weigh the baby Issue Combination Package Schedule appointment for next month Some of the questions and actions we came up with are: Questions to ask [CLICK] Tell me about a typical feeding. Let’s talk more about her diapers. Tell me more about how your baby sleeps. Things to do Refer to Lactation Specialist or send to the Emergency Department Weigh the baby Issue Combination Package Schedule appointment for next month

Enroll and Recertify Now move your taxi cab to “Enroll and Recertify”.
WIC WIC Now move your taxi cab to “Enroll and Recertify”. [CLICK] Thankfully there is nothing new to learn for this part of the appointment!! Woo-hoo!!

Enroll and Recertify Now move your taxi cab to “Isis Documentation”.
WIC Now move your taxi cab to “Isis Documentation”. [CLICK]

BABY NUTRITION QUESTIONS ISIS Documentation [CLICK] COUNSELING QUESTIONS ISIS QUESTIONS

ISIS Documentation NEW Must enter: Reason for formula issuance
Input into the child INEP ISIS Screen NEW In the first thirty days, the only NEW requirement is that you will need to document the reason for formula issuance Must enter reason for formula issuance which is input into the child’s INEP ISIS screen [CLICK]

Issue Food Instruments
ISIS defaults to “fully breastfeeding” package when “combination feeding” is entered. You will have to change to “C” ISIS will automatically issue just one month of Food Instruments. The only crucial step you need to do for combination mothers is on the Food Package screen. ISIS defaults to the fully breastfeeding package when “combination feeding” is entered in the previous screen. We are really encouraging mothers to breastfeed and this is a way to remind you to have a dialogue with the mother about continuing to breastfeed. [CLICK] You will have to change it to “c” for combination feeding due to ISIS defaulting. This is ISIS’s way to make sure the mom is REALLY a combination feeder. Breastfeeding is now the default method of feeding! ISIS will only allow you to issue one month of Food Instruments. This is to allow you to follow up with the mother in the next month to continue to encourage as much breastfeeding as possible. And maybe even become a fully breastfeeding mother!

Fully Breastfeeding Package (BE7) BE7 for fully BF mom; BM8 for Fully Multiples IB1 = 0-5 mo. fully breastfed, no check for infants IB2 = 6-11 mo, fully breastfed, infant foods Fully Breastfeeding Package IB1 = 0-5 mo. fully breastfed, no check for infants [CLICK] IB2 = 6-11 mo, fully breastfed, infant foods

Mostly Breastfeeding Package Infant codes: IC1, ICQ, and IC2 Mom certified for 1 year Mom receives more variety of foods Codes: BC5 -X,L,S,T,H,P,G For those of you who were not here yesterday, here is the Mostly BF package. [CLICK] Number of formula cans depend on the baby’s age Mom certified for 1 year Mom receives more variety of foods

Some Breastfeeding Package (BO6) Infant codes: IO1, IOQ, IO2, and IO3 Mom receives checks up to 6 months Mom may choose to attend breastfeeding support up to 1 year. Mom codes: BO6 and B06N Because of our limited time, we can not discuss these codes with you. If you were not here yesterday your designated trainer will give you the full details of these packages and WebEx training will give you the ISIS part. [CLICK]

Schedule Next Appointment
Combination Feeding Must be in second month Must be with a lactation specialist Fully Breastfeeding Based on needs of mom and baby For the combination feeding mother you will need to schedule a second month appointment with a lactation specialist. Who remembers how many hours of breastfeeding education a lactation specialist is supposed to have? [wait for someone to raise hand and reply 20 hours] Right, the lactation specialist has at least 20 hours of breastfeeding education. Can anyone name some staff that might fall into this category? [wait for someone to raise hand and call out, CLE, etc] Right, staff that might fall into this category are certified lactation educators or counselors, registered dietitians, peer counselors, and International Board Certified Lactation Consultants. These are requirements of the policy. Must be in second month [CLICK] Must be with a lactation specialist For the fully breastfeeding mother the second appointment is based on the needs of the mother and baby. Your agency has the option on how you will schedule this appointment. The most crucial period for fully breastfeeding mothers is the first month. It might be necessary to offer breastfeeding support before her next appointment. This could be seeing the lactation specialist, talking to a peer counselor, coming to a support group or class or even over the phone. With all of the skills you have learned today you have LOTS of ways to offer this support through a complete assessment and education. We’re almost to the end of the session and the final cash cab questions. The last thing we need to do is to talk about the Second month Appointment. Ready?

Assessment Completed Assessment DIALOGUE WITH MOMS BABY NUTRITION
QUESTIONS We have just completed the discussion on Part 2 of our breastfeeding policy, “Components of Complete Assessment”. What questions do you have at this point? (wait for a response) Thank you. Now we are ready for the next portion: The second month appointment. [CLICK] COUNSELING QUESTIONS ISIS QUESTIONS

WIC So let’s review our day so far. Please look at your roadmap on your table as I review. In the morning we reviewed the policy and then showed you the counseling skills and information about baby behavior which will support the mother in her decision to breastfeed her baby. In the afternoon we drove through the crossroads on fully breastfeeding and formula feeding and combination feeding. Then we passed by all of the ISIS process in finishing the complete assessment of the infant. So what will happen when the mother returns for her second month appointment? [CLICK] WIC 190

The Second Month Appointment
Fully breastfeeding mothers may see lactation specialist if needed. All combination feeding mothers see a lactation specialist who will: Conduct complete assessment Determine the need for continued formula Provide appropriate breastfeeding support and counseling At the next appointment: Fully breastfeeding mothers may see lactation specialist if needed [CLICK] All combination feeding mothers see a lactation specialist who will: Conduct complete assessment Determine the need for continued formula Provide appropriate breastfeeding support and counseling

Your Souvenir Complete Assessment Checklist for supporting your breastfeeding moms ***Room monitors hand out “Complete Assessment Checklist” form*** Now that we are at the end of our ride we have one more tool for you. It is a “maintenance checklist” to keep your taxi in “tip-top” shape. It will help your staff continue supporting your breastfeeding mothers by reminding them of the steps involved in complete assessment and counseling. Your staff might want to post it somewhere within easy view when counseling the participant. ***Room monitors time 2 minutes*** After this training and with help from your agency, you will be able to use all the tools in the toolkit. Is it possible? Yes it is. Can you do it by yourself, maybe? But can we do it as a TEAM, absolutely. [CLICK]

Supporting Fully and Combination breastfeeding moms Components of Complete Assessment The Second Month Appointment We now have completed the discussions of the new breastfeeding policy and look what just came up with this training today, a healthy, beautiful, breastfed baby. Thank You all for your time and participation. [CLICK]

Review Keys to Success Today you heard 5 Keys for Success from agencies who have already implemented the new 30 day policy. Take the keys out of the toolbox Pass the keys clockwise until you hear “STOP!” Share how you might apply the “key” at your agency Use your “That reMinds Me” form Today you heard 5 Keys to Success from agencies who have already implemented the new 30 day policy. [CLICK] One of the toolboxes on your table has the keys in it. We’d like you to take the keys out of the toolbox because we are going to play a game. I’d like for you to pass the keys clockwise around your table until I say “STOP!”. When I say stop the person holding the key will read it and tell how it might be applied at their agency. Do this for all the keys. Use your “That reMinds Me” form that you have been writing your notes on as we introduced the keys throughout the day. 194

Answers for You Questions & Answers
Now we will answer some of your questions from the index cards. [trainer and room monitors answer questions to your best ability. All questions not answered will be put in Q and A and sent out this fall] [CLICK]

End of the Ride Healthy WIC Baby Roadmap to Infant Feeding
Move your taxi cab to the healthy WIC family. [CLICK] wic

WIC Let’s look at our road map one last time. You have given the mother a great start to her breastfeeding experience! We’re hoping that the activities today equipped you in helping fully and combination breastfeeding mothers and babies. Are you ready to drive your taxi? We have reached our final destination. Give yourselves a BIG hand!!! Now pull out your Certificate of Completion!! You’ve graduated from the WIC Taxi School. But before we go I would like for you to think for a second. Think about your agency 5 years from now. The year is Imagine what you agency looks like now. Are you giving our less formula? Is your agency known as a “that great place where they can help you breastfeed your baby” or “the place where you can get free formula”? 5 years, you can do it!! [CLICK] WIC 197

WIC – Healthy and Happy Wil Sammie Gustavo Carrie
Here is the fruit of all your labor. Healthy, happy children!! [CLICK]

Final Destination Evaluation RAFFLE
We’re just about to have the raffle… [CLICK] But before we do that, don’t forget to fill out your evaluation forms and leave them on your table. If you have any extra healthy bucks give them to a State Staff person. We want you to have a fair chance to win! Let’s redeem your HEALTHY BUCKS for PRIZES!!! [Do raffle] THANK YOU SO MUCH. You’ve been such a wonderful group to work with. For those of you who are trainers, please stay for an extra 30 minutes for some more information about training your staff. [Gather trainers somewhere in the room] RAFFLE

Infant Feeding in the First 30 Days of Life

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Infant Feeding in the First 30 Days of Life

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Presentation on theme: "Infant Feeding in the First 30 Days of Life"— Presentation transcript:

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About project

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