Attachment G Breastfeeding Messages The most important breastfeeding messages for a woman respond to her own unique questions or concerns. Address those first, using open ended questions, affirmations and targeted messages.1 Provide targeted / individualized information that gives her credit for what she already knows. Breastfeeding messages and ideas for conveying each message follow. With your help we can further develop these messages. Please send your ideas for effective messages and related materials and activities to the State WIC Breastfeeding Coordinator. Background information on each message, materials and tips for using the messages are included here. The Breastfeeding Messages are: 1. Surround yourself with supportive people. WIC can help you learn about breastfeeding 2. Discuss your plans to breastfeed with your health care provider. 3. When your baby drinks your milk, your body makes more milk. Breastfeeding early and often helps to get breastfeeding off to a great start. Breastfeeding your baby when she is hungry builds your milk supply to meet her needs. Growing babies want to eat more often. This helps you make more milk! 4. Your milk is best for your baby. Your early milk is made to give your baby a great start. Your milk is all your baby needs in the first months. Breastmilk and formula are different! 5. There are ways to tell that your baby is feeding well. WIC can help you learn them. 6. Breastfeeding is good for your older baby and toddler. “On deck” Contact the state WIC breastfeeding coordinator if it would be helpful to have the following messages developed or if you have other comments on messages. Working? Breastfeeding works too! (See page 13: Resources for breastfeeding and returning to work or school.) Breastfeeding is good for mom! Breastfeeding is convenient Breastfeeding helps you get back in shape. It feels great to know you can produce the very best food for your baby Breastfeeding is good for dads, your family and friends. Healthier babies are happier babies. Breastfed babies smell better. 1 See Page 10 Summary of 3 – step counseling and training resources MN WIC FY 2007 & 2008 Breastfeeding Promotion & Support Plan & Guidance. July 2006.

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1. Surround yourself with supportive people. WIC can help you learn about breastfeeding For CPAs When participants understand that breastfeeding is learned and they have places to get good education and support they may be less discouraged if they feel awkward at first Use this message when: Participant indicates she plans to breastfeed. Participant indicates she isn’t sure she can breastfeed and the reason for her concern is related to people in her life who don’t support breastfeeding. Benefits of identifying people she knows who can support her breastfeeding. We live in a culture that doesn’t always support breastfeeding. A supportive friend, family member, WIC staffperson or WIC peer counselor can encourage her when she Encounters negative comments about breastfeeding or Is feeling tired and discouraged or Is wondering if her baby is getting enough milk, And can remind her that breastfeeding gets easier after the first few weeks. Barriers Subtle cultural messages may encourage formula – feeding. Family members who did not breastfeed may be supportive, but they can also be non-supportive. (You did just fine on formula.) Some healthcare providers support breastfeeding, others may make statements or comments that discourage breastfeeding, or provide formula samples; which imply endorsement or that she might not make enough milk. Open-ended questions For pregnant women: Who do you know who has breastfed? What has (name of the person) shared with you about breastfeeding? Do you feel that you could contact (name of the person) if you have questions about breastfeeding? (Note, this is not an open-ended question and should only be used after the open-ended questions.) For women who breastfed or formula fed their older children: Who supported you when you were breastfeeding (name of child or children)? Where did you get information about feeding and caring for (name of child or children)? Will (name of person) encourage you when you are breastfeeding?

MN WIC FY 2007 & 2008 Breastfeeding Promotion & Support Plan & Guidance. July 2006.

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1. Surround yourself with supportive people, continued. Counseling guidelines / Activities Discuss situations she might encounter while breastfeeding and how the situation might be addressed, how a support person can help. Help her believe – “You can do it!” message from Illinois WIC Remind her that WIC can support her by answering her questions about breastfeeding now, and after her baby is born. New moms have questions. WIC is here to help! Anecdotal story examples Share examples of how other participants have received support from WIC and had a great breastfeeding experience. (Generic enough to respect confidentiality.) For Participants Materials Loving Support for Breastfeeding Magnet. (WIC supplies order form). Add local phone numbers for breastfeeding information and support. Pamphlet: Encouragement (WIC supplies order form) Display ideas Display with stories of WIC participants and staff and the people who supported their breastfeeding. (Include photos of the breastfeeding woman and the people who supported her with her story!) (Get her written permission to use her story and picture) Graffiti board for women to share their ideas on how they found support for breastfeeding or how they overcame situations that were discouraging. (Use a white board, large sheet of poster board, or something similar and encourage participants and staff to write ideas for how they found support for breastfeeding.) Individual discussion or class ideas. Discuss where women find support for breastfeeding Share stories of lack of support and how women overcame them. Share stories of wonderful support and how women found it.

MN WIC FY 2007 & 2008 Breastfeeding Promotion & Support Plan & Guidance. July 2006.

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1. Surround yourself with supportive people, continued. For Coordinators Staff as role models Keep formula out of sight. Review materials distributed to participants for breastfeeding messages they convey. (Not just breastfeeding materials.) Scavenger hunt to find and replace items with formula promotion messages (pens, caps, bags, nametags, etc.) Collaboration Identify community resources for breastfeeding support and develop information that can be shared with participants. Invite a LLL leader to WIC clinic for a meet the leader day. A list of many groups in MN can be found on the La Leche League of Minnesota & Dakotas website or contact the MN WIC Breastfeeding Coordinator for a copy of the LLL of Minnesota / Dakota’s brochure.

MN WIC FY 2007 & 2008 Breastfeeding Promotion & Support Plan & Guidance. July 2006.

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2. Discuss your plans to breastfeed with your health care provider. For CPAs Anticipatory guidance, or helping women plan ahead to help them get off to a great start with breastfeeding is critical to the success of breastfeeding. By talking with her health care provider and including breastfeeding in her birth plan she can request practices that will help get breastfeeding off to a good start. Use this message after a woman has decided to breastfeed and you have answered her questions: Benefits. What happens in the hospital can either get breastfeeding off to a great start or contribute to concerns and early breastfeeding cessation. By providing information on how to get breastfeeding off to a great start (anticipatory guidance) and encouraging her to discuss her plans with her health care provider, she is more likely to get a good start and continue breastfeeding. Barriers Women may be hesitant to talk with their health care provider and make requests about breastfeeding. Hospital practices can impact breastfeeding positively or negatively. See the section on 3-step counseling for additional background on the impact of barriers on breastfeeding. Open-ended questions What has your (doctor, nurse, other) told you about breastfeeding? Have you talked with your health care provider about your plans to breastfeed? (Not an open-ended question, so not the first question to start with.) What have you included in your birth plan about breastfeeding? Counseling guidelines / Activities “Make sure your health care provider knows you plan to breastfeed.” Request: to have your baby with you, with the opportunity to breastfeed, within the first hour after birth. baby “room in” with you. no water, glucose water, or formula from a bottle for baby (unless medically necessary). no pacifiers. MN WIC FY 2007 & 2008 Breastfeeding Promotion & Support Plan & Guidance. July 2006.

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2. Discuss your plans to breastfeed with your healthcare provider, continued. Encourage women to breastfeed early (within an hour after birth) and as often as baby wants to feed to Develop your milk supply. Help baby learn. Help baby stay healthy. Help prevent engorgement. Anecdotal story examples We’ve learned that when women have believed they don’t have enough milk, often we find that they didn’t have good information. WIC can help you plan to get breastfeeding off to a great start. For Participants Materials Pamphlets (available on WIC supplies order form) Breastfeeding, Card 1 – What to Expect in First Weeks Breastfeeding: Getting Started in 5 Easy Steps Door hanger for hospital room (privacy please) Templates and instructions available at: Creativity Portal Playground Microsoft homemagazine Projects and Crafts (scroll down) Videos on positioning (all available to borrow from MDH library). Helping a Mother to Breastfeed. No Finer Investment. #PWV29-01 Delivery, Self Attachment #V271-02 Follow Me Mum. The Key to Successful Breastfeeding. 14 Steps to Better Breastfeeding For Coordinators Show a video on positioning at a staff meeting. Share information about breastfeeding support in local hospitals. Collaboration Meet with local hospital & Clinic staff to share what WIC is doing to promote and support breastfeeding and examples of WIC breastfeeding promotion materials. Start a breastfeeding coalition. Request a copy of Community Based Coalition Building for Breastfeeding Promotion from the State WIC Breastfeeding Coordinator. Supplemental Funding Idea.

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3.

When your baby drinks your milk, your body makes more milk. Breastfeeding your baby when she indicates she is hungry builds your milk supply to meet her needs. Breastfeeding early and often helps to get breastfeeding off to a great start. Growing babies want to eat more often. This helps you make more milk!

Some women decide they will feed formula “until my milk comes in,” not realizing that breastfeeding signals a woman’s body to make milk. A woman may also be concerned that there is just a little colostrum and feel she needs to supplement with formula, not realizing that she has just the right amount of colostrum and will make less milk if she is supplementing. Health care providers who are not familiar with how milk supply is developed may inadvertently undermine breastfeeding by encouraging a woman to take a little formula ”in case you need it”. Helping a woman understand that her milk is made just for her baby and in the right amount for her baby will help her get off to a good start with breastfeeding. At times when babies are growing most rapidly they want to breastfeed more often. Women may become concerned that they have lost their milk supply or don’t have enough milk. Helping them expect these times and understand that feeding more frequently will help maintain their milk supply can provide reassurance and lead to longer breastfeeding. Breastmilk is made in response to need. Times of growth spurts can vary with each infant, but commonly occur at two or three weeks, six weeks, and three months of age2. Whenever a woman is concerned about her milk supply assess for signs of adequate intake. Most often there is no problem, but occasionally there is a low or reduced milk supply. For CPAs Use this message when: Women are planning to breastfeed. Women who are breastfeeding come to WIC asking for formula and have concerns about their milk supply. Woman has recently stopped breastfeeding due to milk supply concerns. How milk is made / benefits of exclusive breastfeeding Breastfeeding exclusively is the best way to establish a good milk supply. Breastfeeding exclusively can decrease risk of allergies. Breastfeeding exclusively offers the most health benefits for mother and baby. Breastfeeding exclusively means feeding only breastmilk, and Vitamin D “the sunshine vitamin” for babies living in Minnesota. 2 The Breastfeeding Answer Book, Third revised edition. MN WIC FY 2007 & 2008 Breastfeeding Promotion & Support Plan & Guidance. July 2006.

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3. When your baby drinks your milk, your body makes more milk, continued. Barriers Supplemental formula is common and is often not questioned. Hospital staff who offer to give the baby a bottle so mom can sleep are inadvertently discouraging breastfeeding, by missing an opportunity for the mother to learn how to breastfeed, introducing a bottle nipple, and not providing the stimulation of milk production that breastfeeding provides. Some women believe that colostrum is not good for the baby and that they need to wait until their milk comes in to breastfeed. When women hear that their breastfed baby needs vitamin D, they may be concerned about the quality of their breastmilk. When a baby wants to feed more often the mother may be concerned that she does not have enough milk. This can lead to: Supplementing, which interferes with building milk supply or Stopping breastfeeding. Open-ended questions What have you heard about how you make milk for your baby? What have you told your health care provider about your wishes for breastfeeding? How big do you think your baby’s stomach will be? How much do you think your newborn baby needs to eat? How do you think a mother of twins or triplets can make enough breastmilk to feed two or three babies? If women who are breastfeeding request supplemental formula the CPA can say: “Please tell me about why you’ve decided to supplement with formula.” or “What led you to your decision to request formula?” or a similar question. Counseling guidelines / Activities Share information about the size of an infant’s stomach3 and that colostrum is made in just the right amount for a newborn baby. newborn stomach size 5 – 7 ml (hazelnut, thimble, glass marble) 1 teaspoon is equal to 4.93 milliliters (ml)4 3 days old stomach size 22-27 ml (about 1 oz) (tablespoon, baby’s fist) 1.5 tablespoon is equal to 22.18 ml or 0.75 ounces (US, fluid) 5 teaspoons (1 tablespoon and 2 teaspoons) is equal to 24.64 ml or 0.83 ounces (US, fluid) 10 days old, stomach size 45 – 60 ml, (walnut, golf ball) 3 Adapted from Smith, Linda. Coach’s Notebook. Games and strategies for lactation education. 2002. Jones and Bartlett. Pages 139 – 140 “belly stones” exercise. (You can borrow this book through MDH library.) 4 Conversions from http://www.sciencemadesimple.net/volume.php MN WIC FY 2007 & 2008 Breastfeeding Promotion & Support Plan & Guidance. July 2006. Page 8

3. When your baby drinks your milk, your body makes more milk, continued. Emphasize that her special early milk or colostrum is made to be very good for her baby and help protect her baby against getting sick. Discuss the difference between the milk she makes, which is made for her baby, and cows milk formula, which is modified from milk that is made for a baby cow. The milk she makes will help protect her baby against diseases that she has been exposed to, and will also taste like the foods that she and her family eat. For Participants Messages Women can make enough milk for 2 or 3 babies! Feeding only breastmilk, when the baby (or babies) is hungry (and waking sleepy babies to feed) tells your body how much milk to make. Materials Breastfeeding Card # 1. What to expect in the first weeks. Pictures or items to demonstrate the size of a newborn’s stomach. (Be careful about items that are a choking risk). Display ideas Got mom? (Idea from Olmsted County) Mom’s milk – made with love Pictures of people and animals with comments on the differences in milk Materials and messages from National Breastfeeding Campaign: “Babies were born to be breastfed exclusively for the first 6 months of life.” Message from the National Breastfeeding Campaign

For Coordinators Collaboration Work with others in public health to provide consistent messages about the importance of exclusive breastfeeding and how milk is produced. Talk with staff from your local hospital and share information about materials WIC is using for participant education. Plan a joint workshop with your community hospital. (Supplemental funding idea!)

MN WIC FY 2007 & 2008 Breastfeeding Promotion & Support Plan & Guidance. July 2006.

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4. Your milk is best for your baby. Your early milk is made to give your baby a great start. Your milk is all your baby needs in the first months. Breastmilk and formula are different! For CPAs Use this message when: You are providing anticipatory guidance for women who are planning to breastfeed. Participants plan to combine breastfeeding and formula feeding “to get the benefits of both.” Benefits Colostrum, the early milk, provides the infant with protection from many diseases and acts as a laxative, to help clear out the meconium. No other feeding offers the benefits of breastmilk. Barriers Women see formula advertising in magazines, on television, and sometimes even in the offices of their health care providers. Women may feel that the amount of colostrum they have isn’t enough. Some cultures have taboos about feeding colostrum. “Waiting until my milk comes in” to breastfeed can delay or decrease breastmilk production. Women sometimes believe that they can’t breastfeed or that breastfeeding is contraindicated for them. Often there is not a contraindication and previous experiences with perceived lack of breastmilk or other problems with breastfeeding were due to lack of information / supplementing / hospital practices / poor positioning or other situations that can be addressed. Open-ended questions What have you heard about formula, and how it compares to breastmilk? What have you heard about the differences between breastmilk and breastmilk substitutes? What have you heard about the special early milk, called colostrum? Counseling guidelines / Activities Discuss what the statement “closer to breastmilk” means. (It means it is not the same as breastmilk.) Discuss that a woman’s breastmilk is made to meet the needs of her baby. MN WIC FY 2007 & 2008 Breastfeeding Promotion & Support Plan & Guidance. July 2006.

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1. Your milk is best for your baby, continued For Participants Materials Breastfeeding “Fact Packs” http://bflrc.com/products/factpacks/FactPack.htm Nursing polar bear http://lava.nationalgeographic.com/cgibin/pod/PhotoOfTheDay.cgi?day=04&month=11&year=03 (Can be downloaded as wallpaper on a non-CHIP computer. Request permission for any other uses.) Risks of Infant Formula Feeding. http://www.breastfeedingtaskforla.org/ABMRisks-print.htm or http://www.breastfeedingtaskforla.org/ABMRisks.htm Video. Mommy’s Milk for Mommy’s Baby. English and Spanish. Available to borrow from Minnesota Department of Health Library or to purchase from Texas WIC. Display / Activity ideas Pictures of mammals nursing – with information on the milk they produce and how it meets the needs for that mammal.5 Group discussion: What have you heard about the differences between breastmilk and breastmilk substitutes? Discuss how milk is made to meet the needs of babies. Show pictures of various mammals and ask the group how fast does the baby grow?, What climate does it live in? How smart is that mammal? Then discuss how breastmilk meets the needs for that mammal and how human milk is made for human babies.

5 For information on whales and whale milk see: http://science.howstuffworks.com/whale5.htm For information on milk composition in marsupials, cats, dogs, swine (pigs), humans and camels see http://classes.aces.uiuc.edu/AnSci308/Lactation/lactationresources.html For information on composition of polar bear milk see MN WIC FY 2007 & 2008 Breastfeeding Promotion & Support Plan & Guidance. July 2006.

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4. Your milk is best for your baby, continued For Coordinators Staff education. At a staff meeting view the video Mommy’s Milk for Mommy’s Baby and discuss how breastmilk best meets the needs for human babies. Review 3 – step counseling and how it can be used to help identify potential barriers to breastfeeding. Have staff share stories on how they have used 3-step counseling. Review the rare circumstances when breastfeeding is contraindicated. Discuss resources to learn about other circumstances when women may believe that breastfeeding is contraindicated. Review the signs of adequate breastmilk intake and discuss the importance of assessing for breastmilk intake, and risk factors for reduced milk supply. See Breastfeeding Concerns and Complications section of the Minnesota WIC High Risk Counseling Guide, 4 /06. Review use of the Diaper Diary with staff. (Copy for CPAs available on WIC supplies order form.)

MN WIC FY 2007 & 2008 Breastfeeding Promotion & Support Plan & Guidance. July 2006.

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5. There are ways to tell that your baby is feeding well. WIC can teach you. Concerns about milk supply are common in both pregnant and breastfeeding women. Pregnant women may be concerned because of a previous breastfeeding experience when they felt they did not have enough milk or because a family member has shared that she didn’t produce enough milk. Letting a woman know that there are ways to tell that her baby is feeding well, and that she can learn this information from WIC and there are places she can call with any questions or concerns can reassure her that she can breastfeed. For CPAs Use this message when: Pregnant participants express concerns that they won’t produce enough milk or that they won’t know if their baby is taking enough. Participants request supplemental formula and you find it is because they are concerned about their milk supply. Benefits When women know the signs that baby is feeding well they are less likely to stop breastfeeding or to begin supplementing due to concerns that baby isn’t getting enough breastmilk. Exclusive breastfeeding provides the most benefits to baby and to mom, and is a National Healthy People 2010 goal. Barriers Milk supply concerns is the #1 reason that Minnesota WIC participants stop breastfeeding before they intended to stop. Concern that baby isn’t getting enough breastmilk can lead women to supplement with formula. Supplementing leads to a lower milk supply. Many participants are concerned that without a bottle they won’t be able to tell how much their breastfed baby has consumed. Open-ended questions What have you heard about benefits of providing only breastmilk to your baby? Where have you received information about breastfeeding? And what did you learn about signs that baby is feeding well? Counseling guidelines / Activities Use the Diaper Diary when you are teaching participants about signs that breastfeeding is going well. Review the information on Breastfeeding, Card 1 – What to Expect in the First Weeks, and ask if she has questions about the information on the card. MN WIC FY 2007 & 2008 Breastfeeding Promotion & Support Plan & Guidance. July 2006.

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2. There are ways to tell that your baby is feeding well. WIC can teach you, cont. For Participants Materials Breastfeeding, Card 1 – What to Expect in the First Weeks Display or group discussion ideas Provide a display on “Signs that Baby is Breastfeeding Well” or discuss this topic in a breastfeeding class or group. For Coordinators Discuss the reasons women stop breastfeeding in your agency, including how many quit because of concerns about milk supply. (See the Summary Statistics – Breastfeeding, and the Summary Statistics Supplemental Breastfeeding reports, and the section titled “Reasons Breastfeeding Stopped.”) Review the signs of adequate breastmilk intake and discuss the importance of assessing for breastmilk intake, and risk factors for reduced milk supply. See Breastfeeding Concerns and Complications section of the Minnesota WIC High Risk Counseling Guide, 4 /06. Review use of the Diaper Diary with staff. (Copy for CPAs available on WIC supplies order form.) Review and discuss Breastfeeding, Card 1 – What to Expect in the First Weeks and how the signs help show that a baby is breastfeeding well. Collaboration If you have a local breastfeeding coalition, consider working on consistent messages about signs that baby is feeding well and sharing them throughout your community.

MN WIC FY 2007 & 2008 Breastfeeding Promotion & Support Plan & Guidance. July 2006.

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6. Breastfeeding is good for your older baby or toddler. Breastmilk continues to provide benefits to mother and child into the second year of life and beyond. The American Academy of Pediatrics states: “Breastfeeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child” and “There is no upper limit to the duration of breastfeeding and no evidence of psychologic or developmental harm from breastfeeding into the third year of life or longer.6 For CPAs Use this message when: This topic is most appropriate for participants who are currently breastfeeding, and after breastfeeding is well established and other questions and concerns of the mother have been addressed. Benefits Breastfeeding continues to provide health benefits for toddlers7. Breastfeeding is a way of comforting the older baby and toddler. Mothers and babies both enjoy the closeness that breastfeeding provides. Barriers In the United States breastfeeding initiation rates are increasing, however duration rates are increasing more slowly, so we don’t see many older infants and toddlers who are nursing.. In many cultures it is common to see toddlers breastfeeding. In the US women often breastfeed their toddlers only at home. Prejudice (individual/societal) against breastfeeding older children. Family members who are not familiar with breastfeeding and the benefits of breastfeeding may encourage a woman to stop too soon. Open-ended questions What have you heard about benefits of breastfeeding for children after a year of age? How do you feel when you see older children breastfeeding?

6 American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the Use of Human Milk. Pediatrics, 2005; Feb, 115: 496-506. (http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;115/2/496 ) 7 For more information see: Breastfeed a Toddler – Why on Earth? http://www.bflrc.com/newman/articles.htm MN WIC FY 2007 & 2008 Breastfeeding Promotion & Support Plan & Guidance. July 2006. Page 15

6. Breastfeeding is good for your older baby or toddler, continued. It sounds like you've been thinking about stopping breastfeeding - tell me a little more about what's leading you in that direction. Who do you know who has breastfed an older baby? What was their experience? Counseling guidelines / Activities Address her questions / concerns if any, about continued breastfeeding. If she is concerned about comments from others about breastfeeding an older baby or toddler discuss how other participants have dealt with this issue. Ask if she would like to bring the family member who is expressing concerns along to her next WIC appointment. Encourage her to find a source of support. If you have a LLL group in your area share that information. If WIC or another organization in your community has a nursing mothers group, share that information. For Participants Materials Breastfeeding, Card 4 -Breastfeeding an Older Baby Display ideas Display with photos and / or pictures of infants / toddlers breastfeeding. One source of photos is the photos from the 2004 International Photography Competition, http://www.breastfeeding.org.nz/ . To request permission to use the photos contact: [email protected] For Coordinators Encourage staff who are interested to attend a La Leche League (LLL) meeting as a guest. Contact the meeting leader to introduce yourself and make a request to attend a meeting as a guest. A list of many groups in MN can be found at: http://www.lllusa.org/web/MNDak.html or contact the MN WIC Breastfeeding Coordinator for a copy of the LLL of Minnesota / Dakota’s brochure. At a staff meeting, discuss breastfeeding the older baby or toddler. Possible discussion topics include: What questions are participants asking regarding breastfeeding an older baby or toddler? How are staff answering these questions? The US culture and how it impacts long term breastfeeding. Experiences of staff who have lived in other countries, related to the cultural norms for breastfeeding older babies or toddlers. (If staff are comfortable sharing; talk with them before the meeting.) MN WIC FY 2007 & 2008 Breastfeeding Promotion & Support Plan & Guidance. July 2006.

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“On Deck” We would like to know if it would be helpful to develop similar messages about the following topics: Working? Breastfeeding works too!

Breastfeeding is good for Mom!

Breastfeeding is good for dads, your family and friends.

MN WIC FY 2007 & 2008 Breastfeeding Promotion & Support Plan & Guidance. July 2006.

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