Lactation and Infant Feeding-Friendly Environments Hospital Program

1. a Have a written infant feeding policy that’s routinely communicated to staff and parents with a trauma informed, health equity lens.
   b Comply fully with the International Code of Marketing of Breastmilk Substitutes.
   c Establish on going monitoring and data-management systems that can be disaggregated for continuous quality improvement.
2. Ensure that staff have sufficient knowledge, competency and skills to support lactation.
3. Discuss the importance and management of lactation with pregnant parents and their families.
4. Place stable infants, regardless of feeding method, skin-to-skin with their parent for at least 60 minutes immediately after birth.
5. Show parents how to breastfeed/chestfeed and how to maintain lactation if they’re separated from their infants.
6. Give infants no food or drink other than human milk unless medically indicated.
7. Practice rooming-in to allow parents and infants to remain together 24 hours a day.
8. Support parents to recognize and respond to their infants’ cues for feeding.
9. Give no artificial nipples or pacifiers to nursing infants unless medically indicated.
10. Coordinate discharge so that new parents and their infants have timely access to out-patient care, culturally appropriate resources and community support.

How to submit your LIFE hospital application

1. Download the Lactation and Infant Feeding-Friendly Environment application file (Word) and the Program Authorization Form (PDF)
2. Review the application, authorization form, FAQ below and reach out to LIFEprogram@doh.wa.gov with any questions.
3. Complete application and authorization form then send to LIFEprogram@doh.wa.gov and attach a zip file of all supporting documentation
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Please allow up to 3 weeks for applications to be processed

What is the difference between the Lactation and Infant Feeding-Friendly Environments Hospital program and the Baby-Friendly® Hospital Initiative?

The Lactation and Infant Feeding Friendly Environment (LIFE) Hospital program is a voluntary quality improvement designation developed by DOH and managed in the Prevention and Community Health division, funded through the Center for Disease Control and Prevention.

The Baby-Friendly® Hospital Initiative is an international designation program developed by the World Health Organization and the United Nations Children’s Fund and implemented by Baby-Friendly® USA. Find more information at www.babyfriendlyusa.org.

Both programs are based on the World Health Organization’s Ten Steps for Breastfeeding Success guidelines.

Facilities designated as a LIFE hospital can build on their efforts and increase capacity to begin the journey towards Baby-Friendly® designation. If your hospital is interested in applying for Baby-Friendly® the scoring criteria can be found here.

The steps and required documentation differ for these two programs. This flexible Washington State program is designed to meet the needs of hospitals in urban and rural areas who have unique barriers to reaching Baby-Friendly® designation and to address needs that were expressed by community stakeholders and advocacy groups. The LIFE program factors in a hospital’s size and staffing, number of Medicaid patients they support, community barriers or risk factors such as the opioid crisis or chronic disease, and additional considerations that make each hospital unique.

Washington hospitals currently designated as Baby-Friendly® can automatically earn the Lactation and Infant Feeding-Friendly Environments Hospital Gold Level recognition. Email a copy of your award to LIFEprogram@doh.wa.gov and we will send your facility the Gold Level Recognition promotion package.

Training options and required hours Hospitals have three options for dialectic training
Option 1:	60%-80% of perinatal care staff and providers complete all the required hours of lactation education training, depending on desired designation level
Option 2:	60%-80% of perinatal care staff and providers take an NCC lactation assessment test to identify training needs and provide continuing education based on individual, identified education needs (up to 15 hours) depending on desired designation level
Option 3:	Hybrid of both; working with LIFE program to find combination that works for their needs

Please note, currently credentialed IBCLCs in good standing with the International Board of Lactation Consultant Examiners are exempt from the 20 hours of lactation education but are required to do the one hour of implicit bias training.

Training Hours Needed per Percent of Staff
Training hours	Silver	Gold
15 hours dialectic perinatal  care lactation education	60% Perinatal care staff	80% Perinatal care staff
3 hours perinatal provider dialectic lactation education	60% Perinatal care providers	80% Perinatal care providers
5 hours perinatal care didactic lactation training	60% Perinatal care staff	80% Perinatal care staff
1 hour bias training	100% Perinatal care staff and providers	100% Perinatal care staff and providers

What is the difference in required training for BFWA versus LIFE hospitals?

Silver and Gold Level LIFE hospitals will have differing requirements for training than the previous BFWA program.

Training Requirements of LIFE Program vs. BFWA Program
	Silver		Gold
	LIFE	BFWA	LIFE	BFWA
15 hours dialectic perinatal care lactation education Perinatal care staff	60%	55%	80%	80%
3 hours perinatal provider dialectic lactation education Perinatal care providers	60%	25%	80%	80%
5 hours perinatal care didactic lactation training Perinatal care staff	60%	55%	80%	80%
1 hour bias training Perinatal care staff and providers	100%	None	100%	None

What is an Infant Feeding Policy?

Health policies are an intentional system of guidelines, typically written, that guide rules or procedures that influence positive health outcomes. A policy can:

• Clearly communicate expectations to increase consistency and quality of care
• Institutionalize long term goals, values, or guidelines
• Create sustainability of quality improvement efforts

An infant feeding policy can encompass multiple forms of documented guidelines that ensure perinatal care staff, providers and administration know your commitment to supporting breast/chestfeeding. The LIFE program application has a detailed list of required topics the policies and guidance should include.

Policies can look like many different things depending on the organization's capacity, barriers, and if they are an independently owned facility or part of a large network. Some organizations may adopt entire infant feeding policies that encompass the Ten Steps, whereas some may have the guidelines spread out over multiple policies, procedures, or formal memos sent to staff informing them of new things happening such as changing how skin-to-skin is done in the Operating Room after cesarean section.

What are culturally appropriate resources and where do I find them?

Step 10 is about connecting families to resources that are understandable, helpful, and are inclusive of the rich diversity of people in Washington. Culturally appropriate resources, reflect or incorporate the identities, cultures, mindsets, and personal experiences of the community your hospital serves. These resources are often developed by local coalitions, advocacy groups or the local WIC organization and are available if you reach out and ask.

If you are unsure of the communities your hospital serves, visit Washington County Health Rankings & Roadmaps to learn more. If you need support in identifying local culturally appropriate lactation education resources, reach out to LIFEprogram@doh.wa.gov.

What data is required?

The Lactation and Infant Feeding-Friendly Environments program asks for non-identifiable data about the percent of:

• Breastfeeding/chestfeeding at discharge
• Parents offered lactation support
• Supplementation of non-human milk
• Skin-to-skin between the parent and infant
  • Uncomplicated vaginal deliveries: at least 70%
  • Caesarian section deliveries: at least 50%
• Rooming-in, if there is a well-baby nursery: at least 80%
• Pacifiers given to exclusively nursing infants, if artificial nipples or pacifiers are given freely when non-medically indicated

Chart records should have the ability to disaggregate by:

• Race and ethnicity
• Socioeconomic status
• Maternal Age

These data points are found on Washington Birth Certificate forms (PDF).

Having the ability to disaggregate data can support hospitals continue their quality improvement efforts, monitor progress, and set goals. All levels of the Lactation and Infant Feeding-Friendly Environment program report data. Silver and Gold Levels require data-management systems that can be disaggregated for Step 1c. Hospitals who would like to apply for Silver or Gold Levels who are unable to pull data charts and disaggregate data will need to identify a plan to ensure the facility is monitoring their health outcomes and reporting to quality improvement programs such as JCO, OB COAP, LIFE program, or mPINC. Hospitals will have 12 months to identify and begin implementing their plans after their application and designation.

Bronze facilities with limited flexibility in pulling data from their electronic health record systems have the option to provide alternative ways of showing their facility is implementing the step by providing a one-time option to document the percent of labor and delivery medical staff who are trained to implement skin-to-skin and rooming-in.

What trainings meet Step 2’s requirements for 1-hour implicit bias training

A Practitioner’s Guide for Advancing Health Equity (PDF) (CDC)

Caring for Patients Who Have Experienced Trauma (ACOG)

Trauma-Informed Care Resources Guide

Racial Bias (ACOG)

Implicit Bias in Pediatrics (AAP)

Eradicating Racism from Maternity Care- Addressing Implicit Bias

Other trainings not listed can be submitted to LIFEprogram@doh.wa.gov to see if they qualify.

What is trauma-informed care?

Adopting a trauma-informed approach improves your ability to connect with and care for people who are pregnant and lactating. In the words of Dr. Pickens, “A trauma-informed system allows us to be able to recognize when those invisible injuries, like abuse, have impacted somebody, and then to respond in a way that helps them heal”.

Compassion fatigue, implicit bias and jaded perspectives can happen to anyone. As you start to adopt a trauma informed process, mistakes may happen, and self-judgement or shame are not helpful in the learning process.

What’s important is that you continually conduct an inward reflection and assessment of how you and the perinatal care team interact with families, and where improvements can happen to provide the best care possible.

Learn more about trauma-informed care. (PDF)

Is the LIFE program anti-formula?

Absolutely not.

The “infant feeding” portion of the LIFE program includes the spectrum of ways that caregivers feed their child such as:

• Exclusive pumping
• Feeding at the chest with a supplemental nutrition system or bottle
• Feeding both expressed milk and formula

While 92.5% of families choose to breast/chestfeed their infants, our state and tribal communities have a diversity of needs which means some families will supplement with donor milk or infant formula. Families in the LGBTQAI+ community, foster parents, adopting parents, and people with contraindications

such as trauma, physical assault, or physiological barriers need individualized support to meet their infant feeding goals. While human milk is the most biologically normal food with complete nutrition for infants, formula can be a lifesaving resource for families. (CDC 2020 Breastfeeding Report Card)

The intent of the program is to avoid feeding infant formula as the default protocol, unless its medically needed, because it changes infant hunger cues and can hinder successful establishment of milk production. For the body to make milk, there is a positive feedback loop that requires the breast to be emptied which signals to make more milk. If the infant is eating something else, they will be too full to nurse and the breast won’t make more milk. The first 48 hours of an infant’s life have a critical window for bonding, nursing and establishing a strong milk supply because the frequent nursing establishes a neural pathway in the body to produce milk.

Additionally, the program aims to support parents who aren’t lactating with feeding their infant in a way that offers the health benefits that exclusive breast/chestfeeding provides: skin-to-skin cuddling, rooming-in and attentive paced bottle feeding to avoid over-feeding. Families who desire a combination of feeding methods will be supported with how to maintain milk supply and use formula. The LIFE program focuses on preventing barriers to parents who want to nurse their infants while encompassing a diversity of needs within the Ten Steps.

Are infants who need the NICU included in the LIFE program?

The LIFE program excludes infants who have documented medical contraindications to breast/chestfeeding, including infants in the Neonatal Intensive Care Unit (NICU).

What is the Center of Excellence for Perinatal Substance Use Certification program?

The program encompasses 8 criteria and has resources to support hospitals who want to reach a higher level of patient-centered and trauma-informed perinatal care. Visit the Centers of Excellence for Perinatal Substance Use webpage to learn more.

Why are infants with signs of neonatal abstinence syndrome included in rooming-in, skin-to-skin, and the promotion of breast/chestfeeding?

Non-pharmacological interventions, such as promoting breastfeeding, chestfeeding, rooming in, or skin-to-skin, is the first line of treatment for withdrawal symptoms in infants. There is strong research that shows non-pharmacological interventions reduce the length of time at the hospital recovering and improve birth outcomes when the parent and baby can stay together. Judging people for their emotional coping skills is not in the medical scope of a perinatal care support team.

Learn more about non-pharmacological interventions as the first line of treatment:

• AWHONN Breastfeeding Recommendations for Women Who Receive Medication- Assisted Treatment for Opioid Use Disorders (PDF)
• Eating, Sleeping, Consoling Instruction Manual (PDF)
• California Health Care Foundation Webinar, Matthew Grossman Eat/Sleep/Console

The Center of Excellence for Perinatal Substance Use Certification is a program of the Department of Health that focuses on maternal behavioral health care treatment and aligns with the LIFE program.

Literature for further reading

McGlothen KS, Cleveland LM. The Right to Mother’s Milk: A Call for Social Justice That Encourages Breastfeeding for Women Receiving Medication-Assisted Treatment for Opioid Use Disorder. J Hum Lact. 2018;34(4):799-803. doi:10.1177/0890334418789401

Cook KJ, Larson KL. Breastfeeding Decision-Making in an Addiction Trajectory: An Exploratory Grounded Theory Study. Res Theory Nurs Pract. 2020;34(4):371-388. doi:10.1891/RTNP-D-20-00004

Demirci JR, Bogen DL, Klionsky Y. Breastfeeding and Methadone Therapy: The Maternal Experience. Subst Abus. 2015;36(2):203-208. doi:10.1080/08897077.2014.902417

Howard MB, Wachman E, Levesque EM, Schiff DM, Kistin CJ, Parker MG. The Joys and Frustrations of Breastfeeding and Rooming-In Among Mothers With Opioid Use Disorder: A Qualitative Study. Hosp Pediatr. 2018;8(12):761-768. doi:10.1542/hpeds.2018-0116

MacVicar S, Humphrey T, Forbes-McKay KE. Breastfeeding support and opiate dependence: A think aloud study. Midwifery. 2017;50:239-245. doi:10.1016/j.midw.2017.04.013