The following links to resources are intended as a guide to overcoming barriers to implementation of the Ten Steps to Successful Breastfeeding. Every facility has obstacles to achieving full implementation of the Ten Steps, with the level of readiness for each facility varying around the state. The resources are listed under the step it helps to fulfill. If you are in a facility that has developed a resource that you would like to share with others, please e-mail it to email@example.com
Step 1: Have a written breastfeeding policy that is routinely communicated to all health-care staff.
Model policies are available to assist facilities in developing maternity service policy that includes supportive breastfeeding practices. Facilities can use the model policies as a guide.
- Texas Ten Step Star Achiever Toolkit- step by step implementation guidelines for the Ten Steps to Successful Breastfeeding
- Academy of Breastfeeding Medicine (ABM) Offers a model hospital policy and protocols on a variety of topics such as supplementation, going home/discharge, hypoglycemia, analgesia and anesthesia for the breastfeeding mother, and others.
- New York State Model Hospital Breastfeeding policy
- California Model Hospital Policy toolkit
- Business Case for Breastfeeding Model policy for worksite lactation support
- Illinois Hospital Breastfeeding Toolkit
- Kaiser Permanente Breastfeeding Toolkit
Step 2: Train all health-care staff in the skills necessary to implement this policy.
The Texas Ten Step (TTS) program is guided by the Baby-Friendly hospital (BFHI) designation’s education recommendations. Education guidelines of BFHI should be followed when facilities are developing breastfeeding education for staff. The following documents and resources can be used as a guide to develop breastfeeding training for staff.
- Texas Health Steps - Offers free CE’s through online training modules. Check out the NEW! Ten Steps to Successful Breastfeeding or the general Breastfeeding modules (1.5 CE each).
- The AAP Breastfeeding Residency curriculum
- The Community Health Training Institute provides two online 1.5 hour tutorials, which together provide 3 hours of breastfeeding education that is aligned with the content expected for physicians providing care in Baby-Friendly Hospital facilities.
- Breastfeeding Friendly Consortium- Utilized by hospitals to fulfill the staff education requirements for Baby Friendly, USA; provides CE credits. (for purchase)
- Jones and Bartlett education software for purchase
- Stanford University – includes video demonstrations and resources: http://newborns.stanford.edu/Breastfeeding/MaxProduction.html
- Wellstart International - Free breastfeeding modules for physicians and nurses
- Breastfeeding Resource Materials - Breastfeeding information and educational resources for lactation professionals and patient education
- Step 2 Education- offers an online staff education program to Hospitals and Health Groups requiring staff education for Baby Friendly accreditation or reaccreditation
- Lactation Education Resources- online training for the Baby Friendly Hospital Initiative
- Health e-learning- Accredited courses on breastfeeding
- UC San Diego/ Extension- Baby Friendly Hospital initiative training
- Evergreen Perinatal-Excellence in Care with the Ten Steps (online training)
- Baby Friendly USA’s Q&A on Step 2 Training- (click on link within the FAQ bulleted list)
- ACOG Breastfeeding Toolkit for Healthcare Providers, 2016
- AAP Breastfeeding Initiatives- archived breastfeeding webinars and more!
- Maryland Hospital Policy Committee- This series of six recorded lectures contains insight on important strategies and practices related to promoting and supporting breastfeeding. Continuing Medical Education credits are available at no charge through June 2019 and were designed to help physicians and advanced care providers meet BFHI step 2 training requirements.
- Step 2 BFHI Training- These instructional modules were developed as a collaboration between the Maryland Department of Health and the University of Maryland Upper Chesapeake Medical Center, under the guidance of the Maryland Department of Health Hospital Breastfeeding Policy Committee. These modules were developed to meet the requirements outlined in Step 2 of the Ten Steps to Successful Breastfeeding, developed by UNICEF/WHO.
- The Breastfeeding University Developed through the Carolina Global Breastfeeding Institute (CGBI) by an interdisciplinary team of physicians, nurses, lactation consultants, public health professionals, educators and La Leche League leaders, these trainings will help learners to establish a working knowledge of the importance of breastfeeding and how to support mothers and families to meet their breastfeeding goals.
- CHAMPS/CHEER Breastfeeding- courtesy of this initiative, free webinars on many important BFHI topics and the Ten Steps.
Texas DSHS – “Trained” Breastfeeding Educator Program
Birthing facilities often face challenges when staffing for onsite breastfeeding support. For some, the challenge is a lack of IBCLCs in the area. For others, providing a full- or part-time position for an IBCLC, or including weekend- or night-shift lactation support, are obstacles. The Breastfeeding Educator Program gives a staff member an opportunity to become qualified as a breastfeeding support resource person. Interested staff can attend the two separate 2-day DSHS courses and use this designation for five years.
What is a DSHS-Trained Breastfeeding Educator (TBE)?
- A Trained Breastfeeding Educator earns a certificate stating they have successfully completed the courses, Principles of Lactation Management (POLM) and Lactation Counseling and Problem Solving (LCAPS). TBEs can answer basic breastfeeding questions on such topics as anatomy of the breast, evaluate and assist moms with latch-on, and identify successful breastfeeding.
How do I sign up for the classes to become a Trained Breastfeeding Educator?
- To register for the classes, please visit the registration page.
Is there a fee or test to become a Trained Breastfeeding Educator?
- There is a $60 registration fee for each class but no other cost to receive a TBE certificate. There is no test.
What does the TBE designation allow me to do?
- Having the TBE designation means you are knowledgeable about lactation and able to assist with basic breastfeeding education. Complex breastfeeding issues are not within this scope of practice, and referrals should be made to a health-care provider or an International Board Certified Lactation Consultant (IBCLC) for further evaluation and treatment.
- In some cases, this designation may help you to initiate a lactation program in your facility.
- Courses follow the IBLCE Exam Blueprint and may help you further your education in becoming an IBCLC.
Does my TBE certificate expire?
- Yes. The TBE certificate will expire five (5) years from the date you completed the POLM course.
- We encourage you to seek additional education and possibly pursue IBCLC certification within this five-year period. Our courses do not provide all of the education requirements to sit for the exam. See what is required to sit for the IBLCE exam.
Step 3: Inform all pregnant women about the benefits and management of breastfeeding.
This step assures that consistent prenatal breastfeeding messages are included in all aspects of prenatal care. Facilities are encouraged to provide prenatal breastfeeding education courses and work with their prenatal health-care providers to recommend attendance in these community classes. Local WIC agencies and other community breastfeeding resource organizations can be invited to provide education if the facility has limited staff.
Prenatal education topics that should be covered include: the benefits of breastfeeding, the importance of exclusive breastfeeding, basics of breastfeeding management, possible effect of analgesia/ anesthesia on infant behavior, rationale for care practices such as skin-to-skin contact, rooming-in, and infant feeding cues. All materials and education should be presented without messages promoting artificial feeding or sponsorship.
- DSHS provider support poster
- AAP position statement on breastfeeding and use of human milk
- BreastMilkCounts.com: The provided five activities give mothers the knowledge they need to understand the benefits of exclusively breastfeeding and ensure that breastfeeding is comfortable and enjoyable for both mom and baby.
- ABM Protocol #19- Breastfeeding Promotion in the Prenatal Setting
- The First Step Discusses the importance of exclusive breastfeeding and how choosing a Texas Ten Step hospital benefits both mom and baby.
- Breastfeeding Mother’s Bill of Rights Developed by NY State- provides prenatal education training for staff and community.
- The Joint Commission’s Speak Up Series Urges mothers to exercise their right to breastfeed.
- The Hospital Experience (Spanish) Anticipatory guidance by DSHS WIC on what to expect when having your baby.
- The Breastfeeding Guide (Spanish) Designed to educate moms on the basics of breastfeeding and how to get off to a good start.
- Carolina Global Breastfeeding Institute- Ready, Set, Baby! Free, online prenatal education resources and implementation guide. Also available in Spanish.
Step 4: Help mothers initiate breastfeeding within an hour of birth. Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour. Encourage mothers to recognize when their babies are ready to breastfeed and offer help if needed.
- AAP Position Statement - Breastfeeding and the Use of Human Milk for reference in delayed procedures.
- California WIC-Baby Behavior Campaign - Health-care providers can learn the importance of teaching parents about infant feeding cues, crying, and sleep.
- AWHONN Perinatal Staffing guidelines - Endorsed by ILCA, these guidelines help ensure proper staff-to-patient ratios.
- USLCA/ILCA - IBCLC Staffing Statement
- Improve Skin-to-skin Care and Breastfeeding Rates (Breastfeeding Medicine, volume7, number 2, 2012. DOI:10.1089/bfm.2011.0040) Skin to Skin research-Study by Jeannette Crenshaw and Karin Cadwell
- The Magical Hour - DVD covers the 9 Normal Stages that infants undergo while in skin-to-skin contact.
Step 5: Shows mothers how to breastfeed and how to maintain lactation, even if they should become separated from their infants.
A mother should be assessed within six hours after her delivery and once per shift throughout her stay. Infant feeding cues; correct latch and position; hand-expression and pumping; safe preparation, handling, and storage of formula for the non-breastfeeding mother; and signs of satiety and output are topics for breastfeeding reinforcement.
- Softening and Expressing animated demonstration.
- Dr. Jane Morton and Standford University- Getting Started with Breastfeeding (videos and other helpful resources)
- Texas WIC Breastmilk Storage Guidelines (pdf download)
- How to Prepare Formula for Bottle-Feeding at Home -WHO Publication
- Texas WIC- How Do I Mix My Baby’s Formula? (Spanish)
- Core Competencies in Breastfeeding Care and Services for All Health Professionals -USBC- These core competencies in breastfeeding care and services were developed to provide health professionals with a guideline and framework to integrate evidence-based breastfeeding knowledge, skills, and attitudes into their standard health care delivery practices.
- Your Baby Needs You: Pumping for Your Premature Infant (English/Spanish available) – for DVD. E-mail WICMaterials@dshs.state.tx.us for purchase at cost that can be used for staff and patient education.
- WIC Publication: Making Every Ounce Count: How to Give the Best When Mom is Away (Spanish)- information on how to bottle feed a breast fed baby
Step 6: Give infants no food or drink other than breastmilk unless medically indicated.
Healthy babies should not be routinely supplemented with any food or drink other than human milk unless medical indications for supplementation exist. In addition, parents should be protected from the marketing of breastmilk substitutes.
- ABM Clinical Protocol #3 Hospital Guidelines for the Use of Supplementary Feedings in the Healthy Term Breastfed Neonate (Correction to Protocol #3)
- Implementing the Joint Commission Perinatal Care Core Measure on Exclusive Breastmilk Feeding- USBC Toolkit
- 2010 Guidelines and Criteria- Baby Friendly, USA. Acceptable medical reasons for use of breastmilk substitutes, Appendix B.
- WHO International Code of Marketing of Breastmilk Substitutes
- TTS- Sample Exclusive Breastmilk Audit Form
- Breastfeeding Support Contract Display your facility’s commitment to staff.
- Nurse Scripts for the health care professional- Scripting to aid health-care staff when assisting mothers with breastfeeding challenges.
For mothers who have made the informed decision to provide breastmilk substitutes for their infants, separate education should be provided to them which discusses the risks of using this form of supplementation, how to properly prepare/ bottle feed their infant and newborn stomach capacity.
- UNICEF, UK- A Guide to Infant Formula for Parents that are Bottle Feeding- provides parents an overview of information on the difference between formula types
- UNICEF, UK- The Health Professionals Guide to: “A Guide to Infant Formula for Parent’s that are Bottle Feeding“- assitance for the HCP how to teach parents to use the guide
- UNICEF, UK/ Baby Friendly Project- Guide to Bottle Feeding- provides parent education on how to safely prepare feeding equipment and powdered formula
- ILCA’s Risks of Not Breastfeeding-This publication puts at your fingertips the evidence-base demonstrating breastfeeding as the biologic norm, and a public health imperative. An easy-to-understand explanation of the latest relevant and credible research regarding breastfeeding and human lactation.
- LLL-Newborn Stomach Capacity- visual guide included
- LLL-Bottle Feeding a Breastfed Baby- great information for caregivers and parents on paced feeding
Step 7: Practice rooming-in to allow mothers and infants to remain together 24 hours a day.
Rooming-in should be practiced by all mothers regardless of feeding method to ensure that ample opportunities are available for skin-to-skin contact and early learning of infant feeding cues. A mother who requests to be separated from her infant should receive counseling on the importance and benefits to rooming-in, and staff should explore reasons for the request and provide solutions. Healthy mothers and infants should not be separated during their stay, with the exception of no more than one hour a day to allow for any medically necessary procedures that cannot be conducted at the bedside.
- Mother’s Nap time sign- (Spanish)
- ABM Protocol #6-Guideline to Co-sleeping and Breastfeeding
- Volume and Frequency of Breastfeeding and Fat Content of Breastmilk Throughout the Day - Pediatrics article
- Making the Right Amount of Milk- (Spanish)- DSHS publication
- Breastfeeding Guide (Spanish)- DSHS publication
Step 8: Encourage breastfeeding on demand. Teach mothers cue-based feeding regardless of feeding method.
Mothers and their families should be educated about infant feeding cues and normal infant transitional behavior. They should be supported and provided unlimited opportunities to respond to infant feeding cues.
- How Do I Know Breastfeeding is Going Well? (Spanish)- DSHS publication
- Feeding on Cue -LLL Publication
- Understanding Your Newborn Baby’s Behavior- California Baby Behavior Campaign
- UNICEF, UK- Feeding On Cue- video
Step 9: Give no artificial nipples or pacifiers to breastfeeding infants.
Health-care providers should not offer healthy breastfed infants pacifiers or artificial nipples. Supplementation, when required, should be offered using alternative measures such as a cup, tube or syringe.
- Physiologic stability of newborns during cup and bottle feeding -Pediatrics publication
- ABM Clinical Protocol #3 Hospital Guidelines for the Use of Supplementary Feedings in the Healthy Term Breastfed Neonate (Additional Correction to Protocol #3)
- AAP Policy Statement: SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment
- What Should I Know About Giving My Baby a Pacifier? -Kellymom.com
- ABM Protocol #23 Non-Pharmacologic Management of Procedure-Related Pain in the Breastfeeding Infant
Step 10: Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from hospital or clinic.
Discharge support and follow-up for breastfeeding mothers is imperative to their success in breastfeeding duration and exclusivity. Refer all mothers to the appropriate resources and be aware of the community resources available prior to discharge. Individual care plans should be developed by the health-care team to guide the mother to continued success and achievement of her goals.
- Texas Breastfeeding Coalition – nurses, physicians and lactation support staff can stay connected by joining their local state breastfeeding coalition. Learn more about community activities, legislative efforts and educational opportunities.
- Breastfeeding and Returning to Work (Spanish) DSHS publication
- WIC Peer Counselors – The Support Your Patients Need for Breastfeeding Success DSHS publication
- Breastfeeding Beyond 6 Months (Spanish) DSHS publication
- USDA Loving Support Peer Counselor Program- Learn how to develop a Peer Counselor Program for breastfeeding mothers in your facility
- Sample Community Resource List (doc)
WIC Lactation Support Centers – breastfeeding support for the WIC-enrolled breastfeeding mother.
**Health-care providers have access to breastfeeding management support via the Texas Lactation Support Hotline.
Baby Café – Mom-to-mom breastfeeding support located in drop-in cafés around Texas: