Tools & Resources
Useful Tools and Resources to help you implement The Ten Steps:
Resources For Implementing Step 1:
STEP 1: Have a written breastfeeding policy that is routinely communicated to all health care staff.
All policies or protocols related to breastfeeding and infant feeding should be based on current evidence-based standards. Facilities can use the following model policies as a guide.
Below are links to model hospital breastfeeding policies, protocols and helpful toolkits:
- Academy of Breastfeeding Medicine (ABM)
- American Academy of Pediatrics
- California Model Hospital Policy Toolkit
- California Perinatal Quality Care Collaborative
- Illinois Hospital Breastfeeding Toolkit
- National Institute for Children’s Healthcare Quality (NICHQ)
- New York State Model Hospital Breastfeeding Policy
- Texas Ten Step Star Achiever Toolkit
Below are links to workplace lactation/breastfeeding support model policies and resources:
Resources For Implementing Step 2:
STEP 2: Train all health care staff in the skills necessary to implement this policy.
Education guidelines of the Baby-Friendly Hospital Initiative 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.
The Gift Program has made the innovative online and offline Coffective Training available to participating hospitals and also sponsors community trainings for Louisiana birthing facilities and community partners. These trainings count towards the training requirements for Gift designation.
Below are links to other online training/education:
- Academy of Breastfeeding Medicine Podcasts
- Breastfeeding Friendly Consortium
- Gold Lactation Online Conference
- Health e-learning
- International Lactation Consultant Association Continuing Education
- Jones and Bartlett Education Software
- Lactation Education Resources
- Northeastern University’s “Expanding Pediatricians Roles in Breastfeeding Support: An Online Tutorial“
- Stanford University
- Step 2 Education
Below are links to other toolkits and offline training tools:
- American Academy of Pediatrics: Breastfeeding Residency Curriculum
- American Academy of Pediatrics: Breastfeeding Support and Promotion Speaker’s Kit
- Baby-Friendly Hospital Initiative 20-Hour Course for Maternity Staff Curriculum
- Birth and Beyond California-Hospital Breastfeeding Quality Improvement and Staff Training Demonstration Project
- Educating Physicians In their Communities (EPIC) – Breastfeeding Education, Support and Training (BEST)
- Healthy Children Project, Inc. Center for Breastfeeding
- “Skin to Skin in the First Hour After Birth: Practical Advice for Staff after Vaginal and Cesarean Birth”
- USBC Core Competencies in Breastfeeding Care and Services for All Health Professionals
- Wellstart International
Resources For Implementing Step 3:
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.
The Gift has made the Coffective System of Tools available to participating hospitals. These tools help hospitals deliver consistent evidence-based information about breastfeeding and maternity care practices, as well as facilitate continuity of care.
Below are links to additional patient-related resources for providers on breastfeeding:
- ABM Protocol #19: Breastfeeding Promotion in the Prenatal Setting
- AAP: Position Statement on Breastfeeding and Use of Human Milk
Below are links to patient education resources on breastfeeding:
Resources For Implementing Step 4:
STEP 4: Help mothers initiate breastfeeding within one hour of birth.
Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour and encourage mothers to recognize when their babies are ready to breastfeed, offering help if needed.
Below are links to resources on skin-to-skin care and breastfeeding initiation:
- AAP: Position Statement on Breastfeeding and Use of Human Milk
- Improve Skin-to-skin Care and Breastfeeding Rates (Breastfeeding Medicine, volume7, number 2, 2012. DOI:10.1089/bfm.2011.0040)
- Loma Linda University S.O.F.T. Campaign: The Magical Hour
- UL Center for Women and Infants Kangaroo Care Program
Breast Crawl videos of newborns crawling to the breast for their first feeding (YouTube):
Resources For Implementing Step 5:
STEP 5: Show mothers how to breastfeed and how to maintain lactation, even if they are 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 infant formula for the non-breastfeeding mother; and signs of satiety and output are topics for breastfeeding reinforcement.
Below are links to resources to assist staff with showing mothers how to breastfeed and maintain lactation:
- 2011 Best Practice for Expressing, Storing and Handling Human Milk in Hospitals, Homes, and Child Care Settings.© HMBANA. 3rd Edition 2011.
- Academy of Breastfeeding Medicine Policies: Model Hospital Policy and Human Milk Storage
- HMBANA: Lactation Support for the Bereaved Mother
- Massachusetts Breastfeeding Coalition: Handouts for Parents
- Softening and Expressing Animated Demonstration
- Stanford University: Hands on Pumping video
- Why hand expression in the first 3 days is important
- WHO: How to Prepare Formula for Bottle-Feeding at Home
- WIC Publication: Making Every Ounce Count: How to Give the Best When Mom is Away (also available in Spanish)
Resources For Implementing Step 6:
STEP 6: Give infants no food or drink other than breast-milk, 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.
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.
Below are links to resources to help ensure infants only receive breast milk:
- ABM Clinical Protocol #3 Hospital Guidelines for the Use of Supplementary Feedings in the Healthy Term Breastfed Neonate
- Baby Friendly, USA: 2016 Guidelines and Criteria: Acceptable medical reasons for use of breastmilk substitutes, Appendix B
- Best Practices Guide for Implementation of Newborn Exclusive Breast Milk Feeding in Electronic Health Records (2014)
- Breastfeeding Support Contract
- Implementing the Joint Commission Perinatal Care Core Measure on Exclusive Breastmilk Feeding Toolkit
- Nurse Scripts for the Health Care Professional
- Texas Ten Step Program Sample Exclusive Breastmilk Audit Form
- Sample Consent for Supplementation
- WHO International Code of Marketing of Breastmilk Substitutes
Below are links to resources on breastmilk substitutes for patient and staff education:
Resources For Implementing Step 7:
STEP 7: Practice rooming in – 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. 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.
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.
Below are links to resources related to rooming-in:
- Louisiana SIDS Risk Reduction and Safe Sleep Campaign (Promote safe sleep in the hospital and at home)
- Volume and Frequency of Breastfeeding and Fat Content of Breastmilk Throughout the Day
Resources For Implementing Step 8:
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.
Below are patient education resources on cue based feeding:
Resources For Implementing Step 9:
STEP 9: Give no pacifiers or artificial nipples 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.
Below are resources to help staff with this step:
- AAP Policy Statement: SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment (Pertains to pacifier use.)
- ABM Clinical Protocol #3 Hospital Guidelines for the Use of Supplementary Feedings in the Healthy Term Breastfed Neonate (Additional Correction to Protocol #3)
- ABM Protocol #23 Non-Pharmacologic Management of Procedure-Related Pain in the Breastfeeding Infant
- Physiologic stability of newborns during cup and bottle feeding
- Rationale and resources about artificial nipple use in the breastfed baby
Below is a patient education resource:
Resources For Implementing Step 10:
STEP 10: Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center.
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.
Parents /new mothers should be referred to LABreastfeedingSupport.org to find local breastfeeding support. In addition, Louisiana hospitals can provide mothers with the hospital’s custom We’re Prepared Checklist. The back of the We’re Prepared Checklist provides numbers and websites to breastfeeding support services as well as WIC and home visiting.
Below are links to resources for the facility to use with patients:
- ABM Clinical Protocol #2 (2007 Revision): Guidelines for Hospital Discharge of the Breastfeeding Term Newborn and Mother: “The Going Home Protocol”
- Discharge Instructions and Guidelines in English and Spanish
- Baby Cafe, USA
- Black Mothers’ Breastfeeding Association
- Breastfeeding and Returning to Work (Handout for moms)
- Breastfeeding and Returning to Work (Handout for employers)
- Breastfeeding Beyond 6 Months (also available in Spanish)
- Dealing with breast edema and engorgement: Reverse Pressure Softening
- Indian Country Breastfeeds
- It’s Only Natural. Mother’s Love. Mother’s Milk.
- Infant Risk Center – A resource on using medications during pregnancy or breastfeeding
- Louisiana Breastfeeding Coalition
- LABreastfeedingSupport.org – Find local breastfeeding support
- Office on Women’s Health, U.S. Department of Health and Human Services Breastfeeding Resources
- Signs Baby is Getting Enough Milk
- Reaching Our Sisters Everywhere (ROSE)
Below are resources on milk banking:
- Human Milk Banking Association of North America
- HMBANA Milk Bank Locations
- Mothers’ Milk Bank of Louisiana at Ochsner Baptist
Below are links to patient breastfeeding support resources:
Other Resources and General Information:
Baby-Friendly Hospital Initiative Resources
- Baby-Friendly USA, Inc. – The accrediting body and the national authority for the Baby-Friendly Hospital Initiative in the United States. In this capacity, BFUSA is responsible for coordinating and conducting all of the activities necessary to confer the Baby-Friendly designation.
- “Working Toward Baby-Friendly: Improving Breastfeeding Support in US Hospitals” – A video by NICHQ presents the stories of four hospitals as they journey toward Baby-Friendly status.
- The Evidence for the Ten Steps – A detailed analysis of the evidence supporting the ten steps to successful breastfeeding.
Perinatal/Lactation Consultant Staffing Recommendations
- USLCA/ILCA – IBCLC Staffing Statement.
Medications and Breastfeeding
- American Academy of Pediatrics: The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected Topics
- Drugs and Lactation Database (LactMed) (also available for mobile devices)
- Infant Risk Center: A resource on using medications during pregnancy or breastfeeding
- Medications and Mothers’ Milk
- Nonprescription Drugs for the Breastfeeding Mother
Content on this page was adapted from the Texas Ten Step Program.