The Baby-Friendly Hospital Initiative (BFHI) Baby-Friendly USA Guidelines and Evaluation Criteria 2016 v.2 (GEC) was used to provide a brief outline the GEC.

Hospitals planning to obtain Baby-Friendly designation should adhere to the GEC.

GEC is available to download from the Baby-Friendly USA website.

Georgia 5-STAR Ten Steps to Excellence is based on the B-F Ten Steps.

Georgia 5-STAR Ten Steps to Excellence uses more inclusive language of ‘all infants’ where appropriate as well as support for mother’s informed decision and choice.

a.                      Breast milk should be the standard for infant feeding unless, after giving birth and being offered help to breastfeed, the mother has specifically stated she has no plans to breastfeed.

b.                      Policy should address implementation of Steps 2 – 10 and the International Code of Marketing of Breast milk Substitutes (WHO Code).

c.                       Policy is readily available to all staff.

d.                      The Ten Steps to Successful Breastfeeding (Ten Steps) and statement showing adherence to WHO Code related to the purchase of breast milk substitutes, bottles, nipples, pacifiers are prominently displayed in all areas that serve mothers, infants and young children.

a.       Same as B-F.

b.       Policy should include Steps 2 – 10. There should be a statement regarding the use of WHO Code compliant education materials for prenatal and postnatal, formula gift bags are not provided to any patient regardless of feeding intent.

c.       Same as B-F.

d.       Either the 5-STAR Ten Steps to Excellence or Ten Steps to Successful Breastfeeding are prominently displayed

i.Special Note: hospitals planning to seek B-F designation should use B-F Ten Steps and include WHO Code compliance statement as well as the purchase of formula, bottles, nipples, etc.

a.                      A designated healthcare professional should be responsible for implementing competency-based training for breastfeeding and formula feeding/formula preparation for all healthcare staff caring for mothers, infants and young children. Training may differentiate the competency level required/ needed based on staff function. Training should be completed within 6 months of hire.

i.    Maternity nursing staff – total of 20-hours: 15 sessions identified by UNICEF/WHO and 5-hours supervised clinical experience.

ii.    Healthcare providers – minimum of 3-hours with topics identified in the Guidelines.

iii.    Hospitals should determine the amount and content of training required for other staff and their anticipated contact with mothers and infants (examples include hospital staff in other units, patient care techs/nursing assistants, social worker, discharge planner, anesthesiologist, radiology, dietary, housekeeping, pharmacist).

b.                      A copy of curricula or course outlines for competency-based training in breastfeeding and lactation management will be available for review covering Steps 3 – 10.

c.                      A master list of staff should be kept with name, date of hire, date of competency completion and available.

d.                      Employee files should contain proof of competency.

2.       Train all healthcare staff in skills to support the infant feeding policy

a.A designated Maternity Leader/Team should be responsible for implementing a competency-based training for all healthcare staff regarding all infant feeding choices. Training should be completed within 6 months of signing Georgia 5-Star letter of intent or within 6 months of hire for new employees.

        i.      Maternity staff (Labor & Delivery, Mother-Baby, Nursery) – same as B-F.

      ii.      Obstetric and pediatric healthcare providers including mid-levels – same as B-F.

b.       Same as B-F

c. Same as B-F

d.       Same as B-F

a.                      With affiliated prenatal services.

i.    Individual or group breastfeeding education provided to all pregnant women.

ii.    Education includes importance of exclusive breastfeeding, nonpharmacological pain relief, early skin-to-skin contact, early initiation of breastfeeding, rooming-in, feeding on demand, frequent feeding for optimal milk supply, positioning and attachment, exclusive breastfeeding for 6 months and continued breastfeeding with introduction of solid foods at 6 months.

b.                      Without affiliated prenatal services

i.    Foster development or coordinate services with programs to make breastfeeding education available to pregnant women with coordinated messages about breastfeeding.

ii.    Prenatal education includes importance of exclusive breastfeeding, nonpharmacological pain relief, early skin-to-skin contact, early initiation of breastfeeding, rooming-in, feeding on demand, frequent feeding for optimal milk supply, positioning and attachment, exclusive breastfeeding for 6 months and continued breastfeeding with introduction of solid foods at 6 months.

a. and b. – same as B-F.

Note: GEC includes a new interpretation of Step 4

a.                      Vaginal birth – all mothers are given their infant to hold with uninterrupted and continuous skin-to-skin immediately after birth and until the first breastfeeding is completed or at least 60 minutes if not breastfeeding. (Unless there is documented medical indication for delay or interruption). Breastfeeding mothers are offered help with breastfeeding. Routine procedures should be done skin-to-skin. Procedures requiring separation should be delayed until skin-to-skin is completed.

b.                      Cesarean birth – mother and infant should be placed in skin-to-skin contact as soon as mother is responsive and alert with the same support identified above.

c.                       Skin-to-skin should be encouraged throughout the hospital stay.

d.                      If mother and infant are separated for documented medical reasons, skin-to-skin should be initiated as soon as mother and infant are reunited.

e.                      SCN / NICU admission – mother should be given the opportunity to provide skin-to-skin care as soon as the infant is considered ready.

i.Using good communication skills, determine mother’s feeding intent after labor and delivery admission and before birth providing evidence-based education as appropriate and document education and mother’s feeding intent in the MR.

ii.B-F a. – e. – same for Georgia 5-Star.

a.                      Staff should assess mother’s breastfeeding techniques and, if needed, demonstrate appropriate positioning and latch, optimally within 3 hours of birth and no later than 6 hours of birth. Prior to discharge breastfeeding education: importance of exclusive breastfeeding, how to maintain exclusive breastfeeding for about 6 months, assess infant getting enough breast milk, how to express, handle and store breast milk, how to sustain lactation if mother is separated form infant or will not be exclusively breastfeeding after discharge.

b.                      Individualized assistance should be provided to high risk and special needs mothers and infants who are separated. Breast milk expression is initiated as soon as possible, but no later than 6 hours after birth. Expressed breast milk is given to infant as soon as infant is medically ready.

c.                       Mothers who feed formula should receive verbal instruction and written instruction (non-brand specific) about safe preparation, handling, storage and feeding of infant formula.

a. – c. same as B-F.

a.                      Exclusive breast milk feeding shall be is expected feeding method from birth to discharge.

b.                      Hospitals should track rate of formula supplementation of breastfed infants; the rate of supplementation for nonmedical reasons should be analyzed and compared to CDC data for hospitals geographic region; year-by-year reduction in nonmedical supplementation is expected in B-F designated facilities.

c.                       Formula feeding or breastfeeding mothers requesting formula, staff should discuss her reasons for request, address concerns raised, educate on possible consequences to health of her infant and impact on successful breastfeeding.

i.    Formula feeding – if mother continues to request formula feeding, request is granted and documented in medical record (MR).

ii.    Breastfeeding requesting formula – should only be for medically indicated reasons and requires a written medical order.

1. Parental request: staff should explore reason for request and possible negative consequence on breastfeeding with MR documentation and other feeding options are discussed.

a. Exclusive breastfeeding is encouraged for mothers choosing to breastfeed.

i.Exclusive breastfeeding rates should be tracked and compared to geographic region and an increase in exclusive breastfeeding rate year-by-year is expected.

b. Formula feeding infants – confirm mother’s feeding intent using good communication skills and probe for any additional questions or concerns mother may have and document in MR.

c. Breastfeeding mothers requesting formula – explore reason for request, provide evidence-based education on the impact of formula feeding on breastfeeding, offer other feeding options and document in MR.

d. Medically indicated supplementation should be discussed with option of mother’s own milk, donor breast milk (if available) or formula with documentation in MR.

a.                      Rooming-in 24 hours a day should be the standard for mother baby care regardless of feeding choice.

b.                      When mother requests for infant to cared for in nursery, staff should explore her reasons and should encourage and educate mother about the advantages of having infant with her 24 hours per day.

c.                       If mother still requests infant to be cared for in nursery, informed decision should be documented.

d.                      Medical and nursing staff should perform routine care and exams in the mother’s room and should avoid frequent separations; separation if required should be less than 1-hour.

e.                      If infant is separated for medical reasons, mother should be provided access to feed her infant at any time.

a. Same

b. When a mother requests her infant be cared for in nursery, staff should explore her reason and provide appropriate support, encouragement and education.

c. Mothers who desire their infant be cared for in the nursery should be supported; the mother and nurse should discuss a plan for feeding if the breastfeeding infant shows hunger cues.

d. Same

e. Same

a.                      Help all mothers, regardless of feeding choice, 1. understand there should be no restrictions on frequency or length of feeding, 2. understand newborns usually feed at least 8 times in 24 hours, 3. recognize cues infants use to signal readiness to begin and end feeding, 4. understand physical contact is important along with nourishment.

a. Same

a.                      Bottle and artificial nipples

i.    Breastfeeding mothers should be educated on how the use of bottles and artificial nipples may interfere with optimal breastfeeding.

ii.    When breastfeeding mother requests a bottle, staff should explore reasons for request, address concerns, educate on possible consequences to breastfeeding success and discuss alternate methods of feeding and soothing her infant.

iii.    Supplementation (medically indicated or mother’s choice) should be given by tube, syringe, spoon or cup in preference to artificial nipple/bottle.

b.                      Pacifiers

i.    Breastfeeding mothers should be educated on how use of pacifiers may interfere with development of optimal breastfeeding.

ii.    Breastfeeding infants should not be given pacifiers except for limited use for painful procedures in the event infant cannot be held or breastfed during procedure. Pacifiers should be discarded after use.

iii.    When breastfeeding mother requests a pacifier (or has her own), staff should explore reasons for request, address concerns, educate on possible consequences to breastfeeding success and discuss alternate methods to soothe her infant.

a. Bottle and artificial nipples

Same as i., ii., iii.

iv.If mother chooses to use a bottle or nipple, she should be taught how to ‘mimic breastfeeding’ using paced bottle-feeding technique.

c. Pacifiers – same.

d. Breastfeeding mothers should be educated on:

i.American Academy of Pediatrics (AAP) guidelines on pacifier use with breastfeeding infants.

ii.When to introduce bottles with breast milk if mother plans to use bottles.

a.                      Staff should explore with mother (and support person) plans for infant feeding after discharge.

b.                      Discussion should include importance of exclusive breastfeeding for 6 months, available and culturally specific breastfeeding support services without ties to commercial interests.

c.                       Schedule an early post-discharge follow-up appointment with a healthcare provider.

d.                      The hospital or birth center should establish in-house breastfeeding support services if no adequate source of support is available for referral.

a. Same.

b. Discussion should include the importance of Breastfeeding and breast milk feeding for 6 months.

c. Same.

d. Provide written list of breastfeeding support services (free of commercial interests); if there are no adequate support resources available, the hospital is encouraged to establish in-house breastfeeding support.

a.                      Hospital/birth centers must demonstrate compliance with the WHO Code by refusing to accept supplies of breast milk substitutes (formula) and feeding supplies at no cost or below fair market value cost.

b.                      Mothers must be protected from the influence of breast milk substitutes and feeding supply vendors; mothers are not given marketing ‘patient education materials,’ samples or gift packs.

c.                      Staff are also to be protected from breast milk substitutes and feeding supply vendors; staff do not receive free gifts, money, breastfeeding education or events from manufacturers or distributors of breast milk substitutes, nipples, bottles, pacifiers or other infant feeding supplies.

d.                      Staff will be educated on the WHO Code and its role in ethical healthcare practices.

e.                      Records and receipts indicate breast milk substitutes, bottles, nipples, pacifiers and other infant feeding devices are purchased at fair market value price.

f.                       Public areas are free of materials that promote or show breast milk substitutes, etc.

g.                      Infant formula is kept out of view of patients and general public.

a. Hospital/birth centers demonstrate WHO Code compliance by:

i.All (prenatal and postpartum) patient education materials are free from formula, bottles, nipples, and pacifiers advertising.

ii.All patient education materials do not contain formula feeding/preparation education.

iii.Mothers are not given formula samples or gift packs.

iv.Formula or infant feeding supply vendors are not allowed access to provide gifts, education or meals to staff.

v.Staff are educated on the WHO Code and role in ethical healthcare practices.

vi.Public areas are free of materials that promote or show formula, pacifiers and other infant feeding devices.

vii.Infant formula is kept out of the view of patients and general public.

Hospitals receive designation once all 10 Steps have been successfully implemented and

1.                      Enter the 4-D Pathway: each D has multiple tasks to be completed before moving to the next D: hospitals can expect up to one year to move through each of the remaining Ds (D2 – D3 – D4).

D1 – Discovery

D2 – Development*

D3-Dissemination*

D4 – Designation* (plus travel expenses for 2 B-F surveyors)

2. Baby-Friendly Designation – 5 years

Years 1*, 2* and 3*: annual QI project

Years 4* and 5*: 2-year redesignation project with year 5 on-site re-survey

For more information on Baby-Friendly designation process see: https://www.babyfriendlyusa.org/for-facilities/de

signation-process

One star is awarded for every 2 steps implemented.

The number of stars earned is determined by the

hospital.

Georgia 5-STAR plaques are awarded once 3 stars are earned.

Georgia 5-STAR Support

o No fees

o Staff training at no cost

o Mock assessment at no cost

Hospital Responsibility / Requirements

1. Letter of intent signed by CEO.

2. Hospital assembles a Georgia 5-Star team and reports team members with contact information to DPH.

3. Conference call meeting with Georgia 5-Star program manager and technical advisor.

4. Complete Step 2 – staff training.

5. Implement staff interviews following completion of staff training.

6. Implement steps desired using Plan-Do-Study-Act (PDSA) model of change.

7. After PDSAs are completed and step is implemented, begin patient interviews.

8. Continuing patient interviews and record results monthly.

9. Once hospital has achieved scores of at least 80% for 6 months, submit results to Georgia 5-STAR for review.

10. Report exclusive breastfeeding rates on a quarte

rly basis.