Gec 2016

The Baby-Friendly Hospital Initiative
Guidelines and
Evaluation Criteria
for Facilities Seeking

Baby-Friendly Designation
2016 revision
Baby-Friendly USA, Inc.

Title: Guidelines and Evaluation Criteria Revision date: 06/30/16
File name: GEC2016 Page 2 of 32
Copyright 2010, 2016 Baby-Friendly USA, Inc.
This document is an adaptation of the following documents:
 The UNICEF/WHO Global Criteria for the Baby-Friendly Hospital Initiative, developed in 1991
 The Guidelines & Evaluation Criteria for the U.S. Baby-Friendly Hospital Initiative, developed in
1996 by the United States Fund for UNICEF and Wellstart International
 The 2004 adaptation of the U.S. Guidelines & Evaluation Criteria for the U.S. Baby-Friendly
Hospital Initiative
 The 2006 UNICEF/WHO Global Criteria for the BFHI
 The 2010 adaptation of the U.S. Guidelines and Evaluation Criteria for Facilities Seeking Baby-
Friendly Designation
Suggested citation:
Baby-Friendly USA. “Guidelines and Evaluation Criteria for Facilities Seeking Baby-Friendly Designation.”
Albany, NY: Baby-Friendly USA, 2016.
© 2010, 2016 Baby-Friendly USA, Inc.
Baby-Friendly® (“Baby-Friendly”) is a registered certification mark owned by Baby-Friendly USA, Inc.

Acknowledgements
Grateful appreciation is extended to the following people for the update and review of this document:
Baby-Friendly USA (BFUSA) Program Committee members: Ann Brownlee, MA, PhD; Sarah
Coulter Danner, RN, MSN, CNM, CPNP; Lawrence M. Gartner, MD; Theresa Landau, MS, RD;
Ruth Lawrence, MD; Kathie Marinelli, MD, IBCLC, FABM, FAAP; Sallie Page-Goertz, RN, BSN, MN,
CPNP, IBCLC; Heather Suzette Swanson, DNP, CNM, FNP, IBCLC; Marsha Walker, RN, IBCLC
BFUSA Staff: Sarah Avellino, BS; Jillian Carter, BS, RN, IBCLC; Lora L. Elston, BSN, RNC-NIC, IBCLC;
Trish MacEnroe, BS, CDN, CLC; Jennifer Matranga, MS, BSN, RN, CCE, IBCLC; Elizabeth McIntosh
BA, BSN, RN, IBCLC; Christie Ziegler, BA
Recognition is also due to the contributors, authors, and editors of the 2004 and 2010 updates to the
Guidelines and Evaluation Criteria:
Karin Cadwell, PhD, RN, FAAN, ANLC, CLC, IBCLC; Cindy Turner-Maffei, MA, ALC, IBCLC
Finally, our deepest appreciation goes to the contributors and authors of the original U.S. Guidelines and
Evaluation Criteria:
U.S. Committee for UNICEF: Minda Lazarov
Wellstart International: Audrey Naylor, MD, DrPH; Ruth Wester, BA, RN; Ann Brownlee, MA,
PhD; Janine Schooley, MPH
UNICEF: Helen Armstrong, Paula Donovan, Lida Lhotska

Dedication
Audrey J. Naylor, MD, DrPH
Baby-Friendly USA, Inc. dedicates the 2016 edition of the Guidelines and Evaluation Criteria to Audrey J.
Naylor, MD, DrPH. Dr. Naylor was a visionary and passionate leader who devoted her career to
improving maternity care practices throughout the world to support breastfeeding and mother-baby
bonding. In 1985, she co-founded Wellstart International, a nonprofit organization established to
educate health care providers on the importance and management of optimal infant and young child
feeding. She was a driving force in both international and U.S. efforts to promote breastfeeding as the
normal way to feed infants and young children. She was a staunch advocate for the Baby-Friendly
Hospital Initiative, helping to shape both the Ten Steps to Successful Breastfeeding and the Initiative
itself.
Dr. Naylor was a founding member of the World Alliance of Breastfeeding Action, the United States
Breastfeeding Committee, the Academy of Breastfeeding Medicine, the Section on Breastfeeding of the
American Academy of Pediatrics and helped to launch the U.S. Baby-Friendly Hospital Initiative. She was
an experienced medical school educator and had been a member of several medical school faculties,
including Ohio State University College of Medicine, the University of Southern California School of
Medicine, The University of California San Diego School of Medicine and The University of Vermont
College of Medicine where she was a Clinical Professor of Pediatrics (voluntary, part-time).
Dr. Naylor passed away on June 23, 2016. The field of lactation has lost one of its greatest leaders. Her
legacy is substantial and will continue to live through our work.

Preamble to the U.S. Baby-Friendly

Guidelines and Evaluation Criteria
Human milk provided by direct breastfeeding is the normal way to feed an infant. There are very few
true contraindications to breastfeeding and scientific evidence overwhelmingly indicates that it is
nutritionally superior, offers substantial immunological and health benefits, facilitates mother-baby
bonding, and should be promoted and supported to ensure the best health for women and their
children. Breastfeeding is the single most powerful and well-documented preventative modality
available to health care providers to reduce the risk of common causes of infant morbidity. Significantly
lower rates of diarrhea, otitis media, lower respiratory tract infections, Type 1 and Type 2 diabetes,
childhood leukemia, necrotizing enterocolitis, and Sudden Infant Death Syndrome occur among those
who were breastfed.1 Women who breastfeed have a lower risk of Type 2 diabetes and breast and
ovarian cancers.2 Evidence suggests that reduction in the risk of cardiovascular and other related
diseases may be added to the benefits of breastfeeding for women.3 The American Academy of
Pediatrics, the American Congress of Obstetricians and Gynecologists, the Centers for Disease Control
and Prevention, and the World Health Organization all recommend exclusive breastfeeding for about 6
months and continued breastfeeding while adding complimentary foods for one year and beyond.
The U.S. Department of Health and Human Services has included breastfeeding among the national
Healthy People (HP) objectives since their inception for the year 1990. The HP20204 objectives state:
MICH-21.1 Increase the proportion of infants who are ever breastfed Target 81.9%
MICH-21.2 Increase the proportion of infants who are breastfed at 6 months Target 60.6%
MICH-21.3 Increase the proportion of infants who are breastfed at 1 year Target 34.1%
MICH-21.4 Increase the proportion of infants who are breastfed exclusively Target 46.2%
through 3 months
MICH-21.5 Increase the proportion of infants who are breastfed exclusively Target 25.5%
through 6 months
MICH-23 Reduce the proportion of breastfed newborns who receive Target 14.2%
formula supplementation within the first 2 days of life
MICH-24 Increase the proportion of live births that occur in facilities that Target 8.1%
provide recommended care for lactating mothers and their
babies
Despite the significant gains made during the past few years, the initiation, duration, and exclusivity of
breastfeeding continue to lag behind the national objectives, particularly among the most vulnerable
1
Stanley Ip, et al. “Breastfeeding and maternal and infant health outcomes in developed countries,” Evidence Report/Technology Assessment
NO. 153 (Prepared by Tufts-New England Medical Center Evidence-Based Practice Center, under Contract No. 290-02-0022), AHRQ Publication
No. 07-E007, (Rockville, MD: Agency for Healthcare Research and Quality, 2007).
2 Ibid.
3E. B. Schwarz, et al. “Duration of lactation and risk factors for maternal cardiovascular disease,” Obstetrics & Gynecology 113, 5 (2009): 974-
82.
4Healthy People 2020, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion Accessed June 21,
2016, https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health/objectives

populations of African American and low income women. In 2012, approximately 80% of all women
initiated breastfeeding; however, only 66% of non-Hispanic black women and 74% of women with
incomes below the poverty line initiated breastfeeding.5
While causes of this trend are multifactorial and complex, health care practices have been shown to play
a fundamental role in impacting breastfeeding initiation, exclusivity, and duration. Unsupportive
practices during the perinatal period can disrupt the unique and critical link between the prenatal
education and the community postpartum support provided after discharge from the birthing facility.
Conversely, supportive practices positively impact breastfeeding outcomes. The Ten Steps to Successful
Breastfeeding, which form the foundation of the Baby-Friendly Hospital Initiative, are a package of
evidence-based practices shown to improve breastfeeding outcomes. Studies have shown that the more
steps a mother reports experiencing, the more likely she is to meet her breastfeeding goals.6,7
Numerous government and professional organizations actively encourage a strong program of

information and support to promote the successful establishment and maintenance of breastfeeding,
including:
 Academy of Breastfeeding Medicine

 Academy of Nutrition and Dietetics
 American Academy of Family Physicians
 American Academy of Nursing
 American Academy of Pediatrics
 American College of Nurse-Midwives
 American Congress of Obstetricians and Gynecologists
 American Nurses Association
 American Public Health Association
 Association of Women’s Health, Obstetric and Neonatal Nurses
 Centers for Disease Control and Prevention
 National Academies of Science, Engineering and Medicine
 National WIC Association
 Office on Women’s Health – United States Department of Health and Human Services
 United States Breastfeeding Committee
 United States Preventive Services Task Force
 United States Surgeon General
The diverse benefits of breastfeeding translate into hundreds of dollars of savings at the family level and
billions of dollars at the national level through decreased hospitalizations and pediatric visits.
Researchers have estimated that were the national initiation and 6 months goals (above) to be met,
between 3.6 and 13 billion dollars would be saved on pediatric health care costs.8,9 Consequently,
5“Rates of Any and Exclusive Breastfeeding by Socio-demographics among Children Born in 2012,” National Immunization Survey, Centers for
Disease Control and Prevention, Department of Health and Human Services, Accessed June 21, 2016,
www.cdc.gov/breastfeeding/data/nis_data/rates-any-exclusive-bf-socio-dem-2012.htm
6 Ann M. DiGirolamo, Laurence M. Grummer-Strawn, Sara B. Fein, “Effect of maternity-care practices on breastfeeding,” Pediatrics 122, 2 (2008)
7Rafael Perez-Escamilla, Josefa L. Martinez and Sofia Segura-Perez, “Impact of the Baby-friendly Hospital Initiative on breastfeeding and child
health outcomes: a systematic review,” Maternal & Child Nutrition, doi: 10.1111/mcn.12294.
8Jon Weimer, “The Economic Benefits of Breastfeeding: A Review and Analysis,” ERS Food Assistance and Nutrition Research Report 13, (2001)

activities to promote the national objectives are clearly among the best and most cost-effective health
promotional strategies available.
The Baby-Friendly Hospital Initiative (BFHI) was established in 1991 by the United Nations Children’s
Fund (UNICEF) and the World Health Organization (WHO). The BFHI is a global program to encourage
and recognize birthing facilities that offer an optimal level of care for infant feeding and mother-baby
bonding. The core components of the BFHI are the UNICEF/WHO Ten Steps to Successful Breastfeeding,
which are designed to facilitate the role of the birthing facility in providing women the information, care
practices, and opportunity to breastfeed, regardless of the method of birth. More than 170 countries
have undertaken implementation of the Ten Steps to Successful Breastfeeding, resulting in the
designation of more than 20,000 birth facilities throughout both the developing and industrialized
world. The BFHI has been endorsed by hundreds of organizations worldwide.
In the United States, Wellstart International, in cooperation with the U.S. Fund for UNICEF, piloted the
development of tools for the assessment of the first U.S. Baby-Friendly hospitals, including the original
Guidelines and Evaluation Criteria, which provided the basic guidance for birthing facility
implementation of the program. In 1997, Baby-Friendly USA, Inc. was created at the request of the U.S.
Fund for UNICEF to administer the BFHI program in U.S. birthing facilities.
9M Bartick, A Reinhold, “The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis,” Pediatrics 125, 5 (2010): 1048-
56.

The Guidelines and Evaluation Criteria

for Hospital and Birthing Center Implementation
of the U.S. Baby-Friendly Hospital Initiative
The guidelines in this document describe the standard of care which facilities should strive to achieve for
all patients, while the accompanying criteria provide the specific quantifiable measures used by Baby-
Friendly USA (BFUSA) assessors to determine the birthing facility’s conformity with the BFHI.
The U.S. BFHI Guidelines and Evaluation Criteria and the assessment and accreditation processes are
predicated on the following tenets:
1. Well-constructed, comprehensive policies effectively guide staff to deliver evidence-based care.

2. Well-trained staff provide current, evidence-based care.
3. Monitoring of practice is required to assure adherence to policy.
4. Breastfeeding has been recognized by scientific authorities as the optimal method of infant
feeding and should be promoted as the norm within all maternal and child health care facilities.
5. The most sound and effective procedural approaches to supporting breastfeeding and human
lactation in the birthing environment that have been documented in the scientific literature to
date should be followed by the health facility.
6. The health care delivery environment should be neither restrictive nor punitive and should
facilitate informed health care decisions on the part of the mother and her family.
7. The health care delivery environment should be sensitive to cultural and social diversity.
8. The mother and her family should be protected within the health care setting from false or
misleading product promotion and/or advertising which interferes with or undermines informed
choices regarding infant health care practices.
9. When a mother has chosen not to breastfeed, when supplementation of breastfeeding is
medically indicated, or when supplementation is chosen by the breastfeeding mother (after
appropriate counseling and education), it is crucial that safe and appropriate methods of
formula mixing, handling, storage, and feeding are taught to the parents.
10. Recognition as a Baby-Friendly institution should have both national and international credibility
and prestige, so that it is marketable to the community, increases demand, and thereby
improves motivation among facilities to participate in the Initiative.
11. Participation of any facility in the U.S. BFHI is entirely voluntary and is available to any institution
providing birthing services. Each participating facility assumes full responsibility for assuring that
its implementation of the BFHI is consistent with all of its safety protocols.
Step 1: Have a written breastfeeding policy that is routinely

communicated to all health care staff.
1.1 Guideline: Breast milk should be the standard for infant feeding. All infants in the facility should
be considered to be breastfeeding infants unless, after giving birth and being offered help to
breastfeed, the mother has specifically stated that she has no plans to breastfeed. (See Steps 4
and 5.) The facility should have a written policy that addresses the implementation of Steps 2

through 10, as well as the International Code of Marketing of Breast-milk Substitutes

(International Code), and communicates the Baby-Friendly philosophy that mothers room with,
care for, and feed their own well infants and should be protected from the promotion of breast
milk substitutes and other efforts that undermine an informed feeding choice. All areas of the
facility that potentially interact with childbearing women and infants will have language in their
policies about the promotion, protection, and support of breastfeeding. Policies of all
departments will support, and will not countermand, the facility’s breastfeeding policy, and will
be based on recent and reliable scientific evidence.
1.1.1 Criterion for evaluation: The facility will have written maternity care and infant feeding
policies that address all Ten Steps, protect breastfeeding, and adhere to the
International Code. All areas of the facility that potentially interact with childbearing
women and infants will have language in their policies about the promotion, protection,
and support of breastfeeding. Policies of all departments will not countermand the
facility’s breastfeeding policy. Review of all clinical protocols, standards, and educational
materials related to breastfeeding and infant feeding used by the maternity services
indicates that they are in line with the BFHI standards and current evidence-based
guidelines.
1.1.2 Criterion for evaluation: The nursing director/manager will be able to identify the
health care professional(s) who has ultimate responsibility for assuring implementation
of the breastfeeding policy.
1.2 Guideline: The designated health care professional(s) should ensure that maternity care and
infant feeding policies are readily available for reference by all staff who care for mothers,
infants, and/or young children and are communicated to new employees in their orientation
and at other times as determined by the health care facility. The facility should have a
mechanism for monitoring the effectiveness of the maternity care and infant feeding policies
that is incorporated into routine quality improvement procedures.
1.2.1 Criterion for evaluation: The nursing director/manager of the maternity unit and/or the
designated health care professional within the facility will be able to locate the
maternity care and infant feeding policies and describe how the other staff, including
new employees, are made aware of the content.
1.2.2 Criterion for evaluation: Of randomly selected maternity staff members, at least 80%
will confirm that they are aware of the facility’s maternity care and infant feeding
policies, know where the policies are kept or posted, and have received orientation
regarding the policies.
1.2.3 Criterion for evaluation: The nursing director/manager of the maternity unit and/or the
designated health care professional within the facility will be able to produce evidence
of routine quality improvement procedures that have monitored the maternity care and
infant feeding policies.
1.3 Guideline: The Ten Steps to Successful Breastfeeding (Ten Steps) and a statement indicating the
facility’s adherence to the WHO International Code requirements related to the purchase and
promotion of breast milk substitutes, bottles, nipples, pacifiers, and other infant feeding

supplies should be prominently displayed in all areas that serve mothers, infants, and young
children. This information should be available in the language(s) most commonly understood by
patients, and, if needed and possible, should be available in appropriate formats for illiterate
and visually impaired patients.
1.3.1 Criterion for evaluation: The Ten Steps and the statement indicating the facility’s
adherence to the WHO International Code restricting the promotion of breast milk
substitutes, bottles, nipples, and other infant feeding supplies will be prominently
displayed in all areas of the health care facility which serve mothers, infants, and/or
young children, including labor and delivery, the postpartum unit, all infant and child
care areas, affiliated prenatal services, ultrasound, screening, antenatal testing, and the
emergency room. This information will be displayed in the language(s) most commonly
understood by patients.
Step 2: Train all health care staff in the skills necessary to implement
this policy.
2.1 Guideline: A designated health care professional should be responsible for assessing needs,
planning, implementing, evaluating, and periodically updating competency-based training in
breastfeeding and parent teaching for formula preparation and feeding for all health care staff
caring for mothers, infants, and/or young children. Such training may differentiate the level of
competency required and/or needed based on staff function, responsibility, and previously
acquired training and should include documentation that essential skills have been mastered.
Training for nursing staff on maternity should comprise a total of 20 hours, inclusive of the 15
sessions identified by UNICEF/WHO and 5 hours of supervised clinical experience. (See Appendix
A.) Clinical competency verification will be a focus of all staff training. Maternity staff will receive
training and mentorship necessary to attain competence in counseling the feeding decision,
providing skin-to-skin contact in the immediate postpartum period and beyond, assisting and
assessing the mother and infant in achieving comfortable and effective positioning and
attachment at the breast, counseling mothers regarding maintaining exclusive breastfeeding,
learning feeding cues, assuring rooming-in, teaching and assisting mothers with hand expression
of milk, teaching formula preparation and feeding to parents when necessary, and assisting
mothers in finding support upon discharge.
Health care providers (physicians, midwives, physician assistants, and advanced practice
registered nurses) with privileges for labor, delivery, maternity, and nursery/newborn care
should have a minimum of 3 hours of breastfeeding management education pertinent to their
role. At minimum, all health care providers must have a true understanding of the benefit of
exclusive breastfeeding, physiology of lactation, how their specific field of practice impacts
lactation, and how to find out about safe medications for use during lactation. If health care
providers do not teach specific skills, it is not expected that they be able to describe or
demonstrate them. However, it is expected that they will know to whom to refer a mother for
help with matters for which they do not possess the skills.
The facility should determine the amount and content of training required by staff in other units
and roles by their anticipated workplace exposure to mothers and infants. The content and

number of hours of training for staff working outside maternity will be developed by each
facility, based on job description and workplace exposure to breastfeeding couplets.
Examples of training for staff outside of maternity include, but are not limited to:
 Pharmacist - importance of exclusive breastfeeding, medications acceptable for

breastfeeding
 Social worker, discharge planner - importance of exclusive breastfeeding, community
resources that support breastfeeding
 Anesthesiologist - importance of exclusive breastfeeding, importance of immediate skin-
to-skin contact
 Radiology - importance of exclusive breastfeeding, where to find out about safe
medications for use during lactation, where to find appropriate information on use of
radioisotopes during lactation
 Dietary - importance of exclusive breastfeeding, practices that support breastfeeding
 Housekeeping staff - importance of exclusive breastfeeding, practices that support
breastfeeding, the facility’s philosophy on infant nutrition, who to call when a mother
needs help
2.1.1 Criterion for evaluation: The head of maternity services will report that all health care
staff members who have any contact with pregnant women, mothers, and/or infants
have received sufficient orientation on the infant feeding policies.
2.1.2 Criterion for evaluation: The head of maternity services will be able to identify the
health care professional(s) responsible for all aspects of planning, implementing, and
evaluating staff training in breastfeeding and parent teaching for formula preparation
and feeding.
2.1.3 Criterion for evaluation: The designated health care professional(s) will provide
documentation that training for breastfeeding and parent teaching for formula
preparation and feeding is provided for all health care staff caring for mothers, infants
and/or young children and that new staff are oriented on arrival and scheduled for
training within 6 months (for example, by providing a list of new staff who are scheduled
for training).
2.1.4 Criterion for evaluation: If training acquired prior to employment with this facility is
accepted as a means of meeting the minimum competencies, the designated health
care professional will be able to describe the process used to verify the previously
acquired competencies.
2.1.5 Criterion for evaluation: The designated health care professional(s) will provide
documentation of training offered to staff outside the maternity unit.
2.1.6 Criterion for evaluation: A copy of the curricula or course outlines for competency-
based training in breastfeeding, lactation management, and parent teaching for formula
preparation and feeding will be available for review and a schedule for training all newly
hired staff will exist. Maternity staff training will cover Steps 3 through 10 and include
the topics and subtopics of all 15 sessions identified by the UNICEF/WHO 20 hour

curriculum. (See Appendix A.) The training will include a minimum of five hours of
supervised clinical experience.
2.1.7 Criterion for evaluation: Of randomly selected maternity staff members, including the
nursery staff and health care providers with privileges, at least 80% will confirm that
they have completed the described training and competency verification, or, if they
have been on the unit less than 6 months, have at minimum been oriented.
2.1.8 Criterion for evaluation: Of health care providers with privileges, at least 80% will be
able to correctly answer 4 out of 5 questions demonstrating they have a true
understanding of the benefit of exclusive breastfeeding, physiology of lactation, how
their specific field of practice impacts lactation, and how to find out about safe
medications for use during lactation.
2.1.9 Criterion for evaluation: Of randomly selected maternity staff members, at least 80%
will be able to answer 4 out of 5 questions on breastfeeding management correctly.
2.1.10 Criterion for evaluation: Of randomly selected maternity staff members and health care
providers, at least 80% will be able to identify 2 topics to discuss with women who are
considering feeding their infants something other than human milk.
Step 3: Inform all pregnant women about the benefits and management
of breastfeeding.
Guidelines and criteria only for facilities with an affiliated prenatal clinic or services
3.1 Guideline: Education about breastfeeding, including individual counseling, should be made
available to pregnant women for whom the facility or its associated services provide prenatal
care. The education should begin in the first trimester whenever possible.
3.1.1 Criterion for evaluation: If the facility has an affiliated prenatal clinic or services, the
nursing director/manager will report that individual counseling or group education on
breastfeeding is given to at least 80% of the pregnant women using those services.
3.2 Guideline: The education should cover the importance of exclusive breastfeeding, non-
pharmacological pain relief methods for labor, the importance of early skin-to-skin contact,
early initiation of breastfeeding, rooming-in on a 24-hour basis, feeding on demand or baby-led
feeding, frequent feeding to help assure optimal milk production, effective positioning and
attachment, exclusive breastfeeding for the first 6 months, and that breastfeeding continues to
be important after 6 months when other foods are given. Individualized education on the
documented contraindications to breastfeeding and other special medical conditions should be
given to pregnant women when indicated.
3.2.1 Criterion for evaluation: A written description of the content of the prenatal education
will be available and will cover, at minimum, the importance of breastfeeding, the
importance of exclusive breastfeeding for about 6 months, and basic breastfeeding
management.

3.2.2 Criterion for evaluation: Of the randomly selected pregnant women in the third
trimester who are using the facility prenatal services, at least 80% will confirm that a
staff member has talked with them or offered a group talk that includes information on
breastfeeding.
3.2.3 Criterion for evaluation: Of the randomly selected pregnant women in the third
trimester who are using the facility prenatal services, at least 80% are able to
adequately describe what was discussed concerning 2 of the following topics:
importance of skin-to-skin contact, rooming-in, or risks of supplements while
breastfeeding in the first 6 months.
Guidelines and criteria for all facilities with or without an affiliated prenatal clinic or services
3.3 Guideline: All facilities should foster the development of or coordinate services with programs
that make education about breastfeeding available to pregnant women. All facilities should
foster relationships with community-based programs that make available individual counseling
or group education on breastfeeding and coordinate messages about breastfeeding with these
programs. The education should begin in the first trimester whenever possible.
3.3.1 Criterion for evaluation: The nursing director/manager will report that the facility
fosters relationships with community-based programs that make available individual
counseling or group education on breastfeeding and coordinates messages about
breastfeeding with these programs.
3.3.2 Criterion for evaluation: The nursing director/manager will report that the facility has
fostered the development of or coordinated services with one or more of the following
programs: in-house breastfeeding education, childbirth education, hospital pre-
registration visits, hospital tours, in-patient services, etc.
3.4 Guideline: Prenatal education should cover the importance of exclusive breastfeeding, non-
pharmacological pain relief methods for labor, the importance of early skin-to-skin contact,
early initiation of breastfeeding, rooming-in on a 24-hour basis, feeding on demand or baby-led
feeding, frequent feeding to help assure optimal milk production, effective positioning and
attachment, exclusive breastfeeding for the first 6 months, and the fact that breastfeeding
continues to be important after 6 months when other foods are given. Individualized education
on the documented contraindications to breastfeeding and other special medical conditions
should be given to pregnant women when indicated.
3.4.1 Criterion for evaluation: A written description of in-house and/or community-based

programs and projects the facility has fostered will be available and will cover, at
minimum, the importance of breastfeeding, the importance of exclusive breastfeeding
for about 6 months, and basic breastfeeding management (e.g. skin-to-skin contact,
rooming-in, and risks of supplements while breastfeeding in the first 6 months).

Step 4: Help mothers initiate breastfeeding within one hour of birth.

This Step is now interpreted as:
Place infants in skin-to-skin contact with their mothers immediately following birth for at
least an hour and encourage mothers to recognize when their infants are ready to
breastfeed, offering help if needed.
This Step applies to all infants, regardless of feeding method.
4.1 Guideline: All mothers should be given their infants to hold with uninterrupted and continuous
skin-to-skin contact immediately after birth and until the completion of the first feeding, unless
there are documented medically justifiable reasons for delayed contact or interruption. Routine
procedures (e.g. assessments, Apgar scores, etc.) should be done with the infant skin-to-skin
with the mother. Procedures requiring separation of the mother and infant (bathing, for
example) should be delayed until after this initial period of skin-to-skin contact and should be
conducted, whenever feasible, at the mother’s bedside. Additionally, skin-to-skin contact should
be encouraged throughout the hospital stay.
4.1.1 Criterion for evaluation: Of randomly selected mothers in the postpartum unit who
have had normal vaginal births, at least 80% will confirm that their infants were placed
in skin-to-skin contact with them immediately after birth and that skin-to-skin contact
continued uninterrupted until the completion of the first feeding (or for at least one
hour if not breastfeeding), unless there were documented medically justifiable reasons
for delayed contact.
have had normal vaginal births, at least 80% will confirm that they were encouraged to
look for signs that their infants were ready to feed during this first period of contact and
offered help if needed. (The infant should not be forced to feed, but rather, supported
to do so when ready.)
4.1.3 Criterion for evaluation: Observations of vaginal births, if necessary to confirm

adherence to Step 4, show that (regardless of the mother’s feeding intentions) at least
80% of infants are placed skin-to-skin with their mothers within 5 minutes after birth
and are held continuously skin-to-skin until completion of the first feeding, or for at
least one hour if not breastfeeding, unless there were documented medically justifiable
reasons for delayed contact.
4.1.4 Criterion for evaluation: Observations of vaginal births, if necessary to confirm

adherence to Step 4, show that (regardless of the mother’s feeding intentions) at least
80% of mothers are shown how to recognize the signs that their infants are ready to
feed and offered help, or there are documented justifiable reasons for not following
these procedures.
4.2 Guideline: After cesarean birth, mothers and their infants should be placed in continuous,
uninterrupted skin-to-skin contact as soon as the mother is responsive and alert, with the same
staff support identified above regarding feeding cues, unless separation is medically indicated.

have had cesarean births of a healthy infant, at least 80% will confirm that their infants
were placed in skin-to-skin contact with them as soon as the mother was responsive and
alert and that skin-to-skin contact continued uninterrupted until completion of the first
feeding (or at least one hour if not breastfeeding), unless there were documented
medically justifiable reasons for delayed contact.
have had cesarean births of a healthy infant, at least 80% will confirm that they were
encouraged to look for signs that their infants were ready to feed during this first period
of contact and offered help if needed. (The infant should not be forced to feed, but
rather, supported to do so when ready.)
4.2.3 Criterion for evaluation: Observations of cesarean births and recovery, if necessary to
confirm adherence to Step 4, show that (regardless of the mother’s feeding intentions),
at least 80% of infants are placed with their mothers and held continuously skin-to-skin
as soon as the mother was responsive and alert and until completion of the first feeding.
4.2.4 Criterion for evaluation: Observations of cesarean births and recovery, if necessary to
confirm adherence to Step 4, show that (regardless of the mother’s feeding intentions),
at least 80% of mothers are shown how to recognize the signs that their infants are
ready to feed and offered help, or there are documented justified reasons for not
following these procedures.
4.3 Guideline: In the event that a mother and/or infant are separated for documented medical
reasons, skin-to-skin contact will be initiated as soon as the mother and infant are reunited.
4.3.1 Criterion for evaluation: Of randomly selected mothers who gave birth either vaginally
or via cesarean, at least 80% will confirm that in the event of medically-indicated
separation, skin-to-skin contact was initiated when they were reunited with their
infants.
Recommendation for facilities with an affiliated special care nursery or neonatal intensive
care unit
4.4 Recommended guideline: Mothers whose infants are being cared for in the special care nursery
should be given the opportunity to practice Kangaroo Mother Care as soon as the infant is
considered ready for such contact.
4.4.1 Recommended criterion for evaluation: The facility has a quality improvement goal and
tracking method to assure that at least 80% of randomly selected mothers with infants
in special care will have the opportunity to practice Kangaroo Mother Care, unless there
are documented medically justifiable reasons why they could not.

Step 5: Show mothers how to breastfeed and how to maintain lactation,

even if they are separated from their infants.
5.1 Guideline: Health care professionals should assess the mother’s breastfeeding techniques and, if
needed, should demonstrate appropriate breastfeeding positioning and attachment with the
mother and infant, optimally within 3 hours and no later than 6 hours after birth. Prior to
discharge, breastfeeding mothers should be educated on basic breastfeeding practices,
including: 1) the importance of exclusive breastfeeding, 2) how to maintain lactation for
exclusive breastfeeding for about 6 months, 3) criteria to assess if the infant is getting enough
breast milk, 4) how to express, handle, and store breast milk, including manual expression, and
5) how to sustain lactation if the mother is separated from her infant or will not be exclusively
breastfeeding after discharge.
5.1.1 Criterion for evaluation: Of randomly selected postpartum mothers, at least 80% will
report that nursing staff offered further assistance with breastfeeding the next time
they fed their infants or within 6 hours of birth, or of when they were able to respond.
5.1.2 Criterion for evaluation: Of randomly selected postpartum mothers, at least 80% of
those who are breastfeeding will be able to demonstrate correct positioning and
attachment with their own infants and will report that breastfeeding is comfortable for
them.
5.1.3 Criterion for evaluation: Of randomly selected postpartum mothers, at least 80% of
those who are breastfeeding will report that they were shown how to express their milk
by hand.
5.1.4 Criterion for evaluation: Of randomly selected health care staff caring for postpartum
mothers, at least 80% will report that they teach mothers how to position and attach
their infants for breastfeeding and are able to describe or demonstrate correct
techniques for both.
5.1.5 Criterion for evaluation: Of randomly selected health care staff caring for postpartum
mothers, at least 80% will report that they teach mothers how to hand express breast
milk and can describe or demonstrate an adequate technique for this.
5.2 Guideline: Additional individualized assistance should be provided to high risk and special needs
mothers and infants and to mothers who have breastfeeding problems or must be separated
from their infants. The routine standard of care should include procedures that assure that milk
expression is begun as soon as possible, but no later than 6 hours after birth, expressed milk is
given to the infant as soon as the infant is medically ready, and the mother’s expressed milk is
used before any supplementation with breast milk substitutes when medically appropriate. For
high risk and special needs infants who cannot be skin-to-skin immediately or cannot suckle,
beginning manual expression within one hour is recommended. Assistance should be provided
as needed.
5.2.1 Criterion for evaluation: Of randomly selected mothers with infants in special care, at
least 80% of those who are breastfeeding or intending to do so will report that they

have been offered help to begin expressing and collecting milk as soon as possible, but
no later than 6 hours after their infants’ births, unless there is a medically justifiable
reason to delay initiation of expression.
least 80% of those who are breastfeeding or intending to do so report that they have
been shown how to express their milk by hand or other method.
least 80% of those who are breastfeeding or intending to do so can adequately describe
and demonstrate how they were shown to express their milk.
least 80% of those who are breastfeeding or intending to do so will report that they
have been told they need to breastfeed or express their milk 8 times or more every 24
hours to establish and maintain their milk supply.
5.3 Guideline: Mothers who feed formula should receive written instruction, not specific to a
particular brand, and verbal information about safe preparation, handling, storage, and feeding
of infant formula. Staff should document completion of formula preparation instruction and safe
feeding in the medical record. This information should be given on an individual basis only to
women who are feeding formula or mixed feeding their infants.
5.3.1 Criterion for evaluation: Of maternity staff members, at least 80% can describe how
mothers who are feeding formula can be assisted to safely prepare and feed formula to
their infants.
5.3.2 Criterion for evaluation: Of mothers who are feeding formula, at least 80% will report
that someone discussed their feeding choice with them.
5.3.3 Criterion for evaluation: Of mothers who are feeding formula, at least 80% will report
that they have been provided education about preparing and giving their infants feeds
and can describe the advice they were given.
Step 6: Give infants no food or drink other than breast milk, unless
medically indicated.
Exclusive breast milk feeding shall be the feeding method expected from birth to discharge.
Each facility should track its rate of formula supplementation of breastfed infants. Facilities should strive
to reach the Healthy People 2020 goal for exclusive breastfeeding. The rate of supplementation for non-
medical reasons should be analyzed and compared to the annual rate of supplementation of breastfed
infants reported by the Centers for Disease Control and Prevention (CDC) National Immunization Survey
data for the geographic region in which the facility is located. In addition, a year-by-year reduction in
non-medically indicated supplementation is expected in Baby-Friendly designated facilities.
6.1 Guideline: When a mother specifically states that she has no plans to breastfeed or requests
that her breastfeeding infant be given a breast milk substitute, the health care staff should first

explore the reasons for this request, address the concerns raised, and educate her about the
possible consequences to the health of her infant and the success of breastfeeding. If the
mother still requests a breast milk substitute, her request should be granted and the process
and the informed decision should be documented. Any other decisions to give breastfeeding
infants food or drink other than breast milk should be for acceptable medical reasons and
require a written order documenting when and why the supplement is indicated. (See Appendix
B.)
6.1.1 Criterion for evaluation: Of randomly selected mothers who are breastfeeding, at least
80% will report that:
 to the best of their knowledge, their infants have received no food or drink other
than breast milk while in the facility, or
 that formula has been given for a medically acceptable reason, or
 that formula has been given in response to a parental request.
6.1.2 Criterion for evaluation: Of breastfeeding mothers whose infants have been given food
or drink other than breast milk, at least 80% of those who have no acceptable medical
reason will report that the health care staff explored the reasons for and the possible
negative consequences of the mother’s decisions.
6.1.3 Criterion for evaluation: Of infants who have been given food or drink other than breast
milk, at least 80% will have the reasons for supplementation and evidence of parental
counseling (in the event of parental choice) clearly documented in the medical record.
6.1.4 Criterion for evaluation: Of randomly selected mothers who have decided to feed
formula, at least 80% will report that the staff discussed with them the various feeding
options and helped them to decide what was suitable in their situations.
6.1.5 Criterion for evaluation: Of mothers with infants in special care who have decided to
feed formula, at least 80% will report that staff have talked with them about the risks
and benefits of the various feeding options, including feeding expressed breast milk.
6.1.6 Criterion for evaluation: Observations in the postpartum unit/rooms and any well-baby
observation areas show that at least 80% of breastfed infants are being fed only breast
milk, or documentation indicates that there are acceptable medical reasons or fully
informed choices for formula feeding.
Step 7: Practice rooming in - allow mothers and infants to remain

together 24 hours a day.
7.1 Guideline: The facility should provide rooming-in 24 hours a day as the standard for mother-
baby care for healthy term infants, regardless of feeding choice. When a mother requests that
her infant be cared for in the nursery, the health care staff should explore the reasons for the
request and should encourage and educate the mother about the advantages of having her
infant stay with her in the same room 24 hours a day. If the mother still requests that the infant
be cared for in the nursery, the process and informed decision should be documented. In
addition, the medical and nursing staff should conduct newborn procedures at the mother’s

bedside whenever possible and should avoid frequent separations and absences of the newborn
from the mother for more than one hour in a 24-hour period. If the infant is kept in the nursery
for documented medical reasons, the mother should be provided access to feed her infant at
any time.
7.1.1 Criterion for evaluation: Of randomly selected mothers with vaginal births, at least 80%
will report that their infants were not separated from them before starting rooming-in,
unless there are documented medical reasons for separation.
7.1.2 Criterion for evaluation: Of randomly selected mothers with healthy term infants, at
least 80% will report that since they came to their room after birth (or since they were
able to respond to their infants in the case of cesarean birth), their infants have stayed
with them in the same room day and night except for up to one hour per 24-hour period
for facility procedures, unless there are documented justifiable reasons for a longer
separation.
7.1.3 Criterion for evaluation: Observations in the postpartum unit and any well-baby
observation areas and discussions with mothers and staff confirm that at least 80% of
the mothers and infants are rooming-in or have documented justifiable reasons for
separation.
Step 8: Encourage breastfeeding on demand.

This step applies to all infants, regardless of feeding method, and is now interpreted as:
Encourage feeding on cue.
8.1 Guideline: Health care professionals should help all mothers, regardless of feeding choice: 1)
understand that no restrictions should be placed on the frequency or length of feeding, 2)
understand that newborns usually feed a minimum of 8 times in 24 hours, 3) recognize cues that
infants use to signal readiness to begin and end feeds, and 4) understand that physical contact
and nourishment are both important.
8.1.1 Criterion for evaluation: Of randomly selected mothers of normal infants (including
those of cesarean birth), at least 80% will report that they have been told how to
recognize when their infants are hungry and can describe at least 2 feeding cues.
8.1.2 Criterion for evaluation: Of breastfeeding mothers, at least 80% will report that they
have been advised to feed their infants as often and as long as the infants want.
8.1.3 Criterion for evaluation: Of mothers who are feeding their infants formula, at least 80%
will report that they have been taught appropriate formula feeding techniques,
including feeding on cue, eye-to-eye contact, and holding the infant closely.
8.1.4 Criterion for evaluation: The nursing director/manager on the maternity unit will
confirm that no restrictions are placed on the frequency or length of feeds.

Step 9: Give no pacifiers or artificial nipples to breastfeeding infants.

9.1 Guideline: Health care professionals, including nursery staff, should educate all breastfeeding
mothers about how the use of bottles and artificial nipples may interfere with the development
of optimal breastfeeding. When a mother requests that her breastfeeding infant be given a
bottle, the health care staff should explore the reasons for this request, address the concerns
raised, educate her on the possible consequences to the success of breastfeeding, and discuss
alternative methods for soothing and feeding her infant.
If the mother still requests a bottle, the process of counseling and education and the informed
decision of the mother should be documented.
Any fluid supplementation (whether medically indicated or following informed decision of the
mother) should be given by tube, syringe, spoon, or cup in preference to an artificial nipple or
bottle.
9.1.1 Criterion for evaluation: Of breastfeeding mothers, at least 80% will report that, to the
best of their knowledge, their infants have not be fed using bottles.
observation areas will indicate that at least 80% of breastfeeding infants are not using
bottles.
9.1.3 Criterion for evaluation: The nursing director/manager will confirm that breastfed
infants are not routinely given bottles.
9.2 Guideline: Health care professionals, including nursery staff, should educate all breastfeeding
mothers about how the use of pacifiers may interfere with the development of optimal
breastfeeding. Breastfeeding infants should not be given pacifiers by the staff of the facility,
with the exception of limited use to decrease pain during procedures when the infant cannot
safely be held or breastfed (pacifiers used should be discarded after these procedures), by
infants who are being tube-fed in NICU, or for other rare, specific medical reasons.
When a mother requests that her breastfeeding infant be given a pacifier, the health care staff
should explore the reasons for this request, address the concerns raised, educate her on the
possible consequences to the success of breastfeeding, and discuss alternative methods for
soothing her infant.
If the breastfeeding mother still requests a pacifier, the process of counseling and education and
informed decision should be documented.
9.2.1 Criterion for evaluation: Of breastfeeding mothers, at least 80% will report that:
 to the best of their knowledge, their infants have not sucked on pacifiers, or
 that pacifier use was limited to painful procedures, or
 that pacifier use was chosen by the infant’s parents after receipt of appropriate
education and counseling from staff.

observation areas will indicate that at least 80% of breastfeeding infants are not using
pacifiers, or, if they are, their mothers have been informed of the risks and this
interchange is documented in the medical record.
9.2.3 Criterion for evaluation: The nursing director/manager will confirm that breastfeeding
infants are not routinely given pacifiers and that use of pacifiers in term infants is
restricted to cases where there is a medical indication.
Step 10: Foster the establishment of breastfeeding support groups and

refer mothers to them on discharge from the hospital or birth center.
10.1 Guideline: The designated health care professional(s) should ensure that, prior to discharge, a
responsible staff member explores with each mother and a family member or support person
(when available) the plans for infant feeding after discharge. Discharge planning for
breastfeeding mothers and infants should include information on the importance of exclusive
breastfeeding for about 6 months and available and culturally-specific breastfeeding support
services without ties to commercial interests. Examples of the information and support to be
provided include giving the name and phone numbers of community-based support groups,
breastfeeding support services, telephone help lines, lactation clinics, home health services, and
individualized specialized resource persons. An early post-discharge follow-up appointment with
their pediatrician, family practitioner, or other pediatric care provider should also be scheduled.
The facility should establish in-house breastfeeding support services if no adequate source of
support is available for referral (e.g. support group, lactation clinic, home health services, help
line, etc.).
10.1.1 Criterion for evaluation: The nursing director/manager on the maternity unit will report
that mothers are given information on where they can find support if they need help
with feeding their infants after returning home.
that the facility fosters the establishment of and/or coordinates with mother support
groups and other community services that provide breastfeeding/infant feeding support
to mothers, and the designated staff member can describe at least one way this is done.
that the staff assures that mothers and infants receive breastfeeding assessment and
support after discharge (preferably 2 to 4 days after discharge and again the second
week) at the facility or in the community by a skilled breastfeeding support person who
can assess feeding and give any support needed.
that the staff can describe an appropriate referral system and adequate timing for the
visits.
10.1.5 Criterion for evaluation: A review of documents indicates that printed information is
distributed to mothers before discharge on how and where mothers can find help on

feeding their infants after returning home and includes information on the types of help
available.
10.1.6 Criterion for evaluation: Of breastfeeding mothers, at least 80% will report that they
have been given information about how to get help from the facility and how to contact
support groups, peer counselors, or other community health services if they have
questions about feeding their infants after they return home, and can describe at least
one type of help that is available.
Compliance with the International Code of Marketing of Breast-milk

Substitutes
11.1 Guideline: The facility will demonstrate its compliance with the International Code by refusing
to accept supplies of breast milk substitutes and feeding supplies at no cost or below fair market
cost (see Appendix C), by protecting new parents from the influence of vendors of such items,
by practicing in accordance with its vendor and ethics policies regarding appropriate interaction
between vendors of such items and facility staff, and by educating staff members about the
International Code and its role in ethical health care practices.
that no employees of manufacturers or distributors of breast milk substitutes, bottles,
nipples, pacifiers or other infant feeding supplies have any direct or indirect contact
with pregnant women or mothers.
that the facility and its staff members do not receive free gifts, non-scientific literature,
materials or equipment, money, or support for breastfeeding education or events from
manufacturers or distributors of breast milk substitutes, bottles, nipples, pacifiers or
other infant feeding supplies. All other interactions with these
manufacturers/distributors are in compliance with the facility’s vendor/ethics policy.
that pregnant women, mothers, and their families are not given marketing materials or
samples or gift packs by the facility that include breast milk substitutes, bottles, nipples,
pacifiers, or other infant feeding supplies, or coupons for any of the above items.
that any educational materials distributed to breastfeeding mothers are free of
messages that promote or advertise infant food or drinks other than breast milk.
that no educational materials used refer to proprietary products or bear a product logo,
unless specific to the mother’s or infant’s needs or condition. (For example, information
about how to safely use a needed product such as a formula or breast pump would be
acceptable to give to a mother or infant needing such a product. Marketing information
for such products would not be acceptable.)

11.1.6 Criterion for evaluation: A review of records and receipts indicates that any breast milk
substitutes, including special formulas, bottles, nipples, pacifiers and other infant
feeding supplies are purchased by the health care facility at a fair market price. (See
Appendix C for definition.)
11.1.7 Criterion for evaluation: Observations in the antenatal and maternity services and other
areas where nutritionists and dietitians work indicate that no materials that promote
breast milk substitutes, bottles, nipples, pacifiers or other infant feeding supplies are
displayed or distributed to mothers, pregnant women, or staff.
11.1.8 Criterion for evaluation: Infant formula cans and prepared bottles are kept out of view
of patients and the general public.
11.1.9 Criterion for evaluation: Of randomly selected staff members, at least 80% can give 2
reasons why it is important not to give free samples or other items from formula
companies to mothers.

Appendix A:
20-Hour Course Topic and Competency Skills List for the U.S.
Adapted for use in the United States from the WHO/UNICEF International Guidelines
Objectives Content
Discuss the rationale for Session 1: The BFHI – a part of the Global Strategy
professional, government  The Global Strategy for Infant and Young Child Feeding and how
and international policies the Global Strategy fits with other activities
that promote, protect and  The Baby-Friendly Hospital Initiative
support breastfeeding in  How this course can assist health facilities in making
the United States. improvements in evidence-based practice, quality care and
continuity of care
Demonstrate the ability to Session 2: Communication skills
communicate effectively  Listening and learning
about breastfeeding.  Skills to build confidence and give support
 Arranging follow-up and support suitable to the mother’s situation
Describe the anatomy and Session 3: How milk gets from the breast to the baby
physiology of lactation  Parts of the breast involved in lactation
and the process of  Breast milk production
breastfeeding.  The baby’s role in milk transfer
 Breast care
Identify teaching points Session 4: Promoting breastfeeding during pregnancy

appropriate for prenatal  Discussing breastfeeding with pregnant women
classes and in interactions  Why breastfeeding is important
with pregnant women.  Antenatal breast and nipple preparation
 Women who need extra attention
Discuss hospital birth Session 5: Birth practices and breastfeeding

policies and procedures  Labor and birth practices to support early breastfeeding
that support exclusive  The importance of early skin-to-skin contact
breastfeeding.  Helping to initiate breastfeeding
 Ways to support breastfeeding after a cesarean birth
 BFHI practices and women who are not breastfeeding
Demonstrate the ability to Session 6: Helping with a breastfeed

identify the hallmarks of  Positioning for comfortable breastfeeding
milk transfer and optimal  How to assess a breastfeeding
breastfeeding.  Recognize signs of optimal positioning and attachment
 Help a mother to learn to position and attach her baby
 When to assist with breastfeeding
 The baby who has difficulty attaching to the breast

Objectives Content
Discuss hospital Session 7: Practices that assist breastfeeding
postpartum management  Rooming-in
policies and procedures  Skin-to-skin contact
that support exclusive  Baby-led feeding
breastfeeding.  Dealing with sleepy babies and crying babies
 Avoiding unnecessary supplements
 Avoiding bottles and teats
Discuss methods that may Session 8: Milk supply

increase milk production  Concerns about “not enough milk”
in a variety of  Normal growth patterns of babies
circumstances.  Improving milk intake and milk production
Identify teaching points to Session 9: Supporting the non-breastfeeding mother and baby
include when educating or  Counseling the formula choice: a pediatric responsibility
counseling parents who  Teaching/assuring safe formula preparation in the postpartum
are using bottles and/or  Safe bottle feeding; issues with overfeeding and underfeeding
formula.
Discuss contraindications Session 10: Infants and mothers with special needs
to breastfeeding in the  Breastfeeding infants who are preterm, low birth weight or ill
United States as well as  Breastfeeding more than one baby
commonly encountered  Prevention and management of common clinical concerns
areas of concern for  Medical reasons for food other than breast milk
breastfeeding mothers  Nutritional needs of breastfeeding women
and their babies.  How breastfeeding helps space pregnancies
 Breastfeeding management when the mother is ill
 Medications and breastfeeding
 Contraindications to breastfeeding
Describe management Session 11: Breast and nipple concerns
techniques for breast and  Examination of the mother’s breasts and nipples
nipple problems.  Engorgement, blocked ducts, and mastitis
 Sore nipples
Identify acceptable Session 12: If the baby cannot feed at the breast
medical reasons for  Learning to hand express
supplementation of  Use of milk from another mother
breastfed babies  Feeding expressed breast milk to the baby
according to national and
international authorities.

Objectives Content
Describe essential Session 13: Ongoing support for mothers
components of support  Preparing a mother for discharge
for mothers to continue  Follow-up and support after discharge
breastfeeding beyond the  Protecting breastfeeding for employed women
early weeks.  Sustaining continued breastfeeding for 2 years or longer
Describe strategies that Session 14: Protecting breastfeeding

protect breastfeeding as a  The effect of marketing on infant feeding practices
public health goal.  The International Code of Marketing of Breast-milk Substitutes
 How health workers can protect families from marketing
 Donations in emergency situations
 The role of breastfeeding in emergencies
 How to respond to marketing practices
Identify barriers and Session 15: Making your hospital or birth center Baby-Friendly®
solutions to  The Ten Steps to Successful Breastfeeding
implementation of the Ten  What “Baby-Friendly” Practices mean
Steps to Successful  The process of becoming a Baby-Friendly hospital or birth center
Breastfeeding that
comprise the Baby-
Friendly Hospital Initiative.
Skills Competencies for Maternity Staff:
1. Communicating with pregnant and postpartum women about infant feeding

2. Observing, assessing and assisting with breastfeeding
3. Teaching hand expression and safe storage of milk
4. Teaching safe formula preparation and feeding

Appendix B:
Acceptable medical reasons for use of breast milk substitutes
Almost all mothers can breastfeed successfully, which includes initiating breastfeeding within the first
hour of life, breastfeeding exclusively for the first 6 months, and continuing breastfeeding along with
giving appropriate complimentary foods up to 2 years of age or beyond.
The facility should develop a protocol/procedure that describes the current, evidence-based medical
indications for supplementation. Staff and care providers should be trained to utilize the
protocol/procedure as guidance in the case of supplementation. A facility may utilize the
recommendations of national and international authorities (e.g. Centers for Disease Control and
Prevention (CDC), World Health Organization (WHO), and Academy of Breastfeeding Medicine (ABM)) in
developing this protocol/procedure, however the facility is responsible for ensuring that its medical
indications for supplementation are supported by current evidence.

Appendix C:
Definitions of terms and abbreviations used in this document
Affiliated prenatal services – Primary prenatal care delivered through a close formal or informal
association with a birthing facility. For Baby-Friendly purposes, the affiliation is determined through
completion of a questionnaire regarding specific aspects of the relationship, such as business
relationship, personnel relationship, and marketing of services.
Criteria for evaluation – The minimum standards which must be achieved in order to achieve Baby-
Friendly designation.
Exclusive breast milk feeding – Refers to the optimal practice of feeding infants no food or drink other
than human milk unless another food is determined to be medically necessary.
Fair market price – The International Code of Marketing of Breast-milk Substitutes, and subsequently,
the BFHI, call for health systems to purchase infant foods and feeding supplies at a fair market value.
Fair market pricing can be determined by calculating the margin of retail price the facility pays on other
items available on the retail market.
Guidelines – The standards of care which facilities strive to achieve for all patients.
Kangaroo Mother Care (KMC) – In this document, the term Kangaroo Mother Care refers to skin-to-skin
care provided by the mother or father of a preterm infant. The infant is worn against the parent’s naked
chest in such a fashion that the infant is held upright. The parent is then wrapped in a blanket or other
clothing to secure the infant against her or his chest. Infants may be held continuously in this fashion for
many hours. Optimally, KMC begins as soon as the infant is judged ready for skin-to-skin contact.
Policy – An enforceable document that guides staff in the delivery of care. At the facility level, this may
include policies, practice guides and protocols.
Skin-to-skin contact (STS) – Skin-to-skin contact or skin-to-skin care refers to contact between the
newborn infant and its mother. (In the case of incapacitation of the mother, another adult, such as the
infant’s father or grandparent, may hold the infant skin-to-skin.) After birth, the infant is completely
dried and placed naked against the mother’s naked ventral surface. The infant may wear a diaper and/or
a hat, but no other clothing should be between the mother’s and infant’s bodies. The infant and mother
are then covered with a warm blanket, keeping the infant’s head uncovered. STS should continue,
uninterrupted, until completion of the first feeding, or at least one hour if the mother is not
breastfeeding. STS should be encouraged beyond the first hours and into the first days after birth and
beyond.
ABM – Academy of Breastfeeding Medicine NICU – Neonatal Intensive Care Unit

BFHI – Baby-Friendly Hospital Initiative STS – Skin-to-skin contact
CDC – Centers for Disease Control and UNICEF – United Nations Children’s Fund
Prevention WHO – World Health Organization
KMC – Kangaroo Mother Care

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The Baby-Friendly Hospital Initiative

for Facilities Seeking

Baby-Friendly USA, Inc.

Copyright 2010, 2016 Baby-Friendly USA, Inc.

This document is an adaptation of the following documents:

© 2010, 2016 Baby-Friendly USA, Inc.

Baby-Friendly® (“Baby-Friendly”) is a registered certification mark owned by Baby-Friendly USA, Inc.

U.S. Committee for UNICEF: Minda Lazarov

UNICEF: Helen Armstrong, Paula Donovan, Lida Lhotska

© 2010, 2016 Baby-Friendly USA, Inc.

Baby-Friendly® (“Baby-Friendly”) is a registered certification mark owned by Baby-Friendly USA, Inc.

Audrey J. Naylor, MD, DrPH

© 2010, 2016 Baby-Friendly USA, Inc.

Baby-Friendly® (“Baby-Friendly”) is a registered certification mark owned by Baby-Friendly USA, Inc.

Preamble to the U.S. Baby-Friendly

© 2010, 2016 Baby-Friendly USA, Inc.

Baby-Friendly® (“Baby-Friendly”) is a registered certification mark owned by Baby-Friendly USA, Inc.

Numerous government and professional organizations actively encourage a strong program of

 Academy of Breastfeeding Medicine

Baby-Friendly® (“Baby-Friendly”) is a registered certification mark owned by Baby-Friendly USA, Inc.

© 2010, 2016 Baby-Friendly USA, Inc.

Baby-Friendly® (“Baby-Friendly”) is a registered certification mark owned by Baby-Friendly USA, Inc.

The Guidelines and Evaluation Criteria

1. Well-constructed, comprehensive policies effectively guide staff to deliver evidence-based care.

Step 1: Have a written breastfeeding policy that is routinely

© 2010, 2016 Baby-Friendly USA, Inc.

Baby-Friendly® (“Baby-Friendly”) is a registered certification mark owned by Baby-Friendly USA, Inc.

through 10, as well as the International Code of Marketing of Breast-milk Substitutes

Baby-Friendly® (“Baby-Friendly”) is a registered certification mark owned by Baby-Friendly USA, Inc.

Baby-Friendly® (“Baby-Friendly”) is a registered certification mark owned by Baby-Friendly USA, Inc.

 Pharmacist - importance of exclusive breastfeeding, medications acceptable for

Baby-Friendly® (“Baby-Friendly”) is a registered certification mark owned by Baby-Friendly USA, Inc.

Baby-Friendly® (“Baby-Friendly”) is a registered certification mark owned by Baby-Friendly USA, Inc.

3.4.1 Criterion for evaluation: A written description of in-house and/or community-based

© 2010, 2016 Baby-Friendly USA, Inc.

Baby-Friendly® (“Baby-Friendly”) is a registered certification mark owned by Baby-Friendly USA, Inc.

Step 4: Help mothers initiate breastfeeding within one hour of birth.

This Step applies to all infants, regardless of feeding method.

4.1.3 Criterion for evaluation: Observations of vaginal births, if necessary to confirm

4.1.4 Criterion for evaluation: Observations of vaginal births, if necessary to confirm

Baby-Friendly® (“Baby-Friendly”) is a registered certification mark owned by Baby-Friendly USA, Inc.

© 2010, 2016 Baby-Friendly USA, Inc.

Baby-Friendly® (“Baby-Friendly”) is a registered certification mark owned by Baby-Friendly USA, Inc.

Step 5: Show mothers how to breastfeed and how to maintain lactation,

Baby-Friendly® (“Baby-Friendly”) is a registered certification mark owned by Baby-Friendly USA, Inc.

Baby-Friendly® (“Baby-Friendly”) is a registered certification mark owned by Baby-Friendly USA, Inc.

Step 7: Practice rooming in - allow mothers and infants to remain

Baby-Friendly® (“Baby-Friendly”) is a registered certification mark owned by Baby-Friendly USA, Inc.

Step 8: Encourage breastfeeding on demand.

Encourage feeding on cue.

© 2010, 2016 Baby-Friendly USA, Inc.

Baby-Friendly® (“Baby-Friendly”) is a registered certification mark owned by Baby-Friendly USA, Inc.

Step 9: Give no pacifiers or artificial nipples to breastfeeding infants.

© 2010, 2016 Baby-Friendly USA, Inc.

Baby-Friendly® (“Baby-Friendly”) is a registered certification mark owned by Baby-Friendly USA, Inc.

Step 10: Foster the establishment of breastfeeding support groups and

Baby-Friendly® (“Baby-Friendly”) is a registered certification mark owned by Baby-Friendly USA, Inc.

Compliance with the International Code of Marketing of Breast-milk

© 2010, 2016 Baby-Friendly USA, Inc.

Baby-Friendly® (“Baby-Friendly”) is a registered certification mark owned by Baby-Friendly USA, Inc.